Based on record review and interviews during abbreviated survey (NY00317123), the facility did not ensure residents were free from abuse and failed to protect residents from further abuse for 2 of 2 residents (Resident #2 and 4) reviewed, and 6 unidentified residents. Specifically, Resident #1 was cognitively impaired with a history of sexually inappropriate behaviors and there were no documented interventions to address the resident's ongoing behaviors or to protect other residents from abuse. Resident #2, a cognitively impaired resident, was touched on their breast by Resident #1. Two weeks later, Resident #2 was documented as being touched inappropriately by Resident #1. There was no documented evidence Resident #2 was assessed timely, no evidence the provider and the resident's family were notified timely and interventions to protect Resident #2 and other vulnerable residents were not effective to prevent recurrence. Resident #4, a cognitively impaired resident had their back and buttocks rubbed by Resident #1. Subsequently, Resident #1 kissed unidentified residents on two occasions, and continued to expose themselves and masturbate in front 6 unidentified residents on multiple occasions and the unidentified residents were not documented as assessed to determine if they had a negative outcome. Findings include: The undated facility policy, Abuse Prevention and Reporting, documented all residents would be kept free from abuse and neglect. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment which resulted in physical harm, pain, or mental anguish. Sexual abuse included, but was not limited to, sexual harassment, or sexual assault. The facility would immediately take steps to ensure resident safety and provide medical attention when necessary. They would secure statements from all parties involved. Social Services would be contacted to interview all parties involved. The facility policy, Resident Supervision 15 Minute/Frequent Checks, revised 3/2021, documented 15 Minute or Frequent Checks was a resident being monitored by a facility staff member to ensure the resident or other residents were safe. Prior to considering a resident for 15 Minute/Frequent Checks, an assessment and plan was to be completed by the Interdisciplinary Team to assess need. Interventions should be developed to recognize, evaluate, and analyze specific behaviors to help identify interventions; identify and develop behavior plans; and address, eliminate or reduce underlying causes of distressed behavior. Medical evaluation was required for any resident determined to be in need of intensive supervision. The Comprehensive Care Plan and certified nurse aide plan would be updated and reviewed at least weekly for appropriateness of 15 Minute/Frequent Checks and possible care plan changes. The certified nurse aide was to document all resident activity, behaviors, etc. This would be completed each shift. Resident #2 had diagnoses including stroke and dementia. The 12/15/2023 Minimum Data Set assessment documented the resident's cognition was severely impaired. Resident #4 had diagnoses including bipolar disorder. The 5/1/2023 Minimum Data Set assessment documented the resident's cognition was moderately impaired. Resident #1: Resident #1 had diagnoses including dementia and sexual dysfunction not due to a substance or known physiological condition. The 5/2/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, exhibited physical behaviors directed towards (hitting, kicking, pushing, scratching, grabbing, and abusing others sexually) 1-3 of 7 days which significantly interfered with the resident's care and put others at risk for physical injury, and required supervision for walking in their room and corridor. Resident #1's Comprehensive Care Plan initiated 4/27/2023 documented the resident demonstrated episodes of inappropriate reaching and touching of others, inappropriate comments with sexual overtones, and exposing body parts. Interventions included: 2 staff members for all care; provide support to the resident; and psych evaluation as needed. The resident had the potential to abuse others. Interventions included monitor mood and behavior and provide early interventions; room change or unit change if possible; set limits, and counsel on inappropriate behaviors; if behavior symptoms were unmanageable, call 911 and send the resident to the emergency room for further evaluation. The 4/24/2023 Physician #18 progress note documented the resident was deemed incompetent to make decisions and guardianship was in place. The resident had dementia from a traumatic brain injury and currently had no behaviors. The 5/13/2023 at 12:10 AM note Licensed Practical Nurse #9 progress note documented the resident was reported to have made inappropriate comments towards a unit assistant and stated they should get naked together. The resident was reminded to be appropriate, and staff would continue reminding the resident to not make comments. The 5/20/2023 Incident Report recorded on 5/24/2023 by Registered Nurse #10 documented at 1:20 PM, Resident #1 was observed hugging Resident #4 and rubbing their hand up and down Resident #4's back and buttocks. An assessment was completed and there were no marks on Resident #4. The residents were immediately separated. Resident #1 was also educated to keep their hands to themselves and placed on 15-minute checks. The 5/20/2023 nursing schedule did not document Registered Nurse #10 on duty on all 3 shifts the day of the incident. There was no documented evidence Resident #1's care plan was updated timely and no documented evidence Resident #4 was assessed timely. A 5/23/2023 at 11:16 AM Social Worker #5 progress note documented they spoke with Resident #1 regarding the incident with Resident #4. Resident #1 could not recall the incident. The resident was educated on keeping their hands to themself, as that type of behavior could get them in trouble. The resident was asked to repeat what Social Worker #5 said and if they understood. The resident said they understood. The updated 5/23/2023 comprehensive care plan completed by Registered Nurse #10 documented the resident had altered health maintenance and was an abuser/aggressor. Goals included the resident would stop abusive behavior immediately after staff intervened x 90 days. Interventions included 15-minute checks, cause of the abuse would be ascertained and addressed, residents would be immediately separated, further abusive behaviors would be observed, and the rights of others would be reviewed as needed. The 8/13/2023 at 9:30 PM Registered Nurse #19 progress note documented the resident remained on 30-minute checks throughout the shift. There were no issues noted until 9:30 PM when the resident was found with their pants down in the dining room demonstrating inappropriate sexual behavior while another resident was present at a distant table. The resident was encouraged to return to their room and would continue 30-minute checks. There was no documented evidence the facility investigated the incident to identify the other resident present at the time of the inappropriate sexual behavior and no documented evidence the facility determined if the other resident was impacted by the behavior. There was no documented evidence the care plan was updated with interventions to prevent recurrence. The 10/30/2023 at 9:29 PM Licensed Practical Nurse #15 progress note documented Resident #1 was in dining room with others present (unidentified). The resident's pants were pulled down to their thighs, exposing themself and they were rubbing their genitals. The resident was educated that the behavior was not acceptable. There was no documented evidence the facility investigated the incident to identify the other residents present at the time and if the other residents were impacted by Resident #1's behavior. There was no documented evidence the care plan was updated with interventions to prevent recurrence of inappropriate sexual behaviors in the dining room. The 10/31/2023 at 10:08 AM Social Worker #5 progress note documented Resident #1 was spoken to about their behavior in the dining room. They were educated that the behavior was not acceptable, and they would not be able to go to the dining room if the behavior continued. The 1/9/2024 at 10:11 PM Licensed Practical Nurse #16 progress note documented an aide reported the resident was touching another resident's breast (Resident #2) outside of their clothing during breakfast and they were immediately separated. Resident #2 did not appear aware of incident. Resident #1 was educated about inappropriate behavior and kept on the other side of the dining room. They discussed with staff to keep the resident at a table to include the same sex, moving forward. The 1/9/2024 Incident Report completed by Licensed Practical Nurse #4 (also the Assistant Director of Nursing) documented at 9:44 PM, the resident was seen touching Resident #2's breast around mealtime and Resident #2 appeared unaware of incident and was without injury. Immediate measures taken included redirection which was effective. The physician was notified on 1/10/24 at 2:10 PM. There was no documented evidence the residents were assessed timely. The Comprehensive Care plan, updated 1/11/2024 documented Resident #1 was to have immediate redirection to private areas during acts/times of sexual behavior, provide redirection as needed away from peers of opposite sex, follow with psychiatry, and medications were to be reviewed. There was no documented evidence the care plan was updated with interventions to keep the resident at the dining room table with the same sex and no documented interventions to protect Resident #2 from further abuse. The 1/22/2024 at 6:05 PM Licensed Practical Nurse #14 progress note documented the resident was seen rubbing their genitalia on Resident #2. As soon as Resident #1 noticed they were seen, they stopped and headed out of the dining room. The 1/22/2024 at 8:30 PM Licensed Practical Nurse #8 progress note documented the nurse reported earlier in the shift, Resident #2 was touching Resident #1's private areas. The 1/22/2024 at 8:30 PM Incident Report, recorded on 1/23/2024 at 8:26 PM by Licensed Practical Nurse #8 documented a nurse reported that Resident #1 had Resident #2 touch their genitals. The residents were immediately separated, and Resident #1 was placed on 15-minute checks. The incident was reported to the Department of Health and the physician and resident representative were notified on 1/24/2024. There was no documented evidence the residents were assessed timely. The Comprehensive Care Plan, updated 1/22/2024 documented new interventions included to approach Resident #1 in a calm consistent manner, for refusals of care, reapproach at another time, monitor changes in mood/behavior and report to provider, provide resident with opportunity to express feelings through 1:1 and group visits, use the resident's name and explain the purpose upon approach, Resident #1's 1/23/2024 updated Comprehensive Care Plan documented 15-minute checks. The 1/23/2024 at 10:00 PM Licensed Practical Nurse #8 progress note documented while walking to the nursing station they observed Resident #1 take their genitalia out of their pants in proximity of a resident (unidentified). They told the resident to pull their pants up and they then walked to their room. There was no documented evidence the facility investigated the incident to identify the other resident present at the time of the inappropriate sexual behavior and no documented evidence the facility determined if the other resident was impacted by the behavior. There was no documented evidence Resident #1's care plan was updated with interventions to prevent recurrence. The 1/24/2024 at 7:16 PM Licensed Practical Nurse #1 progress note documented Resident #1 was in the dining room with another resident (unidentified) who was asleep at the next table. Resident #1 changed chairs to be closer to the sleeping resident, they pulled their pants down, exposed themself and was touching themself. They told the resident to pull their pants up and instructed aides to move the resident. Resident #1 continued 15-minute checks. There was no documented evidence the facility investigated the incident to identify the other resident present at the time of the inappropriate sexual behavior and no documented evidence the facility determined if the other resident was impacted by the behavior. There was no documented evidence the care plan was updated with interventions to prevent recurrence. The 1/30/2024 at 11:12 PM Assistant Director of Nursing Licensed Practical Nurse #4 progress note documented the resident was seen by the nurse practitioner (unidentified) to review medications and recent sexual behaviors. There was a new order for Depakote (antiepileptic medication used for behaviors) 125 milligrams twice daily. The 5/24/2024 Medical Director progress note documented nursing notes were reviewed with times of inappropriate sexual behavior documented. The resident's dementia was permanent and progressive. They documented to start Tagamet (gastrointestinal medication, sometimes used for hypersexuality) 200 milligrams twice daily for inappropriate sexual behaviors. The 5/30/2024 at 12:07 PM Licensed Practical Nurse #3 progress note documented the resident was being sexually inappropriate to staff and other residents. No contact was made. The resident was encouraged to keep their hands to themself and not to use language around the opposite sex. The 7/29/2024 at 3:02 PM former Director of Nursing #20 progress note documented the resident wheeled up to another resident of the opposite sex (unidentified) and kissed them on the mouth. Staff immediately intervened and separated the residents. A new order was obtained to increase Tagamet to 400 milligrams twice daily. They would have 15-minute checks daily for 3 days to assist with monitoring the Resident #1's whereabouts and interactions with others. There was no documented evidence of an incident report and no documented evidence the facility determined if the other resident was impacted by the incident. The 7/30/2024 at 7:57 AM Licensed Practical Nurse #23 progress note documented the resident was observed several times standing in the hallway exposing themself and was redirected. The 7/30/2023 at 1:02 PM Licensed Practical Nurse #3 progress note documented the resident continued to be verbally inappropriate asking staff and residents of the opposite sex for sexual favors and they continued 15-minute checks. The 7/30/2024 at 8:49 PM Social Worker #5 progress note documented they spoke with Resident #1 about the incident of kissing another resident (unidentified). The resident did not recall the incident. They were educated to keep their hands to themselves, so they did not get in trouble. Resident #1's 7/30/2024 updated Comprehensive Care Plan documented 15-minute checks for 3 days. The 8/19/2024 updated Comprehensive Care Plan documented interventions included upon completion of meals, Resident #1 would be escorted from the dining room and encouraged to sit in highly visible areas. The 8/26/2024 Nurse Practitioner #22 progress note documented the resident was seen because staff reported despite Tagamet 400 milligrams twice daily, the resident continued with sexual behaviors. The plan included to increase Tagamet to 600 milligrams twice daily. The 9/20/2024 at 12:02 PM Licensed Practical Nurse #3 progress note documented the resident verbalized wanting female residents and staff to perform sexual acts and saying they wanted to do sexual acts to them. No interventions stopped the behavior. The 9/21/2024 physician order documented 15-minute checks every shift for 3 days. The 10/12/2024 at 10:48 PM Registered Nurse Supervisor #7 progress note documented they were notified Resident #1 attempted to kiss another resident (unidentified) in the dining room and the residents were separated. The Director of Nursing and provider were notified. Resident #1 was placed on 15-minute checks. The 10/12/2024 Incident Report, recorded on 11/7/2024 at 4:34 PM by Licensed Practical Nurse #4 (Assistant Director of Nursing) documented the resident was observed to have kissed a resident of the opposite sex. The 10/12/2024 updated Comprehensive Care Plan documented Resident #1 had behavior symptoms. Interventions included 15-minute checks (discontinued on 10/24/2024). The updated 10/17/2024 Comprehensive Care Plan documented Resident #1 would be escorted in and out of the dining room for activities, meals, and supervised at all times while in the dining room area. The resident would be escorted out of the dining room immediately following completion of the meal/activity. The 10/24/2024 at 6:09 PM Registered Nurse #25 progress note documented the resident touched the arm of another resident (unidentified). Both residents assessed with no injury or distress. Resident #1's care plan was updated and orders for 15-minute checks ordered. Placed in physician book for medication review. The 10/24/2024 at 6:11 PM Incident Report completed by Licensed Practical Nurse #4 (Assistant Director of Nursing) documented the resident was observed grabbing another resident's arm (Resident #6). The provider and family were notified on 10/24/2024. The 10/24/2024 at 9:01 AM Social Worker #5 progress note documented they spoke to the resident who had no recollection of inappropriate behaviors the day before. They were re-educated on keeping hands off others. They also contacted the resident's guardian about inappropriate sexual behaviors and to inquire about alternate facilities that could accommodate the resident. The resident likely needed an all-male unit. The 10/24/2024 updated Comprehensive Care Plan documented Resident #1 had behavior symptoms. Interventions included 15-minute checks for 3 days, the resident would not be seated with any residents of the opposite sex during activities or meals. During an interview on 11/26/2024 at 12:03 PM, Resident #5 stated they resided on the resident's unit and the resident had behaviors that made them very uncomfortable, and they were terrified of them. Resident #1 had come to their room door (did not recall date), pulled their pants down exposing their genitals and told Resident #5 look at it. This past Saturday, they were wheeling by Resident #1's open door (bed closest to the doorway) and Resident #1 was naked and masturbating. They reported it to staff and staff closed the resident's door. In the dining room, they had seen the resident approach multiple residents of the opposite sex and try to touch them. They also witnessed the resident kiss another resident although that was a while ago. They stated it seemed like nothing was ever done to prevent the resident from behaving badly. During an interview on 11/26/2024 at 12:55 PM, Certified Nurse Aide #17 stated the resident had a history of touching themself and masturbating in common areas in front of other residents. When the resident displayed the behavior, they were to take them back to their room. The resident was supposed to always be within eyesight of staff. In the dining room in the past, the resident had tried to reach out and grab residents of the opposite sex. Now the resident was brought to the dining room after everyone else was seated and sat with residents of the same sex. They were aware of other instances where the resident was sexually inappropriate with other residents but did not recall the circumstances or what was done as a result. During a telephone interview on 11/29/2024 at 9:36 AM, Licensed Practical Nurse #15 stated residents involved in sexually inappropriate behaviors needed to be assessed. They could not assess residents to determine if there was negative impact as it was not in their scope. They expected a registered nurse to assess. On 10/20/2023, they did not recall who the other residents were in the dining room and did not recall if the other residents were assessed. If there was a supervisor on shift, they would have notified them for an assessment. They did not recall who the supervisor was. They stated the resident was mean and the facility just allowed the behavior. During a telephone interview on 11/29/2024 at 10:23 AM, Licensed Practical Nurse #1 stated when there was an incident, the registered nurse took care of care plan changes. If someone was exposed to a resident's inappropriate sexual behavior, they would monitor the other resident, talk with them to ensure they were alright and note any concerns. When there were instances of resident sexually inappropriate behaviors, the registered nurse should be notified for an assessment. On 1/24/2024, they did not recall who Resident #1 exposed themself to and did not recall if a registered nurse assessed the other resident. Resident #1 continued to have current sexually inappropriate behaviors and 15-minute checks were not effective in preventing recurrence of behaviors. Licensed Practical Nurses #8 and #9 and Registered Nurse #19 were not able to be reached for interviews. During a telephone interview on 12/10/2024 at 2:13 PM and on 12/11/2024 at 12:02 PM, Licensed Practical Nurse #4 (Assistant Director of Nursing) stated incident reports were completed at the time of the incident and the provider and family were notified immediately. If contact was made between two residents a registered nurse assessment was needed. If residents were exposed to another resident's sexually inappropriate behavior, then a social worker typically followed up. On 1/9/2024, they could not recall why there was no assessment completed for Resident #2 and there should have been an assessment completed. They stated they started the incident report the day after the incident (1/10/2024) because one was not started on 1/9/2024. Staff were trained to start incident reports and they were not sure why one was not started on 1/9/2024. The provider and family were not notified timely for Residents #1 and #2. Licensed Practical Nurse #16 should have updated the care plan per their nursing note for keeping the resident seated at a table with residents of the same sex and they were not aware the care plan was not updated. On 10/12/2024, they were updated while at home by Registered Nurse Supervisor #7 that Resident #1 kissed another resident and they did not recall who the other resident was. They completed the incident report on 11/7/2024 after it was found nobody completed the paperwork. They believed the incident was investigated timely and just the incident paperwork was not. New interventions were put in place on 10/12/2024 at the time of the incident for 15-minute checks. During a telephone interview on 12/11/2024 at 6:59 AM, the facility's Corporate Director of Nursing stated incident reports could be started by all nurses and were necessary so incidents could be investigated to rule out abuse and neglect. However, not all nurses completed incident reports and when the incident was reported to the Director of Nursing, the Director of Nursing was responsible to ensure the incident report was started if one had not been. Incident reports should be initiated as soon as possible, and family and providers notified as soon as possible. All incidents required a registered nurse assessment including resident to resident sexual incidents and kissing. If a resident exposed themself in front of others and was masturbating, they expected the other resident would be assessed to ensure they were not touched. The other resident should also be interviewed to determine if they were emotionally alright, and it should be documented. Any staff could observe a resident for signs and symptoms of distress however the registered nurse assessed, and social work followed up. If no registered nurse was in the building at the time of an incident, the Director of Nursing or registered nurse on-call would come into the facility for assessment, or the registered nurse coming on duty the next shift assessed. The Interdisciplinary Team reviewed incidents to ensure current care planned interventions were effective and determined if they needed to change interventions. The Corporate Director of Nursing stated the following about incidents involving Resident #1: - on 5/20/2023, they expected an incident report to have been started immediately as well as an assessment by a registered nurse. Registered Nurse #10 was the covering Director of Nursing and was not sure why the assessment was not documented that day. They were not sure why the incident was documented late. - On 1/9/2024, they expected an assessment by a registered nurse and notifications were not timely. - On 1/22/2024, they expected an assessment by a registered nurse and notifications should have happened at the time of the incident. - On 10/12/2024, the former Director of Nursing was responsible to ensure the incident report was initiated. When the Administrator noted there was no incident report, they directed Licensed Practical Nurse #4 (Assistant Director of Nursing) to initiate it on 11/7/2024. - For the incidents where other residents were exposed to Resident #1's genitalia or to acts of masturbation, there should have been documentation who the other resident(s) were and whether the other resident(s) had any negative effects from the behavior. 10 NYCRR 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during abbreviated survey (NY00317123), the facility did not ensure allegations of abuse and neglect were thoroughly investigated for 3 of 4 residents (Resident #1, #3, and #4) reviewed and for an additional 6 unidentified residents. Specifically, facility investigations did not identify concerns related to: -Resident #2, a cognitively impaired resident, was touched on their breast by Resident #1. Two weeks later, Resident #2 was documented as having Resident #1 rub their genitals against them. There was no documented evidence Resident #2 was assessed timely, no evidence the provider and the resident's family were notified timely and interventions to protect Resident #2 and other vulnerable residents were not implemented timely. - Resident #4, a cognitively impaired resident had their back and buttocks rubbed by Resident #1. - Resident #1 had sexually inappropriate behaviors towards unidentified residents documented in their medical record on 6 occasions (including kissing 2 residents and exposing self and masturbating in front of 4 residents). The 6 residents involved were not identified and there were no corresponding investigations related to the incidents. Findings include: The undated facility policy, Abuse Prevention and Reporting, documented all residents would be kept free from abuse and neglect. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment which resulted in physical harm, pain, or mental anguish. Sexual abuse included, but was not limited to, sexual harassment, or sexual assault. The facility would immediately take steps to ensure resident safety and provide medical attention when necessary. They would secure statements from all parties involved. Social Services would be contacted to interview all parties involved. 1) Resident #2 had diagnoses including Alzheimer's disease. The 12/15/2023 Minimum Data Set assessment documented the resident's cognition was severely impaired. Resident #1 had diagnoses including dementia and sexual dysfunction not due to a substance or known physiological condition. The 5/2/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, exhibited physical behaviors directed towards (hitting, kicking, pushing, scratching, grabbing, and abusing others sexually) 1-3 of 7 days which significantly interfered with the resident's care and put others at risk for physical injury, The 1/9/2024 at 9:44 PM Incident Report by Licensed Practical Nurse #4 (Assistant Director of Nursing), documented Resident #1 was seen touching Resident #2's breast around mealtime and Resident #2 appeared unaware of incident and was without injury. Immediate measures taken included redirection which was effective. The physician was notified on 1/10/2024 at 2:10 PM and family notified on 1/11/2024 at 9:24 PM. The 1/9/2024 at 10:11 PM Licensed Practical Nurse #16 progress note documented an aide reported Resident #1 was touching Resident #2's breast outside of clothing during breakfast. The residents were immediately separated, and Resident #2 did not appear aware of incident. Resident #1 was educated about inappropriate behavior and kept to other side of the dining room. There was no documented evidence Resident #2 was assessed immediately following the incident. There was no documented evidence Resident #2's family, and the medical provider were notified of the incident on 1/9/2024. There was no documented evidence Resident #1 was assessed immediately following the incident. There was no documented evidence Resident #1's family, and the medical provider were notified of the incident on 1/9/2024. The 1/22/2024 at 6:05 PM note completed by Licensed Practical Nurse #14 documented Resident #1 was seen rubbing their genitalia on Resident #2. As soon as Resident #1 noticed they were seen, they stopped and headed out of dining room. The 1/22/2024 at 8:30 PM Incident Report recorded on 1/23/2024 at 8:26 PM by Licensed Practical Nurse #8 documented a nurse reported that Resident #1 had Resident #2 touch their genitals. The residents were immediately separated, Resident #1 was placed on 15-minute checks and the incident was reported to the Department of Health. The 1/22/2024 at 8:30 PM Licensed Practical Nurse #8 note documented the nurse reported earlier in the shift, Resident #2 was touching Resident #1's private areas. There was no documented evidence Resident #2 was assessed immediately following the incident. There was no documented evidence Resident's #1 and #2's family or medical provider were notified of the incident on 1/22/2024. 2) Resident #4 had diagnoses including dementia. The 5/1/2023 Minimum Data Set assessment documented the resident's cognition was moderately impaired. Resident #1 had diagnoses including dementia and sexual dysfunction not due to a substance or known physiological condition. The 5/2/2023 Minimum Data Set assessment documented the resident had moderately impaired cognition, exhibited physical behaviors directed towards (hitting, kicking, pushing, scratching, grabbing, and abusing others sexually) 1-3 of 7 days which significantly interfered with the resident's care and put others at risk for physical injury. The 5/20/2023 at 10:28 PM Licensed Practical Nurse #9 progress note documented it was reported to them Resident #1 had engaged in inappropriate sexual behavior with a resident on the North Unit (grabbing their buttocks with both hands). It was also reported the resident was still on the North side, near the other resident, because attempts to redirect Resident #1 back to the South Unit were in [NAME]. The licensed practical nurse managed to get the resident back on the South Unit at dinnertime when the resident attempted several times to return to the North Unit. At that point they instructed the unit assistant to be 1:1 with the resident to avoid any further behaviors. The 5/20/2023 Incident Report recorded on 5/24/2023 by Registered Nurse #10 documented at 1:20 PM, Resident #1 was observed hugging Resident #4 and rubbing their hand up and down Resident #4's back and buttocks. An assessment was completed and there were no marks on Resident #4. The residents were immediately separated. Resident #1 was also educated to keep their hands to themselves. Resident #1 was redirected and placed on 15-minute checks. The 5/20/2023 nursing schedule did not document Registered Nurse #10 on duty on all 3 shifts the day of the incident. The 5/23/2023 at 11:10 AM Registered Nurse #10 note documented the resident had no recollection of the incident on 5/20/2024 when another resident forcibly hugged them and no indication of psychological harm. There was no documented evidence Resident #4 was assessed immediately following the incident. There was no documented evidence Resident #4's family and medical provider were notified on 5/20/2023. 3) Unidentified Residents The 8/13/2023 at 9:30 PM Registered Nurse #19 progress note documented Resident #1 remained on 30-minute checks throughout shift. There were no issues noted until 9:30 PM when Resident #1 was found with their pants down in the dining room demonstrating inappropriate sexual behavior while another resident was present at a distant table. Resident #1 was encouraged to return their room and would continue 30-minute checks. The 10/30/2023 at 9:29 PM Licensed Practical Nurse #15 progress note documented Resident #1 was in dining room with others present when they pulled their pants down exposing self and was rubbing their genitals. The resident was educated that the behavior was not acceptable. The 1/23/2024 at 10:00 PM Licensed Practical Nurse #8 progress note documented while walking to the nursing station, they observed Resident #1 take their genitalia out of their pants in proximity of a resident. The 1/24/2024 at 7:16 PM Licensed Practical Nurse #1 progress note documented Resident #1 was in the dining room with another resident who was asleep at the next table. Resident #1 changed chairs to be closer to the sleeping resident, pulled their pants down, exposed themself and was touching their genitals. The 7/29/2024 at 3:02 PM former Director of Nursing #20 progress note documented Resident #1 wheeled up to another resident and kissed them on the mouth. Staff immediately intervened and separated residents. There was no documented evidence the facility investigated any of the incidents to identify the other residents present at the time of the inappropriate sexual behavior and no documented evidence the facility determined if the other residents were impacted by Resident #1's inappropriate behavior. The 10/12/2024 at 3:06 PM Licensed Practical Nurse #4 (Assistant Director of Nursing) progress note documented a housekeeper reported they observed Resident #1 kiss another resident in the dining room. Staff intervened, the residents were easily redirectable and there were no signs of emotional distress. Resident #1 was placed on 15-minute checks for 3 days. The corporate Director of Nursing was updated. The supervisor was contacting family and the provider. The 10/12/2024 at 10:48 PM Registered Nurse Supervisor #7 progress note documented they were notified Resident #1 attempted to kiss another resident in the dining room and the residents were separated. The Director of Nursing and provider were notified. Resident #1 placed on 15-minute checks. No signs and symptoms of distress. The 10/12/2024 Incident report, recorded on 11/7/2024 at 4:34 PM by Licensed Practical Nurse #4 (Assistant Director of Nursing) documented the resident was observed to have kissed a resident of the opposite sex. There was no documented evidence the incident was investigated timely and no documented evidence the residents were assessed on 10/12/2024. During a telephone interview on 11/29/2024 at 9:36 AM, Licensed Practical Nurse #15 stated an incident report was completed when there was something out of the normal that needed to be noted like an injury of unknown origin, resident to resident abuse and elopement. Sexually inappropriate behaviors would also require an incident report. If other residents were exposed to a resident's inappropriate sexual behavior, they needed to be assessed and that was something they could not do as a licensed practical nurse. Sometimes there was a registered nurse on duty who could assess though not always. On 10/30/2023, they did not recall if they completed an incident report however one would have been required. They did not recall who the other residents were present at the time of the behavior. They stated if there was a supervisor in the building on 10/30/2024, they would have notified them and did not recall if they notified. During a telephone interview on 11/29/2024 at 10:23 AM, Licensed Practical Nurse #1 stated the purpose of an incident report was to document falls, resident to resident abuse, as well as any resident-to-resident contact if there was a chance of injury. Sexually inappropriate behaviors also required an incident report and assessment by the registered nurse. They reported incidents to the supervisor and if the supervisor was not a registered nurse, then the Assistant Director of Nursing was notified, and the Assistant Director of Nursing would find a registered nurse to come to the building to assess. Licensed Practical Nurse #1 was responsible to obtain staff statements and notify the provider and family. If residents were exposed to inappropriate sexual behaviors, they would monitor the residents, note any concerns, and speak with them to make sure they were not affected. On 1/24/2024, 15-minute checks were not effective, and the resident continued with sexually inappropriate behaviors during the shift. They did not recall who the other resident was present during the behavior. There should have been an incident report completed and was not sure why one was not completed. On 11/29/2024 at 10:49 AM, Licensed Practical Nurse #8 was not reached in a telephone interview. On 11/29/2024 at 12:51 PM, Registered Nurse #19 was not reached in a telephone interview. On 12/9/2024 at 12:23 PM, Licensed Practical Nurse #9 was not reached in a telephone interview. During a telephone interview on 12/10/2024 at 2:13 PM and on 12/11/2024 at 12:02 PM, Licensed Practical Nurse #4 (Assistant Director of Nursing) stated incident reports were completed at the time of the incident and provider and family notified immediately. If contact was made between two residents, a registered nurse assessment was needed. If residents were exposed to another resident's sexually inappropriate behavior, then a social worker typically followed up. On 1/9/2024, they could not recall why there was no assessment completed for Resident #2 and there should have been an assessment completed. They stated they started the incident report the day after the incident (1/10/2024) because one was not started on 1/9/2024. Staff was trained to start incident reports and they were not sure why one was not started on 1/9/2024. The provider and family were not notified timely for Resident #1 and #2. Licensed Practical Nurse #16 should have updated the care plan per their nursing note for keeping the resident seated at a table with residents of the same sex and they were not aware the care plan was not updated. On 10/12/2024, they were updated while at home by Registered Nurse Supervisor #7 that Resident #1 kissed another resident and they did not recall who the other resident was. They completed the incident report on 11/7/2024 after it was found nobody initiated the paperwork. They believed the incident was investigated timely however the incident paperwork was not. New interventions were put in place on 10/12/2024 at the time of the incident for 15-minute checks. During a telephone interview on 12/11/2024 at 6:59 AM, the facility's Corporate Director of Nursing stated incident reports could be started by all nurses and were necessary so incidents could be investigated to rule out abuse and neglect. However, not all nurses completed incident reports and when the incident was reported to the Director of Nursing, the Director of Nursing was responsible to ensure the incident report was started if one had not. Incident reports should be initiated as soon as possible, and family and providers notified as soon as possible. All incidents required a registered nurse assessment including resident to resident sexual incidents and kissing. If a resident exposed themself in front of others and was masturbating, they expected the other resident would be assessed to ensure they were not touched. The other resident should also be interviewed to determine if they were emotionally alright, and it should be documented. Any staff could observe a resident for signs and symptoms of distress however the registered nurse assessed, and social work followed up. If no registered nurse was in the building at the time of an incident, the Director of Nursing or registered nurse on-call would come into the facility for assessment, or the registered nurse coming on duty the next shift assessed. The Interdisciplinary Team reviewed incidents to ensure current care planned interventions were effective and determined if they needed to change interventions. - On 5/20/2023, they expected an incident report to have been started immediately as well as an assessment by a registered nurse. 5/20/23 was a Monday, Registered Nurse #10 was the covering Director of Nursing (current Director of Nursing was on leave) and was staying locally. They believed Registered Nurse #10 would have come to the facility for assessment and was not sure why the assessment was not documented that day. They were not sure why the incident was documented late. - On 1/9/2024, they expected an assessment by a registered nurse and notifications were not timely. - On 1/22/2024, they expected an assessment by a registered nurse and notifications should have happened at the time of the incident. - On 10/12/2024, the former Director of Nursing was responsible to ensure the incident report was started. When the Administrator noted the incident report was not started on 11/7/2024, they directed Licensed Practical Nurse #4 (Assistant Director of Nursing) to initiate it. - For the incidents where other residents were exposed to the resident's genitalia or to acts of masturbation, there should have been documentation who the other resident(s) were and whether the other resident(s) had any negative effects from the behavior. 10NYCRR 415.4(b)(3)

Based on observation, record review, and interview during the recertification and abbreviated (NY00335434) surveys conducted 4/29/2024-5/3/2024, the facility did not review and revise the comprehensive care plan based on needs of the residents and responses to current interventions for 1 of 4 residents (Resident #47) reviewed. Specifically, Resident #47 had resident-to-resident altercations and their care plans were not reviewed and revised after the incidents to determine if current interventions were effective or if additional interventions were needed. Findings include: The facility policy Resident-to-Resident Altercations revised 12/2016 documented the facility was to make any necessary changes in the care plan approaches to any or all the involved residents. The facility policy Care Plans, Comprehensive Person-Centered revised 3/2023 documented the interdisciplinary team developed and implemented a person-centered care plan for each resident. Care plans were revised as information about the resident's condition changed. The interdisciplinary team would review and update the care plan when there was a significant change in the resident's condition. The facility policy Traumatic Brain Injury dated 5/2024 facility policy documented residents with a known or suspected history of a traumatic brain injury received a thorough assessment by the interdisciplinary team to determine their specific needs and capabilities. Regular interdisciplinary meetings were held to adjust care plans as needed. Resident #47 had diagnoses including traumatic brain injury, irritability, and impulse disorder. The 1/25/2024 Minimum Data Set assessment documented the resident had severely impaired cognition, rarely made self understood or understood others, had inattention and disorganized thinking, had trouble concentrating daily, was short-tempered or easily annoyed most days, had physical and verbal behaviors directed towards others, required supervision or was independent for most activities of daily living, received an antipsychotic and antidepressant, and did not have active discharge planning to return to the community. The comprehensive care plan initiated 8/26/2-21 documented return to community discharge referral: the resident remained at the facility for long term care placement. The resident had not expressed wishes to leave the facility and the resident representative agreed. The 12/7/2023 updated comprehensive care plan documented the resident had aggressor/behavioral symptoms of tensing up and clenching their fist, beating on their chest when agitated, and received psychotropic medications. Interventions included 15-minute checks, 1:1 monitoring for 3 days and assess as needed, attempt to find appropriate environment, attempt to increase activity for helping around the facility, attempt gradual dose reduction of medications, follow up with psychiatrist, initiate non-pharmacological interventions, provide 1:1 activities as needed, talking books or large print material, 1:1 activity visits for stimulation, engage in purposeful activities such as sweeping floors/wiping tables/wiping counters/washing dishes, keep resident in high visibility areas, and redirect. The 3/7/2024 at 8:30 PM incident report completed by registered nurse #18 documented Resident #47 was standing in the North Hallway in front of the unit dining room while Resident #49 was ambulating in the hallway heading in the direction of Resident #47. The residents had a verbal interaction and Resident #47 struck Resident #49 causing Resident #49 to fall to the floor and strike their head. Resident #47 went to their room immediately after being separated from Resident #49. Licensed practical nurse #14's witness statement documented they saw Resident #49 on the ground with Resident #47 standing over them. Licensed practical nurse #14 documented contributing factors to the incident were Resident #47 was known to have extremely violent outbursts and was not being properly supervised. Resident #47 was placed on 15-minute checks all shift for 3 days and the care plan was reviewed. There were no documented evidence Resident #47's care plan was reviewed to determine if interventions for aggressive behaviors remained effective following the 3/7/2024 incident. The 3/13/2024 at 6:44 PM progress note by licensed practical Nurse Manager #12 documented Resident #47's aggressive behavior was reviewed with the medical provider and the provider increased risperidone (antipsychotic) to 2 milligrams twice a day. The risperidone increase was not documented on the care plan. The 3/14/2024 at 11:12 AM social worker #13 progress note documented the facility's goal was to get Resident #47 transferred to a group-like setting. The care plan did not include potential discharge goals to a group setting. The 4/12/2024 at 10:18 PM licensed practical Nurse Manager #12's progress note documented Resident #47 had been seen by neurology in the past for traumatic brain injury and was last seen May 2023. The resident had aggressive intermittent disorder. Neurology notes documented the resident had behaviors for years with psychosis and paranoia. Neurology suggested the resident's behaviors be addressed by psychology. The 4/22/2024 at 4:20 PM incident report completed by licensed practical Nurse Manager #12 documented Residents #47 and #49 were at the nursing station. Resident #49 approached Resident #47 and Resident #49 began shaking their fist at Resident #47. Resident #47 shoved Resident #49 and then grabbed Resident #49's hands to prevent Resident #49 from hitting Resident #47. There were no observed verbal altercations prior to the incident. The residents were immediately separated and there were no injuries to either resident. The incident report documented both residents' care plans were updated, and the residents were placed on 15-minute checks for 3 days. Resident #47s care plan, updated on 4/23/2024, documented an intervention of 15-minute checks for 3 days. The intervention was in place prior to the 4/22/2024 incident. There were no documented evidence Resident #47's care plan was reviewed to determine if interventions for aggressive behaviors remained effective following the 4/22/2024 incident. Resident #47 was observed: - on 4/30/2024 from 10:27 AM until 10:45 AM, sitting in a straight back chair across from the North nursing station, looking up and down the hallway. The resident was not given any form of activity. The resident rose from the chair at 10:45 AM to go to a formal activity occurring on another unit. - on 5/1/2024 from 9:16 AM until 9:49 AM, standing in the unit dining room doorway with no activity or task. The resident walked and entered their room at 9:49 AM. At 10:09 AM, the resident was standing in the dining room doorway. Another resident began knocking on the activities department door located in the unit dining room. Resident #47 began yelling at the resident to stop the banging and became agitated. Staff immediately intervened and told the resident to stop yelling. Resident #47 returned to their room and closed the door. - on 5/1/2024 at 11:44 AM, seated at a table in the unit dining room, other residents were present in the room, and the TV was on. Another resident was continuously yelling out and other residents were telling them to stop yelling. Resident #47 began to get upset, swore, and raised their hands in the air. Staff intervened and asked Resident #47 to not swear. No tasks or independent activities related materials were offered to Resident #47. During an interview on 5/2/2024 at 3:20 PM, licensed practical nurse #14 stated resident specific care was documented in the care plan and care instructions, including behavioral interventions. Staff tried to intervene between Resident #47 and Resident #49 and separate them before the situations escalated. On 3/7/2024, the nurse was down the hall passing medications, the unit assistant made a verbal sound, the nurse turned, and saw Resident #49 going to the floor. The nurse got in front of Resident #47, told the resident to stop and go to their room, and the resident did. On 4/22/2024, the nurse stated they were passing medications, heard Resident #47 make a random noise, turned, and saw Resident #47 attempt to step in front of Resident #49. The residents got into a shoving match and staff were able to intervene prior to either getting injured. The nurse felt Resident #47 was not properly supervised both days of the incident. Interventions for Resident #47 were for staff to give the resident a simple task, a snack or drink, or an electronic tablet. Staff did not provide the resident those things prior to the incidents as it was difficult to know when the resident was going to have an impulsive behavior. During an interview on 5/2/2024 at 3:45 PM, unit assistant #15 stated Resident #47 had previous altercations with other residents, got a weird look on their face, and raised their fist prior to an altercation. On 3/7/24, the unit assistant was handing out bedtime snacks in the hallway, went into another resident's room, exited the room, and saw Resident #49 walking with a walker down the hall in front of the dining room. Resident #49 stated something to Resident #47, they did not hear what was said, Resident #47 drew their fist back and struck Resident #49 in the left cheek. During an interview on 5/3/2024 at 11:45 AM, the Director of Nursing stated a registered nurse initiated a specific care plan topic and any nurse was able to update the care plan once that was done. Each discipline was responsible for their own area in the care plan. The care plan, which incorporated the care instructions, included resident specific interventions. Resident #47's interventions were to watch for triggers and redirect with signs of agitation. Staff supervised both Residents #47 and #49 to prevent injury to another resident. Resident #47 lingered around the nursing station or unit dining room when out of their room and turned into an aggressor when they thought another individual was acting aggressively. There were no new interventions added after the 3/7/2024 incident and there should have been. The facility had busy boxes on the unit that were not added to the care plan interventions. Resident #47 used to have task-related interventions in the care plan that must have dropped off. The 15-minute checks were not new interventions and were only to be done for 3 days after each incident. A medical review was done for Resident #47 after the 3/7/2024 incident and that was not added to the care plan. The care plans were to be reviewed and updated with new interventions after each incident if altercations continued. The facility was also trying to find a more suitable setting for Resident #47 as they were a younger adult with a traumatic brain injury. The facility nursing staff had not had any traumatic brain injury training. During an interview on 5/3/2024 at 12:30 PM, the Administrator stated the expectation was for staff to follow the care plan and new interventions to be implemented with each resident-to-resident altercation. The Administrator expected staff to redirect Resident #47, have them remain around the nursing station for monitoring, and keep them occupied when out of their room. During an interview on 5/3/2024 at 1:11 PM, social worker #13 stated each resident's care plan was reviewed quarterly, annually, and with each significant change. Behavioral interventions were part of the care plan. The care plan was to be updated with each new behavioral intervention. Resident #47's care plan should have been reviewed and updated with each of the incidents and all planned interventions followed by staff. 10NYCRR 415.11(c)(2)(iii)

Based on observation, interview, and record review during the recertification survey conducted 4/29/2024 - 5/3/2024, the facility did not ensure a resident with limited range of motion received appropriate treatment and services to prevent further decrease in range of motion for 1 of 2 residents (Resident #39) reviewed. Specifically, Resident #39 did not have their right resting hand splint applied as ordered. Findings include: The facility policy Adaptive Position Equipment dated 8/28/2007 documented the rehabilitation department staff would issue the prescribed equipment. The nursing supervisor would be responsible for ensuring the adaptive equipment would be consistently done on all shifts. It was the responsibility of nursing to investigate or locate the equipment if it became lost or misplaced. Resident #39 had diagnoses including diffuse traumatic brain injury with loss of consciousness and right upper extremity weakness. The 3/26/2024 Minimum Data Set assessment documented the resident had moderately impaired cognition, required partial to moderate assistance with upper body dressing, supervision or touching assistance with personal hygiene, and had upper and lower extremity functional limitation on one side. The 4/9/2024 comprehensive care plan documented the resident had an alteration in activities of daily living performance related to a diagnosis of traumatic brain injury and the right arm had limitations in the fingers, wrist, and shoulder. Interventions, edited on 4/17/2024, were right hand resting splint, on 4 hours after AM care. A physician order dated 4/17/2024 documented right hand resting splint, on 4 hours after AM care once a day, 8:00 AM. The order was not listed on the medication administration record, the treatment administration record, or the certified nurse aide task documentation for staff to sign for the splint's use. The certified nurse aide care instructions as of 5/2/2024, with a start date of 7/19/2023, documented right hand resting splint, on 4 hours after AM care. The Point of Care Activities of Daily Living Category Report (certified nurse aide documentation) for April 2024 and May 2024 under the area of devices provided choices for cane/crutch, walker, wheelchair, limb prosthesis, and none of the above. It did not reflect a category for the application of splints or braces. There was no documented evidence in nursing progress notes from 4/29/2024-5//3/2024 the resident refused to wear their right hand resting splint. The resident was observed without a right hand resting splint applied: - on 4/30/2024 at 9:22 AM sitting in their bed, dressed. Their right hand, with long fingernails, was contracted. When interviewed and asked if they wore a splint to their right hand, the resident pointed to their nightstand to the right side of their bed. The right hand resting splint was sitting on top of items on the nightstand, out of reach of the resident. - on 5/1/2024 at 10:04 AM the resident was not in their room. The right hand resting splint was sitting on the top of the nightstand. At 10:33 AM at an activity in the South dining room without their right hand resting splint. When interviewed about their right hand resting splint, the resident stated staff did not put it on. An unidentified resident sitting at the table with Resident #39 stated they never saw the splint on Resident #39, and it was supposed to be on for 4 hours each day. - on 5/3/2024 at 9:11 AM sitting in their wheelchair in their room. The right hand resting splint was lying on the bed. The resident stated, Look, not on. During an interview on 5/1/2024 at 10:48 AM certified nurse aide #8 stated the resident did have a splint for their right hand contracture that they thought the resident was supposed to wear during the day. The resident did not like to wear it and would slip it through their hand and hide it under the bed covers. During an interview on 5/1/2024 at 10:53 AM certified nurse aide #11 stated they got the resident out of bed that morning. The resident had a splint because their hand did not stretch out and the splint would prevent it from becoming worse. The resident was supposed to wear it during the day but sometimes the resident would tuck it in their pocket or hide it under the bed if they did not want to wear it. During an interview on 5/1/2024 at 11:05 AM the Director of Therapy stated the resident was supposed to be wearing their right hand splint for up to 4 hours a day due to their right hand contracture and it was to be applied by nursing staff. The resident had the right hand splint order for a long time. The resident was wearing it Monday (4/29/2024) because they went around and checked all the residents who were supposed to be wearing adaptive equipment devices. The resident was currently not being seen by therapy but had been seen on and off in the past, every 3-6 months. During an interview on 5/3/2024 at 11:43 AM licensed practical nurse Unit Manager #12 stated they expected certified nurse aides to follow the order programmed in the Kiosk (the electronic resident chart) so they would know the right hand resting splint was in Resident #39's plan of care. They expected the certified nurse aides to document any refusals by the resident to wear their right hand resting splint and to notify them of the refusals. If staff did report refusals, they would document it and place it on report. 10 NYCRR 415.12 (e) (2)

Based on record review and interview during the recertification survey conducted 4/29/2024-5/3/2024, the facility did not ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with facility assessment for 2 of 2 licensed nurse records (registered nurse #6 and licensed practical nurse #7) reviewed. Specifically, registered nurse #6 and licensed practical nurse #7 did not receive annual competency evaluations to measure their pattern of knowledge, skills, abilities, and other characteristics to perform their work roles successfully as outlined in the 2023 facility assessment and per regulations. Findings include: The Facility Assessment Tool updated 10/2/2023 documented all staff members had or would have yearly competencies, or would receive the facility orientation, including competencies, if employed for less than one year. The facility did not have a policy and procedure for competency evaluations. Nursing personnel records were reviewed for registered nurse #6 and licensed practical nurse #7. Both staff had been employed for over a year and there were no competency evaluations within the last year. During an interview on 5/2/2024 at 10:15 AM the Corporate Director of Nursing stated nursing personnel files were kept in the Human Resources office. They currently did not have a staff educator as the position had been vacant since Fall of 2023. They were planning to transition a Unit Manager into the role of licensed practical nurse/Assistant Director of Nursing to help with staff education. The current Director of Nursing had been performing the staff educator role since January 2024. During a follow-up interview on 5/22024 at 10:45 AM the Corporate Director of Nursing stated they could not find any further documentation on nursing competencies for registered nurse #6 and licensed practical nurse #7. During an interview on 5/3/2024 at 12:11 PM the Administrator stated the current staff educator was the Director of Nursing. They had been hired as the Director of Nursing in November 2023. During survey they promoted a Unit Manager into the role of licensed practical nurse/Assistant Director of Nursing and the plan was to get them involved in staff education, which would include doing annual nursing competencies. 10 NYCRR 415.26(c)(1)(iv)

Based on observation, interview, and record review during the recertification survey conducted 4/29/2024-5/3/2024, the facility did not ensure each resident received and the facility provided food and drink that was palatable, flavorful, and at appetizing temperatures for 1 of 2 meals sampled (Resident #66). Specifically, food items on 1 of 2 test trays (4/30/2024 lunch meal) were not at acceptable temperatures. Findings include: The facility policy Food Holding Temperatures dated 1/30/2024, documented if temperatures of food were below 140 degrees Fahrenheit, remove them from the steam table and reheat to required minimum preparation temperature of: 165 degrees Fahrenheit - poultry; 150 degrees Fahrenheit - all other meats; 145 degrees Fahrenheit - eggs. The facility policy Temperatures dated 9/2002, documented test trays would be done randomly by the diet technician, registered dietitian, and Food Service Director three days a week and temperature sheets would be kept for sample trays by the diet technician. The policy did not document appropriate food temperatures for meal items when conducting a test tray. During an observation on 4/30/2024 at 11:22 AM, the internal temperatures of lunch food items were measured in the steam table within the main kitchen and included; chicken gravy mix was 190 degrees Fahrenheit, and spinach was 150 degrees Fahrenheit. During an observation on 4/30/2024 at 11:58 AM, the North Unit meal cart left the main kitchen. During an observation on 4/30/2024 at 12:10 PM, a test tray was conducted on a randomly selected North Unit resident's meal tray (Resident #66). A replacement meal tray was requested for the resident. The food was below acceptable palatability ranges. Specifically, the internal temperature of the chicken and gravy mix was measured to be 121 degrees Fahrenheit, and the spinach was measured to be 130 degrees Fahrenheit. During an interview on 4/30/2024 at 12:15 PM, the Food Service Director stated they were surprised foods were measured so low. They wanted foods on resident meal trays to be at least 140 degrees Fahrenheit and they should be warmer for eating. The facility did periodic test trays, and 140 degrees Fahrenheit would be the minimum expected temperature. 10NYCRR 415.14(d)(2)

Based on observation, record review, and interview during the recertification survey conducted 4/29/2024-5/3/2024, the facility did not ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in the main kitchen. Specifically, the kitchen ventilation hood was unclean and laden with grease and dust buildup; the floor in the walk-in freezer was unclean with food items under shelving storage; and a section of flooring in front of the main dish machine was in disrepair and had unclean water and food debris. The facility policy Cleaning/sanitation of Kitchen dated 8/2016, documented food service workers and/or cooks were responsible for maintaining a clean environment in the kitchen. All persons were responsible for cleaning up after themselves. The Supervisor Cook, Food Service Manager, diet technician, or dietitian as needed, would ensure this. The Food Service Manager, diet technician, and /or dietitian were responsible party to check on cleaning and maintenance of equipment. The April 2024 weekly cleaning audits documented all areas of the kitchen were signed off as being done. This included sweeping and mopping under the counter, sweeping and mopping under all equipment, and racks in the cooler. No issues were identified on the audits. During observations on 4/29/2024 at 10:00 AM, 4/30/2024 at 10:50 AM, and 5/1/2024 at 11:44 AM the main kitchen hood was unclean, dusty, and grease laden. The hood was over the stove top and ovens. During an interview on 4/29/2024 at 10:00 AM, the Food Service Director stated the hood cleaning vendor came to the facility to clean the hood. They were not sure how often they came in. They stated the kitchen staff did not clean the hood and it should be cleaner. During an observation on 4/29/2024 at 10:05 AM, the section of flooring under the shelving unit within the walk-in freezer on the left side was unclean with food product on the floor. There were single serve ice cream cups, two hamburger buns, and ice buildup under the shelving rack. During observations on 4/29/2024 at 10:13 AM, 4/30/2024 at 10:50 AM, and 5/1/2024 at 11:44 AM there was an approximate 3 inch by 12 inch section of broken flooring in front of the commercial dish machine that had food debris and was holding water. The area under this section was in disrepair and was not smooth and cleanable. During an interview on 4/29/2024 at 10:13 AM, the Food Service Director stated they were not sure how long the floor was broken. Maintenance was made aware. They would like the flooring fixed as it could not be cleaned properly. Dietary staff performed deep cleaning in the kitchen weekly. During an interview on 4/30/2024 at 2:00 PM, the Director of Facilities stated they were aware of the broken section of kitchen flooring and was waiting on a quote to get replacement flooring. The repairing contractor had not sent the quote back. They were not sure how long the flooring had been broken or when the flooring would be replaced. NYCRR10 415.14(h)

Based on record review and interview during the recertification survey conducted 4/29/2024-5/3/2024 the facility did not ensure certified nurse aide performance reviews were completed once every 12 months for 2 of 3 certified nurse aides (certified nurse aides #9 and #10) reviewed. Specifically, certified nurse aides #9 and #10 did not have performance reviews documented at least once every 12 months. Findings included: The facility In-Service Training Program, Nurse Aide, revised October 2017, documented the facility would complete a performance review of certified nurse aides at least once every 12 months. Records would be filed in the employee's personnel file or would be maintained by the department supervisor. During a review of personnel files for certified nurse aides #9 and #10 there was no documented evidence of performance reviews completed at least once every 12 months. During an interview on 5/2/2024 at 10:15 AM, the Corporate Director of Nursing stated the certified nurse aide personnel files containing annual performance reviews were kept in the Human Resources office. If they were not there then, they might be in the storage units kept on the facility's grounds and they would look for them. The current facility Director of Nursing was then included in the interview by the Corporate Director of Nursing. The Director of Nursing stated they had only started in the role at the facility in November 2023 and had not done any annual performance reviews for certified nurse aides and they were unsure of where any previous performance reviews were kept. During a follow-up interview on 5/2/2024 at 10:45 AM, the Corporate Director of Nursing stated they could not find the annual performance reviews for certified nurse aides #9 and #10. 10 NYCRR 415.26 (d) (7)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the abbreviated survey (NY00308047), the facility did not ensure the development and implementation of an effective transfer or discharge planning process including documentation in the resident's medical record and appropriate communication of information to the receiving health care institution or provider for 1 of 3 residents (Resident #1) reviewed. Specifically, Resident #1 was issued a facility-initiated discharge notice and there was no supporting documentation related to the reasons the facility was unable to meet the resident's needs. There was no care plan related to the discharge, and when discharge plans changed, there was no new plan put in place. Additionally, when the resident was denied readmission to the facility from a hospital stay, they did not provide the hospital with the resident's information and did not contact the hospital for discharge planning. Findings include: The undated facility policy Transfer and Discharge Requirements/Documentation documented: - The facility must permit residents to remain in the facility and not transfer or discharge unless: it was necessary for the resident's welfare and their needs could not be met at the facility; the safety of individuals in the facility was endangered due to the clinical or behavioral status of the resident; and the health of other individuals would be endangered. - When the facility discharged the resident under any of the circumstances above, the facility must document the resident's transfer or discharge in the medical record and appropriately communicate the information to the receiving health care institution. - The physician, with the input of the interdisciplinary care team (IDT), will assess the resident's care requirements for the need to be transferred or discharged . - If determined the resident has a need for transfer based on the above criteria, it will be documented in the medical record. The basis for transfer will specify the resident's needs that could not be met and the facility's attempts to meet those needs. - The following information will be provided to the receiving provider: contact information of the resident's practitioner, resident representative's contact, Advance Directives, special instructions for ongoing care, comprehensive care plan goals, discharge summary, and any other documentation as applicable to ensure a safe and effective transition of care. Resident #1 was admitted to the facility with diagnoses including vascular dementia with behavioral disturbance, restlessness, and agitation. The 10/28/2022 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and did not exhibit behavioral symptoms. The section Participation in Assessment and Goal Setting documented the resident participated in the assessment and the resident's overall expectation of being discharged to the community, remaining in the facility, being discharged to another institution, or unknown/uncertain was blank. The comprehensive care plan (CCP) initiated 10/31/2022 and reviewed/revised 11/3/2022 did not include any documentation related to discharge planning. The 12/12/2022 Nursing Home Transfer and Discharge Notice documented the reason for discharge or transfer was the safety of the individuals in the facility was endangered due to the clinical or behavioral status of the resident. There were no other reasons for discharge noted on the form. The effective date was blank. The notice was signed by the Administrator (former) on 12/12/2022. There was no physician signature or resident/representative signature on the form. There was no documented evidence in the resident's medical record related to the basis for the discharge notice. There was no documentation from a medical or psychiatric provider related to the reasons the facility could not meet the resident's needs. The 12/12/2022 at 3:44 PM progress note entered by the Director of Work (DSW) documented the DSW, Administrator, and (former) Director of Nursing (DON) #9 discussed with the resident's relative/HCP (health care proxy, person designated to make health care decisions on behalf of the resident) via telephone, about a 30-day notice. The plan was to have the resident move with their relative in another state. The relative was to arrive to the facility on 1/14/2023 to bring the resident home with them. The relative was to keep staff up to date via email. There was no documented evidence the CCP was updated to reflect a plan for the resident's discharge. There was no documented evidence of resident needs for the anticipated lengthy car trip, no documentation related to medication management, or documentation related to how the resident's needs would be met upon discharge to the setting of their relative's home. The 12/14/2022 at 5:36 PM nursing progress note entered by licensed practical nurse (LPN) #7 documented they spoke to the resident's relative, who expressed fear they would not be able to safely transport the resident to another state. Verbal assurance was given to the relative and the LPN was to call back later that evening as requested. The 12/19/2022 at 2:46 PM progress noted entered by the DSW documented the DSW and Administrator called the resident's relative to follow up about the report from the nurse that the relative was not able to take the resident to their home state. The DSW asked if they were certain, and if they needed to work on another placement. The relative stated they would still like to take the resident and they were worried the resident was not able to sit in a car for the long trip. The relative then stated they could make multiple stops along the way. The DSW sent out the 30-day discharge notice again via certified mail. There was no documented evidence the CCP was updated to reflect the resident's discharge plan. There was no documented evidence of resident needs for the anticipated lengthy car trip, no documentation related to medication management, or documentation related to how the resident's needs would be met upon discharge. The 1/1/2023 at 10:20 AM progress note entered by DON #9 documented the resident was combative and aggressive, police officers and ambulance drivers restrained the resident and transported them to the hospital. The 1/1/23 at 12:01 PM nursing progress note entered by registered nurse (RN) #8 documented they called the hospital for an update. The resident was still in the emergency room waiting for a psychiatric bed/evaluation. The RN was advised the resident was positive for COVID-19. The DON was called, and they stated they spoke to the corporate offices who stated they could not take the resident back due to changes. There was no documented evidence the resident's representative was notified of the resident's discharge to the hospital on 1/1/2023 and no documented evidence of any changes to the discharge plan. The 1/4/2023 at 3:08 PM progress note entered by the DSW documented they faxed a copy of the 30-day notice and progress notes supporting that the team spoke to the resident's relative (HCP) about the notice to the hospital case manager. There was no documented evidence any other information related to the resident's care or discharge plan was sent to the hospital. An email correspondence from the DSW to the resident's HCP dated 1/6/2023 at 11:19 AM documented they had been trying to contact the HCP to discuss the 30-day notice. The DSW noted if the HCP had any questions to please contact them. The email included an attached document that was named only by a series of numbers. The Nursing Home Transfer and Discharge Notice dated 1/6/2023, documented the resident was being discharged to their relative's address in another state. The effective date of the discharge was 2/6/2023 and documented the resident was being discharged for the following reasons: - The transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility. - The safety of the individuals in the facility was endangered due to the clinical or behavioral status of the resident. - The health of individuals in the facility would otherwise be endangered. The notice was signed by DON #9 on 1/6/2023. There was no documented evidence in the resident's medical record related to the basis for the 1/6/2023 discharge notice. There was no documentation from a medical or psychiatric provider related to the reasons the facility could not meet the resident's needs. There was no documented evidence of confirmation of the resident's discharge location or explanation of the effective date (2/6/2023). The 1/6/2023 at 11:24 AM progress noted entered by the DSW documented a 30-day notice of discharge was sent to the resident's relative via certified mail and email, a copy was sent to the Ombudsman, and a copy was also sent to the hospital. The 1/9/2023 at 4:19 PM progress note entered by the Medical Director documented the resident started exhibiting aggressive behaviors immediately after admission. The resident had poor impulse control, was angry, combative, relatively young, and strong. The resident frequently voiced suicidal and homicidal intentions and was found in possession of sharp objects and in their opinion, had the capacity to commit a suicidal or homicidal act. On 1/1/2023, 6 police officers escorted the resident to an ambulance. The resident was admitted to the hospital for psychiatric evaluation. According to hospital records, the resident was receiving multiple IV (intravenous) and IM (intramuscular) medications and the facility could not administer antipsychotic medications parenterally (administering other than oral route). If readmitted , the resident would decompensate very soon, and they were not appropriate for the level of care the facility could provide. The resident should not be sent back to the facility and required a higher level of care, preferably a psychiatric institution. There was no documented evidence in the resident's medical record of any prior evaluation or progress note related to the information as documented in the 1/9/2023 Medical Director note. The 6/23/2023 hospital discharge summary documented the resident was originally evaluated and discharged on 1/4/2023 and was brought back to the hospital after the facility refused to readmit the resident. The resident remained in the hospital pending a safe discharge until 6/23/2023. The hospital case manager was interviewed on 1/10/2023 at 12:15 PM and stated the resident had been cleared medically and psychiatrically and did not require IM medications and was ready to return to the facility on 1/4/2023. During an interview with the hospital ER Manager on 8/25/2023 at 10:43 AM, they stated after the facility refused to readmit the resident on 1/4/2023 the resident was returned to the hospital. The ER Manager called the facility the following day and their call was not returned. The hospital had no information on the resident at that time and was unaware of the resident's status at the facility. The facility's DSW later sent the resident's chart after another request was made. The facility never contacted the hospital back regarding the resident or for any discharge planning. During a telephone interview with the DSW on 8/29/2023 at 8:09 AM, they stated the facility issued a 30-day discharge notice on 12/12/2022 due to the resident's behaviors and safety issues. There was no psychiatry involvement, and the physician was aware of the resident's behaviors and was adjusting their medications. The DSW was not aware of the specific documentation required in the medical record for a facility-initiated discharge and stated it was an administrative decision to discharge the resident. The DSW was responsible for care plans and was unaware of the reason there was no care plan for the resident's discharge. After the resident's relative was notified on 12/12/2022, a plan was set for the resident to be picked up on 1/14/2023. The DSW was unaware of any further plans related to that discharge date . After the relative expressed concern about the discharge plan, the DSW spoke to them on 12/19/2022 and thought the plan may have changed and was unsure of what changes and there was no documentation. The DSW was unaware of the status of the discharge plan that was in place prior to the resident's hospitalization and attempted to reach the resident's relative on 1/4/2023. The DSW could not recall if they attempted to notify the relative prior to the facility's refusal to readmit the resident. Following the resident's hospitalization, the facility would not take the resident back and the DSW had no further involvement in the resident's discharge planning. The DSW was not involved in the 1/6/2023 30-day discharge notice and was directed by Administration to forward it to the relative, Ombudsman, and hospital on that date. The DSW was unaware of the reason for the updated notice, which was issued after the facility did not readmit the resident. During a telephone interview with the Administrator on 8/29/2023 at 3:18 PM, they stated the resident was issued a 30-day discharge notice on 12/12/2022 due to the resident's unsafe behaviors. The resident could not be managed at the facility, was aggressive, got into fights, and the facility was not the appropriate placement. The Administrator was aware of the requirement for the medical record to reflect the basis for discharge and the supporting documentation that the facility could not provide the needed care. The record did not reflect the needed documentation due to the lack of psychiatric providers available at that time. The Medical Director wrote a statement on 1/9/2023, after the resident's discharge and must have been behind in their notes. When the resident was hospitalized on [DATE] and subsequently not permitted to return to the facility on 1/4/2023, the reason was due to the resident's COVID-positive status and their unsafe behaviors. The Administrator then stated the resident's COVID status was not the overwhelming issue, it was the hospital's lack of planning when they (the hospital) knew of the resident's violent behaviors. The hospital should have made a plan and communicated it to the facility to address the resident's behaviors prior to sending them back. The resident was at risk of harming themselves or others and the facility did not have adequate time to plan for the resident's return. Following the facility's refusal to take the resident back on 1/4/2023, the facility did not hear back from the hospital and expected them to reach out to pursue further discharge planning. 10 NYCRR 415.3(h)(1)(ii)(a)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated survey (NY00308047), the facility did not notify the resident and the resident's representative of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 was issued a 30-day discharge notice, was transferred to the hospital prior to their anticipated discharge date , and the resident's representative was not notified. The facility would not readmit the resident from the hospital and the representative was not notified in writing prior to the facility's refusal to readmit the resident. The facility issued a second 30-day discharge notice after they refused to readmit the resident. Additionally, the discharge notice was not sent to the Ombudsman as required and did not contain the required information. Findings include: The undated facility policy Notice Before Transfer documented before the facility transferred or discharged a resident it was the facility policy to: - Notify the resident and a family member or legal representative of the transfer or discharge and the reasons for the move in writing and in a language, they understand; - Send a copy of the discharge notice to a representative of the Office of the State Long Term Care Ombudsman; - Record the reasons in the resident's medical record; - Include in the notice the items mandated by the NYS Department of Health; - Except when otherwise allowed, the notice must be made by the facility at least 30 days before the resident was transferred or discharged ; - The notice may be made in less than 30 days when: the health or safety of individuals in the facility would be endangered; or an immediate transfer or discharge was required by the resident's urgent medical needs. Resident #1 was admitted to the facility with diagnoses including vascular dementia with behavioral disturbance and restlessness and agitation. The 10/28/2022 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and exhibited no behavioral symptoms. The section Participation in Assessment and Goal Setting documented the resident participated in the assessment and the resident's overall expectation of being discharged to the community, remaining in the facility, being discharged to another institution, or unknown/uncertain was blank. The Nursing Home Transfer and Discharge Notice documented the reason for discharge or transfer was the safety of the individuals in the facility was endangered due to the clinical or behavioral status of the resident. There were no other reasons for discharge noted on the form. The date notice given was documented 12/12/2022 and the effective date was blank. The discharge location was the resident's relative's address in another state. The notice was signed by the Administrator (former) on 12/12/2022. There was no physician signature or resident/representative signature on the form. The bottom of the notice had an area to document when the notice was given to the resident or representative, the local Long Term Care Ombudsman Council, and the resident's clinical record and was not completed. The form did not include a local agency or individual to contact the Ombudsman, and the advocacy center contact information was not correct. The 12/12/2022 at 3:44 PM progress note entered by the Director of Work (DSW) documented the DSW, Administrator, and Director of Nursing (DON) #9 discussed with the resident's relative/HCP (health care proxy, person designated to make health care decisions on behalf of the resident) via telephone, about a 30-day notice. The plan was to have the resident move with their relative in another state. The relative was to arrive to the facility on 1/14/2023 to bring the resident home with them. The relative was to keep staff up to date via email. The 1/1/2023 at 10:20 AM progress note entered by DON #9 documented the resident was combative and aggressive, police officers and ambulance drivers were required to restrain the resident and transport them to the hospital. The 1/1/23 at 12:01 PM nursing progress note entered by registered nurse (RN) #8 documented they called the hospital for an update. The resident was still in the emergency room waiting for a psychiatric bed and evaluation. The RN was advised the resident was positive for COVID-19. The DON was called, and they stated they spoke to the corporate offices who stated they could not take the resident back due to changes. There was no documented evidence the resident's representative was notified of the hospital transfer on 1/1/2023 or that the facility would not accept the resident for readmission due to positive COVID-19 status. The 1/4/2023 at 9:24 AM nursing progress note entered by RN #3 documented they spoke to staff at the hospital, the resident tested positive for COVID-19 on 1/1/2023. The resident was sent back from the hospital at 4:00 AM on 1/4/2023 and was returned (to the hospital) due to the COVID diagnosis. The 1/4/2023 at 3:08 PM progress note entered by the DSW documented they faxed a copy of the 30-day notice and progress notes supporting that the team spoke to the resident's relative (HCP) about the notice to the hospital case manager. There was no documented evidence the resident's representative was notified of the hospital discharge on [DATE], the facility would not accept the resident for readmission, or that the resident was sent back to the hospital. The 1/5/23 at 12:24 PM progress note entered by the DSW documented they received a message from the resident's relative stating they needed a call back to let them know what was going on with the resident. The DSW and DON did call them on 1/4/2023 and left a message on their phone as well as message left with another relative to call the facility and also called back this day and left a message. An email correspondence from the DSW to the resident's HCP dated 1/6/2023 at 11:19 AM documented they had been trying to contact the HCP to discuss the 30-day notice. The DSW noted if the HCP had any questions to please contact them. The email included an attached document that was named only by a series of numbers. The Nursing Home Transfer and Discharge Notice dated 1/6/2023, documented the resident was being discharged to the relative's out of state address, effective 2/6/2023. The resident was being discharged for the following reasons: - The transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility. - The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident. - The health of individuals in the facility would otherwise be endangered. The notice was signed by DON #9 on 1/6/2023. The bottom of the notice documented it was given to the resident or representative, the local Long Term Care Ombudsman Council, and the resident clinical record on 1/6/2023. The form did not include a local agency or individual to contact the Ombudsman, and the advocacy center contact information was not correct. The 1/6/2023 at 11:24 AM progress noted entered by the DSW documented a 30-day notice of discharge was sent to the resident's relative via certified mail and email, a copy was sent the Ombudsman, and a copy was also sent to the hospital. A certified mail receipt, made out to Resident #1, with the address of the hospital was signed as received (signature illegible). There were no dates noted for when the mail was sent or signed as received. A certified mail receipt, made out to Resident #1's relative/HCP at an out of state address documented the HCP received the mail on 1/25/2023. During a telephone interview with the Ombudsman for the facility's county on 8/24/2023 at 8:58 AM, they stated they did not receive a discharge notice for Resident #1 on or around 12/12/2022. The facility was not sending discharges notices and the Ombudsman had to contact them and request they be sent. During a telephone interview with the DSW on 8/29/2023 at 8:09 AM, they stated the facility issued a 30-day discharge notice on 12/12/2022 due to the resident's behaviors and safety issues. The DSW spoke to the resident's relative, who agreed to pick up the resident on 1/14/2023 at the facility. The DSW emailed the notice to the relative, did not retain a copy of the email, and did not receive the signed notice back. The DSW was uncertain if they sent the notice to the Ombudsman and stated they thought they always sent them. The DSW sent the 12/12/2022 discharge notice to the hospital case manager on 1/4/2023 and stated the DSW and DON #9 attempted to notify the resident's relative that same day. When a resident was sent to the hospital, it was the responsibility of nursing to notify and update the family. The 1/6/2023 discharge notice was completed by DON #9 and the DSW was made aware of the notice. The DSW was not aware of the reason the effective date was 2/6/2023, as the facility had not readmitted the resident from the hospital on 1/4/2023. The DSW was uncertain of the discharge location, which was noted on the form as the relative's address. The facility had not been able to reach the relative and the discharge plan was not finalized. The DSW was unaware of the updated discharge form that required specific contact information for the Ombudsman or the current advocacy center. DON #9 was no longer employed at the facility and was not available for interview. 10NYCRR415(h)(1)(iii)(a-c)

Based on record review and interview during the abbreviated survey (NY00308047), the facility did not permit a resident to return to the facility after they were hospitalized for 1 of 3 residents reviewed (Resident #1). Specifically, Resident #1 was sent to the hospital for evaluation for behaviors. The resident was medically cleared, transported back to the facility, and the facility refused to accept the resident. Findings include: The facility policy COVID-19 Mitigation Plan and Prevention and Control last revised 12/2022 documented: - New admissions and readmissions were to be tested on days 1, 3, and 5 except for residents within 30-days of a COVID infection. A negative COVID antigen test was recommended for all new admissions and readmissions prior to admission, unless a COVID test was positive in the last 30 days of admission to the facility. The policy did not address admission or readmission of residents with positive COVID-19 status. Resident #1 was admitted with diagnoses including vascular dementia with behavioral disturbance and restlessness and agitation. The 10/28/2022 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and did not exhibit behavioral symptoms. The 1/1/2023 at 10:20 AM progress note entered by Director of Nursing (DON) #9 documented the resident was combative and aggressive, police officers and ambulance drivers were required to restrain the resident and transport them to the hospital. The 1/1/23 at 12:01 PM nursing progress note entered by registered nurse (RN) #8 documented they called the hospital for an update. The resident was still in the emergency room waiting for a psychiatric bed and evaluation. The RN was advised the resident was positive for COVID-19. The DON was called, and they stated they spoke to the corporate offices who stated they could not take the resident back due to changes. The facility Vacancy Reports for 1/3/2023 and 1/4/2023 documented a total of 19 available beds (2 on the North unit and 17 on the South unit) and no bed holds. The 1/4/2023 at 12:08 AM hospital discharge summary and CPEP (Comprehensive Psychiatric Emergency Program) evaluation documented the resident was transferred from another hospital for evaluation. The resident reportedly had aggressive behaviors at the nursing facility. The resident was noted to be calm and cooperative with no suicidal or homicidal ideations. The resident was evaluated by the nurse practitioner (NP), who recommended they return to the nursing facility and follow up with established providers. The resident was at low risk for violence and did not meet the criteria for involuntary commitment and declined a voluntary hospitalization. The nursing facility staff reported they felt safe with the resident being discharged . Nursing staff at the facility were provided with the number for the crisis hotline and was asked to call 911 and/or bring the resident to the nearest emergency room if they were unsafe, suicidal, or a danger to themselves or others. The 1/4/2023 Emergency Medical Service (EMS) report documented the resident was scheduled for transport from the hospital to the facility and was picked up at 2:45 AM. Upon arrival to the facility at 4:15 AM, the crew transported the resident to the facility lobby. Licensed practical nurse (LPN) #4 was in the lobby and stated the resident could not be brought into the facility due to being COVID positive. The LPN then called DON #9, who stated the facility could not take the resident back due to them having COVID-19. The EMS crew member called the CPEP nurse who completed the resident's discharge. The phones were on speaker, and the DON (on LPN #4's phone) and the CPEP nurse (on the EMS crew's phone) spoke. The DON repeated the resident could not be accepted due to COVID and they were no longer a resident of the facility, as the resident had been evicted. The CPEP nurse stated the facility illegally evicted the resident and the resident was still the facility's responsibility. The DON stated they would go to the facility and arrived approximately 15 minutes later. The DON stated again the resident was not allowed back due to COVID. The EMS crew received directives from their supervisor to return to the hospital with the resident and left the facility at 5:06 AM. The 1/4/23 at 9:24 AM nursing progress note entered by RN #3 documented they spoke to staff at the hospital and the resident tested positive for COVID-19 on 1/1/2023. The resident was sent back from the hospital at 4:00 AM and was returned (to the hospital) due to the COVID diagnosis. During an interview with the Regional DON on 1/5/2023 at 1:00 PM, they stated the resident resided at the facility since 4/2022, and their behaviors escalated after they had COVID-19 (prior diagnosis, 8/2022). The resident had altercations with peers and staff and made threats to them as well. The resident was taken to the hospital on 1/1/2023 after being removed by multiple police officers and tested positive for COVID-19 in the hospital. The resident was then sent to another hospital, and then returned to the facility on 1/3/2023 (actually 1/4/2023) at 4:00 AM without any clearance and was COVID positive status. The facility was not able to accept the resident back due to their COVID status. The resident's representative was given a discharge notice on 12/12/2022 and planned to bring the resident to their home in another state. The representative had since changed their mind and stated they could not manage the resident. The Nursing Home Transfer and Discharge Notice dated 1/6/2023, documented the resident was being discharged to their relative's out of state address, effective 2/6/2023. The resident was being discharged for the following reasons: - The transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility. - The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the resident. - The health of individuals in the facility would otherwise be endangered. The notice was signed by the DON on 1/6/2023. The resident's medical record did not contain any documentation related to the specific needs that could not be met by the facility or any alternative plans made for the resident. The 6/23/2023 hospital discharge summary documented the resident was evaluated and discharged on 1/4/2023, was brought back to the hospital after the facility refused to readmit the resident. The resident remained in the hospital pending a safe discharge until 6/23/2023. During an interview with the hospital emergency room (ER) Manager on 1/6/2023 at 9:14 AM, they stated the resident was sent to the hospital (from another hospital) and was receiving intramuscular (IM, injected into the muscle) medications to calm them. The resident also tested positive for COVID-19. The resident was sent to their hospital for a psychiatric evaluation. The resident has been cleared by medical and psychiatry. A nurse-to-nurse report was completed, and the facility accepted the resident back and the hospital made the transportation arrangements. When the resident got to the facility, they changed their minds and refused to admit the resident saying they could not take them because they were COVID positive. The resident returned to the hospital was currently a social admission. The resident had been calm and was asymptomatic COVID positive. The facility refused to readmit the resident. The hospital case manager was interviewed on 1/10/2023 at 12:15 PM and stated the resident had been cleared medically and psychiatrically and did not require IM medications and was ready to return to the facility on 1/4/2023. During a follow-up interview with the hospital ER Manager on 8/25/2023 at 10:43 AM, they stated the resident was evaluated by psychiatry at approximately 12:00 AM on 1/4/2023 and was dispositioned for discharge at approximately 1:30 AM. The CPEP nurse at the hospital called the facility and spoke to LPN #4 on 1/4/2023. The LPN was advised the resident was to be transported back that night and the hospital had arranged transportation. The resident was refused admission upon arrival to the facility and brought back to the hospital. During a telephone interview with the DSW on 8/29/2023 at 8:09 AM, they stated the facility issued a 30-day discharge notice on 12/12/2022 due to the resident's behaviors and safety issues. The DSW spoke to the resident's relative, who agreed to pick up the resident on 1/14/2023 at the facility. On 1/4/2023, the DSW sent the 12/12/2022 discharge notice to the case manager at the hospital. The facility could not take the resident back due to their behaviors and placing others at risk. The former DON (#9) and former Administrator were involved in the decision and the DSW was directed to send the notice to the hospital. The DSW was unaware of the status of the discharge plan that was in place prior to the resident's hospitalization and attempted to reach the resident's relative on 1/4/2023. The DSW could not recall if they attempted to notify the relative prior to the facility's refusal to readmit the resident. During a telephone interview with the Administrator on 8/29/2023 at 3:18 PM, they stated the resident was not taken back to the facility on 1/4/2023 due to the hospital's lack of planning and the resident's positive COVID-19 status. The facility could not accept a resident back who was positive for COVID-19, as they were not prepared. It was the Administrator's understanding that current COVID-19 guidelines included a negative COVID-19 test was required prior to admission. The facility did not have the ability or space to provide appropriate isolation. The Administrator was unaware of the census at the time and stated they believed they did not have any available private rooms. The Administrator was not aware that the facility was notified by the hospital on 1/1/2023 of the resident's COVID status and was unaware of any plans that were made as a result. The Administrator was unaware that the facility was notified by the hospital on 1/4/2023 that the resident was to be transported back to the facility prior to their arrival. The Administrator then stated the resident's COVID status was not the overwhelming issue, it was the hospital's lack of planning when they (the hospital) knew of the resident's violent behaviors. The hospital should have made a plan and communicated it to the facility to address the resident's behaviors prior to sending them back. The resident was at risk of harming themselves or others and the facility did not have adequate time to plan for the resident's return. Following the facility's refusal to take the resident back on 1/4/2023, the facility did not hear back from the hospital and expected them to reach to pursue further discharge planning. DON #9 and LPN #4 were no longer employed at the facility and were not available for interview. RN #8 was contacted for an interview and did not return the call prior to the survey exit date. 10NYCRR415.3(h)(4)(iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification survey conducted 1/31/22 - 2/4/22 the facility failed to assess residents to determine their ability to safely self-administer medication when clinically appropriate for 2 of 2 residents (Residents #108 and #206) reviewed. Specifically, Residents #108 and #206 had inhalers (hand-held, portable devices that deliver medication to the lungs) at their bedsides and there were no physician orders for self-medication administration or resident assessments to determine ability to safely self-administer medications. Findings include: The facility policy Storage of Medications revised 01/2020, documented each resident's medications shall be assigned to an individual cubicle, drawer, or other holding area. The facility policy Medication Administration revised 6/4/21, documented medications must be administered in accordance with the orders. 1) Resident #108 had a diagnosis of chronic obstructive pulmonary disease (COPD, airflow blockage). The Minimum Data Set (MDS) assessment dated [DATE] documented the resident had moderate cognitive impairment, required supervision for most activities of daily living (ADLs) and had shortness of breath with exertion and when lying flat. Physician orders dated 5/4/21 documented: Ventolin HFA (albuterol sulfate, a bronchodilator) for diagnosis of COPD, 90 mcg (micrograms) /actuation, 2 inhalations every 4 hours PRN (as needed). The 1/1/22 - 2/2/22 medication administration record (MAR) did not document PRN use of the Ventolin HFA inhaler by the resident. On 2/1/22 at 9:29 AM the Ventolin HFA inhaler was observed on the resident's overbed table. The resident stated they were allowed to keep it in their room. On 2/2/22 at 2:49 AM the Ventolin HFA inhaler was observed lying on the floor under the resident's bed. There was no documented evidence the resident had been assessed for the ability to safely self-administer the Ventolin inhaler. During an interview on 2/2/22 at 12:57 PM with licensed practical nurse (LPN)/Assistant Director of Nursing (ADON) #1 they stated if a resident were allowed to keep a medication at the bedside it would be in the physician's orders. The facility did not have a self-medication assessment tool. The Corporate Director of Nursing (DON) who was present during the interview added that the facility currently did not have any residents who could self-administer medications. During an interview on 2/2/22 at 2:49 PM with Resident #108, they stated the last time they used their Ventolin HFA inhaler was, two or three weeks ago. They could use the inhaler whenever they wanted to but knew they could only take two puffs at a time. The resident stated the nurse who was on vacation knew they kept the inhaler in their room. The resident stated they carried the inhaler with them whenever they left their room and used it more when the weather was hot because they became short of breath and more anxious in the hot weather. The resident stated they did not always tell a nurse when they used it. During an interview 2/3/22 at 11:20 AM with the Medical Director, they stated Resident #108 could not always be trusted to use the inhaler properly so the resident should probably not keep the inhaler at their bedside. If the resident was able to safely keep the inhaler at the bedside, they stated they would write a specific order. During an interview 2/4/22 at 9:51 AM the DON stated Resident #108 would likely not be taking the Ventolin HFA inhaler appropriately at the bedside. There was the possibility the resident could take too many inhalations and overdose. The resident had no self-medication administration assessment. The Medical Director stated the resident absolutely should not have the inhaler at bedside. 2) Resident #206 had a diagnosis of COPD. The MDS assessment dated [DATE] documented the resident had moderately impaired cognition, required extensive to total dependence for most ADLs, had dyspnea (shortness of breath) and received oxygen. Physician orders dated 7/22/21 documented Anoro Ellipta blister with device (inhaler) 62.5 - 25 micrograms (mcg)/actuation; one inhalation, rinse mouth after each use, once a day at 8:00 AM for COPD and Arnuity Ellipta (corticosteroid inhaler) blister with device, 100 mcg/actuation; one puff, rinse mouth after each use, once a day 8:00 AM. The 1/1/22 - 2/2/22 MARs documented both inhalers were administered each day. The resident refused both inhalers on 2/2/22. On 2/2/22 at 3:52 PM the resident was observed in their room with both inhalers at the bedside. Resident #206 stated they self-administered the inhalers every morning, they waited a minute between each inhaler, and they rinsed their mouth afterwards. There was no documented evidence the resident had been assessed for the ability to safely self-administer the inhalers. During an interview with the Medical Director on 2/3/22 at 11:13 AM they stated Resident #206 had no dementia or confusion. They had long-standing COPD and they were probably safe to have the inhalers at the bedside and they should have a self-medication assessment completed. During an interview 2/4/22 at 1:01 PM with the LPN/ADON/IP #1 they stated the resident had no self-medication assessment. If there were no orders to self-administer medications, the medications should not be left at the bedside as there was no way to monitor proper usage. 10NYCRR 415.3(e)(1)(vi)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification survey conducted 1/31/22- 2/4/22, the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment for 6 of 12 bathrooms/shower rooms reviewed. Specifically, hot water temperatures were not comfortable and safe for resident use; the hot water temperatures measured at the sinks in shared resident bathrooms between rooms [ROOM NUMBERS] was 128 Fahrenheit (F); between rooms [ROOM NUMBERS] was 128 F; between rooms [ROOM NUMBERS] was 124 F; between rooms [ROOM NUMBERS] was 124 F; between rooms [ROOM NUMBERS] was 122 F; and the south wing shower room water was measured at 122 F. Findings include: The undated and untitled facility policy documents hot water supplied to sinks, tubs, and showers in resident areas shall be regulated to a maximum temperature of 115 F at the terminal end to prevent injury or discomfort due to extreme water temperatures. The Environmental Services Supervisor or designee will maintain hot water temperatures at safe and appropriate levels. This will be monitored daily by checking the outgoing hot water temperatures at the thermometer located in the boiler room and various locations throughout the facility. On 2/1/22 the following hot water temperatures were measured: North wing: - at 9:33 AM at the sink in the common bathroom between rooms [ROOM NUMBERS] was measured at 128 F. - at 9:35 AM at the sink in the common bathroom between rooms [ROOM NUMBERS] was measured at 128 F. - at 9:38 AM at the sink in the common bathroom between rooms [ROOM NUMBERS] was measured at 124 F. - at 9:40 AM at the sink in the common bathroom between rooms [ROOM NUMBERS] was measured at 124 F. South Wing: - at 9:45 AM the shower in the south shower room was measured at122 F. - at 9:47 AM at the sink in common bathroom between rooms [ROOM NUMBERS] was measured at 122 F. During an observation on 2/2/22 at 10:30 AM, maintenance technician #27 was measuring hot water temperatures. When compared to the temperatures to those measured using the New York State calibrated thermocouple, the measured temperature of the manual probe used by the facility was reading 4-5 F lower. When interviewed on 2/1/22 at 9:33 AM, the Director of Facilities stated they were not sure why the temperatures were getting that high as the mixing value was not that high. Temperatures should be taken daily, and they were not aware of any issues. When interviewed on 2/1/22 at 10:15 AM, the Director of Facilities states it takes some time to get to temperature at times. The hot water temperatures were taken in the morning by maintenance and should not be higher than 115 F. When interviewed on 2/2/22 at 10:00 AM, maintenance technician #27 stated they recorded water temperatures daily in rooms when they arrived at 9 AM each morning. They stated they had a logbook and used a manual probe thermometer that was calibrated 2 times per month. They stated they had not noticed any hot water temperatures being too high during rounds. 10 NYCRR 415.29(j)(1)

Based on observation, record review, and interview during the recertification and abbreviated surveys (NY283054) conducted 1/31/22-2/4/22, the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents(Resident #208) reviewed. Specifically, Resident #208's pressure ulcer treatments were not completed as ordered. Findings include: The facility policy Wound Care revised 1/2020 documents to notify the Supervisor if the resident refuses the wound care. Resident #208 had diagnoses including diabetes, morbid obesity, and an unstageable (full thickness tissue loss where the base of the wound is covered with dead tissue) pressure area to the left gluteal fold. The 11/18/21 Minimum Data Set (MDS) assessment documented the resident had intact cognition, required extensive assistance for bed mobility, transfers and dressing, did not reject care, was not at risk for the development of pressure ulcers, did not have one or more unhealed pressure ulcers, and used pressure reducing devices for the chair and bed. The Wound Management Detail Report dated 1/10/22 created by the Corporate Director of Nursing (DON) documented an unspecified ulcer located on the gluteal fold was identified on 1/10/22 and was not present on admission. The wound measured 1.5 centimeters (cm) x 1.0 cm, with no depth. The physician's order dated 1/10/22 documented to cleanse the area to the gluteal fold with wound cleanser, pat dry, apply Hydrogel (used to assist with removing dead tissue) and cover with DPD (dry protective dressing) twice daily, apply skin prep (protectant) to peri wound. The comprehensive care plan (CCP) initiated 1/10/22 documented the resident had a pressure ulcer and was at risk for pressure ulcers due to moisture. Approaches included weekly skin rounds and treatments per order. The 1/2022 Treatment Administration Record (TAR) documented to cleanse the area to gluteal fold with wound cleanser, pat dry, apply Hydrogel and cover with DPD twice daily, apply skin prep to peri wound with a start date of 1/10/22. The treatment was documented as not administered: - on 1/10/22 6:30 AM-2:30 PM by licensed practical nurse (LPN) #28, not done. - on 1/12/22 6:30 AM-2:30 PM by Assistant Director of Nursing (ADON), not administered, refused. - on 1/13/22 6:30 AM-2:30 PM and 2:30 PM-10:30 PM by LPN #3, refused. - on 1/14/22 6:30 AM-2:30 PM by LPN #29, not administered. - on 1/16/22 6:30 AM-2:30 PM by LPN #3, refused. The 1/20/22 telemedicine wound assessment documented the resident had an unstageable pressure injury located on the left gluteal area measuring 1.3 centimeters (cm) x 2.2 cm with 10% granulation and 90% slough. The wound onset date was documented as 1/20/22. The physician order dated 1/21/22 documented cleanse area to gluteal fold with wound cleanser, pat dry, apply Alginate (absorbs wound fluid) and cover with Optifoam every day and prn (as needed). The 1/2022 TAR documented cleanse area to gluteal fold with wound cleanser, pat dry, apply Alginate and cover with Optifoam every day and prn with a start date of 1/21/22. The treatment was documented as not administered; - on 1/23/22 6:30 AM-2:30 PM by LPN #3, resident unavailable at activities. - on 1/24/22 6:30 AM-2:30 PM by LPN #3, resident unavailable involved in activity. - on 1/25/22 6:30 AM-2:30 PM by the DON, refused three times-activities. - on 1/26/22 6:30 AM-2:30 PM by LPN #3, resident unavailable out of facility at appointment. The 1/27/22 telemedicine wound assessment documented the resident had an unstageable pressure injury on the left gluteal fold measuring 2.2 centimeters (cm) x 1.7 cm. The wound bed contained 10% granulation (new tissue) and 90% slough (moist, dead tissue). The treatment order was wound gel (helps to remove dead tissue) and Optifoam (dressing) every day and as needed (prn). The physician order dated 1/29/22 documented cleanse area on left gluteal fold with wound cleanser, pat dry, apply wound gel, cover with Optifoam daily and prn (as needed). The 2/2022 TAR documented cleanse left gluteal fold with wound cleanser, pat dry, apply wound gel, cover with Optifoam daily and prn with a start date of 1/29/22. The treatment was documented as not administered on 2/1/22 6:30AM-2:30PM by LPN #3, resident unavailable out of facility at appointment. On 2/01/22 at 10:53 AM during an interview with Resident #208, they stated the treatment to their pressure area was not done daily as ordered. On 2/2/22 at 10:48 AM the treatment to the resident's left gluteal fold was observed with LPN #3. The undated dressing was removed and was saturated with tan drainage. The wound was an open circular area approximately the size of a quarter in the fold between the left buttock and upper thigh. There was slough present in the wound bed. The wound was moist in appearance with some surrounding redness. Wound gel was placed using a clean cotton swab and covered with Optifoam, and the dressing was dated. The resident stated the wound caused discomfort at times, especially while on the toilet. On 2/3/22 at 11:15 AM during an interview with physician #12 they stated due to the amount of time the resident spent in a wheelchair, the resident's wound could be hard to heal. The physician stated that wound care not being done daily could increase the risk of infection and cause the wound to worsen. On 2/4/22 at 1:13 PM during an interview with the ADON they stated the resident refused care frequently. If the resident was playing cards or out of the building, they may not get the dressing changed. The danger of the treatment not getting done as ordered was worsening of the wound. The ADON stated residents could not be forced if they refused treatments. They stated staff should make multiple attempts to provide treatments as ordered. 10NYCRR 415.12(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification and abbreviated surveys (NY00283712, NY00283446, and NY00283054) conducted 1/31/22-2/4/22, the facility failed to ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences for 2 of 2 residents (Residents #155 and 205) reviewed. Specifically, Resident #155 had a significant weight loss and did not receive nutritional supplements at meals as ordered. Resident #205 had a documented dairy and lactose allergy and received vanilla mousse containing lactose. Findings include: 1)Resident #155 had diagnoses including other specified eating disorder and dysphagia (difficulty swallowing). The 12/21/21 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment, required limited assistance with eating, weighed 120 pounds, did not have significant weight change, and received a therapeutic, mechanically altered diet. On 12/19/21, LPN #16's progress note documented the resident refused solids for breakfast but accepted 360 ml of fluid. On 12/22/21 the Assistant Director of Nursing's (ADON) progress note documented the resident needed much encouragement at meals and accepted fluids. The 12/31/21 resident profile (care instructions) documented the resident required supervision at meals and received a pureed diet with nectar thick liquids. The resident's weight record documented on 1/7/22, the resident weighed 110.6 pounds and on 1/8/22, the resident weighed 108.6 pounds (11.4 pound /9.5% loss in 1 month, 12.9 pounds/10.6% loss at 3 months, and 12 pound/10% loss at 6 months). The 1/11/22 physician order documented the resident was started on 240 milliliters (mls) of nectar thick Boost Breeze (an oral nutrition supplement) at meals, three times daily. On 2/1/22 at 8:52 AM, Resident #155 was observed in the north unit dining room. Their meal ticket documented they were to receive 4 oz of nectar thick cranberry juice, 8 oz of nectar thick water, 6 oz of nectar thick coffee, 1 nectar thick Boost Breeze, 1/2 cup of puree cream of wheat, 1 pureed muffin and (2) 3 oz of pureed scrambled eggs. The resident was not provided with Boost Breeze. On 2/2/22 at 8:19 AM, Resident #155 was observed in the north unit dining room. Their meal ticket documented they were to receive 4 oz of nectar thick cranberry juice, 8 oz of nectar thick water, 6 oz of nectar thick coffee, 1 nectar thick Boost Breeze, puree bread, and (2) 3 oz of puree scrambled eggs. The resident was not provided with Boost Breeze or pureed bread. During an interview with CNA #4 on 2/2/22 at 8:39 AM they stated the resident did not receive the Boost Breeze or pureed bread and they were unsure who passed the resident their meal tray. On 2/2/22 at 12:07 PM, Resident #155 was served their lunch meal tray by Admissions Coordinator #5. Their meal ticket documented they were to receive 4 oz of nectar thick cranberry juice, 8 oz of nectar thick water, 6 oz of nectar thick coffee, 1 nectar thick Boost Breeze, 1/2 cup of pureed pasta [NAME], 1 pureed slice of garlic bread, and 1/2 cup of pureed mixed vegetables. The resident did not receive Boost Breeze. During an interview with Admissions Coordinator #5 on 2/2/22 at 12:14 PM, they stated the nurse checked the tray against the meal ticket to ensure residents were receiving the proper consistency and they provided the tray to the resident. They did not verify if the resident received all their items on the meal ticket. They stated the resident's Boost Breeze was not on the tray and it should have been. They stated LPN #3 checked the resident's meal tray prior to them passing it. During an interview with LPN #3 on 2/2/22 at 12:20 PM, they stated the nurses checked the trays to ensure the residents received the proper consistency, but the nurses did not check to make sure all the items on the meal ticket were on the tray. They stated whoever was passing the tray should check to make sure all the items were on the tray. During a telephone interview with diet technician #13 on 2/3/22 at 9:56 AM they stated Resident #155 had a significant weight loss in 1/2022 and 240 ml of nectar thick Boost Breeze was added to each meal to promote weight gain. They stated if a supplement was added to a resident's meal ticket, they would expect the resident to be provided with the supplement as ordered. During a telephone interview with registered dietitian (RD) #14 on 2/3/22 at 10:21 AM, they stated Resident #155 had a significant weight loss in 1/22 and they had added 240 ml of nectar thick Boost Breeze to the resident's meal ticket at all meals to promote weight gain. They expected the resident to receive their nutritional supplements if it was on their meal ticket. During an interview with LPN #3 on 2/3/22 at 1:41 PM they stated if the resident did not receive their nutritional supplements on their meal tray the tray passer should have let them know and they would have called the kitchen to get the supplement. The tray passer should be checking the meal ticket to ensure all items were received. They stated they provided Resident #155 with their nectar thick Boost Breeze at med pass instead of at meals. They did not realize it was ordered to be provided at mealtime. During an interview with the DON on 2/4/22 at 9:44 AM, they stated it was expected that a nurse checked each meal tray to ensure proper diet order consistency and to make sure all items on the meal ticket were on the tray. The person who provided the resident their meal tray should also check for consistency and accuracy. If a resident had supplements ordered at mealtimes they should be provided with their meal, and it should not be provided during a medication pass. It was important to provide Resident #155 with their supplements as they had a recent weight loss. 2) Resident #205 had diagnoses including dementia and moderate protein-calorie malnutrition. The resident's meal tray ticket dated 2/1/22 documented the resident was to receive a regular, low lactose diet with thin liquids and had an allergy to lactose and dairy. During a meal observation on 2/1/22 at 11:47 AM, Resident #205 was observed eating their meal in the north unit dining room. The assistant director of nursing (ADON) #1 was serving Resident #205 their lunch meal. The resident's meal ticket documented they were to receive 4 oz assorted juice, 6 oz iced tea, 4 oz juice, 8 oz water, 4 oz meatloaf, 1/2 cup whipped sweet potatoes, 1 slice of buttered bread, 1/2 cup of green bean casserole, and 1/2 cup of Jello. The resident did not receive the Jello and received vanilla mousse. During an interview with ADON #1 on 2/1/22 at 11:47 AM, they stated Resident #205's meal ticket did not document they should receive vanilla mouse and their meal ticket listed allergies to milk and lactose. They stated the vanilla mousse should not have been provided to the resident. During an interview with the Food Service Director on 2/2/22 at 12:38 PM, they reported the vanilla mousse served during the 2/1/22 lunch meal was not lactose-free and did contain dairy. They stated residents who had allergies to milk or lactose should have received Jello. All staff should be checking the meal trays for accuracy. During an interview with dietary aide #20 on 2/2/22 at 2:49 PM, they stated all kitchen staff should and were expected to check the meal trays for accuracy. They reported they placed drinks, cold items, condiments, and utensils on the residents' meal trays. The cook then checked the meal tickets for accuracy prior to the meal cart being brought to the unit. It was normal for the nursing staff to check the meal trays to ensure the meal consistencies were correct and the tray contained all items on the meal ticket. They should be our last set of eyes for accuracy of food items. During an interview with the DON on 2/4/22 at 9:44 AM they stated nursing staff should be on the units checking meal trays to ensure accuracy of the food consistencies. The kitchen staff should ensure all items on the meal ticket were on the tray. 10NYCRR 415.14(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** - Based on observation, record review and interview during the recertification and abbreviated surveys (NY00283712, NY00260801, NY00283446, NY00283054, and NY00267378) conducted 1/31/22- 2/4/22, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 6 residents (Residents #104, 155, 156, 158, and 160) reviewed. Specifically, Residents #104, 158, and 160 did not receive showers as planned, Resident #156 did not receive incontinence care as planned and Resident #155 was observed with unclean nails. Finding included: The facility policy Activities of Daily Living (ADLs) revised 1/2020 documented residents who are unable to carry out ADLs independently will receive services needed to maintain good nutrition, grooming, and both personal and oral hygiene. Appropriate care and services for residents who are unable to carry out ADLs independently included: A) Hygiene (bathing, dressing, grooming, and oral care); B) Mobility (transfers and ambulation); and C) Elimination (toileting). 1) Resident #158 was admitted to the facility with diagnoses including multiple sclerosis (MS, a central nervous system disease) and morbid obesity. The 1/15/22 Minimum Data Set (MDS) assessment documented the resident had intact cognition. The MDS section for activities of daily living (ADLs) was not complete. A physician order dated 9/22/20 documented body audit weekly on shower days once a day on Mondays. The Comprehensive care plan (CCP) initiated 1/10/22 documented the resident had an alteration in ADLs related to a recent hospital stay and MS. Approaches included extensive assistance of 1 with personal care tasks. The ADL Point of Care (POC, CNA documentation) documented no bathing activity occurred from 1/20/22-1/31/22. The 1/24/22 resident profile (care instructions) documented the resident required extensive assistance of 1 with personal care tasks. During an interview with Resident #158 on 1/31/22 at 11:15 AM, they stated they were readmitted to the facility on [DATE] and had not received showers on a regular basis and would like to. During an interview on 2/3/22 at 1:41 PM, certified nurse aide (CNA) #7 stated each resident was assigned a shower day and it was documented in the shower book. CNAs documented in the electronic ADLs POC if a resident received their bath or shower and the level of assistance required. If a resident received a bed bath instead of a shower, they could document that activity had occurred instead of a shower. The CNA stated Resident #158 required extensive assistance of 2 for bathing. They stated if someone documented activity did not occur in POC it meant either the resident did not receive a bath or shower, or the assigned CNA did not document in POC. POC should be filled out every shift. There was not always enough time to document in POC or to complete care. 2) Resident #155 was admitted to the facility with diagnoses including hypertension and diabetes mellitus (DM). The 12/22/21 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition and required extensive assistance of 1 staff for personal hygiene and total dependence of 1 staff assist for bathing. The CCP dated 1/6/21 documented the resident required limited assistance with hygiene and grooming. The ADLs point of care (POC) dated 1/20/22-1/31/22 documented resident had received personal hygiene care daily (which included nail care) ranging from limited assist of 1 staff to total dependence of 1 staff. The undated resident profile (care instructions) documented the resident required limited assistance with hygiene/grooming. The skin monitoring/shower review book documented for Resident #155: - 1/12/22 no skin issues noted; nails to be cut. - 1/20/22 no skin issues noted. Resident #155 was observed with brown debris under their fingernails: - On 1/31/22 at 10:13 AM, in their bed. - On 1/31/22 at 3:30 PM, in their bed. - On 2/1/22 at 8:52 AM, in the North dining room at breakfast. - On 2/2/22 at 8:19 AM in the North dining room at breakfast. - On 2/2/22 at 1:54 PM in their room. - On 2/3/22 at 9:02 AM in the North dining room at breakfast. During an interview 2/3/22 at 1:51 PM CNA #6 stated nail care was supposed to be done daily or at least when bathed. The CNA stated Resident #155's nails needed to be cleaned and trimmed. During an interview 2/3/22 at 2:23 PM LPN #3 stated the CNAs cleaned the residents' nails during baths or showers, or anytime they were unclean. During an interview 2/3/22 at 2:32 PM CNA #8 stated they did not document in the shower book if a resident needed their nails cut or trimmed. The CNA stated Resident #155 would touch their feces and the CNA would expect staff to clean the resident's fingernails. During an interview 2/3/22 at 2:40 PM CNA #9 stated they noticed Resident #155's nails were unclean and they should have cleaned them. 3) Resident #156 was admitted to the facility with diagnoses including dementia. The 12/3/21 Minimum Data Set (MDS) documented the resident had moderately impaired cognition, required extensive assistance of 1 staff for toileting, was occasionally incontinent of bladder and frequently incontinent of bowel. The 1/14/22 comprehensive care plan (CCP) documented the resident required limited assistance with toileting and was at risk for skin breakdown due to occasional incontinence of bladder. The 2/1/22 ADL (activities of daily living) POC (point of care) toileting section documented the resident was toileted at 2:02 AM with limited assistance of 1; and at 1:20 PM with extensive assist of 1. The resident was observed continuously on 2/1/22 from 9:01 AM- 11:58 AM with a large, wet area on the back of their pants. - At 9:01 AM, after being brought into their room by staff; standing at their bedside with the call bell alarming. - At 9:11 AM, staff turned off the resident's call bell. At 9:13 AM the resident was placed in bed with a blanket over the front of them. There was a large, wet area on the back of their pants. - At 9:28 AM, the resident placed themself in their wheelchair with the wet area remaining on the back of their pants. - At 9:32 AM, the resident self-propelled to the doorway of their room, yelling out help. The resident's pants remained wet. - At 10:03 AM, the resident transferred out of their wheelchair and placed themself back into bed. There was a large wet area on the back of their pants. - At 11:58 AM CNA #6 was observed in the resident's room providing care and then transported the resident from their room to the North dining room for lunch. At 12:00 PM, CNA #6 stated this was the first time the resident had been provided incontinence care since before breakfast. During an interview on 2/2/22 at 1:54 PM, CNA #6 stated the CNAs had no special time to check and change residents. Most residents were provided incontinence care every 2 hours but Resident #156 was not. The CNA stated from breakfast to lunch was a long time to go without being changed. They were not sure if any other staff had checked on the resident. The resident had wet pants from urine and had a bowel movement (BM) and needed to be changed. There were days that were very hectic and sometimes they had 1 CNA. They usually let the nurse know when they were running behind, but they had not done that on 2/1/22. During an interview 2/3/22 at 2:46 PM LPN #3 stated most residents would tell staff when they needed to be toileted. If a resident was unable to state they needed toileting, staff should see the signs. CNAs should be checking residents every 2 hours. Resident #156 could verbalize when they needed to be changed. Going from breakfast to lunch was a long time to wait with wet pants before being changed. They were not aware that the CNA was unable to get to the resident in a timely manner and if they had been made aware, they would have followed up on it. During an interview 2/4/22 at 9:44 AM, the DON stated showers were performed minimally weekly by the CNAs. The CNAs completed the skin sheets and the charge nurse signed off on them. CNAs should document when a shower or bath was completed in the ADLs POC and in the shower/skin books on the units. Nails should be trimmed minimally weekly and as needed. The CNAs and activities aides could clean nails. Nails should be cleaned every shift. The nurse should be notified if the resident refused. Toileting should be done at least every shift or during rounding. Resident #156 was able to use the bathroom on their own, but they needed help. If their pants were wet, they should have been cleaned and changed. That was a long time to wait from 9:00 AM until noon to be toileted. Rounding by CNAs should be done at least every 2 hours or sooner. 10NYCRR 415.12 (a)(1)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review during the recertification survey conducted 1/31/22 - 2/4/22, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, including COVID-19, for 1 of 3 residents (Resident #108) reviewed and for 3 staff (certified nurse aid, [CNA] #7, physical therapist [PT] #17 and activity aide #18). Specifically, the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) did not perform appropriate hand hygiene during a wound treatment for Resident #108, and CNA #7, PT #17, and activity aide #18 were observed wearing face masks below their nose while in residential areas and in proximity (less than 6 feet) to residents. Findings include: Wound Dressing Observation The facility policy Wound Care revised 01/2020 documents to wash and dry hands thoroughly after establishing a clean field on the resident's overbed table, with supplies on the clean field so they can easily be reached. Exam gloves are donned (put on) to remove the soiled dressing, then doffed (removed) after removing the soiled dressing. Hands are washed and dried thoroughly before donning clean gloves to dress the wound. After dressing the wound and discarding disposable items, gloves are doffed, and hands are washed and dried thoroughly. Any reusable supplies that were touched by unclean hands should be wiped with alcohol. Resident #108 had diagnoses including diabetes and Stage 3 (full thickness skin loss) pressure ulcer to natal cleft (groove between buttocks). The 12/31/21 Minimum Data Set (MDS) assessment documented the resident had moderately impaired cognition, required supervision for most activities of daily living (ADLs), had 1 Stage 3 pressure ulcer, received pressure ulcer care, and application of non-surgical dressings. A 1/27/22 telemedicine wound consult documented the presence of a Stage 3 pressure injury located on the coccyx (end of spine) measuring 2.5 centimeters (cm) length x 1.5 cm width x 1.0 cm. The recommended treatment was to pack with Iodoform packing (antiseptic gauze strips) and cover with Optifoam gentle border (wound dressing) with zinc 20% cream to wound edges every day and as needed (PRN). A 1/29/22 physician order documented: cleanse natal cleft wound with wound cleanser, pat dry. Thoroughly pack wound with Iodoform. Zinc oxide to wound edges and cover with Optifoam daily and PRN 6:30 AM - 2:30 PM. During an observation of Resident #108's wound dressing treatment performed by the ADON/IP on 2/2/22 at 9:42 AM the following was observed. The ADON/IP washed their hands in the central supply room, then gathered dressing supplies. On their way out of the central supply room, they dropped a supply box on the floor, picked it up with their bare hands and proceeded into the resident's room. The ADON/IP set the dressing supplies on one end of the resident's cluttered overbed table without sanitizing it or placing a barrier. The ADON/IP discarded 4 empty beverage cups and food wrappers on the overbed table, in the trash. The ADON/IP opened the Optifoam dressing packaging and set some of the supplies on the packaging. They took out a black marker from their pocket and dated the Optifoam dressing. The ADON/IP donned clean exam gloves without performing hand hygiene and removed the soiled dressing. The soiled dressing had a scant amount of drainage on it. Without changing gloves or performing hand hygiene the ADON/IP sprayed wound cleanser on gauze pads and wiped around the wound, then patted it dry with gauze pads. They removed the soiled exam gloves and donned clean exam gloves without performing hand hygiene between the glove changes. The ADON/IP packed the wound with Iodoform (gauze packing strips), applied zinc oxide around the wound edges, and placed the Optifoam dressing over the wound. They disposed of the remaining soiled items in the trash, doffed their soiled exam gloves and washed their hands in the bathroom sink. During an interview 2/3/22 at 4:40 PM with the ADON/IP they stated they performed hand hygiene before and after the dressing change and did not think they needed to perform hand hygiene between the glove changes. They stated when they picked up supplies from the floor and discarded the trash on the overbed table they did not think they needed to wash their hands again prior to donning clean gloves as they had already washed them in the sink in the central supply room. They had never performed hand hygiene between glove changes during any dressing changes and did not think it needed to be done. They were not aware of the facility policy that documented performing hand hygiene before starting a procedure and between glove changes. During an interview with the Director of Nursing (DON) on 2/4/22 at 9:46 AM they stated hand hygiene should be performed before a dressing change and between glove changes. The DON stated picking an item off the ground would contaminate the hands and they should be washed. The bedside table should be wiped, and a barrier placed. Face Masks The facility policy Personal Protective Equipment-Using Face Masks dated 3/2020, documents face masks were to be worn by all staff and visitors while in the facility, with the mask covering the nose and mouth. A facility training on infection control attended by all facility staff on 12/29/21 included the procedure for donning and doffing of personal protective equipment (PPE). The inservice sign-in sheet documented the signatures of CNA #7, PT #17, and activity aide #18. The following observations were made of CNA #7 wearing their face mask below their nose: - On 2/1/22 at 12:19 PM taking Resident #168 to the bathroom. - On 2/1/22 at 12:24 PM assisting Resident #168 to the North dining room. The following observations were made of PT #17 wearing their face mask below their nose: - On 1/31/22 at 11:10 AM working with Resident #164 in room [ROOM NUMBER]. - On 1/31/22 at 12:16 PM working with Resident #165 in room [ROOM NUMBER]. - On 1/31/22 at 12:29 PM taking Resident #160 to the therapy gym. - On 2/1/22 at 11:57 AM talking to Resident #166 in room [ROOM NUMBER]. - On 2/1/22 at 12:04 PM assisting Resident #166 with their meal in room [ROOM NUMBER]. - On 2/1/22 at 12:15 PM talking to Resident #167. - On 2/1/22 at 12:29 PM taking a beverage to Resident #167. - On 2/1/22 at 12:30 PM talking to Resident #165 in room [ROOM NUMBER]. - On 2/2/22 at 9:02 AM in hallway talking to Resident #163. - On 2/2/22 at 12:19 PM working with Resident #165 in room [ROOM NUMBER]. - On 2/3/22 at 10:48 AM transporting Resident #165 to therapy. - On 2/3/22 at 10:50 AM assisting Resident #165 in South hall with arm exercises. - On 2/3/22 at 1:09 PM transporting Resident #156 in the hall. The following observations were made of activity aide #18 wearing their mask below their nose: - On 1/31/22 at 10:28 AM transporting Resident #162 to an exercise group. - On 1/31/22 at 10:52 AM supervising an exercise class in North dining room with Residents #162, 163, 169, 170, 171, 205, 206 and 209. - On 1/31/22 at 3:11 PM supervising an exercise class in North dining room with Residents #156 and 208. - On 1/31/22 at 3:17 PM walking with Resident #166 in the North hall. - On 2/3/22 at 10:47 AM walking in the hall to an exercise group with Residents #163 and #212. During an interview on 2/3/22 at 1:41 PM with CNA #7 they stated the facility performed mask audits. The registered nurse (RN) or licensed practical nurse (LPN) walked around the units watching for correct face mask usage. The facility had plenty of masks so if the mask was slipping you could get a replacement mask. The CNA stated they sometimes pull their mask down due to respiratory issues. The CNA stated that had been told to go to a non-resident area to pull the mask down if they needed a break, but they did not always have the time to do so. The CNA stated they knew the correct way to wear a mask and the importance for infection control purposes. During an interview on 2/3/22 at 3:26 PM with activity aide #18 they stated they had been working at the facility for 3 months and upon hire they received education on how to wear a face mask. The mask should cover the nose and the mouth. They stated the nurses in the facility did mask roundings to make sure masks were worn appropriately. They stated there had been a couple of times their mask had fallen below their nose and mouth, but they were aware of the proper way to wear a mask. When they tried talking with residents it was difficult and there were no amplifiers to talk to the residents in groups. They stated they would pull their mask down to read an article to residents. It was important to wear the face mask correctly to prevent the spread of COVID-19. During an interview on 2/3/22 at 3:29 PM with PT #17 they stated all staff were supposed to wear a mask at all times while in the facility. The mask was to be worn over the nose and mouth to protect residents and staff from infections. They stated their mask fell down a lot and it would not stay up. During an interview on 2/4/22 at 1:47 PM with the ADON/IP they stated personal protective equipment (PPE) should be worn at all times. PPE included a surgical face mask, which needed to cover the nose and mouth. They stated staff were educated on the proper way to wear face masks. They stated wearing the face masks appropriately was important to help keep residents and staff safe from infections. 10NYCRR 415.19(a)(1)(b)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification survey, the facility did not ensure a resident's right to request, refuse, and/or discontinue treatment, and to formulate an advance directive for 1 of 1 resident (Resident #43) reviewed for advance directives. Specifically, Resident #43's advance directive was changed to do not resuscitate, do not intubate (DNR/DNI, allow natural death) by her primary healthcare proxy (HCP, person appointed to make medical decisions when the resident is unable or lacks capacity) and the resident had intact cognition and did not consent to the change. Additionally, the resident's comprehensive care plan was not updated to reflect the change in advance directives. Findings include: The facility's undated Advance Directives policy documents: - The Social Service department gives information and explanation of DNR and advance directives, Medical Orders for Life Sustaining treatment (MOLST) upon or shortly after admission. Resident #43 was admitted to the facility on [DATE], re-admitted on [DATE], and had diagnoses including heart failure and anxiety disorder. The [DATE] Minimum Data Set (MDS) assessment documented the resident had intact cognition and the resident participated in the assessment and did not have a family member or representative participate. The Health Care Proxy form dated [DATE] documented the resident had a primary HCP and two alternate representatives. The form documented the proxy would go into effect only when the resident became unable to make her own health care decisions. The MOLST (legal document containing the resident's end of life decisions regarding treatment) signed by the resident and dated [DATE] documented the resident requested cardio-pulmonary resuscitation (CPR), a trial period of intubation (breathing tube) and mechanical ventilation, and a trial period of a feeding tube. The CCP initiated [DATE] and last updated [DATE] documented the resident's advance directives were full code (perform CPR). Interventions included to see the MOLST form, the MOLST was reviewed with the resident and/or family as needed, keep the physician informed, have the physician review the MOLST per protocol, and have social services involved. The nursing progress note dated [DATE] at 7:53 AM documented the resident and her alternate HCP requested the resident be sent to the hospital due to labored abdominal breathing, cough, and wheezing. The MOLST form dated [DATE] documented the resident's advance directive was DNR/DNI, and no feeding tube. The form was signed by the resident's primary HCP as the decision-maker. The nursing progress note dated [DATE] at 6:49 PM documented the resident returned from the hospital, was alert and oriented to person, place, and time and had a DNR/DNI order per the MOLST form and resident wishes. The physician orders dated [DATE] documented the Full Code (CPR) order was discontinued and an order for DNR/DNI was initiated. There was no documentation the CCP was revised to reflect the resident's change in advance directives. The nurse practitioner (NP) progress note dated [DATE] documented the resident was seen to address advance care planning, was changed from full code to DNR following the hospital admission, and the resident was not up to discussing this from an emotional standpoint. According to the family, the primary HCP listed was not in communication with the family and was unable to be reached. The prior MOLST (CPR, trial intubation and tube feeding) was voided and the resident was referred to the social worker for follow-up. There was no documented evidence from 8/22-[DATE] the social worker addressed the change in the MOLST with the resident. On [DATE] at 11:23 AM, the resident stated in an interview she had not been approached regarding her wishes for advance directives. She made her own decisions and if she were unable, she would like a different family member to be her primary HCP. She stated she would not want to be resuscitated but she did not want the current primary HCP to make any of her healthcare decisions as the primary HCP had no contact with the resident and would not know her wishes. When interviewed on [DATE] at 2:30 PM, social worker #1 stated the HCP should not have signed the MOLST as the resident had full decision-making capacity. In the event the resident did not have capacity while in the hospital, the MOLST should have been updated and advance directives reviewed with the resident immediately upon her return from the hospital on [DATE]. She was unaware of the change to the resident's advance directives. When the resident was readmitted with a new MOLST, her care plan should have been updated immediately. During an interview on [DATE] at 4:37 PM, registered nurse (RN) acting Unit Manager #2 stated the resident made her own decisions and upon return from the hospital on [DATE], the admitting nurse should have immediately verified the resident's wishes, had the resident sign the MOLST, and updated the CCP. 10NYCRR 415.3(e)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey, the facility did not ensure the residents' right to privacy for 1 of 2 residents reviewed for privacy (Resident #38) and 2 additional residents (Residents #47 and 75) identified during survey. Specifically, Residents #38, 47, and 75 were included in a recorded video by a local news station during a facility event, the footage aired, and the facility did not have the residents' or their representatives' permission to be recorded and have the recording used publicly. Findings include: The Videotaping, Photographing, and Other Imaging of Residents policy dated 1/2018 documents: - Resident image means the likeness of a resident captured through still photography, videotaping, digital imaging, scans, audio recording, etc. - Staff may not take or release images or recordings of any resident without explicit written consent. - Written consent must be obtained from the resident or representative prior to obtaining images or recordings of the resident for any purpose other and investigation of abuse, neglect, or emergencies. - Transmitting unauthorized images of any resident through email, internet, or social media is considered a violation of resident rights. 1) Resident #38 was admitted to the facility on [DATE] and had diagnoses including post-traumatic stress disorder (PTSD) and anxiety disorder. The 7/4/19 Minimum Data Set (MDS) assessment documented the resident had intact cognitive and was independent for most activities of daily living (ADLs) with set up only support. A Photo Release Form signed by the resident on 8/1/19 documented the resident agreed to have her photo or video taken for in-house display only at the facility. The option to consent for photo/video uses both in-house and for outside publications or media outlets was not checked. A grievance form submitted by the resident on 8/19/19 documented: - The resident attended a facility event on 8/16/19 and local news staff were there recording the event. - The resident informed the news staff and facility staff she did not want her image aired on television. - The resident advised the staff she provided only consent for in-house photos and did not consent to her image being used in any other manner. - She was informed by another resident she was observed on the news report that aired that evening. - The conclusion noted the Administrator was working with the news channel to have the video removed. - The resident was contacted on 8/22/19 in person and was noted to have been happy with the outcome and signed by the Administrator and social worker #3. 2) Resident #47 was admitted to the facility on [DATE] and had diagnoses including anoxic (lack of oxygen) brain damage and permanent vegetative state. The 7/20/19 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and was totally dependent for all activities of daily living (ADLs). A Photo Release Form dated 11/2/16 documented the resident's representative agreed to have his photo or video taken for in-house display only at the facility. The option to consent for photo/video uses both in-house and for outside publications or media outlets was not checked. 3) Resident #75 was admitted to the facility on [DATE] and had diagnoses including depression and hypertension. The 8/25/19 Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and required supervision and set-up assistance for most activities of daily living (ADLs). A Photo Release Form signed by the resident on 8/20/19 documented the resident agreed to have her photo or video taken for both in-house display and for outside publications or media outlets. There was no documented evidence the resident provided consent prior to 8/20/19. On 9/12/19 at 11:02 AM, the surveyor accessed and viewed a video on the local news station's website. The video link dated 8/17/19 contained multiple images of Residents #38, 47, and 75 clearly visible in the background during the 2 minute, 40 second video. When interviewed on 9/13/19 at 10:45 AM Resident #38 stated she never provided permission for her image to be shown on the local news station. She stated at the time of the event, she advised staff and news team personnel she did not want her image to be included in any recordings. She stated she did not watch the news, but another resident told Resident #38 she was observed in the background when the story aired on television that evening. The resident stated she was very upset that her privacy had been violated. She stated after she filed the grievance, she was told the video was no longer available for viewing and was pleased. The resident stated it was her understanding the video could not be accessed and stated she would not want the video to be publicly available, as she was a very private person. During an interview with social worker #1 on 9/13/19 at 2:30 PM, she stated it was her understanding the video from the 8/17/19 event was no longer available on the news channel's website. The social worker and the surveyor reviewed the video accessible through the news channel's website. The social worker confirmed the identity of Residents #38, 47, and 75 in the video. The social worker stated Resident #38 did not provide consent and the consent form in her record was for in-house photos and videos only. The resident's image should not have been shown on the news without the resident's consent. Resident #47's representative did not provide consent according to his Photo Release Form. At the time of the video recording and airing, Resident #75 had not provided consent, as her Photo Release Form was dated after the event. The social worker stated the residents observed in the video should not have been recorded and their images should not have been aired. The residents or resident representative did not provide consent and it was a violation of the resident's privacy. When interviewed on 9/13/19 at 3:07 PM, the Administrator stated she thought the video had previously been removed from the news station's website. She stated she called the news station and left a message asking them to remove the video at the time the resident filed the grievance on 8/19/19. She stated she never spoke to anyone at the news station in person and did not receive confirmation the video was removed. She stated she attempted to access the video following her call to the news station and was unable to. She stated she was unaware the video was still able to be viewed on the website. She stated residents must provide permission for their images to be shown via the Photo Release Form which included an area to check for video recordings for outside media usage. If Residents #38, 47, and 75 had not signed a consent form prior to the news team entering the facility and recording, they should not have been recorded or shown in the news clip when it aired on television. 10NYCRR 415.3(d)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey, the facility did not ensure that each resident and resident representative participated in developing the care plan and making decisions about his or her care for 1 of 20 residents (Residents #23) reviewed for care plans. Specifically, Resident #23's family representative did not receive an invitation to participate in the interdisciplinary team comprehensive care plan (CCP) meeting. Findings include: The facility's Comprehensive Care Plan policy, effective 11/2017 documents: - The Interdisciplinary Care Team (IDCT) shall develop an individualized comprehensive care plan (CCP) for each resident that is reviewed and revised in accordance with State and Federal regulations and professional standards of practice for nursing. - The CCP will be reviewed and updated as necessary, or when there is a change in the resident's condition or physician's orders. - Each resident and responsible party will be notified by the social service department of the date and time of the IDCT meeting. The facility's Care Planning, Interdisciplinary Team policy dated 1/2018 includes: - The resident, resident's family and/or resident's legal representative are encouraged to participate in the development and revisions to the resident's care plan. - Every effort will be made to schedule care plan meetings at the best time of the day for the resident and family. Resident #23 was admitted to the facility on [DATE] and had diagnoses including Alzheimer's Disease and pressure ulcer of sacral (low back) region. The 7/4/19 Minimum Data Set (MDS) assessment documented the resident had moderate cognitive impairment and required extensive to total assistance of one to two staff for activities of daily living (ADLs). Social services progress notes from 10/17/18 - 9/12/19 contained no documented evidence the resident and/or family representative received an invitation to or participated in a care plan conference. The electronic medical record (EMR) section under care planning documented care plan conferences were held on 10/17/18 (annual), 1/14/19, 4/8/19, and 7/18/19. There was no documented evidence of the resident's and/or resident representative's participation in the listed care plan conferences. During an interview on 9/12/19 at 2:27 PM, the resident's representative stated he had not been invited to a care plan conference in two years. He had not received any notices in the mail or a phone call from a social worker or nurse regarding the meetings and he stated he would like to attend the meetings. During an interview with social worker #1 on 9/13/19 at 9:58 AM, she stated the care plan conference schedule came to the social services department from the MDS department. Letters were then sent to the families a week before the care conference inviting them to the meeting. Residents were invited in person. If the family did not respond, social services would follow up with a phone call. She presented a binder with care plan conference dates and attendance forms since July 2019. She stated the new Director of Social Services began working at the facility in July 2019. Social worker #1 could not find any documentation prior to that date to show if Resident #23 or her representative were invited to or attended any care plan meetings in the last year. She stated there should be documentation indicating if a family representative had attended a care plan conference. Residents and/or representatives should be invited to at least the annual care plan conference and there should also be a progress note documenting when a care conference took place. During an interview with the Administrator on 9/13/19 at 10:28 AM, she stated there was no consistency in tracking which family members were being invited to care plan conferences. The previous Director of Social Services would not always document if a family member was invited or attended. When the new Director of Social Services began working in July 2019, she made a lot of changes and kept track of care plan conferences and attendance in a binder in the social services office. 10NYCRR 415.11(c)(1)(2)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the recertification survey, the facility did not ensure that each resident environment remained free of accident hazards for 1 of 3 residents (Resident #59) reviewed for accidents. Specifically, Resident #59 was suspected of smoking in the facility and there was no investigation completed to assess safety and address interventions to prevent reoccurrence. Additionally, the resident's history of smoking was not care planned timely to ensure the safety of herself and other residents. Findings include: The facility's Smoke Free Facility policy dated 8/29/19 documents: - smoking is prohibited in all work areas , on or around the grounds, as well as near exits and entranceways. - The policy includes all employees, medical staff, clients, visitors, and residents. - Residents will be informed of the smoke free policy on admission through the admission packet. The facility's Accidents/Incidents and Events policy dated 5/16/19 documents: - The policy is to ensure the resident environment remains as free from accident hazards as possible. - There will be procedures in place to provide a comprehensive assessment following an accident/incident and will establish the cause of the accident/incident which will help identify interventions needed to reduce reoccurrences. - An accident refers to any unexpected or unintentional incident which may result in injury or illness to a resident. - The resident statement form should be used for any added resident statements (possible witnesses) to the accident/incident. Resident #59 was admitted to the facility on [DATE] and had diagnoses including nicotine dependence and bipolar disorder. The 5/21/19 Minimum Data Set (MDS) assessment documented the resident had intact cognitive, required supervision and assistance of one person for most activities of daily living (ADLs) and currently used tobacco. The physician order dated 6/27/19 and currently active, documented the resident may go out on leave of absence with family. The nurse practitioner (NP) progress note dated 6/28/19 documented the resident asked for nicotine replacement patch to help with cravings. The physician's order dated 6/29/19 and discontinued 7/27/19 documented nicotine OTC (over the counter) patch, 24 hour, 21 milligram (mg)/24 hour, 1 patch, transdermal (on the skin) once per day for nicotine dependence. The 7/1/19 at 5:41 PM nursing progress note documented the nurse was called to the resident's bathroom for reports of smelling cigarette smoke. Bathroom does smell like a cigarette was just smoked in there, resident denies but cigarette pack with 3 cigarettes and a lighter found in top drawer of dresser. The resident was re-educated on safety concerns regarding smoking in a room when the roommate uses oxygen. The Director of Nursing (DON) was updated. There was no documented evidence of an investigation or other documentation on 7/1/19 to determine if the resident smoked in the facility, to identify the source of her smoking materials, or to address interventions to ensure the safety of residents in the facility. There was no further nursing documentation from 7/1/19 to 9/13/19 regarding the resident's suspected smoking or monitoring for smoking and smoking materials. The Resident Profile (care instructions) updated 7/17/19 did not contain any documentation about the resident's potential to smoke or any interventions to address potential smoking or possession of smoking materials. A social service progress note dated 8/13/19 at 8:41 AM documented social worker #3 spoke to the resident about alleged smoking. The resident stated she did not and the social worker advised it was dangerous due to her roommate's use of oxygen. The nurse manger confiscated cigarettes and the social worker was holding on to them. A social service progress note dated 8/28/19 at 8:57 AM documented social worker #3 spoke to the resident about the smoking policy stating it was a smoke-free facility and cigarettes were not permitted on the property. The resident stated she understood and the social worker notified the family of the policy. The comprehensive care plan (CCP) initiated 8/28/19 documented the resident had a history of smoking with the potential for reoccurrence. Interventions included offer smoking cessation alternatives and review the policy with the resident and her contacts. There was no documented evidence of a care plan for smoking behaviors or safety interventions prior to 8/28/19. The CCP did not include any documented evidence of safety interventions to address the resident's smoking while on leave from the facility, or how to address the potential of her possessing smoking materials upon return. When interviewed on 9/12/19 at 5:30 PM, the resident stated she still craved cigarettes and was unaware of any plan in place to address her smoking. She stated she no longer smoked at the facility and did not smoke in her room. When interviewed on 9/13/19 at 1:55 PM, certified nurse aide (CNA) #4 stated the resident actively smoked cigarettes and she had been caught smoking in her bathroom a few times. She stated she had never witnessed the resident smoking and thought she now smoked when she left the facility. She was unaware of any safety interventions to address her potential to smoke in the facility or to possess smoking materials. During an interview on 9/13/19 at 2:13 PM, registered nurse (RN) #5 stated the resident smoked when she left the facility with friends or family. The RN was unaware of any interventions to assess for safety or to ensure the resident did not return with smoking materials. When interviewed on 9/13/19 at 2:30 PM, social worker #1 stated she was aware the resident had been suspected of smoking and her cigarettes were removed from her room. She stated social worker #3 stored the resident's cigarettes when the resident returned from an offsite visit. She was unaware of any care planned interventions or of other staff who knew about the resident's smoking plan. She stated the resident no longer had cigarettes at the facility. The resident was known to smoke when she was admitted and her smoking should have been care planned at that time. The care plan should have been updated to include the suspected smoking with interventions to ensure the safety of all residents. During an interview on 9/13/19 at 2:45 PM, Admissions Coordinator #11 stated the resident was known to smoke when she left the building and when she returned she would bring her cigarettes to social worker #3, who would take them to another office and lock them in a lock box or safe. She stated when social worker #3 was not in the office, she was unaware of what the resident did with her cigarettes and lighter. She was unsure if any cigarettes were kept in the facility at this time as she had not seen the resident bring any back to the office. When interviewed on 9/13/19 at 3:07 PM, the Administrator stated she did not think it was necessary to complete an incident report or investigation after the resident was suspected of smoking in her room on 7/1/19. She stated it was a serious risk to all residents due to the resident's roommate using oxygen. Incident reports and investigations were used to identify cause and interventions to prevent reoccurrence. There were no employee or resident statements obtained to determine if the resident smoked in the building or had smoking material in her possession on a regular basis. The Administrator stated there should have been steps documented to address the safety of the residents. She was unaware if social worker #3's note from 8/13/19 was due to a separate incident, and the note on 8/28/19 was in response to the facility's policy to go entirely smoke-free. She stated she was not aware social worker #3 maintained the resident's smoking materials in a locked area and stated she understood the smoking materials were confiscated on one occasion, and to be returned upon discharge. She stated the social worker should not have continued to receive smoking materials from the resident as there was no plan in place to address this. She stated the resident was educated on the non-smoking policy and was not provided a contract or other form to sign indicating her understanding. When interviewed on 9/13/19 at 4:37 PM, RN acting Unit Manager #2 stated a care plan should have been initiated at the time of admission, as the resident was a known smoker. Following the incidents where she was suspected of smoking in the facility, or known to have smoked while out on leave, a care plan should have been updated to include steps to ensure resident safety and to ensure staff were aware of the risks and interventions. 10NYCRR 415.12(h)(1)