**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the recertification survey and complaint (NY00308289) survey, the facility did not ensure that a resident was free from financial abuse. This was evidnet for 1 (Resident #19) of 11 residents sampled for abuse. Specifically, a Certified Nursing Assistant (CNA #1) with a history of a misappropriation allegation at the facility took money from Resident #19. The findings are: The facility's policy and procedure entitled Abuse Prohibition Program, last reviewed 10/24/2022, documented that all residents have the right to be free from abuse, neglect, exploitation or misappropriation of resident property. The policy defines exploitation as 'when a vulnerable adult or their resources/income are used for another's profit or gain.' Resident #19 was initially admitted to the facility with diagnoses including schizophrenia, alcohol abuse and cerebral infarction. The Minimum Data Set 3.0 (MDS), a resident assessment tool, dated 11/22/2022 documented the resident had intact cognition. A Nursing progress note dated 01/06/2023 at 12:50 PM documented that at about 1:15 AM, one of Resident #19's roommates reported that they were getting awakened at night by CNA #1 continually coming into thier room to ask Resident #19 for money. The Assistant Director of Nursing (ADON) and social worker interviewed Resident #19 and both their roommates. Both roommates corroborated that CNA #1 comes into the room at night and asks the resident for money, and Resident #19 gives money to CNA #1. No staff members witnessed the incident. Resident #19 stated, I told the CNA to come to my room for money whenever they need it. The last time they came was 01/04/2023, and I gave them $20. The resident stated that it was their money and they could give it to anyone they wanted. The staff reminded Resident #19 that it was against facility policy for a resident to give money to staff or for staff to ask residents for money. A Potential for Abuse Care Plan was initiated for Resident #19 on 01/06/2023, and the resident was refunded their money. An undated Summary of Investigation documented the allegation was made on 1/6/23 by Resident #19's roommate. CNA #1 was not assigned to Resident #19's unit, but they reported they went to the unit to say hi to the nurse. CNA #1 denied asking Resident #19 for money or going into any resident's rooms. CNA #1 stated they used to order food for Resident #19 in the past, but that was all they did. The facility concluded there was cause to believe misappropriateion occurred. Statements from Resident #19, their two roommates, and CNA #1 were attached to the investigation. A Psychiatry consult dated 01/18/2023 states that the resident was seen due to staff reporting that the resident was giving money to a CNA. The psychiatrist stated that the resident's insight and judgment were limited and that they were unable to make financial decisions. Review of CNA #1's employee file, revealed CNA #1 had previous complaints against them for regarding dignity/privacy (exposing a resident's private area to a roommate), poor customer service (telling a family member they are always complaining and need a wife), failure to follow the abuse policy (failure to report a right eye bruise), and misappropriation. A Record of Corrective Warning dated 11/29/22 documented that on 11/27/2022 two residents reported that on 11/26/2022, during the evening shift whle they were in bed, CNA #1 asked them each for $5.00 and they each gave CNA #1 $5.00. CNA #1 was suspended for one day and re-educated to reinforce that staff members are never allowed to ask residents for money, goods, or property. CNA #1 was also informed future action would be termination if it occurred again. This previous incident occurred on Resident #19's unit. CNA #1 was terminated 1/10/2023. There was no documented evidence CNA #1 would be under any supervision to prevent a reocurrence. On 07/20/2023 at 9:43 AM, Resident #19 was interviewed and stated, There used to be this CNA I used to give money to. They used to buy me things and sometimes they would give me back the change, but they were a little bit crooked and sometimes they kept the change. And because they were a lady, I let them. On 07/28/2023 at 9:10 AM, CNA #1 was contacted and stated that when they worked on Resident #19's unit, there was one staff member who had a problem with them and reported them for taking money from residents. It was common for staff to order outside food for residents when asked and to pay for it using the residents' money, bringing them back the change. The CNA stated that on 01/04/2023, they returned to the unit to see a nurse who had returned from a trip to [NAME], and they went back to their assigned unit immediately afterwards. The CNA stated, I think the same CNA who talked about me the first time set me up. On 07/26/2023 at 9:16 AM, the Director of Nursing (DON) was interviewed and stated that the facility does constant in-services for staff on abuse and misappropriation. They had been hesitant to keep CNA #1 on staff after the first incident but decided to give CNA #1 a second chance after re-educating them and relocating them away from the unit where they had been assigned. However, The CNA #1 returned to the unit without permission on 01/04/2023, stating that they wished to say hello to the nurses there. The DON stated that the facility does not have surveillance footage proving that the CNA spoke only to staff and did not enter any resident rooms on the unit. Attempts were made to reach Resident #19's two roommates, both of whom had been discharged and not left forwarding telephone numbers, but in each case their family members would not provide a phone number for them. 483.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews conducted during a Recertification Survey from 7/19/23 through 7/26/23, the facility did not ensure that the residents and their representatives received a written summary of the Baseline Care Plan (BCP). This was evident for 3 of 3 residents reviewed for the Baseline Care Plan out of 38 sampled residents. (Residents #177, #235, and #382). The Findings are: The facility policy and procedure titled 48-Hour Baseline Care Plan dated 4/15/19 documented that the facility will develop and implement a baseline care plan summary for each new resident within 48 hours of admission. The Social Service Director/designee will print the 48-hour baseline care plan summary and review it with the resident/representative. The resident/representative signature will be obtained to verify the meeting and agreement with the plan. A signed copy will be maintained in the medical record. 1) Resident #235 was admitted with diagnoses that include a Left Lower leg Fracture and Lower Back pain. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident # 235 had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15. Resident #235's BCP, initiated on 6/22/23 and completed on 6/29/23, had no documented evidence of resident or representative signature. The progress notes from 6/23/23 to 7/11/23 in the Electronic Medical Record (EMR) contained no documented evidence Resident #235 was provided with a copy of or signed the baseline care plan. During an interview on 7/24/23 at 12:02 PM, Resident #235 stated that they did not sign or receive a copy of the BCP. 2) Resident #382 was admitted with diagnoses that include Hypertension and Heart Failure. The admission MDS dated [DATE] documented Resident #382's cognition as intact, with a BIMS score of 15. Resident #382's BCP, initiated on 6/27/23 and completed on 7/6/23, had no documented evidence of resident or representative signature. The progress notes from 6/28/23 to 7/12/23 in the EMR contained no documented evidence Resident #382 was provided with a copy of or signed the baseline care plan. During an interview on 7/26/23 at 10:30 AM, Resident #382 stated that they did not receive a copy of the BCP. 3) Resident #177 was admitted to the facility 06/08/2023 with diagnoses that included Hypertension, Benign Prostatic Hyperplasia (BPH), and Renal Insufficiency, Renal Failure, or End-Stage Renal Disease (ESRD). The admission Minimum Data Set (MDS) assessment dated [DATE] documented the resident had intact cognitive status. The MDS documented that Resident #177 participated in the assessment and had no guardian or legally authorized representative. On 07/24/23 at 02:21 PM, Resident #177 was interviewed and stated they came to the facility about a month ago, and can not recollect being given any written summary of the BCP. There was no documented evidence in the resident's chart that a signed copy of the Baseline Care Plan was given to the resident/resident's representatives. During an interview on 7/24/23 at 2:45 PM, the Social Worker (SW) stated that BCP is completed within 48 hours of admission, except when the resident comes in on the weekend. They offer a copy of the BCP to the residents and their representatives. They do not have it documented that the BCP provided to the residents. Moving forward, they will enter it in the computer because if it is not written, then it is not done. During an interview on 7/24/23 at 3:27 PM, Registered Nurse Supervisor #2 (RNS #2) stated that a copy of the BCP is offered to the residents/representatives. Resident # 235 did not receive a physical copy of the BCP, but they were informed of the plan of care. There is no indication that the BCP was offered to the resident. It is not documented that it was verbally offered. On 07/26/23 at 10:05 AM, the MDS Coordinator was interviewed and stated that baseline care plan has to be completed within 48 hours of the resident's admission by the team, discussed with the resident and the family, a copy needed to be given to the resident. The MDS Coordinator stated that they are not aware that the copy is not being given to the resident/resident's family. During an interview on 7/25/23 at 8:14 AM, the Director of Social Service (DSS) stated that the BCP is completed within 48 hours after admission. They do not print it out and give a copy to the residents or document it in the EMR. From now on, they will provide a copy to the resident/representative. The SW will ensure that a copy of the BCP is provided and documented. During an interview on 7/25/23 at 3:49 PM, the Director of Nursing (DNS) stated that once BCP is completed, the resident or family should get an overview of the care plan. It should be printed, and a copy should be given to the resident or the family member. They have not been doing it all the time. Moving forward, they will follow the policy 100%. 415.11 (c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) Resident #382 had a diagnosis of Bacteriuria. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #382 was cognitively intact with a Brief Interview for Mental Status score of 15. Physician Orders dated 7/11/23 documented to provide Resident #382 with 250 cc of extra fluid per shift and levofloxacin for 7 days for bacteriuria. There was no documented evidence a CCP related to Resident #382's bacteriuria (UTI) was developed. During an interview on 7/21/23 at 3:49 PM, the Assistant Director of Nursing (ADNS) stated that Resident #382 does not have a CCP related to bacteriuria ( UTI) in place. The Registered Nurse Supervisor is responsible for initiating episodic CCPs. The UTI CCP should have been developed for Resident #382 415.11(c)(1) Based on record review and staff interviews conducted during a Recertification Survey from 7/19/23 through 7/26/23, the facility did not ensure that Comprehensive Care Plans (CCP) were developed and implemented to meet resident needs. This was evident for 1 (Resident #235 and #382) of 38 sampled residents. Specifically,1) Resident #235 did not have a CCP related to leg fracture and pain management developed, and 2) Resident #382 did not have a CCP related to bacteriuria, Urinary Tract Infection (UTI) developed. The findings are: The facility policy titled Comprehensive Care Plan dated 3/5/19 documented that the facility will develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetable to meet a resident medical, nursing, mental and psychological needs, which are identified in the comprehensive assessments and leads to the resident's highest obtainable independence. 1. Resident #235 was admitted with diagnoses that include a Left Lower Leg Fracture and Lower Back Pain. The admission Minimum Data Set (MDS) assessment dated [DATE] documented Resident # 235 cognition as intact with a Brief Interview of Mental Status (BIMS) score of 15. On 7/21/23 at 9:24 AM Resident # 235 was observed resting in bed-left leg external fixation noted in place. On 7/24/23 at 10:00 AM, Resident # 235 was observed resting in bed and left leg external fixation in place. On 7/25/23 at 9:40 AM, Resident # 235 was observed resting in bed. Left leg external fixation was noted in place. Medical Doctor's Order dated 6/22/23 documented Acetaminophen 325mg, three tablets every 6 hours for low back pain, Oxycodone 5 mg every 6 hours as needed for low back pain, and gabapentin 400mg every 8 hours for low back pains. Physician Note dated 7/4/23 at 12:41 PM documented that Resident # 235 has Chronic back pains post Open Reduction Internal Fixation (ORIF) with external fixation. Pain is being controlled with Oxycodone. The Medication Administration record dated 6/22/23 to 7/24/23 documented that Resident #235 received pain medication as ordered. CCP related to Left Ankle Fracture was created on 6/22/23. There was no documented evidence that interventions were implemented. There was no documented evidence a CCP related to pain management was developed. During an interview on 7/25/23 at 9:40 AM, Resident # 235 stated that they get oxycodone for the pain. During an interview on 7/24/23 at 3:49 PM, Registered Nurse Supervisor # 2 (RNS #2) stated that Resident # 235 was admitted with an ankle fracture and had an external fixation. CCP for the left ankle fracture was initiated on 6/26/23, but no interventions were documented. There should have been interventions documented in the care plan. CCP for pain management was not initiated. Pain management care plans should have been created with interventions implemented for the resident. During an interview on 7/24/23 at 4:02 PM, the Assistant Director of Nursing (ADNS) stated that the left ankle fracture care plan was initiated on 6/26/23, and there were no interventions. The ADNS created the care plan but forgot to add the interventions. The CCP for pain management was initiated today (7/24/23). It should have been initiated on admission with interventions. The ADNS is responsible for creating the care plan. The ADNS does not know why the pain management care plan was not initiated. During an interview on 7/25/23 at 3:49 PM, the Director of Nursing (DNS) stated that the ADNS is responsible for initiating the care plans on admissions. The DNS does not know what happened or why the pain management and fracture care plan was not developed and implemented. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews conducted during the Recertification survey from 7/19/2023 to 7/26/2023, the facility did not ensure comprehensive care plans (CCP) were reviewed and/or revised after each assessment and as needed. This was evident for 2 (Resident #84 and #6) of 38 total sampled residents. Specifically, 1) Resident #84's CCP related to dementia was not reviewed upon each assessment and 2) Resident #6's CCPs related to Advance Directives and cognitive loss/dementia were not reviewed and revised. The findings are: A facility policy titled Comprehensive Care Planning dated 3/5/2019 documented the facility will develop a comprehensive, person-centered care plan for each resident. Goals and objectives are reviewed and/or revised when there has been a significant change in the resident's condition and at least quarterly. 1) Resident #84 had diagnoses of peripheral vascular disease and anemia. The Minimum Data Set 3.0 (MDS) dated [DATE] documented Resident #84 was cognitively intact. The CCP related to cognitive loss/dementia was initiated 3/3/2020 and documented the last review date of 3/27/2023. There was no documented evidence the CCP related to cognitive loss/dementia was reviewed and revised upon the assessment dated [DATE]. 2) Resident #6 had a diagnosis of dementia. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #6 had moderately impaired cognition. The CCP related to Resident #6's Advance Directives was initiated 7/24/2018 and last reviewed 8/30/2022. The CCP related to Resident #6's cognitive loss/dementia was initiated 7/24/2018 and last reviewed 2/2/2022. There was no documented evidence the CCP related Resident #6's Advance Directive status and cognitive loss/dementia was reviewed and revised upon the assessment dated [DATE]. An interview was conducted on 7/24/2023 at 11:05 AM with the Social Worker (SW) who stated they probably missed updating one of Resident #84's CCPs because it gets overwhelming to keep up with updating CCPs. An interview was conducted on 7/25/2023 at 11:11 AM with the Director of Nursing (DNS) who stated the facility recently hired a 2nd CCP nurse to complete CCP updated quarterly. The CCPs are updated according to the MDS assessment schedule. 415.11(c)(2) (i

2) Resident #5 had diagnoses of schizophrenia and anxiety disorder. On 7/19/2023 at 3:18 PM, the Unit 4 medication room narcotics locker was observed with Registered Nurse Supervisor (RNS) #1. The locker contained 2 blister packs for Resident #5 containing 34 half (1/2) tablets Clonazepam 0.5mg. A Physician Order dated 11/18/2022 and renewed 6/24/2023 documented Resident #5 was prescribed Clonazepam 0.5 mg, give 1/2 tablet (0.25 mg) at 10:00 AM, 2:00 PM and 6:00 PM. The PNL form dated 7/19/2023 documented Resident #5 had 35 of the 1/2 tablets of Clonazepam .5mg remaining in their blister packs. On 7/19/2023 at 3:18 PM, RNS #1 was interviewed and stated the blister packs contained 37 of the 1/2 tablets of Clonazepam this morning and RNS #1 administered a 1/2 tablet to Resident #5 at 10 AM and 2 PM. The narcotics count was done with the outgoing nurse this morning and RNS #1 cannot explain why there is 1 missing 1/2 tablet of Clonazepam missing from the resident's blister pack. On 7/19/2023 at 4:19 PM, the Assistant Director of Nursing (ADNS) was interviewed and stated we are going to interview RNS #1, do an investigation, and try and figure out the cause of the missing dose of Clonazepam. Nurses are instructed to document on the PNL after the resident takes their medication. The ADNS further stated maybe there was a slit in the bag of the blister pack and the 1/2 tablet fell out. On 7/21/2023 at 4:15PM, the DNS was interviewed and stated they don't know what happened to the 1/2 tablet of Clonazepam for Resident #5. The facility searched and was unable to find the missing tablet. RNS #1 reported they counted in the morning and gave 2 doses, and during the afternoon they noticed the count was short 1 dose. The previous shift nurse stated they counted in the morning with the incoming RNS #1, and the count was correct. In addition, the facility had the pharmacy consultant come and check narcotics on all units to make sure counts were accurate. The ½ tablet may have accidentally popped out. The DNS further added they completed one on one education with RNS #1 and in-serviced all other nurses on the policy of Controlled Substances. The pharmacy consultant is going to continue doing monthly narcotic counts with the nurse on each unit. 415.18(e)(1-4) Based on observations, record review, and interviews conducted during the recertification survey from 7/19/2023 to 7/26/2023, the facility did not ensure all drugs and biologicals were stored in accordance with State and Federal laws. This was evident for 2 (Unit 4 and 6) of 5 units observed for medication storage. Specifically, 1) narcotics medications were not stored in a double-locked compartment in the medication cart on the 6th Floor, and 2) the Patient Narcotic's Log (PNL) did not match the narcotics medication count for Resident #5 on the 4th Floor. The findings are: The facility's policy titled Medication Labeling and Storage dated 02/2023 documented controlled substances and other drugs subject to abuse are separately locked in permanently affixed compartments. The facility policy titled Controlled Substances dated 7/20/2019 documented the facility shall comply with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of Schedule II and other controlled substances. The Director of Nursing (DNS) shall investigate any discrepancies in narcotics reconciliation to determine the cause and identify any responsibility parties and shall give the Administrator a written report of such findings. On 07/24/2023 at 11:47 AM, the medication cart on the 6th Floor was observed with Registered Nurse (RN) #1 present. The second locked compartment designated for narcotics was in the 3rd drawer of the cart and was observed empty. The 2nd drawer of the cart contained 9 medication blister packs containing the following narcotics: 1 pack Tramadol, 2 packs Lyrica, and 6 packs Clonazepam. RN #1 was interviewed on 07/24/2023 at 3:07 PM and stated they have not done medication pass in some time. RN #1 stated when they came to the unit, residents were already asking for their medications and there was no time to search the medication cart for the narcotics lockbox. The narcotics medications were stored in the single-locked medication cart and RN #1 locked the medication cart when they stepped away. The narcotics were returned to the medication room once medication pass was complete. RN #1 stated they were not familiar with the keys on the 6th Floor. There are many residents taking narcotics on the 6th Floor and RN #1 would not be able to finish their medication pass if they had to retrieve narcotics from a 2nd locked compartment. The Director of Nursing (DON) was interviewed on 07/26/2023 at 9:37 AM and stated that narcotics must be kept in the lockbox in the medication room and are moved during each shift to the lockbox in the medication cart. Some medication carts have the lockbox in the bottom drawer and some in the middle drawer, but these lockbox must be used. In-services are held regularly for nurses and supervisors on using the medication carts, and since the supervisors spend most of their time on the units, they are available to remind medication nurses to use the lockbox for all controls.

Based on interviews and records review conducted during an Abbreviated Survey (NY00304629), the facility failed to report an alleged violation of abuse immediately but not later than 2 hours to the Administrator, as well as to the State Survey Agency. This was evident in 1 out of the 5 residents sampled (Resident #1). Specifically, Resident #1 reported to Registered Nurse Supervisor (RNS) #1 that Certified Nursing Assistant (CNA) #1 was rough with them during care, causing their private organ (PO) to bleed on 10/28/2022 at approximately 4:00 PM. The facility's Administrator and New York State Department of Health (NYSDOH) were not notified of the allegation of abuse. The facility became aware of the allegation during an onsite visit from NYS DOH on 11/02/2022. The findings are: The facility's Policy and Procedure entitled Abuse and Neglect with revision date 02/07/2022 documented that it is the responsibility of facility employees, facility consults, Attending Physicians, family members, visitors, etc., to promptly report any incident or suspected incident of neglect or resident abuse, including injuries of unknown source, and theft or misappropriation of resident property to facility management. Once an allegation of abuse has been made, the supervisor who initially received the report must inform the Administrator/Director of Nursing as soon as possible and initiate gathering requested information. Federal Regulation (42 CFR 483.13) requires the reporting of all alleged violations involving abuse, neglect, and exploitation of resident property, are reported to the department of health immediately but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. Resident #1 was admitted to the facility with diagnoses including bipolar disorder and Diabetes. The Minimum Data Set (MDS, a resident assessment tool) dated 08/20/2022 documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and a score of 15 indicating intact cognition. A review of the Nursing Progress Note, by RNS #1, dated 10/28/2022 at 5:05 PM documented that RNS #1 was present on the 5th floor and witnessed Resident #1 getting verbally aggressive toward CNA #1. Resident #1 picked up an adult undergarment and attempted to throw it at CNA #1. RNS #1 stood up at the desk and Resident #1 saw RNS #1 and threw the pack of undergarment backward. CNA #1 firmly told Resident #1 not to attempt to hit CNA #1 again. RNS #1 documented that no other incident was witnessed. RNS #1 also documented that at approximately 4:00 PM Resident #1 came to the nursing station and attempted to show RNS #1 a picture of what Resident #1 said was their bleeding penis. Resident #1 stated that it happened to them while CNA #1 washed them roughly during care. RNS #1 documented that he/she told Resident #1 to wait until he/she was off the phone and Resident #1 started to yell at RNS #1. Resident #1 wheeled themselves off the unit to go to the Administrator. During an interview on 11/02/2022 at 10:15 AM, Resident #1 stated that on 10/28/2022 at around 1:30 PM, they grabbed a pack of incontinent briefs from the closet located in the hallway across from their room and CNA #1 approached and screamed at them what are you doing, no, no, no. Resident #1 stated that he/she was startled and raised their hand with the pack of incontinent briefs. Resident #1 stated that CNA #1 thought that Resident #1 tried to hit CNA #1 with the pack of incontinent briefs. Resident #1 stated that they just wanted to prevent CNA #1 from taking the briefs away from them. Resident #1 stated that after the incontinent brief incident, CNA #1 came to their room and washed them roughly. Resident #1 stated that after CNA #1 completed care Resident #1 took a nap and when they woke up, Resident #1 had bleeding to the PO. Resident #1 stated that they reported to RNS #1 that CNA #1 washed their PO roughly causing them to bleed. Resident #1 stated that they called 911 but that they did not report the rough handling to the 911 team. During an interview on 11/02/2022 at 11:40 PM, RNS #1 stated that at around 4:00 PM Resident #1 attempted to show RNS #1 a picture of their PO that Resident #1 said was bleeding because CNA #1 washed them roughly. RNS #1 stated that he/she was on the phone and told Resident #1 as soon as he/she was off the phone he/she would see Resident #1. RNS #1 stated that he/she reported the allegation to the Assistant Director of Nursing (ADON) and the incoming supervisor. During an interview on 11/02/2022 at 1:04 PM, the ADON stated that at approximately 3:50 PM Resident #1 came downstate in the lobby and said that they have bleeding in the genital area. The ADON stated that he/she instructed Resident #1 to go back to their room and he/she will assess them. Resident #1 called 911 and the Emergency Medical Service (EMS) team went to Resident #1's room with the ADON. The ADON said that he/she assessed Resident #1, but he/she did not report the incident to the DON or to the Administrator. The ADON stated that the Administrator and the DON should have been notified. During an interview on 11/02/2022 at 1:57 PM, the DON stated that he/she was not aware that Resident #1 complained that CNA #1 was rough during care. The DON stated that RNS #1 or the ADON should have notified the DON. The DON also stated that the incident should have been reported immediately but no later than 2 hours to the Administrator and to the NYSDOH. The DON stated that he/she became aware of the incident on 11/02/2022 during the onsite investigation. During an interview on 11/03/2022 at 12:00 PM, the Administrator stated that he/she was not notified of the incident on 10/28/2022. The Administrator stated that he/she became aware of the incident on 11/02/2022 during the onsite investigation. The Administrator stated that the incident should have been reported to them immediately and to NYSDOH. 10 NYC RR 415.4(b)(1)(i)

Based on interviews and records review conducted during an Abbreviated Survey (NY00304629), the facility failed to investigate an alleged violation of abuse and to prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation of an alleged violation is in progress. This was evident in 1 out of the 5 residents sampled (Resident #1). Specifically, Resident #1 reported to Registered Nurse Supervisor (RNS) #1 that Certified Nursing Assistant (CNA) #1 was rough with them during care, causing their private organ (PO) to bleed on 10/28/2022 at approximately 4:00 PM. The facility did not have evidence that an investigation was initiated on 10/28/2022. The findings are: The facility's revised Policy and Procedure entitled Abuse and Neglect dated 02/07/2022, documented that the facility shall conduct a thorough investigation of alleged violation/sexual abuse involving mistreatment, neglect, or abuse, including injuries of an unknown source, and prevent further potential abuse while the investigation is in progress. Resident #1 was admitted to the facility with diagnoses including bipolar disorder and Diabetes. The Minimum Data Set (MDS, a resident assessment tool) dated 08/20/2022 documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and a score of 15 indicating intact cognition. A review of the Nursing Progress Note, by RNS #1, dated 10/28/2022 at 5:05 PM documented that RNS #1 was present on the 5th floor and witnessed Resident #1 getting verbally aggressive toward CNA #1. Resident #1 picked up an adult undergarment and attempted to throw it at CNA #1. RNS #1 stood up at the desk and Resident #1 saw RNS #1 and threw the pack of undergarment backward. CNA #1 firmly told Resident #1 not to attempt to hit CNA #1 again. RNS #1 documented that no other incident was witnessed. RNS #1 also documented that at approximately 4:00 PM Resident #1 came to the nursing station and attempted to show RNS #1 a picture of what Resident #1 said was their bleeding penis. Resident #1 stated that it happened to them while CNA #1 washed them roughly during care. RNS #1 documented that he/she told Resident #1 to wait until he/she was off the phone and Resident #1 started to yell at RNS #1. Resident #1 wheeled themselves off the unit to go to the Administrator. Review of the facility's Accident/Incident Reports from 10/28/2022 through 11/03/2022 revealed there was no investigation for the alleged allegation of rough handling. During an interview on 11/02/2022 at 10:15 AM, Resident #1 stated that they reported to RNS #1 and the ADON that CNA #1 was rough with them during care on 10/28/2022. Resident #1 also stated that they reported that they did not want CNA #1 taking care of them and that CNA #1 was still on their assignment. During an interview on 11/02/2022 at 11:40 PM, RNS #1 stated that at around 4:00 PM Resident #1 attempted to show RNS #1 a picture of their private organ that Resident #1 stated was bleeding because CNA #1 washed them roughly. RNS #1 stated that he/she was on the phone and told Resident #1 as soon as he/she was off the phone he/she would see Resident #1. RNS #1 stated that an investigation should have been initiated and that CNA #1 should have been taken off the schedule pending the investigation outcome. RNS #1 stated that CNA #1 was still assigned to Resident #1 after the allegation was made. During an interview on 11/02/2022 at 1:04 PM, the ADON stated that at approximately 3:50 PM Resident #1 came downstate in the lobby and reported that they were bleeding in the genital area. The ADON stated that Resident #1 did not report any allegations of abuse. The ADON stated that RNS #1 should have initiated an investigation and that CNA #1 should have been removed from the schedule. During an interview on 11/02/2022 at 1:57 PM, the DON stated he/she was not aware that Resident #1 complained that CNA #1 was rough during care. The DON stated that RNS #1 is responsible for initiating the investigation and reporting to the ADON. The DON also stated that the ADON is responsible for the continuation the investigation and notifying the DON of the outcome. The DON stated that RNS #1 should have initiated the investigation on 10/28/2022. 10 NYC RR 415.4 (b)(3)

Based on observations, staff interviews, and record reviews conducted during an abbreviated survey (NY00304629), the facility failed to ensure that a resident's medical record accurately reflected the resident's medical condition. This was evident in 1 out of 5 residents sampled (Resident #1). Specifically, Resident #1 reported to Registered Nurse Supervisor (RNS) #1 that Certified Nursing Assistant (CNA) #1 was rough with them during care, causing their private organ (PO) to bleed on 10/28/2022 at approximately 4:00 PM. Record review of Resident #1's medical record from 10/28/2022 through 11/03/2022, revealed that an assessment of Resident #1 was not documented in the resident's medical record. The findings are: The facility Policy and Procedure entitled Charting and Documentation with dated 12/01/2017 documented that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychological condition, shall be documented in the resident's medical record. Resident #1 was admitted to the facility with diagnoses including bipolar disorder and Diabetes. The Minimum Data Set (MDS, a resident assessment tool) dated 08/20/2022 documented that Resident #1 had a Brief Interview of Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and a score of 15 indicating intact cognition. A review of the Nursing Progress Note, by RNS #1, dated 10/28/2022 at 5:05 PM documented that at approximately 4:00 PM, Resident #1 came to the nursing station and attempted to show RNS #1 a picture of what Resident #1 said was their bleeding penis. Resident #1 stated that it happened to them when CNA #1 washed them roughly during care. RNS #1 documented that he/she told Resident #1 to wait until he/she was off the phone and Resident #1 started to yell at RNS #1 and wheeled themselves off the unit. A review of the progress notes dated from 10/28/2022 to 11/03/2022 revealed there was no documented evidence to support that Resident #1 was assessed. During an interview on 11/02/2022 at 10:15 AM, Resident #1 stated that on 10/28/2022 (does not remember the time) CNA #1 provided care to them and washed their private organ roughly. Resident #1 stated that when they woke up from a nap their private organ (PO) was bleeding. Resident #1 stated that they reported to RNS #1 that CNA #1 washed their PO roughly causing them to bleed. Resident #1 stated that they called 911 but did not report the rough handling to the Emergency Medical Service (EMS) team. Resident #1 also stated that the ADON looked at their PO in the presence of the EMS team. During an interview on 11/02/2022 at 1:04 PM, the ADON stated that he/she assessed Resident #1's PO but did not document the assessment in Resident #1's medical record. The ADON verbalized that he/she observed bilateral redness to Resident #1's groin and scrotal area. The ADON stated that there was no active bleeding from Resident #1's PO and there was no blood on the incontinent brief. The ADON stated that Resident #1 had no swelling and denied pain. The ADON stated that the assessment should have been documented in Resident #1's chart. During an interview on 11/02/2022 at 1:57 PM, the DON stated that RNS #1 or the ADON should have assessed Resident #1 and documented the assessment in the resident's medical record. 10 NYC RR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure that the assessment accurately reflected the resident's status. Specifically, the Minimum Data Set (MDS) did not accurately code a resident who was receiving dialysis services. This was evident for 1 of 1 resident reviewed for Dialysis out of a sample of 35 residents. (Resident 172) The findings are: The facility policy and procedure titled MDS 3.0 dated 10/26/17 documented the purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. Resident 172 was readmitted to the facility on [DATE], with diagnoses that included Hypertensive Chronic Kidney disease with Stage 5 Chronic Kidney Disease or End Stage Renal Disease, Dependence on Renal Dialysis and Hypertension. The Significant Change of Status MDS with ARD date 3/12/21 documented the resident reentry on 2/27/21 from the hospital with intact cognition. The MDS documented Chronic Kidney Disease, Stage 3b as an active diagnosis. The Physician's Orders order dated 2/27/21 documented active diagnoses which included Hypertensive Chronic Kidney disease with Stage 5 Chronic Kidney Disease or End Stage Renal disease, Dependence on Renal Dialysis and Hypertension. Orders also documented Hemodialysis on Tuesday, Thursday and Saturday, and no blood pressure/blood drawn on left arm. Nursing note dated 2/17/21 documented Resident 172 was transferred to the hospital and admitted for End Stage Renal Disease (ESRD). Nursing note dated 2/27/21 documented readmission of Resident 172 from the hospital with primary diagnosis of ESRD - new dialysis . Resident 172 was started on dialysis and was dialyzed today; dialysis schedule is Tuesday, Thursday, and Saturday. Central Venous Catheter (CVC) for dialysis noted intact on Right upper chest wall, site clean and dry. Medical note dated 3/1/21 documented patient was re-admitted after hospitalization at hospital for ESRD and was newly on Hemodialysis three times per week. Medical note dated 3/2/21 documented resident alert and verbally responsive and returned to the facility from dialysis around 11:25 AM. MDS note dated 3/3/21 documented resident has new diagnosis of ESRD on Hemodialysis. Discussed with ITD (Inter Disciplinary Team), will proceed with Significant Change assessment. The Significant Change of Status dated 3/12/21 MDS did not document Dialysis care in the Special Treatment Section O for the resident. On 04/20/21 at 11:25 AM, an interview was conducted with the MDS Coordinator (RN #1) who completed the MDS. RN #1 stated a Significant Change MDS dated [DATE] was due to the change in status to End Stage Renal Disease worsening leading to Hemodialysis. RN #1 stated Dialysis was not coded on the MDS and the MDS will need to be modified. 415.11(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility did not ensure that a resident who is unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Specifically, a resident was observed on more than one occasion over 2 days to have fingernails approximately half an inch from the tip of the fingers. The fingernails were observed with a black substance imbedded underneath them. This was evident for 1 of 2 residents reviewed for Activities of Daily Living out of a sample of 35 residents. (Resident # 87) The facility policy on Resident Grooming dated 09/08/2020 documented the facility will ensure a resident is given the appropriate treatment and services to maintain or improve ability to carry out activities of daily living. The policy also documented that the facility will provide the necessary care and services for the following activities of daily living hygiene- bathing, dressing, grooming and oral care. The finding is: Resident # 87 was admitted to the facility on [DATE] with diagnoses that included Hypertension, Benign Prostatic Hypertrophy, Muscle Weakness, and Schizophrenia. The Minimum Data Set (MDS) 3.0 dated 01/29/2021 documented the resident as cognitively intact and required extensive assistance of 1 person for grooming, dressing and personal hygiene. On 04/16/2021 at 12:35 PM, an interview was conducted with Resident #87. Resident was observed with fingernails on both hands a half inch in length from the tip of the finger with a blackish colored substance underneath the fingernails. During the interview, Resident #87 stated I will appreciate it if someone will trim them (fingernails). On 4/19/2021 at 12:00 PM, Resident #87 was observed sitting in chair in room. Resident fingernails were observed to be un-trimmed, half an inch in length with a blackish colored substance imbedded under the fingernails. The Comprehensive Care Plan for ADL's dated 03/19/2021 documented resident needed assistance with grooming, dressing and transfer. Goal was resident's performance in ADL's will not deteriorate for 90 days. Interventions included Active Range of Motion on bilateral upper and lower extremities during care, allow resident freedom to choose clothes, praise effort, monitor any decline and maintain consistency. Review of the Certified Nursing Assistant Accountability Record (CNAAR) revealed there was no documentation recorded on the specific grooming that had been provided to the resident. An interview was conducted with CNA #1 on 04/19/2021 at 2:45 PM. CNA#1 stated she had been assigned to the resident for the past month. CNA could not provide an explanation as to why the resident's fingernails had not been trimmed recently. CNA #1 also stated that maintaining the resident's fingernails in a clean, trimmed manner is part of her responsibilities. On 04/21/2021 at 3:00 PM, the Unit Charge Licensed Practical Nurse (LPN) #2 was interviewed. LPN#2 stated it is the responsibility of the nurse to monitor the CNA's and ensure that the residents are appropriately dressed and nails are clean, trimmed and cut, if resident so wishes. On 04/21/2021 at 3:45 PM, the Director of Nursing (DNS) was interviewed. The DNS stated there is no particular column in the Sigma EMR where the CNA's can document on grooming provided to the residents. The DNS also stated that the cutting and trimming of nails, and appropriately dressing the resident is discussed as part of CNA orientation and reminders and re-in-service is done as needed. The DNS further stated that monitoring and spot checking of the resident is the responsibility of the charge nurses on the unit. 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews conducted during a Recertification survey, the facility did not ensure that all medications and biologicals used in the facility were stored and labeled properly and included the expiration date when applicable. Specifically, one opened and undated vial of insulin was observed. This was evident on 1 of 5 units during the Medication Storage Task. (Unit 4) The findings are: The facility policy and procedure titled Opened Multidose Vials and Specific Inhalers, revised 01/11 documented that the nurse who opens the vial must write the date on the label and that Lantus insulin must be replaced after 28 days. On [DATE] at 11:30 AM, during an observation of the 4th floor medication room and medication cart an undated vial of Lantus was observed in the medication cart. On [DATE] at 11:35 AM, Registered Nurse (RN) #1 was interviewed. RN#1 stated she usually checks the labels on each vial at the start of every shift and but that she forgot to check at the start of the shift. RN #1 stated nurses are supposed to check medications at the start of the shift and if there is an unlabeled vial, the supervisor is notified. On [DATE] at 11:40 AM, the RN Supervisor was interviewed. The RNS stated that insulin has to be dated with an expiration date when opened. The medication nurse is supposed to check the medication cart at the start of the shift to make sure that the insulin vials have stickers noting their expiration dates. The RNS also stated that pharmacy provides yellow labels to be used, but if there are no labels from the pharmacy the facility has labels than can be used and should be applied directly to the vial and not just on the plastic bag that the vial is placed in. Each nurse on each shift is responsible for checking insulin. The RNS further stated he periodically checks the carts for errors on an informal basis and does not document the findings of these checks. On [DATE] at 04:57 PM, Licensed Practical Nurse (LPN) #1 who worked on the unit on [DATE] and [DATE] was interviewed. LPN #1 stated that insulin should be labeled every time a vial is opened but that she did not put the date on the vial when she opened this insulin vial. LPN #1 also stated that sometimes the bag comes up with the date already on it and she sometimes gets distracted by the residents. LPN #1 further stated that this was an error on her part and if she observed a vial that had been opened and not dated, she would put a date on it when she saw it. On [DATE] at 11:41 AM, the Director of Nursing was interviewed. The DON stated that nurses must label and date vials of insulin when the vial is opened. Labels are provided for this purpose and should contain 2 dates, the date opened and the date expired. The DON also stated that nurses should be checking the dates on all insulin on every shift. Supervisors do checks but not on a daily basis and the pharmacist checks once a month to ensure this is being done. 415.18(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during a Recertification survey, the facility did not maintain medical records on each resident that were accurately documented. Specifically, a resident was noted to have orders for supportive devices which Certified Nurse's Aides (CNA'S) consistently documented were applied however, the resident was observed on multiple occasions to not have any of the devices in place. This was evident for 1 of 2 residents reviewed for Limited Range of Motion out of a sample of 35 residents. (Resident #28.) The findings are: The facility policy and procedure titled Documentation Compliance dated 06/23/2016, documented that the nursing supervisors will monitor documentation compliance by auditing CNA documentation before the end of each shift. On 04/19/21 at 12:39 PM, Resident #28 was observed in a Geri-chair in the resident's room with no splint devices observed on either the upper or lower extremities. During an interview, the resident denied receiving splint devices or braces. On 04/19/21 at 03:18 PM, 04/20/21 at 9:10 AM, and 04/20/21 at 1:25 PM, no brace or splint device was observed. The Minimum Data Set, dated [DATE] documented Resident #28 had intact cognition, required dependent assistance of 1 staff for dressing, extensive assistance of 1 staff for eating and personal hygiene and had impairment on both sides on upper and lower extremity. The Physician's Order dated 3/16/21 documented left Wrist/Hand/Finger/Orthosis (WHFO) to be worn at all times, hip abductor orthosis to be worn at all times, and right elbow contracture orthosis to be worn at all times. The Comprehensive Care Plan titled Resident's Alternate Choice initiated on 5/11/18 and revised on 2/23/21 documented resident refuses to wear splint and other devices at times. Goal included resident will understand risks/complications related to refusals in the next 90 days. Interventions included encourage verbalization of feelings, Psychology consultation as per MD order, acknowledge and strive to maintain positive compliance, reapproach, offer choices, recognize right to choose. Certified Nurse Assistant (CNA) Documentation History for Nursing Rehab Splint/Brace documented that the task was performed every day from 01/01/2021 to 04/20/2021 except on 02/15/2021 and 04/08/2021. The CNA Documentation History did not accurately document when devices had been applied. On 04/20/21 at 02:06 PM, CNA #1 was interviewed. CNA#1 stated Resident #28 always refuses to wear the ordered splints/braces and the devices are kept in a plastic bag at the side of the bed. CNA#1 also stated that when the resident refuses to wear the devices, she is supposed to tell the nurse. CNA#1 further stated she may have made a mistake when documenting by indicating the resident wore the devices because the resident always refuses the device. On 04/20/21 at 03:27 PM, CNA #2, who works on the 3 PM to 11 PM shift was interviewed. CNA#2 stated Resident #28 refuses to wear devices and when she tries to apply the devices the resident always says no. CNA #2 stated that when the resident refuses, she documents it in the CNA Accountability record. Upon review of the CNA record, CNA #2 stated that sometimes she forgets and documents in the wrong place indicating the resident received the device when the resident refused to have devices placed. On 04/21/21 at 10:30 AM, the Registered Nurse Supervisor (RNS) was interviewed. The RNS stated he was aware that Resident #28 had devices but he had not been informed that the resident had been noncompliant with the devices. The RNS also stated he does not make rounds on every unit every day, but when he does, he looks for devices and speaks to staff regarding resident compliance. The RNS stated he does not review the CNA accountability records. On 04/21/21 at 10:46 AM, RN #2 was interviewed. RN#2 stated that the CNAs had informed her that Resident #28 was noncompliant with devices almost every day and that they documented it in the CNA Accountability. RN#2 also stated that she did not review the CNA's records for accuracy or report the resident's refusal to the supervisor. On 04/21/21 at 11:53 AM, the Director of Nursing (DON) was interviewed. The DON stated that the CNA should notify the nurse if a resident is refusing to wear devices and the nurse should in turn notify the supervisor. The CNA should document the refusal on the accountability record, which should be checked by the charge nurse. Checks should be done when doing the monthly renewals since the Charge Nurses are supposed to check everything at that time. CNA's are trained on how to fill out the accountability records and nurses are trained on their responsibility regarding CNA records during their orientation. 415.22(a) (1-4)

Based on observations, record review, and staff interviews conducted during a recertification survey 04/14/2021-04/21/2021, the facility did not ensure that notice of the availability of the survey results in areas of the facility that are prominent and accessible to the public was posted. Specifically, the survey results were located in unlabeled wall-mounted racks in or near the day rooms and in the building lobby but there was no notice about the availability of results in these locations. This was observed on 4 of 5 resident units and in the facility lobby. The findings are: During multiple building observations conducted between 4/15/21 at 11:00 AM and 4/21/21 at 1:00 PM survey results were observed in a binder in the lobby area. There were no notices observed posted on any of the resident units about where the survey results could be located. On 04/16/21 at 02:41 PM, during the Resident Council meeting, residents were asked about the availability of survey results. 5 of the 6 residents in attendance stated they did not know where the results were located and 1 member stated the results were posted somewhere in the facility lobby but that residents were not allowed in the lobby because of space constraints. On 04/21/21 at 09:50 AM, Social Worker (SW) #1, who provides services for residents on Units 2, 4 and some of 5, was interviewed. SW #1 stated she does not discuss survey results with residents or review with residents where survey results can be located. On 04/21/21 at 01:05 PM, the Director Social Services (DSS) was interviewed. The DSS stated survey results come up from time to time during Resident Council meetings. If a resident who does not attend Resident Council meetings asks about survey results, she would direct them where to find them. On 04/21/21 at 01:20 PM, the Administrator was interviewed. The Administrator stated that binders with the latest survey results are posted in front of each unit day room as well as in the facility lobby. Residents are reminded at Resident Council that the results can be found there, but residents who do not attend the Council would not get this information. The Administrator also stated that there is no signage posted about the availability of survey results. On 04/21/21 at 01:31 PM, observations were made on all units. On Units 2, 4 and 6, a binder was observed in the day room in a wall-mounted rack. On Unit 3, a binder was observed in the unit hallway outside the day room. There was no binder on Unit 5. All binders were placed obscurely on walls and not labelled in print large enough to be read from a distance. 415.3 (c)(1)(v)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews conducted during a Recertification survey from 04/14/2021 to 04/21/2021, the facility did not ensure that a clean, comfortable, and homelike environment was provided to residents. Specifically, resident rooms were not maintained in good repair and in a homelike manner. This was observed during Environmental Observations on 1 of 5 resident units. (Unit 4) The findings are: During multiple observations on Unit 4 between 4/15/21 at 11:30 AM and 4/21/21 at 11:00 AM, the following were observed but not limited to: 4th Floor Day Room- rusted heater, rust colored discoloration on top of air conditioner and chipped paint on window ledges. room [ROOM NUMBER]-peeling wallpaper observed on the walls. room [ROOM NUMBER]- chipped wall plate, grey duct tape observed on air conditioner. room [ROOM NUMBER]-peeling, discolored wallpaper on wall. room [ROOM NUMBER]-discolored wallpaper around the air conditioner. room [ROOM NUMBER]- broken face panel on air conditioner unit. room [ROOM NUMBER]- peeling wallpaper. room [ROOM NUMBER]-dislodged switch plate, grey duct tape attaching wallpaper to the wall. In addition, rusted wheelchair guardrails were observed in multiple rooms on all floors. On 04/21/21 at 11:08 AM, Maintenance Worker (MW) #1 was interviewed. MW #1 stated his job included fixing sinks, televisions, light fixtures, changing light bulbs but did not include painting in the facility because it is not included in the union contract. MW #1 also stated the facility does not have a painter but occasionally contracts with someone on the weekends. A lot of painting needs to be done in the facility and the supervisor has been informed. Some of the room air conditioners have duct tape around them as this is used as insulation in the winter since there is nothing else available that can be used. MW#1 further stated wheelchair guards in front of the heaters in the resident's rooms are rusty and need attention. The wallpaper is old and there is no additional paper to make repairs so he uses whatever he has to match the paper when necessary and re-glues it when it starts to come loose. On 04/21/21 at 11:24 AM, the Director of Maintenance (DOM) was interviewed. The DOM stated he has a schedule for making rounds on each unit twice a month and a thorough check is done by him of the call bell, the bathroom, the lights, the heating systems in each room. Rooms, doors, heaters need to be painter but this job cannot be done during the winter. The DOM also stated the Administrator has been informed that there are many things that need to be done on the building and some of the things identified would be a priority. The heater guards are rusted; they were last painted a long time ago. On 04/21/21 01:13 PM, the Administrator was interviewed. The Administrator stated he makes daily rounds on all units and if anything is found on rounds, Maintenance is informed of the need for repairs. The Administrator also stated that the facility is in the process of seeking to hire a painter. The Administrator further stated that a full building renovation is planned however the facility was waiting for a survey to be conducted before proceeding with needed work. 415.5(h)(2)

Based on observation, record review and staff interview, conducted during the Recertification survey, the facility did not ensure that infection control practices were maintained to control and help prevent the development and transmission of communicable diseases and infections. Specifically, (1). The Licensed Practical Nurse (LPN) did not clean and sanitize a glucometer after uses and (2). An LPN did not clean and sanitize a pulse oximeter before and after each use, and prior to using it on another resident. This was observed during the Medication Administration Task. The facility policy and procedure titled Cleaning and Disinfection of Equipment dated 03/24/2020 documented resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. The policy also documented that intermediate and low level disinfectants for non-critical items include amongst other Sani-Cloth Plus Germicidal Disposable wipes. The facility policy and procedure titled Evencare G3 Glucose Testing dated 10/1/17 documented the meter should be cleaned and disinfected between each resident use with Medline Micro-Kill Wipes or Sani-Cloth Plus Germicidal Disposable Cloths. The findings are: 1. On 04/19/2021 at 4:35 PM, Medication Administration was observed with Licensed Practical Nurse (LPN) # 3. LPN #3 washed hands and removed the Glucometer from the drawer of the medication cart, a couple of alcohol prep pads and a lancet. After cleansing Resident #68's finger with an alcohol prep pad, the LPN pierced the resident's finger and the resident smeared the blood by placing fingers together and the test could not be performed. LPN #3 changed gloves and pierced the resident's finger a second time and applied blood to the test strip located in the glucometer. After completing testing for Resident #68 and performing hand hygiene, LPN #3 approached Resident #157 to conduct blood glucose testing. LPN # 3 did not clean the glucometer and LPN #3 inserted a test strip into the glucometer. LPN #3 cleansed the resident's finger and prepared the lancet and before LPN #3 could pierce Resident #157's finger the State Surveyor intervened. An interview was conducted immediately with LPN # 3. LPN #3 stated she was aware that she had not cleaned the glucometer before preparing to test the next resident. LPN #3 then proceeded to the medication cart and cleaned the glucometer with alcohol prep pads. LPN #3 stated that she always uses alcohol prep pads for cleaning. When asked about the facility policy on cleaning of the glucometer, LPN #3 retrieved PDI Sanicloth wipes from the bottom drawer of the Medication Cart. 2. On 04/20/2021 at 10:34 AM, Licensed Practical Nurse # 2 was observed recording Oxygen saturation with the use of the pulse oximeter. LPN # 2 approached Resident # 164. LPN #2 did not clean or sanitize device before or after use. LPN #2 then proceeded to Resident #69 and applied the pulse oximeter to the resident's finger. LPN #2 did not clean the device before or after use and placed the device on top of the medication cart use after she removed it from the resident's finger. An interview was conducted with LPN #2 immediately after the observation. LPN # 2 stated that she is supposed to disinfect the device after each use and in between residents. LPN#2 also stated she usually uses alcohol prep pads to clean the device although disinfectant wipes are also available. LPN#2 could not state what the facility policy was on disinfecting devices after use and before use with another resident. 415.19(a)(1-3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during a Recertification survey from 04/14/2021 to 04/21/2021, the facility did not ensure that a safe, functional, sanitary, and comfortable environment was provided for residents, staff, and the public. Specifically, the staff bathrooms were observed to be dusty and in disrepair. This was evident on 4 of 5 units observed during Environmental Rounds. (Units 2, 3, 4, and 5) During multiple observations conducted in the facility between 4/15/21 at 1:30 PM and 4/21/21 at 1:00 PM the following was observed: Staff bathroom on 1st Floor had mismatched paint on walls, rusted inner lower door area, black scuff marks on wall near toilet, and air vent was dusty. Staff bathroom located between room [ROOM NUMBER] and 203 had a discolored peeling toilet seat, mismatched paint on walls above paper dispenser and next to soap dispenser. Staff bathroom located between room [ROOM NUMBER] and 207 had unsealed holes above paper dispenser, and discolored floor tiles. Staff bathroom located between 306 and 307 had discolored floor tiles, the air vent was partially dislodged with chipped paint around the edges. Staff bathroom located between room [ROOM NUMBER] and 403 had rusted corner of door, and dusty air vents. Staff bathroom located between room [ROOM NUMBER] and 407 had mismatched paint next to the mirror, walls above sink and adjacent to sink were visibly dusty and rusted areas were observed at the base of the door and the door edge. Staff bathroom located between room [ROOM NUMBER] and 503 had mismatched paint on wall adjacent to sink and ceiling above door. Staff bathroom located between room [ROOM NUMBER] and 507 had mismatched paint on wall adjacent to sink. On 04/21/21 at 11:24 AM, the Director of Maintenance (DOM) was interviewed. The DOM stated the Administrator has been informed that there are many things that need to be done on the building and some of the things identified would be a priority. The DOM also stated that since coming onboard in January 2020 he observed that the staff bathrooms were in need of attention and spoke to the Administrator recently in this regard. Dispensers had been changed in some of the staff bathrooms and walls need to be repainted. The DOM also stated that the facility would be in the process of getting a painter onsite to address multiple areas that are in need of attention. On 04/21/21 at 01:13 PM, the Administrator was interviewed. The Administrator stated he makes rounds of staff bathrooms and if anything is found on rounds, Maintenance is informed of the need for repairs. The Administrator also stated that the facility is in the process of seeking to hire a painter. The Administrator further stated that a full building renovation is planned however the facility was waiting for a survey to be conducted before proceeding with needed work. 415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the recertification survey, the facility did not ensure that a resident's right to privacy was respected. Specifically, a resident was observed having blood drawn by a lab technician in the public area of a floor dayroom during meal time. (Resident #78). This was evident for 1 out of 35sampled residents. The findings are: A facility policy titled Resident Privacy and dated 5/20/2014 documents that each resident shall have the right to personal privacy and confidentiality. Resident #78 was admitted to the facility 5/15/2012 and currently has a diagnosis of unspecified dementia. The resident's most current Quarterly Minimum Data Set (MDS) dated [DATE] documents that the resident has severely impaired cognition with short and long-term memory loss. On 02/07/19 at 12:22 PM, resident #78 was observed in the Floor Day Room (FDR) seated in his wheelchair at the back of the room. A lab technician was noted to be kneeling in front of the resident with a lab supply box. There was a vial of blood in her hand and tubing connected to the resident's left arm. Resident #78 was in full view of the rest of the FDR. There were multiple other residents seated in the FDR waiting for lunch to be served. Facility staff were wheeling residents into the room and providing residents with bibs and hand care prior to food being served. The most recent listing of the resident's lab work documents that the resident had a Comprehensive Metabolic Panel test done on 2/7/19. An interview was conducted with the Lab Technician (LT) on 02/07/19 at 12:24 PM. The LT stated that she normally draws blood for labs in the resident's room; however, because she was attempting to fulfill the lab order prior to lunch, she felt that it would take too much time for her to wheel the resident back to his room. The LT further stated that she thought it was acceptable for her to draw labs in the FDR since the resident was seated at the back of the room. The LT confirmed that the resident's blood was being drawn for a Comprehensive Metabolic Panel test. She further stated that she is usually in the facility much earlier to draw resident's blood in private in his room, but that today, she was later than usual. On 02/07/19 at 02:50 PM, an interview was conducted with a Certified Nursing Assistant (CNA #2) who was present at the time that the resident's labs were being drawn in the FDR. CNA #2 stated that a resident's blood is not usually drawn in a public area. Usually the tech will take the resident to their room to draw blood or comes to the facility earlier in the morning when residents are still in bed. CNA #2 did observe that the LT was drawing blood in public view of other residents and staff; however, CNA #2 thought that it may have been an emergency order for labs that needed to be done in a timely manner. CNA #2 believes that the LT should have taken the resident his room, but believes that if there are time constraints, the drawing of the blood should take precedence over the resident's right to privacy. CNA #2 further stated that the facility does provide training and in-service for staff related to dignity and privacy. When CNA #2 was first hired as a full-time staff member in December 18, he was provided in-service on privacy and dignity. An interview was conducted with the Charge Nurse on the unit, Licensed Practical Nurse (LPN) #4, on 02/07/19 at 02:57 PM. LPN #4 has worked in facility for approximately 3 years. She did not observe and was not aware that the LT was present on the unit and was drawing a resident's blood in the FDR. The protocol of the facility and the usual practice of the LT is to draw blood from residents in the privacy of their rooms. This is done to ensure a resident's privacy. The LPN #4 did not give permission for the LT to draw Resident #78 blood in public view in the FDR since she was not aware that the LT was on the unit. The LT did not inquire with the LPN #4 as to the whereabouts of the Resident #78 prior to drawing blood. Usually the LT will communicate with facility staff to ensure that she has the correct resident and to seek assistance with bringing the residents to their rooms. The LPN #4 remembers having an in-service regarding privacy but cannot recall exactly when. 415.3(d)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review conducted during the recertification survey, the facility did not ensure that an alleged violation involving abuse was reported to the NYSDOH (New York State Department of Health) within the acceptable timeframe. Specifically, the facility did not report an allegation of verbal abuse by a resident to the NYSDOH within a 24-hour period. This was evident for 1 of 1 resident investigated for allegations of Abuse out of a sample of 35 residents (Resident #175) The findings are: The facility's Abuse and Neglect Policy and Procedure dated 4/10/2018 documented that the an incident of suspected abuse, resulting in serious bodily injury must be reported to the New York State Department of Health (NYSDOH) within 2 hours after forming suspicion. All other incidents must be reported within 24 hours. The policy further documented that the accused abuser, if it is a staff member, will be removed from their assignment immediately pending investigation. Resident #175 was admitted to the facility on [DATE] with a diagnosis of chronic pain and acute embolism and thrombosis of deep vein of lower extremity. The most recent Annual Minimum Data Set, dated [DATE] documented the resident as being able to understand others and can make self-understood. The resident is also documented as cognitively intact with some minimal judgment impairments. Resident #175 did not exhibit any mood indicators nor adverse behaviors during the assessment period prior to the MDS being completed. An interview with Resident #175 was conducted on 02/06/19 at 09:39 AM. The resident stated to the SA (State Agency Surveyor) that on 02/05/19, he was sitting in the Main Dining Room (MDR) doing some coloring during activities some time before lunch was served. A physical therapist assistant (PTA) came into the MDR and requested the resident give him his wheelchair because the resident had completed his physical therapy program and the Rehabilitation Department (Rehab) wanted to use the wheelchair for another resident. When resident #175 refused, the PTA said f*** you. The PTA then turned to another resident sitting at the table (Resident #45) and told her to get out of my face. No other staff members were close enough to hear the conversation. Resident #175 initially stated that he was unsure of who to report the incident to since her has never had a situation like this happen to him while a resident in this facility. Res stated that he will report this incident to an appropriate staff member in Administration to initiate the grievance/abuse investigation procedure. In a follow up interview with the resident on 2/7/19 at 09:47 AM, Resident #175 stated that he reported the incident shortly after speaking with the SA on the previous day. He said reported the incident to the Charge Nurse, Licensed Practical Nurse (LPN #4) between 11AM-12PM. Resident #175 further stated that he felt angry and hurt by how he was treated and was embarrassed that others saw the interaction. He also stated that he has not had any previous negative interactions with this staff member. On 02/07/19 at 09:33 AM, the PTA that resident made an allegation of verbal abuse against was observed in Rehab (located next to the Activity Room/MDR) working with other residents. No abusive behavior was observed. Nursing Progress Notes and Medical Doctor (MD) Progress Note from 2/6/19 through 2/7/19 have no mention of any allegations of verbal abuse reported by Resident #175. A Comprehensive Care Plan (CCP) related to Potential for Abuse dated 1/24/2018 documented that the resident has the potential for abuse because of tendency to become easily agitated. The CCP documented that the interventions to be used to prevent abuse are to evaluate risk factors for abuse. A CCP related to Criticism of Staff dated 7/10/2018 documented that the resident has a potential for alteration in psychosocial well-being as evidenced by conflict/criticism of staff. Interventions include that the nursing and social services staff are to evaluate any incidents to determine the cause of the conflict and attempt to help the resident feel more comfortable with staff. A CCP related to Behavior and dated 5/4/2018 documented that the resident yells, curses, and screams at staff. The interventions listed to address this type of behavior include providing the resident a calm environment and removing the resident from an over-stimulating environment. A Grievance/Complaint Report form initiated on 2/6/2019 and completed on 2/8/2019 documented that the resident reported that Rehab staff PTA was verbally inappropriate to him. A statement from LPN #4 is dated 2/6/19 at 2pm and documented the initial report from the resident regarding the alleged verbal abuse. A statement from the PTA was dated 2/7/19 and states that the PTA approached the resident and asked whether he would like to keep using his wheelchair. When the resident stated that You are not taking my wheelchair away from me, the PTA attempted several more times to discuss the issue with the resident. The PTA lists 6 separate times in his statement that he continued to try and discuss the wheelchair with Resident #175 as the resident was responding to him in an agitated manner. Statements from Resident #175 and the witness, Resident #45, were not documented until late in the afternoon on 2/7/19, after the SA interviewed the Director of Nursing (DNS) regarding the alleged verbal abuse. The DNS concluded on 2/8/2019 that due to the inconsistencies and lack of details in their stories, resident's history of inappropriate behavior and the PTA's reputation, there is no evidence that abuse occurred. On 02/07/19 at 09:38 AM, the resident witness to the incident, Resident #45 was interviewed. Resident #45 has a diagnosis of COPD, Schizophrenia, and Alzheimer's Disease. The most recent Quarterly MDS dated [DATE] documented that the resident can usually understand and usually make herself understood. The resident is also documented as having a Brief Interview for Mental Status (BIMS) score of 13 indicating some modified judgment impairments. The resident's CCP related to Cognition dated 3/29/2018 documented that the resident does not have any short term or long-term memory impairments. Resident #45 stated that she was unable to recall the time that the incident occurred; however, 2 days prior, the PTA from Rehab came into the MDR while she was coloring with Resident #175. The PTA asked Resident #175 for the wheelchair. Resident #175 stated No and that's when the PTA told the resident, F*** you. The PTA then turned to Resident #45 and stated, Don't ever speak to me again. The PTA did not return to either resident to apologize or address the situation. Resident #45 stated that no other staff member has approached her to interview her. Resident #45 stated that she was able to get over the situation but feels that it was inappropriate for staff to talk to residents that way. On 02/07/19 at 03:08 PM, an interview was conducted with the Social Worker (SW). The SW stated that the most recent complaint/grievance was reported by Resident #175 on 2/6/19. The resident was interviewed at approximately 12PM during regular SW rounds on his unit. The resident stated that a staff member spoke to him inappropriately. A Grievance/Complaint Form was filled out and provided to the DNS. At the time, the resident did not inform the SW whether there were any other witnesses. Once the DNS completes the investigation, the SW will be made aware of the outcome. The SW stated that she spoke with the DNS today around lunch time to follow up on the progress of the investigation. The DNS informed the SW that she is interviewing people and a resolution should be ready by tomorrow. The resident was able to state that staff member involved in the allegation was PTA from Rehab. The resident has not had any issues with this staff member before. Resident #175 is alert and oriented to person, place, and time and has no cognitive impairments. The SW felt it was best to initiate the grievance procedure and allow the DNS to interview the resident to gather the specifics of the complaint and report. An interview was conducted with the DNS on 02/07/19 at 03:34 PM. She has been the DNS for approximately 3 years. The DNS stated that she had received a grievance report from the SW regarding Resident #175 at approximately 2pm on 2/6/19. The resident reported that a PTA was rude to him and cursed at him. When asked whether cursing is considered a form of verbal abuse, the DNS stated that it is. The DNS stated that the grievance form had been filled out and is currently with her so that she can complete the investigation. The DNS stated that the normal procedure to investigate claims of verbal abuse is to initially speak with the SW and then to interview the resident making the allegation. Since the resident is aware of who the alleged abuser is in this case, the DNS will be the one to interview Resident #175. Upon review of the Grievance Form and the statements that have been submitted thus far, the SA pointed out to the DNS that in more than 24 hours since an alleged verbal abuse was reported to her, she only has a statement from PTA (alleged abuser), and the PTA's supervisor, the Director of Rehabilitation (DOR). The DNS stated that she has yet not spoken to or interviewed the Resident #175 or any of the witnesses involved. The DNS stated that she initiated the investigation by speaking to the DOR and to the PTA involved. Even though the SW did not document that the PTA was involved on the Grievance Form, the SW may have mentioned verbally to the DNS that the PTA was involved. The DNS also stated that she did not interview the PTA directly and has only reviewed his written statement. In his statement, the PTA denies the allegation of being verbally abusive to the resident. The DNS stated that in the next steps of the investigation, she will interview the PTA and other witnesses. The DNS stated that she spoke by phone with the Activities Director and is awaiting her written statement. The Activities Director stated that she only heard the resident yelling in response to the PTA approaching him. The DNS stated that although statements have not been gathered from all parties involved, and there has been no official outcome or determination of abuse has yet to be made, the PTA was in-serviced because the resident felt as though he was being rude. The Abuse Policy of the facility is that although an in-service was provided, the DNS still needs to complete her investigation. The NYSDOH regulation regarding abuse is that any allegation that does not involve physical harm to a resident must be reported to the NYSDOH within 24 hours of being reported to the facility staff. The DNS stated that she did not report this allegation of abuse to the NYSDOH within a 24-hour period because she does not believe that this incident rises to the level of abuse. The DNS stated that even though she has not interviewed the alleged victim nor any of the witnesses involved, she has already made the determination that the allegation of verbal abuse is not reportable. When the SA inquired as to the reason that the alleged abuser/PTA was still working while the investigation was ongoing, the DNS stated that the PTA had been in-serviced regarding customer service. Usually in cases where there are allegations of abuse, the alleged abuser will be removed from the schedule to ensure the safety of other residents in the facility until the investigation is completed. The DNS stated that the reason this was not done in this case was because the DNS does not believe that the resident was abused by staff. The DNS stated that she has already determined that this does not rise to the level of abuse without speaking to any residents involved. The DNS does not have all the names of the residents involved in the incident because she has not interviewed the alleged victim. The DNS is unsure whether there are video cameras in the MDR that would have captured the incident on camera. When the SA inquired as to whether cameras are used to determine the events that take place in the MDR if a resident has a fall or other type of incident, the DNS replied that there are cameras present; however, she not aware of whether the incident took place within camera view. The DNS is unsure as to whether the incident occurred within camera view because she has not directly interviewed the PTA, or the resident involved in the allegation to determine their location in the MDR. The DNS stated that her next step is to speak with the Activities Director and gather her statement. On 02/08/19 at 10:19 AM, an interview was conducted with the PTA. The PTA stated to the SA that he knows this conversation is about Resident #175 and that he is not concerned because he did nothing wrong. The PTA stated that on the day of the alleged incident, 2/5/19, at an undetermined time, the resident came into the Rehab Dept to say hello to staff and other residents. The resident then wheeled himself to the MDR for Activities. The resident appeared to be calm and in a good mood. When the PTA saw the resident wheeling himself in a wheelchair, he realized that the resident's discharge order from Rehab was that he could ambulate without a wheelchair. The PTA approached the DOR to discuss a strategy on how to obtain the wheelchair from the resident since he no longer requires it. DOR(?) advised the PTA to speak with the resident regarding his wheelchair use preference. The PTA approached the resident while smiling in the MDR. The resident was seated at a table across from the entry way door to the MDR. The resident was coloring at a table with other residents. The Activities Director was also present but not in the vicinity. The PTA stated, Hello Resident's Name. The resident responded, What? The PTA responded, We would like to know whether you would like to keep the wheelchair because you are still using it despite the order that you can be ambulatory without it. Before the PTA was able to finish his statement, the resident spoke loudly and stated, You are not taking it away from me. The PTA responded, Hear me out first. I'm not trying to take it away from you. The resident responded, I'm going to go to the Administrator about this. The PTA responded, Go to the Administrator about what? You didn't let me finish. The PTA continued to question the resident about this issue even though the resident was becoming agitated. The PTA stated to himself out loud at the end of the conversation, What did I friggin do wrong? The resident believed that the PTA was cursing at him at this point. The PTA tried to explain that this was not directed at the resident and was only a statement to himself. The PTA stated that the resident did not curse at him but was highly agitated. The Activities Director then overheard and indicated to the PTA that he should end the conversation. The Activity Director did not intervene at any point until the resident began yelling that he had been cursed at. The PTA stated that this was something that personally affected him and made him feel very badly because he believes he works very hard for these people and does not deserve this. The PTA then directly reported the interaction to the DOR. He was instructed to write a statement of occurrence the following morning. The PTA stated that he has worked in the facility for approximately 3 years and has never had this type of interaction with any other resident. The PTA stated that he was aware of resident's behavior and history of outbursts with staff prior to this interaction, but thought he had a good relationship with the resident. The PTA stated that there are ongoing trainings and in-services provided to facility staff on how to approach and work with this type of resident population with psychiatric conditions and mood/behavioral issues. He believes there was an in-service related to abuse within the last 6 months. These in-service topics include discussions on how staff are to react to residents when they are being verbally abused by them. The PTA was trained that if you encounter a resident with certain diagnoses or behavioral/abusive/aggressive issues, then the best approach is to get help from another staff member or to allow the resident space and time to calm down. The PTA stated that the situation escalated so quickly that he did not have time to control his reaction or call upon his training to separate himself from the resident. Following the incident, he was questioned by the Administrator, the DNS, and the SW. He has not had any further contact with the resident. The PTA also stated that he has not been in-serviced or re-educated by anyone since the incident occurred. The PTA does not believe that he did anything wrong and would not have done anything differently. An interview was conducted with the DOR on 02/08/19 at 11:11 AM. On 2/5/19, it was determined that resident no longer required the use of a wheelchair. The PTA came to Rehab after speaking with the resident and informed the DOR that the resident 'flipped out' in the MDR. The PTA mentioned that the resident was under the impression that Rehab wanted to take the chair away and that he was going to tell the Administrator. The DOR's response was to keep the order for the wheelchair so that the resident can continue using it. The DOR decided not to re-approach the resident regarding the wheelchair use because he had already had an outburst. The following day, the PTA was asked to write as statement. The Administrator was made aware of the incident on 2/6 in the morning and asked that the PTA be in-serviced in addition to a statement being recorded. The DOR stated that the in-service was, I just told him to have a little more self-control in dealing with outbursts and anger control. Only verbal education was provided, no in-service materials. The DOR stated that the PTA did not have an optimal response to the incident and there is room for improvement. The PTA could have done better in response to the resident and his behavior. The PTA should have terminated the conversation and then called the DOR. It is not normal practice to have these types of discussions in the MDR while other residents are present. On 02/08/19 at 11:36 AM an interview was conducted with the Activities Director. On 2/5/19, she was getting ready to transition from church services to regular activities when she saw the PTA approach the resident. The PTA asked the resident something to the effect of whether the res needed to use the wheelchair. The resident started cursing saying, F you, M***F*** . The resident then stated, Oh your cursing at me. The PTA stated, What are you talking about? At that point, the Activities Director intervened and advised the PTA to leave the area and stop talking to the resident. The resident gets angry and territorial at times. He is known to have a behavior of trying to show off by having public outbursts for others to see. During morning meeting and team meetings, all facility staff are made aware that the resident has this behavior of acting out. Once the resident starts to get agitated while doing activities in the MDR, the Activity Director can redirect that behavior and is able to get the resident to calm down. Other residents that were present were Resident #45 and Resident #165. The PTA was not observed speaking to the other residents at the table during the incident. The Activities Director would not have done anything differently. The Activities Director believes that the best approach with agitated and aggressive residents is to separate and remove yourself from the situation. This is the reason she advised the PTA to leave and stop talking with the resident. The Activities Director was approached the following day after the incident for a statement of occurrence. She stated that there are cameras in the MDR, but only the Administrator has access to them. On 02/11/19 at 03:39 PM, an interview was conducted with the Administrator. He stated that the alleged incident was reported to him on 2/6/19 in the afternoon at approximately 1pm. The Assistant Director of Nursing reported that the PTA said to the resident something to the effect of Can I ask you a damn question? The DOR was instructed to get a statement from the PTA and to provide him with in-service and education regarding customer service. The DON spearheads the investigation into any allegation of abuse. The Administrator is made aware of the incident and then updated at the completion of the abuse allegation investigation. An allegation of any type of abuse must be reported to the NYSDOH within 24 hours. Within 5 days, the conclusion of the investigation must also be reported to the NYSDOH and the Administrator. The Administrator is aware of the practices and procedures that the DON uses to investigate these types of allegations. The investigation was not conducted in an acceptable manner to ensure that there was a determination of whether the allegation could be deemed as a reportable incident. Specifically, the DON did not interview the resident regarding the allegation of verbal abuse within 24 hours. The report of an allegation of verbal abuse was not made to the NYSDOH within 24 hours. The Administrator therefore could not use video evidence in the investigation conclusion. The resident should have been interviewed by the DNS at the time the incident was reported. The general practice of the facility is that staff members involved in abuse allegations are sent home to ensure the safety of the alleged victim and the other residents in the facility. The Administrator does not have an answer as to the reason the PTA was not sent home for the duration of this specific investigation. There are cameras in the MDR that are functional; however, due to the inability to determine the specific time of the incident, the Administrator was unable to determine which timeframe to review the video. 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review conducted during the recertification survey, the facility did not ensure that an alleged violation involving verbal abuse was thoroughly investigated. Specifically, the facility did not take investigative steps to determine whether an allegation of verbal abuse could be substantiated and reported to the NYSDOH (New York State Department of Health)within a 24-hour period. This was evident for 1 of 1 resident investigated for allegations of abuse out of a sample of 35 residents. (Resident #175) The findings are: The facility's Abuse and Neglect Policy and Procedure dated 4/10/2018 documents that the an incident of suspected abuse, resulting in serious bodily injury must be reported to the New York State Department of Health (NYSDOH) within 2 hours after forming suspicion. All other incidents must be reported within 24 hours. The policy further documents that the accused abuser, if it is a staff member, will be removed from their assignment immediately pending investigation. Resident #175 was admitted to the facility on [DATE] with a diagnosis of chronic pain and acute embolism and thrombosis of deep vein of lower extremity. The most recent Annual Minimum Data Set, dated [DATE] documents the resident as being able to understand others and can make self-understood. The resident is also documented as cognitively intact with some minimal judgment impairments. Resident #175 did not exhibit any mood indicators nor adverse behaviors during the assessment period prior to the MDS being completed. An interview with Resident #175 was conducted on 02/06/19 at 09:39 AM. The resident stated that yesterday (2/5/19), he was sitting in the Main Dining Room (MDR) doing some coloring during activities some time before lunch was served. A physical therapist (PTA) came into the MDR and requested the resident give him his wheelchair because the resident had completed his physical therapy program and the Rehabilitation Department (Rehab) wanted to use the wheelchair for another resident. When resident #175 refused, the PTA said f*** you. The PTA then turned to another resident sitting at the table (Resident #45) and told her to get out of my face. No other staff members were close enough to hear the conversation. Resident #175 initially stated that he was unsure of who to report the incident to since her has never had a situation like this happen to him while a resident in this facility. Res stated that he will report this incident to an appropriate staff member in Administration to initiate the grievance/abuse investigation procedure. In a follow up interview with the resident on 2/7/19 at 09:47 AM, Resident #175 stated that he reported the incident shortly after speaking with SA on the previous day, between 11AM-12PM. He reported the incident to the Charge Nurse, Licensed Practical Nurse (LPN #4). Resident #175 further stated that the felt angry and hurt by how he was treated and was embarrassed that others saw the interaction. He also stated that he has not had any previous negative interactions with this staff member. On 02/07/19 at 09:33 AM, the PTA that resident made an allegation of verbal abuse against was observed in Rehab (located next to the Activity Room/MDR) working with other residents. Nursing Progress Notes and Medical Doctor (MD) Progress Note from 2/6/19 through 2/7/19 have no mention of any allegations of verbal abuse reported by Resident #175. A Comprehensive Care Plan (CCP) related to Potential for Abuse dated 1/24/2018 documents that the resident has the potential for abuse because of tendency to become easily agitated. The CCP documents that the interventions to be used to prevent abuse are to evaluate risk factors for abuse. A CCP related to Criticism of Staff dated 7/10/2018 documents that the resident has a potential for alteration in psychosocial well-being as evidenced by conflict/criticism of staff. Interventions include that the nursing and social services staff are to evaluate any incidents to determine the cause of the conflict and attempt to help the resident feel more comfortable with staff. A CCP related to Behavior and dated 5/4/2018 documents that the resident yells, curses, and screams at staff. The interventions listed to address this type of behavior include providing the resident a calm environment and removing the resident from an over-stimulating environment. A Grievance/Complaint Report form initiated on 2/6/2019 and completed on 2/8/2019 documents that the resident reported that Rehab staff PTA was verbally inappropriate to him. A statement from LPN #4 is dated 2/6/19 at 2pm and documents the initial report from the resident regarding the alleged verbal abuse. A statement from the PTA was dated 2/7/19 and states that the PTA approached the resident and asked whether he would like to keep using his wheelchair. When the resident stated that You are not taking my wheelchair away from me, the PTA attempted several more times to discuss the issue with the resident. The PTA lists 6 separate times in his statement that he continued to try and discuss the wheelchair with Resident #175 as the resident was responding to him in an agitated manner. Statements from Resident #175 and the witness, Resident #45, were not documented until late in the afternoon on 2/7/19, after the SA interviewed the Director of Nursing (DNS) regarding the alleged verbal abuse. The DNS concluded on 2/8/2019 that due to the inconsistencies and lack of details in their stories, resident's history of inappropriate behavior and the PTA's reputation, there is no evidence that abuse occurred. On 02/07/19 at 09:38 AM, the resident witness to the incident, Resident #45 was interviewed. Resident #45 has a diagnosis of COPD, Schizophrenia, and Alzheimer's Disease. The most recent Quarterly MDS dated [DATE] documents that the resident can usually understand and usually make herself understood. The resident is also documented as having a Brief Interview for Mental Status (BIMS) score of 13 indicating some modified judgment impairments. The resident's CCP related to Cognition dated 3/29/2018 documents that the resident does not have any short term or long-term memory impairments. Resident #45 stated that she was unable to recall the time that the incident occurred; however, 2 days prior, the PTA from Rehab came into the MDR while she was coloring with Resident #175. The PTA asked Resident #175 for the wheelchair. Resident #175 stated No and that's when the PTA told the resident, F*** you. The PTA then turned to Resident #45 and stated, Don't ever speak to me again. The PTA did not return to either resident to apologize or address the situation. Resident #45 stated that no other staff member has approached her to interview her. Resident #45 stated that she was able to get over the situation but feels that it was inappropriate for staff to talk to residents that way. On 02/07/19 at 03:08 PM, an interview was conducted with the Social Worker (SW). The SW stated that the most recent complaint/grievance was reported by Resident #175 on 2/6/19. The resident was interviewed at approximately 12PM during regular SW rounds on his unit. The resident stated that a staff member spoke to him inappropriately. A Grievance/Complaint Form was filled out and provided to the DNS. At the time, the resident did not inform the SW whether there were any other witnesses. Once the DNS completes the investigation, the SW will be made aware of the outcome. The SW stated that she spoke with the DNS today around lunch time to follow up on the progress of the investigation. The DNS informed the SW that she is interviewing people and a resolution should be ready by tomorrow. The resident was able to state that staff member involved in the allegation was PTA from Rehab. The resident has not had any issues with this staff member before. Resident #175 is alert and oriented to person, place, and time and has no cognitive impairments. The SW felt it was best to initiate the grievance procedure and allow the DNS to interview the resident to gather the specifics of the complaint and report. An interview was conducted with the DNS on 02/07/19 at 03:34 PM. She has been the DNS for approximately 3 years. The DNS stated that she had received a grievance report from the SW regarding Resident #175 at approximately 2pm on 2/6/19. The resident reported that a PTA was rude to him and cursed at him. When asked whether cursing is considered a form of verbal abuse, the DNS stated that it is. The DNS stated that the grievance form had been filled out and is currently with her so that she can complete the investigation. The DNS stated that the normal procedure to investigate claims of verbal abuse is to initially speak with the SW and then to interview the resident making the allegation. Since the resident is aware of who the alleged abuser is in this case, the DNS will be the one to interview Resident #175. Upon review of the Grievance Form and the statements that have been submitted thus far, the SA pointed out to the DNS that in more than 24 hours since an alleged verbal abuse was reported to her, she only has a statement from PTA (alleged abuser), and the PTA's supervisor, the Director of Rehabilitation (DOR). The DNS stated that she has not yet spoken to or interviewed the Resident #175 or any of the witnesses involved. The DNS stated that she initiated the investigation by speaking to the DOR and to the PTA involved. Even though the SW did not document that the PTA was involved on the Grievance Form, the SW may have mentioned verbally to the DNS that the PTA was involved. The DNS also stated that she did not interview the PTA directly and has only reviewed his written statement. In his statement, the PTA denies the allegation of being verbally abusive to the resident. The DNS stated that in the next steps of the investigation, she will interview the PTA and other witnesses. The DNS stated that she spoke by phone with the Activities Director and is awaiting her written statement. The Activities Director stated that she only heard the resident yelling in response to the PTA approaching him. The DNS stated that although statements have not yet been gathered from all parties involved, and there has been no official outcome or determination of abuse, the PTA was in-serviced because the resident felt as though he was being rude. The Abuse Policy of the facility is that although an in-service was provided, the DNS still needs to complete her investigation. The NYSDOH regulation regarding abuse is that any allegation that does not involve physical harm to a resident must be reported to the NYSDOH within 24 hours of being reported to the facility staff. The DNS stated that she did not report this allegation of abuse to the NYSDOH within a 24-hour period because she does not believe that this incident rises to the level of abuse. The DNS stated that even though she has not interviewed the alleged victim nor any of the witnesses involved, she has already made the determination that the allegation of verbal abuse is not reportable. When the SA inquired as to the reason that the alleged abuser/PTA was still working while the investigation was ongoing, the DNS stated that the PTA had been in-serviced regarding customer service. Usually in cases where there are allegations of abuse, the alleged abuser will be removed from the schedule to ensure the safety of other residents in the facility until the investigation is completed. The DNS stated that the reason this was not done in this case was because the DNS does not believe that the resident was abused by staff. The DNS stated that she has already determined that this does not rise to the level of abuse without speaking to any residents involved. The DNS does not have all the names of the residents involved in the incident because she has not interviewed the alleged victim. The DNS is unsure whether there are video cameras in the MDR that would have captured the incident on camera. When the SA inquired as to whether cameras are used to determine the events that take place in the MDR if a resident has a fall or other type of incident, the DNS replied that there are cameras present; however, she not aware of whether the incident took place within camera view. The DNS is unsure as to whether the incident occurred within camera view because she has not directly interviewed the PTA, or the resident involved in the allegation to determine their location in the MDR. The DNS stated that her next step is to speak with the Activities Director and gather her statement. On 02/08/19 at 10:19 AM, an interview was conducted with the PTA. The PTA stated to the SA that he knows this conversation is about Resident #175 and that he is not concerned because he did nothing wrong. The PTA stated that on the day of the alleged incident, 2/5/19, at an undetermined time, the resident came into the Rehab Dept to say hello to staff and other residents. The resident then wheeled himself to the MDR for Activities. The resident appeared to be calm and in a good mood. When the PTA saw the resident wheeling himself in a wheelchair, he realized that the resident's discharge order from Rehab was that he could ambulate without a wheelchair. The PTA approached the DOR to discuss a strategy on how to obtain the wheelchair from the resident since he no longer requires it. DOR advised the PTA to speak with the resident regarding his wheelchair use preference. The PTA approached the resident while smiling in the MDR. The resident was seated at a table across from the entry way door to the MDR. The resident was coloring at a table with other residents. The Activities Director was also present but not in the vicinity. The PTA stated, Hello Resident #175. The resident responded, What? The PTA responded, We would like to know whether you would like to keep the wheelchair because you are still using it despite the order that you can be ambulatory without it. Before the PTA was able to finish his statement, the resident spoke loudly and stated, You are not taking it away from me. The PTA responded, Hear me out first. I'm not trying to take it away from you. The resident responded, I'm going to go to the Administrator about this. The PTA responded, Go to the Administrator about what? You didn't let me finish. The PTA continued to question the resident about this issue even though the resident was becoming agitated. The PTA stated to himself out loud at the end of the conversation, What did I friggin do wrong? The resident believed that the PTA was cursing at him at this point. The PTA tried to explain that this was not directed at the resident and was only a statement to himself. The PTA stated that the resident did not curse at him but was highly agitated. The Activities Director then overheard and indicated to the PTA that he should end the conversation. The Activity Director did not intervene at any point until the resident began yelling that he had been cursed at. The PTA stated that this was something that personally affected him and made him feel very badly because he believes he works very hard for these people and does not deserve this. The PTA then directly reported the interaction to the DOR. He was instructed to write a statement of occurrence the following morning. The PTA stated that he has worked in the facility for approximately 3 years and has never had this type of interaction with any other resident. The PTA stated that he was aware of resident's behavior and history of outbursts with staff prior to this interaction, but thought he had a good relationship with the resident. The PTA stated that there are ongoing trainings and in-services provided to facility staff on how to approach and work with this type of resident population with psychiatric conditions and mood/behavioral issues. He believes there was an in-service related to abuse within the last 6 months. These in-service topics include discussions on how staff are to react to residents when they are being verbally abused by them. The PTA was trained that if you encounter a resident with certain diagnoses or behavioral/abusive/aggressive issues, then the best approach is to get help from another staff member or to allow the resident space and time to calm down. The PTA stated that the situation escalated so quickly that he did not have time to control his reaction or call upon his training to separate himself from the resident. Following the incident, he was questioned by the Administrator, the DNS, and the SW. He has not had any further contact with the resident. The PTA also stated that he has not been in-serviced or re-educated by anyone since the incident occurred. The PTA does not believe that he did anything wrong and would not have done anything differently. An interview was conducted with the DOR on 02/08/19 at 11:11 AM. On 2/5/19, it was determined that resident no longer required the use of a wheelchair. The PTA came to Rehab after speaking with the resident and informed the DOR that the resident 'flipped out' in the MDR. The PTA mentioned that the resident was under the impression that Rehab wanted to take the chair away and that he was going to tell the Administrator. The DOR's response was to keep the order for the wheelchair so that the resident can continue using it. The DOR decided not to re-approach the resident regarding the wheelchair use because he had already had an outburst. The following day, the PTA was asked to write as statement. The Administrator was made aware of the incident on 2/6 in the morning and asked that the PTA be in-serviced in addition to a statement being recorded. The DOR stated that the in-service was, I just told him to have a little more self-control in dealing with outbursts and anger control. Only verbal education was provided, no in-service materials. The DOR stated that the PTA did not have an optimal response to the incident and there is room for improvement. The PTA could have done better in response to the resident and his behavior. The PTA should have terminated the conversation and then called the DOR. It is not normal practice to have these types of discussions in the MDR while other residents are present. On 02/08/19 at 11:36 AM an interview was conducted with the Activities Director. On 2/5/19, she was getting ready to transition from church services to regular activities when she saw the PTA approach the resident. The PTA asked the resident something to the effect of whether the res needed to use the wheelchair. The resident started cursing saying, F you, M***F*** . The resident then stated, Oh your cursing at me. The PTA stated, What are you talking about? At that point, the Activities Director intervened and advised the PTA to leave the area and stop talking to the resident. The resident gets angry and territorial at times. He is known to have a behavior of trying to show off by having public outbursts for others to see. During morning meeting and team meetings, all facility staff are made aware that the resident has this behavior of acting out. Once the resident starts to get agitated while doing activities in the MDR, the Activity Director can redirect that behavior and is able to get the resident to calm down. Other residents that were present were Resident #45 and Resident #165. The PTA was not observed speaking to the other residents at the table during the incident. The Activities Director would not have done anything differently. The Activities Director believes that the best approach with agitated and aggressive residents is to separate and remove yourself from the situation. This is the reason she advised the PTA to leave and stop talking with the resident. The Activities Director was approached the following day after the incident for a statement of occurrence. She stated that there are cameras in the MDR, but only the Administrator has access to them. On 02/11/19 at 03:39 PM, an interview was conducted with the Administrator. He stated that the alleged incident was reported to him on 2/6/19 in the afternoon at approximately 1pm. The Assistant Director of Nursing reported that the PTA said to the resident something to the effect of Can I ask you a damn question? The DOR was instructed to get a statement from the PTA and to provide him with in-service and education regarding customer service. The DON spearheads the investigation into any allegation of abuse. The Administrator is made aware of the incident and then updated at the completion of the abuse allegation investigation. An allegation of any type of abuse must be reported to the NYSDOH within 24 hours. Within 5 days, the conclusion of the investigation must also be reported to the NYSDOH and the Administrator. The Administrator is aware of the practices and procedures that the DON uses to investigate these types of allegations. The investigation was not conducted in an acceptable manner to ensure that there was a determination of whether the allegation could be deemed as a reportable incident. Specifically, the DON did not interview the resident regarding the allegation of verbal abuse within 24 hours. The report of an allegation of verbal abuse was not made to the NYSDOH within 24 hours. The Administrator therefore could not use video evidence in the investigation conclusion. The resident should have been interviewed by the DNS at the time the incident was reported. The general practice of the facility is that staff members involved in abuse allegations are sent home to ensure the safety of the alleged victim and the other residents in the facility. The Administrator does not have an answer as to the reason the PTA was not sent home for the duration of this specific investigation. There are cameras in the MDR that are functional; however, due to the inability to determine the specific time of the incident, the Administrator was unable to determine which timeframe to review the video. 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, records review and staff interviews during the recertification period, the facility did not ensure that comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical , nursing and mental and psychosocial needs are identified in the comprehensive assessment. This was evidenced in 3 of 5 residents reviewed for care planning . Specifically: There was no Comprehensive Care Plan (CCP) developed to address the activity preferences for Resident #98. This was evident for 1 ouf of as sample of 35 residents. The facility policy of care planning stated : The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care . The care plan will be developed within 48 hours of a resident's admission. The finding is: 1. Resident #98 was admitted to the facility on [DATE]. The minimum data set 3.0 (MDS) assessment dated [DATE] identified the resident as cognitively intact. able to make decision and make his needs known. The resident requires assistance in some activities of daily living. The MDS documented that it was not that important to the resident to participate in group activities, or to read newspapers or magazines. It was somewhat important for the resident to keep up with news, go outside and get fresh air and listen to music that he likes. The resident did no have any mood or behaviors indicators noted on the assessment. On 02/07/2019 at 3:03 PM, the resident was observed and interviewed in his room seated in his wheelchair . During the initial interview , when asked about his activities and how he uses his time on a day to day in the facility , he stated : I prefer to be by myself and sometimes, I will join in the activities in group like watching movies and playing bingo . He further stated , I read my newspaper and I watch the news on the TV and some other programs. Resident was seen and interacted with several times during the survey and mostly found in his room seated and watching TV . The CCP) dated 11/02/2018 did not include activities. The Director of activities was interviewed on 02/11/2019 at 12:05 PM and stated in the CCP , for activities I make the care plans for the residents upon admission , quarterly and when it needed to be revised . When asked where is it documented ? She reviewed the CCP and stated, I did not see any care plan done and I made one today. 415.11(c)(1)

Based on observation, interview and record review during the recertification survey, the facility did not ensure that pharmaceutical services (including procedures that assure the accurate acquiring, receiving , dispensing and administering of all drugs and biologicals) met the needs of each resident. Specifically 1) The accurate receiving and administering of medications by the nursing staff. whereby the the facility received an outdated package of GlucaGen from the Vendor Pharmacy and placed it in the active drug supply. The facility policy titled, Storage of Medications dated 1/2011 documents, Procedure 1. (f) Medications shall not be kept on hand after the expiration date on the label and no contaminated or deteriorated medications shall be available. The facility policy titled, The Consultant Pharmacist dated 1/2011 documents, 4) The Consultant Pharmacist .is expected to make inspections of each nursing station, its related drug storage area and resident's medication monthly. 12) The consultant Pharmacist shall monitor the vendor pharmacy to ensure quality service in accordance with regulations and accepted practices. 1) On 02/05/19 at 02:06 PM the facility medication storage task was performed on the 2nd floor medication cart. It was observed that one box of GlucaGen [glucagon (rDNA origin) for injection] 1mg per vial. The box contained one vial of 1 ml of sterile water for reconstitution and one vial of GlucaGen powder. The prescription label attached to the outer box by the Vendor Pharmacy documented the fill date as 11/19/18. The outer box was labeled by the manufacturer with Lot number GW600009 and an expiration date of 10/2018. (meaning it is good until the end of the month 10/31/18). This box was expired on the day the Vendor Pharmacy filled the prescription. The Vendor Pharmacy sent this outdated medication to the facility. On 2/5/19 at 2:17PM the Registered Nurse #1 (RN) Medication Nurse was interviewed and stated, You are showing me a box with 2 vials of Glucagen. the date on the box is expired. The expiration dates says 10/18. Today's date is 2/5/19. This box is sitting here for 97 days. I have worked in this facility since October 2018. I am working on this unit for one month. When I am assigned as the Medication Nurse I am supposed to check the dates of the medication. I check the expiration dates before I give a resident the medication. I never checked this box. It was an over site on my part. On 02/05/19 at 2:27 PM Licensed Practical Nurse (LPN)#1 Charge Nurse was interviewed and stated, As far as the Glucagon I can't tell you what's wrong. You just asked me to look at the expiration date. The expiration date of this Glucagon is 10/2018. I am not sure what the actual date during the month this drug would expire. This box of Glucagon is 97 days past the expiration date. This expired Glucagon should not be here. It should have been reordered. I do not check the medications for expiration dates. I am expecting the Medication Nurse to check the expiration dates on the medications. If they find something expired they are supposed to remove it and reorder the medications. On 2/05/19 at 2:44 PM the Assistant Director of Nursing (ADON) was interviewed and stated, The nurses on all 3 shifts for the past 70 days should have checked the cart for old expired medications and then dispose of the expired meds. It is the responsibility of all the nurses, medication nurses and charge nurses to check the medications on the carts. The Charge Nurses work every other weekend as the Medication Nurses. This box of Glucagon says it expired on 10/2018. I don't know if it expired the first day of the month or the last day of the month. this box of Glucagon is her for 96 days past the expiration date. I would just like to point out that the date the pharmacy filled this medication according to the label is 11/19/18. So the pharmacy filled a prescription with an expired medication and delivered it to us. We have a Pharmacy Consultant who comes by once a month to check the medication carts and the medication rooms. On 2/05/19 at 3:59 PM the ADON was interviewed and stated, All 3 shifts of nurses have the responsibility to check the medication carts, medication room and refrigerators to make sure there are no expired medication. We have a Pharmacy Consultant that comes once a month. We expect him to also check the medication carts, medication rooms and the medication refrigerator to make sure there are no expired medications and all the medications are properly labeled with opening and expire dates where required. On 2/05/19 at 4:39 PM the Pharmacy Consultant was interviewed and stated, My responsibility is to review the residents' charts for any drug interactions, or overdose or under dosing. I look at the lab reports to see any corresponding therapeutic blood levels. I look at the Medication Administration Records, the Doctor Progress Notes and Psyche Notes. I inspect the medication carts, the medication refrigerator, emergency box and the narcotic cabinets. I look and check the expiration dates on all the medications in the carts, the refrigerator and the narcotic box and the Emergency Box. I do this on a monthly basis, and give the report to the Director of Nursing. The GlucaGen expired on 10/2018. This means it expires on the last day of the month which would have been 10/31/18. I was here doing the checks of the expiration dates in the medications cart on the 2nd floor in 11/23/18, 12/24/18 and 1/25/19. I honestly did not see this package of GlucaGen on the cart. As far as the Incruse inhalers not being labeled nobody brought it to my attention yet. When you open a package of Incruse inhaler I would have to look it up as to how long it is good for. I just looked it up and it is good for 6 weeks after opening. The standard of practice is also that the nurses should have labeled the date of opening on the outer box and the plastic inhaler. They should also write the residents name on the plastic inhaler. I was here every month inspecting the medication carts. I must have missed these 2 boxes of the inhalers. On 2/06/19 at 10:52 AM the Director of Nursing was interviewed and stated, I have been the DON here for 3 years. The 3 shifts of nurses over a 97 days period missed this box of expired GlucaGen and it was not taken out of the cart and discarded. The nurses need to be educated that the medications should be checked every shift for any expired medications. They should also label each box and plastic inhaler with the date the package was opened. If the nurses see a package of an inhaler that was not labeled with an opening date they should remove it from the cart and order a new package. I have to take responsibility for this happening under my supervision. Going forward we will educate the nurses. On 2/06/19 at 11:35 AM the Account Executive of the Vendor Pharmacy was interviewed and stated, My company filled this prescription for GlucaGen on 11/19/18. The box has an expiration date of 10/2018. This means the expiration date of the medication would be the last day of the month on 10/31/18. This was clearly an over site by our Pharmacist and Pharmacy Technition. I will call the Pharmacy and let you talk to our Pharmacist. On 2/06/19 at 11:40 AM the Pharmacist and Director of Compliance for the Vendor Pharmacy was interviewed and stated, I know the issue is the GlucaGen which was filled by our pharmacy on 11/19/18 and the box had an expiration date of 10/18. We are not supposed to be sending expired medications to nursing homes. We have Pharmacy Techs fill the prescriptions and we have a Registered Pharmacist review and check the medications before it leaves our pharmacy. Obviously the Pharmacist did not do a thorough job of checking the expiration date on the packaging. The expiration date was not covered and it was easily readable for them to see. Right now we will put together a plan of correction to 1) Review our current system, update the system to make sure it is more thorough. 2) To update our system and change the process. We will do our own audits. We have different departments. Each department will have their own team to look at the shelves and pull the expired items. 3) In-service and education of the Pharmacist. We will write up the Pharmacist. All Pharmacists and Techs will be in serviced. 415.18(b)(1)(2)(3)

**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 drugs were labeled in accordance with currently accepted professional principles and the expiration date when applicable. Specifically, the facility did not ensure that medications were properly labeled with an opening date, as well as an expiration date, removed from the active drug stock according to the manufacturer's recommendation and properly discarded from the medications carts on the 2nd and 3rd floor nursing units. ( one Floven diskus inhaler, 2 Incruse inhalers and one package of GlucaGen]. The facility policy titled, Storage of Medications dated 1/2011 documents, Procedure 1. (f) Medications shall not be kept on hand after the expiration date on the label and no contaminated or deteriorated medications shall be available. The facility policy titled, The Consultant Pharmacist dated 1/2011 documents, 4) The Consultant Pharmacist .is expected to make inspections of each nursing station, its related drug storage area and resident's medication monthly. 12) The consultant Pharmacist shall monitor the vendor pharmacy to ensure quality service in accordance with regulations and accepted practices. On 02/05/19 at 02:06 PM the facility medication storage task was performed on the 2nd floor medication cart. It was observed that one package of Flovent Diskus 100mg was open and in use. The counter read 59 of 60 doses. The prescription label attached to the outer box by the Vendor Pharmacy documented the fill date as 11/27/18. The nursing staff did not label the outer box or the inhaler device with a date of opening. The outer box documents: Discard FLOVENT DISKUS 2 months after opening the foil pouch or when the counter reads 0 (after all blisters have been used) whichever comes first. Also observed was one box of GlucaGen [glucagon (rDNA origin) for injection] 1mg per vial. The box contained one vial of 1 ml of sterile water for reconstitution and one vial of GlucaGen powder. The prescription label attached to the outer box by the Vendor Pharmacy documented the fill date as 11/19/18. The outer box was labeled by the manufacturer with Lot number GW600009 and an expiration date of 10/2018. (meaning it is good until the end of the month 10/31/18). This box was expired on the day the Vendor Pharmacy filled the prescription. The Vendor Pharmacy sent this outdated medication to the facility. On 2/5/19 at 2:17PM the Registered Nurse #1 (RN) Medication Nurse was interviewed and stated, When I open a Flovent inhaler I check the expiration date of the inhaler. I have to know how to use it. I am not supposed to do anything else. You are showing me a box with 2 vials of Glucagen. the date on the box is expired. The expiration dates says 10/18. Today's date is 2/5/19. This box is sitting here for 97 days. I have worked in this facility since October 2018. I am working on this unit for one month. When I am assigned as the Medication Nurse I am supposed to check the dates of the medication. I check the expiration dates before I give a resident the medication. I never checked this box. It was an over site on my part. On 02/05/19 at 2:27 PM Licensed Practical Nurse (LPN)#1 Charge Nurse was interviewed and stated, I have worked on this unit for 3 years. This is an inhaler of Flovent 100mcg which is in use. The name of the resident and the expiration date of the medication are not written on the plastic inhaler. The expiration date is 45 days from the date which the box was opened. The pharmacy label says it was filled on 11/27/18. This box has been opened for 69 days past the pharmacy label date. We cannot calculate the date of when to throw this inhaler out because the nurse did not write the date on the inhaler of the box when it was first put into use. This box should have been reordered and thrown out. The nurses are supposed to check the medication and reorder it when it is needed. The Medication Nurse did not put the residents name on the plastic inhaler with the expiration date of 45 days from the date it was opened. It wasn't checked so it was never reordered. As far as the Glucagon I can't tell you what's wrong. You just asked me to look at the expiration date. The expiration date of this Glucagon is 10/2018. I am not sure what the actual date during the month this drug would expire. This box of Glucagon is 97 days past the expiration date. This expired Glucagon should not be here. It should have been reordered. I do not check the medications for expiration dates. I am expecting the Medication Nurse to check the expiration dates on the medications. If they find something expired they are supposed to remove it and reorder the medications. On 2/05/19 at 2:44 PM the Assistant Director of Nursing (ADON) was interviewed and stated, The pharmacy label is dated November 27, 2018. This is the date the pharmacy filled this prescription. When the nurses open a box of Flovent and start it they should write the date it was opened on the plastic inhaler and the outer box. The name of the resident should also be on the plastic inhaler. Right now, there is no date of opening on the plastic inhaler or the outer box. There is no name of the resident on the plastic inhaler. We would discard this inhaler one month after it was opened. We don't know when it was opened. We would not know when to throw it out. From the pharmacy label date to today's date is 70 days. It is here because it was not discarded when it was supposed to be discarded. The nurses on all 3 shifts for the past 70 days should have checked the cart for old expired medications and then dispose of the expired meds. It is the responsibility of all the nurses, medication nurses and charge nurses to check the medications on the carts. The Charge Nurses work every other weekend as the Medication Nurses. This box of Glucagon says it expired on 10/2018. I don't know if it expired the first day of the month or the last day of the month. this box of Glucagon is her for 96 days past the expiration date. I would just like to point out that the date the pharmacy filled this medication according to the label is 11/19/18. So the pharmacy filled a prescription with an expired medication and delivered it to us. We have a Pharmacy Consultant who comes by once a month to check the medication carts and the medication rooms. On 2/05/19 at 3:18PM the facility Medication Storage task was performed on the 3nd floor medication cart. It was observed that 2 boxes of Incruse Ellipta (umeclidinium inhalation powder) 62.5 mcg. were open and in use. Box #1 contained one inhaler and one foil strip of 30 blisters- Lot number (10) 8ZP1812 Exp [DATE]. The counter read 16 of 30 doses were used. The prescription label attached to the outer box by the Vendor Pharmacy documented the fill date as 12/22/18. The nursing staff did not label the outer box or the inhaler device with a date of opening. The outer box documents Discard 6 weeks after opening the trray or when the counter reaches 0. A line on the plastic inhaler documented Tray opened was not labeled with an opening date by the nursing staff. Under this line for the date were the words Discard (6 weeks).' Box #2 contained one inhaler and one foil strip of 30 blisters - Lot number 8ZP9504 Exp 01-2020. The counter read 13 of 30 doses were used. The prescription label attached to the outer box by the Vendor Pharmacy documented the fill date as 8/29/18. The nursing staff did not label the outer box or the inhaler device with a date of opening. The outer box documents Discard 6 weeks after opening the tray or when the counter reaches 0. A line on the plastic inhaler documented Tray opened was not labeled with an opening date by the nursing staff. Under this line for the date were the words Discard (6 weeks).' On 2/05/19 at 3:23 PM the LPN #3 Medication Nurse was interviewed and stated, 'I have been working in this building for 6 months. I worked on this floor for one week. When I open a package of Incruse ellipta inhalation powder I am supposed to write the date on the outer box and on the plastic inhaler. This box or inhaler for Box #1 does not have the date it was opened written on it. The expiration date on this box says exp [DATE]. The inhaler is good for 30 days from when I open it. I would not know when to discard this inhaler if I did not write the date on the box or the plastic inhaler. As far as the Box #2 inhaler there is no date written on the box or the plastic inhaler of when it was first opened. It is good for 30 days before I have to discard it. I would not know when the 30 days are up because the date is not written on the box or the plastic inhaler. I should have asked the charge nurse when it was opened. The pharmacy label for Box #2 says it was filled on 8/29/18. On 2/05/19 at 3:43 PM LPN #2 was interviewed and stated, I have worked in the facility and on this unit for 2 years. When you open a box with an inhaler and take it out of the foil you are supposed to put the day of opening on it and the expiration date on it. I would put the date on the box and the plastic inhaler. For this medication Incruse the expiration date is 30 days from the opening date. This second box has the pharmacy label and is dated 8/29/18 of when it was filled by the pharmacy. So it seems that this box was in use from 8/29/18 until 2/5/19 which would be 159 days . There is no dates on this box or plastic inhaler For the first box of the Incruse it is the same. The pharmacy label says it was filled on 12/22/18. So from 12/22/18 to 2/5/19 it is 45 days in use. It does not have the date of opening or the date it expires. The nurse that first administers the medication and first opens it should put the date on the box and the plastic inhaler, as well as the expiration date. The next nurse that came should have checked the Medication Administration Record to see when it was first administered and then put the date on the box and the plastic inhaler. Without the date of opening you would not know when this medication was first started. It is the responsibility of all the nurses that worked all the shifts to check to see the medications are dated. On 2/05/19 at 3:59 PM the ADON was interviewed and stated, You just showed me 2 boxes of Incruse inhalers. Neither box of the medication or the plastic inhalers were dated by nurses upon opening or the date it should be discarded. Both plastic inhalers have the residents name on it. The date of discard after opening for this Incruse is 6 weeks after opening. The first box says the pharmacy filled it on 12/22/18. From 12/22/18 to 2/5/19 which is todays date is 45 days in use. It does not have the date of opening or the date it expires written on the box or the plastic inhaler. The second box says the pharmacy filled it on 8/29/18. From 8/29/18 to today it has been here 159 days. The problem is no nurses disposed of it after the 6 weeks. Even if the nurses went by the date the pharmacy sent it to the facility it would still be past the 6 weeks in use date. We would not know when it was opened. The next nurse on the next shift should have realized these boxes of inhalers were not properly dated. The nurses should have consulted with the previous shift to find out when it was opened and date it. If it is too far ahead of time they should have reordered it from the pharmacy and discarded the undated medication. All 3 shifts of nurses have the responsibility to check the medication carts, medication room and refrigerators to make sure there are no expired medication. We have a Pharmacy Consultant that comes once a month. We expect him to also check the medication carts, medication rooms and the medication refrigerator to make sure there are no expired medications and all the medications are properly labeled with opening and expire dates where required. On 2/05/19 at 4:39 PM the Pharmacy Consultant was interviewed and stated, My responsibility is to review the residents' charts for any drug interactions, or overdose or under dosing. I look at the lab reports to see any corresponding therapeutic blood levels. I look at the Medication Administration Records, the Doctor Progress Notes and Psyche Notes. I inspect the medication carts, the medication refrigerator, emergency box and the narcotic cabinets. I look and check the expiration dates on all the medications in the carts, the refrigerator and the narcotic box and the Emergency Box. I do this on a monthly basis, and give the report to the Director of Nursing. I was told you found a Flovent inhaler that was not labeled by the nurses with an opening date. It was filled by the pharmacy on 11/27/18. The Flovent inhaler is good for 60 days after it is first opened. The nurses did not date the package with the opening date. If the box is not dated the nurse should go back to the dispensing date as labeled by the pharmacy. The standard of practice is that the nurses should date this medication. Even if we go back to the 11/27/18 dispensing date it should have been removed and discarded on 1/27/19. It is in use 9 days past the expiration date. I did not come this month to perform the reviews as of this time so I would not have picked this up yet. I was here January 25th to do the checks. The GlucaGen expired on 10/2018. This means it expires on the last day of the month which would have been 10/31/18. I was here doing the checks of the expiration dates in the medications cart on the 2nd floor in 11/23/18, 12/24/18 and 1/25/19. I honestly did not see this package of GlucaGen on the cart. As far as the Incruse inhalers not being labeled nobody brought it to my attention yet. When you open a package of Incruse inhaler I would have to look it up as to how long it is good for. I just looked it up and it is good for 6 weeks after opening. The standard of practice is also that the nurses should have labeled the date of opening on the outer box and the plastic inhaler. They should also write the residents name on the plastic inhaler. I was here every month inspecting the medication carts. I must have missed these 2 boxes of the inhalers. On 2/06/19 at 10:52 AM the Director of Nursing was interviewed and stated, I have been the DON here for 3 years. It was brought to my attention yesterday that on the second floor there was one Flovent inhaler that was expired. The pharmacy label had a date of 11/2018 so it was in the cart more than 30 days from the date the pharmacy filled the prescription. The inhaler was not labeled with a date the nurse first opened the box. The proper procedure is that the nurse opening the box of the Flovent inhaler should label the inhaler with the date it was opened as well as the residents name and room number. If the Flovent is still in use for 30 days from the date it was opened it should be thrown out and a new box ordered. There was also a box of GlucaGen that was never used and that had expired and this box had an expire date of 10/2018. The box was on the cart for 97 days past the expiration date. We have 3 shifts of nurses working in the facility. The 3 shifts of nurses over a 97 days period missed this box of expired GlucaGen and it was not taken out of the cart and discarded. I heard that on the 3rd floor there were 2 boxes of Incruse inhalers that were on the medication cart and were expired. One Incruse had a pharmacy label with a fill date of 8/29/18 and the other had a pharmacy label with a fill dated of 12/28/18. The nurses that first administered the inhalers and opened the box did not label the box and the inhaler with a date of opening. I do not know how long you can use the Incruse inhaler before you discard it. I think it is 30 days but I will get back to you. If the nurses don't label the box and inhaler with a date of opening we would not know when to discard it. So from the pharmacy label dated 8/29/18 until 2/5/19 is 159 days. For the second Incruse inhaler the pharmacy label date is 12/22/18 until 2/5/19 is 45 days. Even if we assume the nurses opened the Incruse inhalers on the date the label says it was filled by the pharmacy both these Incruse inhalers are here past the discard date. The nurses need to be educated that the medications should be checked every shift for any expired medications. They should also label each box and plastic inhaler with the date the package was opened. If the nurses see a package of an inhaler that was not labeled with an opening date they should remove it from the cart and order a new package. I have to take responsibility for this happening under my supervision. Going forward we will educate the nurses. On 2/06/19 at 11:35 AM the Account Executive of the Vendor Pharmacy was interviewed and stated, My company filled this prescription for GlucaGen on 11/19/18. The box has an expiration date of 10/2018. This means the expiration date of the medication would be the last day of the month on 10/31/18. This was clearly an over site by our Pharmacist and Pharmacy Technition. I will call the Pharmacy and let you talk to our Pharmacist. On 2/06/19 at 11:40 AM the Pharmacist and Director of Compliance for the Vendor Pharmacy was interviewed and stated, I know the issue is the GlucaGen which was filled by our pharmacy on 11/19/18 and the box had an expiration date of 10/18. We are not supposed to be sending expired medications to nursing homes. We have Pharmacy Techs fill the prescriptions and we have a Registered Pharmacist review and check the medications before it leaves our pharmacy. Obviously the Pharmacist did not do a thorough job of checking the expiration date on the packaging. The expiration date was not covered and it was easily readable for them to see. Right now we will put together a plan of correction to 1) Review our current system, update the system to make sure it is more thorough. 2) To update our system and change the process. We will do our own audits. We have different departments. Each department will have their own team to look at the shelves and pull the expired items. 3) In-service and education of the Pharmacist. We will write up the Pharmacist. All Pharmacists and Techs will be in serviced. 415.18(d)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews conducted during the receritfication survey, the facility did not provide a sanitary and comfortable environment for residents. Specifically, a resident's shared bathroom was observed to have a very strong odor of urine over an extended period of time. This was evident for 1 resident bathroom. The findings are: The facility's Cleaning of Resident's Room Policy and Procedure dated 12/5/12 does not include specific procedures related to cleaning/sanitizing resident's shared bathrooms. Multiple observations were made of the shared resident bathroom between rooms [ROOM NUMBERS] on 2/04/19, 2/06/19, and 2/07/19. A very strong odor of urine was emanating from the bathroom on each occasion even though there was no urine visible in the toilet bowl or on the floor of the bathroom. On 2/07/19 at 9:55 AM, the odor of urine was so strong that it could be smelled from resident room [ROOM NUMBER] while the bathroom door was closed. On 02/07/19 at 10:31 AM, an interview was conducted with the [NAME] for the 5th floor. The [NAME] stated that she mopped the shared bathroom between room [ROOM NUMBER]-507 and cleaned the toilet around 8am this morning. The [NAME] stated that the resident in room [ROOM NUMBER] has a behavior of urinating on the bathroom floor; and, even after mopping, the bathroom still smells of urine because the liquid is able to permeate underneath the toilet bowl and stays trapped there. The grout at the base of the toilet bowl is coming apart and is no longer able to keep the liquid from the urine and cleaning solution from being pushed under the toilet. As a result, the [NAME] stated that this particular bathroom has a stronger urine smell than any of the others. The [NAME] stated that she has reported the issue previously to her supervisor, the Director of Housekeeping and Maintenance ([NAME]), to make him aware. The [NAME] provided her with a special cleaning solution approximately 1 month ago to address the issue. She does not believe that this solution has adequately addressed the strong urine smell in the shared bathroom. To her knowledge, a different cleaning solution was ordered and provided for her to use in the shared bathroom today. The [NAME] stated that the [NAME] did personally come to the 5th floor unit to observe the shared bathroom and strong urine smell. She believes that the toilet bowl may eventually be replaced altogether to ensure that urine can longer get trapped beneath it during cleaning. An interview was conducted with the [NAME] on 02/07/19 at 10:46 AM. The [NAME] stated that he has spoken to the [NAME] in relation to the 5th floor bathrooms; however, those conversations involved the issues between the Maids and Porters on the unit regarding whose responsibility it was to clean the residents' bathrooms. The [NAME] has not specifically discussed the strong urine smell in shared bathroom in 506-507 with the Porter. He is not aware of any issue involving this particular bathroom. The [NAME] does environmental rounds on a least one floor per day. This includes checking residents' bathrooms for odors and cleanliness. The [NAME] has not noticed a strong odor of urine coming from the shared bathroom between 506-507 on prior rounds. He cannot recall specifically when he last did rounds on this unit but believes it may have been the previous week. Upon observing the shared bathroom between 506-507 with the SA, the [NAME] agreed that there was a strong urine odor emanating from the area. He stated that he was made aware of this previously, he would have taken the toilet out and would have regrouted the bathroom to prevent urine from seeping in and creating a strong foul odor. The [NAME] stated that he will now instruct his Maintenance workers to pull out the toilet bowl and regrout and clean the area. 415.29

Based on observations and interviews during the recertification survey, the facility did not ensure a sanitary environment to help prevent the development transmission of cummunicable diseases and infections. Specifically, On more than one occasion CNA #1 was observed not practicing hand washing or hand hygiene while providing meal service to more than one resident. This was evident for 1 CNA observed on multiple occasions while providing care to more than one resident. The findings are: 1) During the lunch meal observation on 02/04/19 at 12:08 PM, Certified Nursing Assistant (CNA) #1 was observed unfolding and opening a resident's foil packet containing a grilled cheese sandwich. CNA #1 was then observed to handle the grilled cheese sandwich with her bare hands while cutting it in half for the resident. The sandwich was then placed on the resident's plate for him to eat. CNA #1 was then observed going to another resident in the Floor Day Room (FDR) and assisted with opening the resident's carton of milk. While opening the container, it was observed that CNA#1 had her bare hands touching the spout of the milk carton where the resident would place their mouth. CNA #1 did not wash or sanitize her hands prior to or during this observation. 2) CNA #1 was then observed dropping a plastic cup on the floor. She picked up the cup with her bare hands, threw the cup away in the FDR trash receptacle, grabbed another plastic cup and served a tray with the plastic cup on it to a resident. CNA #1 did not wash or sanitize her hands after picking up the plastic cup from the floor. 3) On 02/05/19 at 12:10 PM, CNA #1 was observed during lunch meal service wheeling a resident into the FDR with bare hands. CNA #1 then bent down, and maneuvered the leg rests of the resident's wheelchair while locking it into place. CNA #1 then picked up a meal tray and served the same resident. CNA #1 was not observed washing or sanitizing her hands prior to serving the resident his lunch tray. An interview was conducted with CNA #1 on 02/11/19 at 09:25 AM. She stated that hand washing and sanitizing is to be done after caring for each resident and whenever entering a resident's room. During meal time, hands are to be washed before serving, after feeding residents, and in between serving trays. CNA #1 confirmed that facility staff are supposed to wash their handsprior to serving a resident is they pick something up of the floor in between. CNA #1 stated that this is done to promote a proper infection control policy. CNA #1 stated that her last in-service on infection control was done yesterday and that she is re-inserviced on a regular basis regarding infection control policies and procedures. 415.19(a)(1-3)

Based on observations and interviews conducted during the recertification survey, the facility did not ensure that resident's received oral and written information on how to contact the New York State Long Term Care Ombudsman's Office and the New York State Department of Health (NYSDOH) Complaint Line. This deficient practice affected all residents and their representatives. The findings are: During the Resident Council Meeting held on 02/05/19 at 2:15 PM with 10 regularly attending members of the facility Resident Council and the President of the Resident Council, it was reported by the residents in attendance that they were unaware of how to contact the local NYS Ombudsman and how to formally make a complaint to the NYSDOH Complaint Line. The residents stated that they were not provided this information verbally, or in written communication. Observations were made on 02/05/19 at 03:17 PM on each of the 7 floors of the facility. It was observed that the first floor/lobby area was the only area that displayed the information related to contacting both the Ombudsman's Office and the NYSDOH Complaint Line. This area of the facility is not frequented by residents and is the site of Administration Offices only. The Activity Room/Main Dining Room located on the 1st floor of the facility did not contain any notices related to contacting the Ombudsman or the NYSDOH. Further observations made on the residential units of the facility revealed that the 3rd and 5th floor units contained no posted contact information for the Ombudsman or the NYSDOH. The facility's 4th and 6th floor did not display the NYSDOH Complaint Line contact information. An interview was conducted with the facility's Administrator on 02/06/19 at 12:03 PM. The Administrator stated that signs displaying the Ombudsman's Office and the NYSDOH Complaint Line phone numbers are posted in the lobby and each floor has a bulletin board near the stairwell that should have them posted as well. The Resident [NAME] of Rights should also be posted on each residential unit. The Administrator stated that he is responsible for ensuring that these signs are posted for residents to see. Approximately one month ago, the Administrator checked for these specific signs on each unit. He stated that the wallpaper on each unit was changed within the past 4 weeks. As a result, the bulletin boards were probably removed resulting in missing signage. He further stated that the facility does not place any contact numbers for the Ombudsman or the NYSDOH in the Activity Room/Main Dining Room. 415.3(c)(1)(vi) 415.3(c)(2)(i)(b)