Based on interviews, observations, and record review conducted during a Recertification Survey and complaint investigation (#NY00276039) completed on 8/6/21, it was determined for two (Residents #430 and #261) of three residents reviewed, the facility did not report allegations of abuse, neglect or mistreatment to the New York State Department of Health (NYSDOH) in a timely manner. Specifically, an incident of resident-to-resident physical abuse with injuries was not reported to the NYSDOH in the time frame required. This was evidenced by the following: The facility policy, Abuse Investigation, dated 3/24/21, revealed that NYSDOH would be notified when there is reasonable cause to believe abuse, neglect or mistreatment has occurred. The facility would report to the NYSDOH serious bodily injury within 2 hours after forming a suspicion, and for all other incidents within 24 hours. Resident #261 had diagnoses that included Alzheimer's Disease, dementia, and major depressive disorder. The Minimum Data Set (MDS) Assessment, dated 7/9/21, revealed the resident had severely impaired cognition. Resident #430 had diagnoses including vascular dementia, high blood pressure, and a recent fractured left hip (5/09/21). The MDS Assessment, dated 7/13/21, revealed the resident had severely impaired cognition. Review of the Resident Incident Report, dated 5/9/21, revealed that on 5/9/21 at 12:20 p.m., a Licensed Practical Nurse (LPN), reported that when Resident #430 was walking out of their room, Resident #261 grabbed Resident #430's wrists and pushed them causing Resident #430 to fall onto the floor. A Registered Nurse (RN) completed an assessment of Resident #430, medical was notified, and an x-ray was completed revealing a fracture of the left hip. An undated Incident Investigation Summary completed by the Director of Nursing (DON), included that the incident on 5/9/21 was witnessed by an LPN who recounted that when the Residents passed by one another while walking, Resident #261 impulsively turned toward Resident #430, grasping Resident #430's wrists and pushed the resident toward the wall causing Resident #430 to fall to the ground. The report included that Resident #430 was injured and sent to the hospital for treatment. The Health Electronic Response Data System (HERDS), a reporting system where facilities report incidents to NYSDOH, revealed that the incident was not submitted to NYSDOH until 5/12/21. When interviewed on 8/6/21 at 7:54 a.m., the DON stated both residents were demented and lacked intent, so the incident did not fall under the category of abuse, neglect, or mistreatment. The DON said that the facility had 5 days to report the incident to NYSDOH. [10 NYCRR 415.4(b)(2)]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #15) of two residents reviewed for respiratory care, the facility did not ensure that the resident's care plan was reviewed or revised to reflect the resident's current condition. The issue involved the lack of care plan revisions for Continuous Positive Airway Pressure (CPAP) therapy. This is evidenced by the following: Resident #15 was admitted to the facility on [DATE] for rehabilitation with a diagnosis of obstructive sleep apnea. The Minimum Data Set Assessment, dated 9/16/18, revealed that the resident was cognitively intact. The Physician admission Assessment, dated 4/30/18, revealed that the resident had sleep apnea and used a CPAP machine (a person wears a face mask during sleep which is connected to a pump, CPAP machine that forces air into the nasal passages at pressures high enough to overcome obstructions in the airway and stimulate normal breathing). Physician orders, from 4/30/18 through 10/18/18 and 12/21/18, included to provide the CPAP protocol (put on in the evening and off in the morning, and as needed during the day) and the care of the CPAP equipment. The Comprehensive Care Plan, initiated 5/1/18, revealed that the resident had sleep apnea. Interventions included providing the CPAP as ordered. There were no revisions documented. During an observation and interview with the resident on 1/4/19 at 11:05 a.m. and on 1/7/19 at 12:41 p.m., the resident said that he had sleep apnea and has a CPAP machine at home that does not work very well. The resident said that no one has asked him if he wanted a new CPAP, and he probably would not wear one anyway. There was no CPAP machine observed in the resident's room. Progress notes from admission and throughout the record documented that the resident does not wear, refuses, or does not have the CPAP machine. A progress note, dated 5/2/18, revealed that the resident stated he had a CPAP at home. A progress note, dated 10/5/18, documented that the resident has been refusing CPAP since admission. A progress note, dated 10/14/18, revealed that the resident did not have a CPAP machine in his room. Review of the Treatment Administration Records (TARs) for October 2018 and December 2018 included an entry for the CPAP protocol and the care of the CPAP per the orders. The TAR had not been signed off as completed 86/93 opportunities, and on 12/23/18 and 12/26/18 it was signed off that care for the CPAP machine was done. There was no documentation that education regarding the resident's decision not to use the CPAP machine for his sleep apnea was provided. When interviewed on 1/7/19 at 12:57 p.m., the Clinical Coordinator said the resident refused to wear the CPAP machine since the day he came in and everybody was aware. The Clinical Coordinator said that the physician orders should have been discontinued, and the resident's care plan should have been revised. The Clinical Coordinator said that he did not know if there was any documentation that the resident had been educated regarding his sleep apnea and the use of the CPAP machine. When interviewed on 1/7/19 at 2:04 p.m., the Registered Nurse Manager (RNM) said she just started completing care plans for the unit. She stated if nursing was reporting that the resident was not using the CPAP machine, someone should have had an educated conversation with the resident. The RNM said if the resident was not going to use the CPAP, then it should have been discontinued from the orders and the care plan revised. The facility policy for Comprehensive Care Plans, effective 5/30/18, revealed that the care plan will be updated, reviewed and evaluated including care plan goals, interventions and approaches on an ongoing basis. [10 NYCRR 415.11(c)(2)(iii)]

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #352) of six residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regimen remained free from unnecessary medications. Specifically, the resident received an as needed antipsychotic medication on the day of admission to the facility without documentation that the medication was used to treat a diagnosed specific condition, whether symptoms were clinically significant enough to administer an antipsychotic medication, and what non-pharmacological interventions were attempted prior to the administration of an antipsychotic medication. This is evidenced by the following: Resident #352 was admitted to the facility for rehabilitation on 12/20/18 following surgery for a right femoral neck fracture. The Minimum Data Set Assessment, dated 12/27/18, revealed that the resident had moderately impaired cognition and symptoms of delirium. The hospital discharge paperwork, dated 12/20/18, revealed that the resident was alert and oriented to person, received Haldol (antipsychotic) as needed (last dose documented was 12/18/18), and prior to admission the resident was independent with activities of daily living, driving and working part time without symptoms of confusion. The Registered Nurse (RN) Assessment, dated 12/20/18, included that the resident was alert, oriented to person and very confused on admission. The resident thought he was in a hotel and was dropped off by a taxi. The resident talked about leaving the facility, but then a family member arrived and he calmed down. The Physician admission Exam, dated 12/20/18, revealed that the resident's postoperative course included delirium which was treated with Haldol. The resident was in no acute distress and had a normal mood. The assessment and plan included a delirium workup, repeating lab work, a bladder scan and medications. The plan was discussed with the resident's family member. Physician orders, dated 12/20/18, included Haldol every eight hours as needed for agitation. The related diagnosis field was blank. The December 2018 Medication Administration Record revealed that the resident received an intramuscular (IM) injection of Haldol on 12/20/18 at 5:16 p.m. There was no documentation regarding the resident's behavior or the reason the Haldol was administered. When interviewed on 1/4/19 at 3:19 p.m., the RN who admitted the resident to the facility and administered the IM Haldol said that the resident came in on the evening shift and was extremely confused, talking combatively such as I am going to rip people's heads off, or I am going to shove this . The RN said she was not afraid of the resident. She said the resident was afraid and did not know where he was and commented my family has abandoned me here. The RN said that the resident wanted to leave and went toward the emergency exit to go out the door. The RN said initially the resident would not let the physician examine him. The RN said the physician gave her a verbal order for oral Haldol which the facility did not have, so the physician changed the order to IM. The RN stated that she had mixed feelings about giving the IM Haldol. She said the resident's family member arrived shortly thereafter and the resident calmed down. The RN said that initially she tried reorienting the resident which was not working. The RN said she did not write a behavior note. Interviews conducted on 1/7/19 included the following: a. At 9:30 a.m., the physician said that the resident was admitted to the facility between 4:00 and 5:00 p.m. and wanted to go home. He said the resident was delirious and unable to calm down. The physician said he called the resident's family member, ordered the Haldol, and removed the resident's walker and placed it outside of his room so he would not go far. The physician said that the resident was a risk to himself because he could fall and break his hip without his walker so he needed the Haldol. The physician said that once the resident's family member arrived he was calm and had normal conversation. He said that the resident's diagnosed specific condition would be delirium. When asked about the underlying cause the physician said people with dementia are prone to delirium due to anesthesia and pain, however this resident's hospital record did not mention dementia. The physician said the resident's symptoms were loss of insight as he did not understand that he was at the facility for rehabilitation. The physician said that the staff did not attempt any other non-pharmacologic interventions other than calling the family member and having them with the resident. He said that is the best treatment for residents with delirium. b. At 9:30 a.m., the Medical Director was interviewed with the physician. The Medical Director said she was called at home by the physician due to the resident being agitated and not having capacity to make decisions himself. The Medical Director said that a delirium workup was ordered for the following day which included blood work, urine, and a medication review which was all normal. The Medical Director said that she audited the resident's medical record after discharge (1/4/19), and he was off all antipsychotic medications. The Medical Director said that diagnoses, cause, symptoms, and the non-pharmacologic interventions attempted prior to the administration of the Haldol should have been documented during the time the resident was experiencing symptoms and the Haldol was administered. c. At 1:51 p.m., the Clinical Coordinator said that there should be good documentation as to why an antipsychotic is being administered and the non-pharmacologic interventions attempted beforehand. The Clinical Coordinator said if it was not documented, then it was not done. d. At 2:16 p.m., the Registered Nurse Manager said if a resident warrants IM Haldol within hours of being admitted to the facility, then she would expect detailed documentation. The facility policy for Psychotropic Medications, dated 10/9/17, revealed that the Medical Provider will order psychotropic medication only for treatment of specific medical and/or psychiatric symptoms to alleviate significant distress for the resident when nonpharmacologic approaches are not effective. They are to document diagnosis and rationale for use and identify target symptoms, document discussion with the resident and/or responsible party regarding the risk versus benefit of the medication including any black box warning or off label use. [10 NYCRR 415.12(1-2)]