**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review during the Recertification Survey and Abbreviated Survey (Complaint # NY00319453) completed on 4/23/2024, the facility did not ensure resident rights to be free from abuse. This was identified for one (Resident #311) of two Residents reviewed for Abuse. Specifically, Resident #311 who had a history of verbally disruptive and intrusive behavior such as attempts to enter other resident rooms, antagonize residents, excessive talking, inappropriate outbursts, and mocking other residents, was transferred to Resident #310's unit on 5/3/2023 after returning from emergency room status post verbal altercation with a resident on the previous unit. Resident #311 continued to have disruptive behaviors including paranoia, agitation, incessant speaking, and being accusatory toward others on the newly assigned unit. On 7/3/2023 Resident #310 punched Resident #311 on the face. Resident #310 stated they hit Resident #311 because they (Resident #311) used foul language toward them. Resident #311 sustained a three-centimeter linear scratch to the right face and an open area to the right upper ear. The finding is: The facility policy entitled Abuse Identification and Investigation, Prevention, and Reporting dated 10/31/2022 documented that the Federal definition of abuse is the willful infliction of injury with resulting physical harm, pain, or mental anguish. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The New York State definition of abuse is inappropriate physical contact with a resident of a residential health care facility while the resident is under the supervision of the facility, which harms or is likely to harm the resident. The facility will be cognizant to identify trends in the behaviors of residents that are likely to provoke situations that could lead to abuse and to care plan those behaviors with individualized and appropriate interventions. -Resident #310 was admitted to the facility with the diagnoses of Anxiety Disorder, Depression, and Psychotic Disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #310 had a Brief Interview for Mental Status score of 5, indicating severely impaired cognition. Resident #310 was independent in bed mobility, transfers, and walking. Resident #310 had no behaviors noted on the minimum data set assessment. The Medical Note dated 6/1/2023 documented Resident #310 was noted to be hallucinating therefore urine culture was done along with a psychiatric evaluation. Resident #310 was noted with a history of Anxiety, Depression, and previous psychiatric hospitalization in 2020. Resident #310 with a negative work-up for infection, remains calm, and cooperative with no further Psychosis. Resident #310 is to continue with Risperdal (an antipsychotic medication) 3 milligrams, monitor, and supportive care for now. The Behavior care plan for Resident #310 dated 7/4/2023 documented that Resident #310 was at risk for resident-to-resident altercation related to confusion, impaired judgment, and mood disorder. Interventions included to keep Resident #310 away from other residents exhibiting physical/verbal behavioral symptoms directed towards others, Redirect/Refocus attention by offering alternatives, keep engaged in varied activities to reduce the possible chance of wandering into the space or room of residents exhibiting physical/verbal behavioral symptoms directed towards others, 1:1 observation for 48 hours. Resident #310's medical record lacked documented evidence of an altercation on 7/2/2023 between Resident #310 and Resident #311. The Resident Accident and Incident Report dated 7/3/2023 for Resident #310 documented that at 6:10 PM a Resident-to-Resident incident occurred. Registered Nurse Supervisor # 5 was called to Unit B by Certified Nurse Aide #7 for an altercation between Resident #310 and Resident #311. Certified Nurse Aide #7 reported that Resident #310 punched Resident #311 in the face after Resident #311 cursed at Resident #310. Resident #310 was alert, confused, calm, and cooperative. Resident #310's statement documented I hit [Resident #311] because [they] said F you. -Resident #311 was admitted to the facility with the diagnoses of Coronary Artery Disease, Depression, and bipolar disorder. The Quarterly Minimum Data Set assessment dated [DATE] documented Resident #311 had a Brief Interview for Mental Status score of 15, indicating intact cognition. The Minimum Data Set assessment documented that Resident #311 had verbal behaviors directed towards others. Resident #311 also rejected care and wandered. Resident #311 had impairment on one side at the lower extremity. Resident #311 used a walker and wheelchair for mobility. The Behavior care plan for Resident #311 dated 7/16/2022 and last revised on 5/17/2023 documented that Resident #311 exhibited disruptive behavior including verbal symptoms directed toward others (threatening others, screaming at others, and cursing), cursing and screaming at nursing staff, as well as rolling their (Resident #311) wheelchair around the nursing station to disturb nurses during their med passes. The interventions included to keep Resident #311 within viewing distance for observation as much as possible, redirect and refocus the resident's attention by offering alternatives (comfort foods or engaging in individual therapy). A review of progress notes from 4/5/2023 to 5/2/2023 revealed that Resident #311 presented with paranoid and disruptive behaviors. Resident #311 was noted with intrusive behavior such as attempts to enter other resident rooms, antagonizing other residents, excessive talking, inappropriate outbursts, and mocking other residents. On 5/2/2023, Resident #311 was noted screaming at another resident while sitting outside of the resident's room. Resident #311 made accusations against the resident and was not responsive to redirection. Resident #311 was sent to the emergency room for evaluation. The Social Work progress note dated 5/3/2023 documented that Resident #311 continued to present with increased behavioral symptoms as evidenced by verbal disruption, intrusiveness, and threatening and accusatory behaviors. It was difficult to redirect the resident. The resident is provided with ongoing reminders/cueing/re-direction/reality orientation; however, behaviors persisted. As per the interdisciplinary team's recommendation Resident #311 will be temporarily moved to another unit today. Staff will continue to observe the resident for changes in mood and/or behavior and validate concerns. A review of progress notes from 5/4/2023 to 6/27/2023 (after the resident was moved to Resident #310's unit) revealed that Resident #311 continued to present with disruptive behaviors including paranoia, agitation, incessant speaking, and accusatory towards others. Resident #311 was also noted to be interruptive to other people's conversations while wheeling themselves around the facility. The Resident Accident and Incident Report dated 7/3/2023 for Resident #311 documented that at 6:10 PM a Resident-to-Resident incident occurred. Registered Nurse Supervisor #5 was called to Unit B by Certified Nurse Aide #7 for an altercation between Resident #310 and Resident #311. Certified Nurse Aide #7 reported that Resident #311 was punched by Resident #310 while passing each other in the hallway. Resident #311 was found in the wheelchair in the hallway agitated and uncooperative. Resident #311 had an approximately 3-centimeter linear scratch to the right side of the face and a pinpoint open area to the right upper ear. Resident #310's statement documented [Resident #310] punched me for no reason. The updated Investigative Summary concluded Resident #310 did have intentional contact with Resident #311. The investigation revealed that there is no cause to believe abuse has occurred. Certified Nurse Aide #7 was interviewed on 4/19/2024 at 3:29 PM. Certified Nurse Aide #7 stated they were the regularly assigned Certified Nurse Aide for Resident #311 on the 3:00 PM to 11:00 PM shift since the resident moved to Unit B on 5/3/2023. Certified Nurse Aide #7 stated that Resident #311 had episodes of screaming at others and would sometimes be in a bad mood. Certified Nurse Aide #7 stated that on 7/3/2023 at about 6:00 PM, they (Certified Nurse Aide #7) were serving dinner and heard Resident #310 and Resident #311 yelling back and forth. Certified Nurse Aide #7 overheard Resident #311 say F-you very loudly. Certified Nurse Aide #7 then observed Resident #310 and Resident #311 throwing fists at each other. Certified Nurse Aide #7 stated they (Certified Nurse Aide) immediately separated the residents and called for help. Certified Nurse Aide #7 confirmed that Resident #311 was punched in the face by Resident #310. Registered Nurse Supervisor #5 was interviewed on 4/22/2024 at 10:51 AM and stated that they responded to the incident on 7/3/2023. Registered Nurse Supervisor #5 stated that Resident #311 was struck by Resident #310. Resident #310 told Registered Nurse Supervisor #5 that Resident #311 was always bothering Resident #310 and that is why Resident #310 reacted by punching Resident #311. Registered Nurse Supervisor #5 stated that Resident #311 had a history of behavioral issues and was very persistent and difficult to redirect. The Director of Nursing Services was interviewed on 4/22/2024 at 1:50 PM and stated that on 7/3/2023, they got a call from the Administrator that Resident #310 and Resident #311 had an altercation. When the Director of Nursing Services arrived at the facility, the Administrator had already called the local police for assistance. The Director of Nursing Services stated Resident #311 had a scratch on the right side of their head. Resident #311 was encouraged to go to the hospital but refused. Resident #311 was upset about the situation, saying [Resident #310] punched me for no reason. The Director of Nursing Services stated that Resident #310 admitted to punching Resident #311 because Resident #311 cursed at Resident #310. The Director of Social Work was interviewed on 4/22/2024 at 3:35 PM. The Director of Social Work stated that Resident #311 had consistent behavior of interjecting in other people's conversations and boisterousness with other residents. Resident #311 was difficult to redirect and required to be kept within viewing distance to help avoid potential conflicts with other residents. The Director of Nursing Services was re-interviewed on 4/22/2024 at 3:55 PM. The Director of Nursing Services stated Resident #310 did abuse Resident #311 when Resident #310 hit Resident #311 on 7/3/2023. The Director of Nursing Services stated that in the Incident Report summary dated 7/3/2023, they erroneously documented that the altercation between Resident #310 and Resident #311 was not abuse. The Director of Nursing Services stated that when they reported the incident to the New York State Department of Health they indicated the altercation between Resident #310 and Resident #311 resulted in abuse for Resident #311. The Director of Nursing Services further stated that the incident between Resident #310 and Resident #311 resulted in abuse for Resident #311. 415.4(b)(1)(ii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the Recertification Survey initiated on 4/16/2024 and completed on 4/23/2024, the facility did not ensure that a comprehensive person-centered care plan was implemented for each resident that includes measurable objectives and timeframes to meet resident's medical and nursing needs. This was identified for one (Resident #16) of one resident reviewed for position and mobility. Specifically, Resident #16 had a physician's order for a hip abduction flexion contracture cushion (abduction pillow) to be worn at all times. During observations on 4/17/2024 at 9:00 AM and on 4/19/2024 at 9:00 AM Resident #16 was observed in bed without a hip abduction flexion contracture cushion. The finding is: The facility's policy titled, Assistive Devices last revised 11/2022 documented nursing staff is responsible for ensuring the wearing schedule for assistive devices is followed. Conduct skin inspection at a minimum every shift unless otherwise ordered. Nursing or any other clinical discipline shall report any adverse reaction from the assistive device such as redness, discomfort, discoloration, excoriation, etc to the Occupational or Physical Therapist. Resident #16 was admitted with diagnoses including a Fracture of the Left Femur, Dementia, and Cardiomyopathy. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 3, indicating the resident had severe cognitive impairment. The Minimum Data Set documented the resident had functional limitations in the range of motion to both lower extremities. The Comprehensive Care Plan (CCP) titled, Fracture of Left Hip dated 6/02/2023 documented interventions including a hip abduction pillow to be worn as tolerated for positioning and to prevent contractures. The hip abduction pillow is to be removed for skin checks and hygiene. The Physical Therapist's Evaluation and Plan of Treatment dated 8/11/2023 documented the resident maintains their hip in an adducted and flexed position requiring the need for a hip abduction wedge for positioning. The Physical Therapist's Discharge summary dated [DATE] documented a recommendation for a hip abduction flexion contracture cushion while in bed and to remove it for skin checks and hygiene. The Comprehensive Care Plan titled, Activities of Daily Living effective 9/01/2023 documented an intervention for the placement of a pillow between knees when in bed for comfort as tolerated. A Physician's order dated 2/20/2024 and last renewed on 4/05/2024 documented the hip abduction flexion contracture cushion to be worn at all times in bed and the Geri chair; remove for skin checks/hygiene. On 4/17/2024 at 9:00 AM, Resident #16 was observed curled up in bed. The resident was not wearing the hip abduction flexion contracture cushion. On 04/19/2024 at 9:00 AM, Resident #16 was observed in bed with no hip abduction flexion contracture cushion in place. Certified Nursing Assistant #2 was interviewed on 04/19/2024 at 9:04 AM and stated that Resident #16 often removes and puts the hip abduction flexion contracture cushion on the floor. The Certified Nursing Assistant located the hip abduction flexion contracture cushion in Resident #16's closet. The Certified Nursing Assistant stated the hip abduction flexion contracture cushion was on the floor when they came in to provide care and they put the hip abduction flexion contracture cushion in the closet. Certified Nursing Assistant #2 stated they did not notify anyone regarding the resident's behavior of removing the abduction pillow. Certified Nursing Assistant #2 then asked the resident if they (Certified Nursing Assistant #2) could place the hip abduction flexion contracture cushion on them and the resident refused. Certified Nursing Assistant #2 stated they would notify the nurse that Resident #16 refused their hip abduction flexion contracture cushion. Registered Nurse #4, the Unit Manager, was interviewed on 4/19/2024 at 9:06 AM and stated they were not aware that Resident #16 refused the hip abduction flexion contracture cushion. Registered Nurse #4 stated the Certified Nursing Assistants should have notified them of the resident's refusal to use the abduction pillow. They would have then notified the Rehabilitation department to re-evaluate the resident. The Occupational Therapy Evaluation and Plan of Treatment dated 4/19/2024 documented Splint /Orthotic Recommendations: It is recommended the [resident] continue to wear the current device with current orders as [resident] was able to tolerate today without [complaint of] pain or discomfort. Physical Therapist #1 was interviewed on 4/22/2024 at 9:30 AM and stated Resident #16 has both hips and leg contractures and was recommended by the Rehabilitation Therapy Department to use the hip abduction flexion contracture cushion upon discharge from therapy on 8/31/2023. The cushion is utilized to keep the hips from rotating and the legs from contracting. If Resident #16 was refusing the hip abduction flexion contracture cushion, the nursing staff should have notified the Physical Therapy department to re-evaluate the resident for alternate devices. The Director of Nursing Services was interviewed on 4/23/2024 at 9:22 AM and stated Resident #16 had been refusing the hip abduction flexion contracture cushion; the Physical Therapy Department was alerted on 4/19/2024. The Director of Nursing Services stated the nurses were expected to notify the resident's Physician and/or Physical Therapist to re-evaluate Resident #16 for alternative devices. 10 NYCRR 415.11(c)(1)

Based on observation, record review, and interviews during the Recertification Survey initiated on 4/16/2024 and completed on 4/23/2024, the facility did not ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles. This was identified for one (Resident #312) of four residents reviewed for medication administration. Specifically, during the medication pass observation on 4/17/2024 for Resident #312, the labels on the medication blister packs, for physician-prescribed Allopurinol (a medication to reduce uric acid to treat gout and kidney stones) and Torsemide (a diuretic to help reduce fluid in the body), did not match the physician orders. The finding is: The facility's policy titled, Pharmacy, dated June 2018, documented the facility utilizes its pharmaceutical services system to ensure the safe and effective use of medications for all our residents; this facility does not have an in-house pharmacy; this facility uses a blister pack system; Medications no longer in use shall be returned for credit or destroyed in accordance with established policies and procedures. The facility's policy titled, Medication: Administration-General dated December 2021, documented the nurse will review the physician's orders and compare them against the medication administration record. Compare the medication name, strength, and dosage schedule on the medication administration record against the prescription label. Resident #312 was admitted with diagnoses including Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Peripheral Vascular Disease. The 4/9/2024 nursing admission assessment documented that the resident was alert to person, place, time, and situation. A physician's order dated 4/11/2024 documented Allopurinol, 100 milligrams tablet, give 2 tablets (200 milligrams) by oral route once daily at 8:00 AM for a diagnosis of Gout. A physician's order dated 4/11/2024 documented Torsemide 20 milligrams tablet, give 1 tablet (20 milligrams) by oral route once daily at 8:00 AM for diagnosis of Hypertension. During the medication pass observation for Resident #312, performed by Licensed Practical Nurse #1, on 4/17/2024 at 8:34 AM, the blister pack label for Allopurinol documented 100 milligrams tablet, give one tablet every 12 hours. The delivery date on the blister pack was 4/9/2024. The blister pack label for Torsemide documented 20 milligrams tablet, give two tablets by mouth daily. The delivery date on the blister pack was 4/10/2024. Licensed Practical Nurse #1 acknowledged the blister pack labels did not match the physician's orders and would report this to the supervisor. Licensed Practical Nurse #1 administered the medications as per the physician's order. Licensed Practical Nurse #1 was re-interviewed on 4/17/2024 at 10:48 AM and stated if there was a discrepancy between the physician's order and the medication label, they would report the discrepancy to the nursing supervisor and the supervisor would contact the pharmacy. Licensed Practical Nurse #1 stated they have not reported the discrepancy to the supervisor yet. Registered Nurse Supervisor #1 was interviewed on 4/17/2024 at 10:50 AM regarding the observed discrepancy between the physician order and the blister pack labels. Registered Nurse Supervisor #1 stated when there is an order change, the pharmacy is supposed to send a new blister pack; when there is a change in the physician's orders the facility does not use see the medication administration record labels to be put on a blister pack to indicate changes in the physician's orders. Registered Nurse Supervisor #1 stated if the pharmacy does not send the new blister pack, the facility staff should follow up with the pharmacy. Registered Nurse Supervisor #1 stated the medication nurses have to bring the discrepancy to their attention and they would then call the pharmacy. An email correspondence with pharmacy representative #1 dated 4/17/2024 at 1:10 PM documented, an every-12-hour Allopurinol order blister pack was last provided on 4/9/2024; the order was changed to once a day on 4/11/2024 and the facility was expected to use the supply on hand. A new supply blister pack of Torsemide was delivered on 4/12/2024 that matched the physician's order. Registered Nurse Supervisor #1 was re-interviewed on 4/17/2024 at 2:01 PM and stated the facility just received stickers to put on the medication label that document: see the medication administration record. Registered Nurse Supervisor #1 stated Putting stickers on a blister pack is new to me. Registered Nurse Supervisor #1 stated the sticker will be placed on the Allopurinol blister pack. Regarding the Torsemide, Registered Nurse Supervisor #1 stated they were not aware that a new supply for Torsemide was delivered on 4/12/2024. Registered Nurse Supervisor #1 and Licensed Practical Nurse #1 checked the medication cart and found the not-yet-started Torsemide blister pack that was delivered on 4/12/2024. The Director of Nursing Services was interviewed on 4/18/2024 at 8:04 AM and stated they were not sure of the facility's policy regarding when there is a discrepancy between the physician's order and the medication label; however, they thought the nurses should put a see the medication administration record label on the medication when a physician's order is changed and the medication supply on hand has to be utilized or reach out to the pharmacy to rectify the discrepancy. 10 NYCRR 415.18(e) (1-4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00295436) initiated on 9/18/2022 and completed on 9/22/2022, the facility did not inform the resident's Designated Representative (DR) when a new form of treatment was started. This was identified for one (Resident #90) of six residents reviewed for Unnecessary Medications. Specifically, there was no documented evidence that Resident #190's DR was notified 1) when the resident's Zoloft (an antidepressant medication) dosage was increased on 1/7/2022 and 2) when the resident was started on Remeron (an antidepressant medication often used to increase appetite) on 1/4/2022. The finding is: The facility's policy titled, Notification of Family of Resident Status Change dated 8/25/2021 documented that it was the policy of the facility to inform the DR of any changes in the resident's condition/status and implemented interventions (If applicable). Residents with a Brief Interview for Mental Status (BIMS) of 12 or above will be notified and if requested, DR will also be notified. Resident #190 was admitted with diagnoses including Chronic Obstructive Pulmonary Disorder (COPD) and Diabetes Mellitus (DM). The admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a BIMS score of 13 which indicated Resident #190 had intact cognition. 1) The Medicare Nursing Progress Note dated 12/28/2021 documented that the resident had intermittent bouts of crying/sobbing due to missing their wife and their life in Arizona. The resident was offered emotional support with little/no results. The Physician was notified and a new order to start Zoloft 50 mg (milligrams) once daily was received. The resident's DR was made aware and was in agreement. A psychiatric consult was ordered and is pending. The Physician's Order dated 12/28/2021 documented to give Sertraline (the generic name for Zoloft) one 50 mg tablet once daily for Other Specified Depressive Disorders. The Psychiatric Initial Evaluation Progress Note dated 1/6/2022 documented to start Zoloft 25 mg once daily (QD). The Nursing Progress Note dated 1/6/2022, written by Registered Nurse (RN)#1, documented that the resident was seen and evaluated by the Psychiatrist with a new order for Zoloft 25 mg QD for diagnosis of depression. The Physician's Order dated 1/6/2022 documented to give Zoloft 25 mg tablet by mouth (po) once daily for Major Depressive Disorder. This order was entered into the computer by RN #1. The Nursing Progress Note dated 1/7/2022, written by RN #6, documented that the Psychiatrist was notified for a medication clarification. The Psychiatrist clarified that the resident was to receive Zoloft 75 mg QD. The Physician's Order dated 1/7/2022 documented to give Zoloft 25 tablet po once daily. Give in addition to Zoloft 50 mg (for a total of 75 mg QD) for Major Depressive Disorder. This order was entered into the computer by RN #6. RN #6 was interviewed on 9/20/2022 at 3:05 PM and stated that they (RN #6) had only called the Psychiatrist to see if they (Psychiatrist) wanted the 25 mg of Zoloft added to the resident's already 50 mg dose or if they (Psychiatrist) wanted the Zoloft reduced to a 25 mg dose. RN #6 stated that they did not contact the resident's DR because they (RN #6) only clarified the dosage of Zoloft the Psychiatrist wanted the resident to receive. RN #1 was interviewed on 9/20/2022 at 4:20 PM and stated that if they (RN #1) had called the family, they (RN #1) would have documented that they notified the DR. RN #1 stated that they (RN #1) should have called the family because when any orders change for a resident the family should be called because it is protocol. The Director of Nursing Services (DNS) was interviewed on 9/21/2022 at 3:35 PM and stated that contacting the family when a medication is started or changed would depend on the resident and their cognition. The DNS stated that Resident #190 had a BIMS of 13 and was capable of making their (Resident #190) own decisions. The DNS acknowledged that there was no documentation in the resident's medical record of the resident's wishes and if they (Resident #190) did or did not want their DR contacted when their medication dosage changed. 2) The Physician Follow-Up Progress Note documented on 1/4/2022 that the resident was depressed and would be started on Remeron 7.5 mg QD. The Physician's Order dated 1/4/2022 documented to give Remeron 15 mg tab - give 0.5 tab (7.5 mg) po once daily in the morning for Major Depressive Disorder. The order was entered into the computer by RN #3. RN #3 was interviewed on 9/21/2022 at 10:15 AM and stated that the resident was alert and oriented. For someone who is alert and oriented, their care is discussed with the resident and if the resident tells us not to call their family, we do not. RN #3 stated that they (RN #3) did not remember the specifics of this resident, whether they (Resident #190) wanted their family involved or not. RN #3 stated that Resident #190 was alert and oriented and they (RN #3) did not call the resident's family or write a progress note regarding the initiation of Remeron. The resident's Physician was interviewed on 9/21/2022 at 1:00 PM and stated that they (Physician) had ordered the Remeron on 1/4/2022 because the resident was not eating and was depressed. Remeron is an appetite stimulant and an antidepressant. The Physician stated that they (Physician) always call the resident's family member when the resident is not eating and when they (Physician) start Remeron. The Physician stated that they (Physician) had talked to the resident's DR, but was not sure if it was about the start of the Remeron. The Physician stated that they (Physician) would usually write in their note which family member they spoke to and their phone number. The Physician stated that they (Physician) did not write that in their note of 1/4/2022 and understood that if the information was not written, it was not done. The Director of Nursing Services (DNS) was interviewed on 9/21/2022 at 3:35 PM and stated that contacting the family when a medication is started or changed would depend on the resident and their cognition. The DNS stated that Resident #190 had a BIMS of 13 and was capable of making their (Resident #190) own decisions. The DNS acknowledged that there was no documentation in the resident's medical record of the resident's wishes and if they (Resident #190) did or did not want their DR contacted when their medications started. 415.3(e)(2)(ii)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during the Recertification survey and Abbreviated survey (NY00282386) initiated on 9/18/2022 and completed on 9/22/2022 the facility did not ensure that all allegations of abuse were thoroughly investigated. This was identified for one (Resident #187) of one Resident reviewed for Abuse. Specifically, Resident #187 complained that three facility staff handled the resident roughly during a transfer from one surface to another. The facility investigation did not include all statements necessary to rule out abuse, neglect, and mistreatment including a statement from Resident #187's assigned Certified Nursing Assistant (CNA) #4. The finding is: The facility Accident and Incident Reporting Policy dated 12/1/2019 documented that when an incident occurs to a resident, it will be documented in an Accident Incident Report and an internal investigation will be conducted to determine the root cause of the accident/incident. The facility Resident Abuse, Mistreatment, Neglect and Exploitation policy, and procedure dated 3/2019 documented an abuse investigation trigger includes resident/family/visitor allegation of abuse. A review of the investigation procedure revealed that the policy and procedure did not include a protocol on how an investigation should be completed including obtaining statements from appropriate staff and residents. Resident #187 was admitted with the diagnoses of Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, and Pneumonia. The admission Minimum Data Set, dated [DATE] documented that Resident #187 had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS further documented that Resident #187 required extensive assistance of two persons for bed mobility and transfers. The Abuse Care Plan dated 8/29/2021 documented that Resident #187 was at risk for potential abuse as evidenced by loss of independence. The interventions included reporting any unusual markings on the body and reporting to the nurse in charge; monitoring for any signs and symptoms of distress and or sadness, monitoring the resident's body language and/or facial expression; encourage the resident to verbalize any concerns, report any suspected abuse via the facilities chain of command as in policy and procedure of abuse, educate the resident and family and ask resident/family to explain the procedure to assure understanding. The Activities of Daily Living Care Plan dated 8/30/21 documented that Resident #187 required extensive assistance of two people for bed mobility and transfers. The facility C-Wing 3 PM-11 PM Shift Assignment Sheet dated 8/29/21 documented CNA #4 was assigned to Resident #187. The sheet also documented CNA #2 and CNA #3 were on duty on the C-Wing during the 3 PM-11 PM shift. The Nursing Note dated 8/29/2021 documented that at approximately 8 PM, Resident #187 complained about the time they (Resident #187) went to bed today. Resident #187 stated that they were put in bed too early, and they wanted to be in bed at around 9 PM every night. CNA staff were made aware to accommodate Resident #187 with the time they want to be put in bed moving forward. Resident #187 and the family member agreed with the plan of care. Resident Grievance log completed by the Director of Social Work dated 8/31/2021 documented that Resident #187 reported to a family member over the weekend that Resident #187 was handled roughly by 3 staff members. A document entitled, Resident #187 statements regarding allegation of recent incident dated 8/31/2021 documented that the social worker met with Resident #187 who was alert, oriented, and able to make needs known with mild forgetfulness. Resident #187 stated that on Saturday or Sunday (8/28/2021 or 8/29/2021) one staff member was standing in front [of the resident] watching while 2 other staff members grabbed Resident #187's arms and legs. Resident #187's family member filed a police report, and an officer came to the facility and met with Resident #187. The facility Summary of Investigation dated 8/31/2021 documented that the date of the incident was 8/29/2021 at 7:00 PM. On 8/30/2021 at 10 AM, Resident #187's family member approached this writer and said Resident #187 was put back in bed by three staff members in a rough way. Resident #187 was assessed immediately by the on-duty supervisor for injury or pain. Resident #187 did not complain of pain or rough handling by caregivers during her care. The resident is alert and able to communicate with clear speech. Staff who did direct hands-on care was interviewed by the Director of Nursing and were not aware of any issues. Resident #187 was interviewed by the nursing administration and made no complaint. Statements were obtained by staff who provided care for Resident #187. The investigation revealed there is no cause to believe that alleged Resident abuse, mistreatment, or neglect regarding Resident #187 has occurred. RN #3 signed the summary. The Summary of Investigation did not document the resident's allegation that was received by the social worker on 8/31/2021. A statement from CNA #2 dated 8/31/2021 was reviewed. CNA #2 documented that on Sunday, 8/29/21, at around 7 PM to 8 PM, CNA #2 was helping CNA #4 provide care for Resident #187's roommate while CNA #3 was helping Resident #187 to bed. CNA #2 went over to help CNA #3 move Resident #187 over to the middle of the bed. A statement from CNA #3 dated 8/31/2021 was reviewed. CNA #3 documented that on Sunday, 8/29/2021, between 7 PM and 8 PM, CNA #3 was giving care to Resident #187 because CNA #4 who was the assigned CNA for Resident 187 had worked the 7 AM-3 PM shift. CNA #3 documented that there were 3 CNAs in the room including CNA #4 who was providing care to the roommate. A review of all statements associated with the incident investigation for Resident #187 (8/31/2021) revealed there were no statements from Resident #187's assigned CNA (CNA # 4). The Director of Nursing Services (DNS) was interviewed on 9/21/2022 at 1:09 PM. The DNS stated upon review of the investigation for Resident #187, they (DNS) believe that CNA #4 provided care to Resident #187's roommate. The DNS stated that CNA #4 may have left the room while Resident #187 was being transferred by CNA #2 and CNA #3. The DNS stated that this information was not included in the investigation summary. CNA #2 was interviewed on 9/21/2022 at 2:47 PM. CNA #2 stated that on 8/29/2021 they were providing care for Resident #187's roommate in Resident #187's room with CNA #4. CNA #3 was interviewed on 9/21/2022 at 3:07 PM. CNA #3 stated that Resident #187 used the call bell and when CNA #3 entered the room, Resident #187 complained about pain. Resident #187 asked to be put to bed but then complained to RN #7 that they (Resident #187) did not want to be put to bed early. CNA #3 assisted Resident #187 to the bathroom and then back to the wheelchair. Resident #187 did not have any discomfort or complaint when being transferred. CNA #2 and CNA #3 only placed Resident #187 into the bed because Resident #187 requested to be placed in the bed. CNA #4 was the assigned CNA but did not assist in the transfers. CNA #2 and CNA #3 wanted to assist CNA #4 who was busy with Resident #187's roommate in the resident's room. Voicemails were left for Resident #187's assigned CNA, CNA #4, on 9/21/2022 and 9/22/2022. CNA #4 was unavailable for an interview. The DNS was interviewed on 09/22/2022 at 11:49 AM. The DNS stated that they (DNS) were not in the DNS role on 8/31/2021 and were not involved in the investigation. The DNS stated that after reviewing the investigation, it appeared that Resident #187 did not want to go to bed at 7 PM, and there was something about grabbing arms and legs. The DNS stated that it seems that the staff used a draw sheet to reposition Resident #187. The DNS stated that the investigation summary documented that Resident #187 did not complain to the nursing administration that the staff had rough-handled the resident. The investigation summary did not reflect the statement that the Director of Social Work obtained from the direct Resident interview. The DNS would expect Resident #187's statement to be included in the summary. The DNS stated that the assigned CNA was not interviewed for a statement, and it would be expected as part of the investigation. 415.4(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint #NY00295436) initiated on 9/18/2022 and completed on 9/22/2022, the facility did not ensure that each resident had a Comprehensive Care Plan (CCP) developed to meet each resident's individualized care needs. This was identified for one (Resident #190) of one resident reviewed for Unnecessary Medications. Specifically, Resident #190 had a diagnosis of Diabetes Mellitus (DM) and had a Physician's Order to receive finger sticks without coverage four times a day. There was no CCP developed to address the DM diagnosis and blood sugar monitoring. The finding is: The facility's policy titled, Comprehensive Care Plans (CCP) and Resident/Patient Meeting dated 11/27/2017 documented that a comprehensive assessment for resident's needs shall be prepared within 14 days from admission and a CCP developed within 21 days from admission. The policy also documented that information obtained from the comprehensive assessment and staff interviews enables the facility staff to plan care that focuses on the resident's ability to achieve his/her practicable mode of functioning that includes, but is not limited to the following: Medically defined condition(s) and Past Medical History. Resident #190 was admitted with diagnoses including Chronic Obstructive Pulmonary Disorder (COPD) and Diabetes Mellitus (DM). The admission Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a BIMS score of 13 which indicated Resident #190 had intact cognition. Diabetes Mellitus was listed as one of the resident's Active Diagnoses in the last 7 days. A Physician's Order dated 12/20/2021 documented for the resident to receive Finger Sticks (blood glucose test) without insulin coverage every day at 6:30 AM, 11:30 AM, 4:30 PM, and 8:00 PM to monitor the resident's blood sugar. There were no blood glucose parameters for nursing staff to notify the physician when abnormal results are identified. The Physician's Order dated 1/21/2022 documented to administer Admelog U-100 Insulin lispro 100 unit/ milliliter (ml) subcutaneously (sc) solution every day at 6:30 AM, 11:30 AM, 4:30 PM, and 8:00 PM. Insulin Sliding Scale if BS (blood sugar) is between 60 - 150 give 0 units of insulin; 151 - 200 give 2 units of insulin; 201 - 250 give 4 units of insulin; 251 - 300 give 6 units of insulin; 301 - 350 give 8 units of insulin; 351-400 give 10 units of insulin. If greater than 400 or below 60 Call MD. The resident's entire CCP was reviewed on 9/21/2022 at 3:00 PM. There was CCP found to address the resident's diagnosis of DM. The Director of Nursing Services (DNS) was interviewed on 9/21/2022 at 3:30 PM and stated that they (DNS) would have expected the resident to have a Diabetes Care Plan. The DNS stated that the resident should have had a CCP developed for DM because the resident had a diagnosis of Type 2 DM. The care plan would have described the type of care and the medications the resident is receiving. The DNS stated that it was the responsibility of the RN Unit Manager to put the care plan into place. 415.11(c)(1)

Based on record review and staff interviews during the Recertification survey and Abbreviated survey (NY00287018) initiated on 9/18/2022 and completed on 9/22/2022, the facility did not ensure that each resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This was identified for one (Resident #189) of one resident reviewed for change of condition. Specifically, Resident #189 had a Pleurx catheter (a drainage system that allows for the drainage of pleural effusion, which is a build-up of fluid in the chest) with orders for the catheter to be drained two times per week. On 11/8/2021 the drainage of the catheter was scheduled; however, the treatment was not administered, although there was qualified staff in the facility that day to provide the treatment. There was no documentation in the medical record regarding the treatment was not administered or that the physician was notified. Furthermore, on two occasions when the Pleurx catheter was drained, there was no documentation of the amount of fluid that was drained. The finding is: The facility's undated policy, titled Pleurx Catheter, documented that the objective is to facilitate drainage of fluid from the chest and prevent infection and to document fluid drainage amount and resident's tolerance to the procedure in the nurses' notes. Resident #189 was admitted with diagnoses including Malignant Pleural Effusion, Acute Respiratory Failure with Hypoxia, and heart failure. The 11/11/2021 Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. A physician's order dated 11/7/2021 documented Pleurx catheter: Drain Pleurx twice weekly on Monday and Friday on the 7 AM-3 PM shift and when needed. Document output. Notify Registered Nurse (RN)/Physician of any abnormalities. The diagnosis was pleural effusion. A physician's order dated 11/7/2021 documented Pleurx catheter: Monitor site for signs and symptoms of infection every dressing change (Monday and Friday) and when needed. Notify RN/Physician of any abnormalities. The diagnosis was for prophylactic measures. The facility's competency, titled Pleurx Catheter Change and Drainage, documented that two staff members, RN #1 and the current Director of Nursing Services (DNS), who was an RN supervisor on 11/8/2021, were the only two staff members who received training and completed the competency to perform the Pleurx catheter drainage and dressing change. The date of the competencies was 10/28/2021. Review of the Treatment Administration Record (TAR) for November 2021 revealed that on 11/8/2021 (Monday) Licensed Practical Nurse (LPN) #1 documented that both treatment orders for the Pleurx catheter (the drainage and dressing change) were not administered. There were no reasons provided in the comments section of the TAR. In addition, review of progress notes for 11/8/2021 revealed no progress note was written indicating why the treatments were not administered. As per the staffing data provided by the facility for 11/8/2021, the RN supervisor for the 7 AM-3 PM shift was the current DNS, who was one of the nurses who received the competency to perform the Pleurx drainage. Further review of the TAR for November 2021 revealed that the Pleurx drainage was performed by RN #1 on 11/5/2021 (Friday) and 11/12/2021 (Friday) and 11/16/2021 (Tuesday). Review of the TAR revealed that RN #1 documented the drainage on 11/12/2021 as 25 cubic centimeters (cc) of pleural fluid. There was no documentation of drainage amount on 11/5/2021 or 11/16/2021 in either the TAR or the progress notes. LPN #1 is no longer employed at the facility and was not reachable by phone. RN #2, who is the current inservice coordinator and Infection Preventionist, was interviewed on 9/20/2022 at 10:07 AM. RN #2 stated that if the drainage of the Pleurx catheter was not done as ordered, then there should have been documentation as to why it was not done. RN #2 further stated that the amount of drainage should be documented in the medical record. RN #4 (Corporate Educator) was interviewed on 9/20/2022 at 12:44 PM. RN #4 stated that in order for a nurse to perform the Pleurx catheter drainage the nurse would have to be inserviced and pass a competency. RN #4 stated they (RN #4) only provided inservice to RN #1 and the current DNS, who was a supervisor at the time of the competency. LPN #2 was interviewed On 9/20/2022 at 2:46 PM. LPN #2 stated they (LPN #2) were the Unit C manager on 11/8/2021 for the 7 AM-3 PM shift. LPN #2 stated they have no recollection of LPN #1 reporting that the Pleurx treatment was not done for Resident #189. LPN #2 stated that if they (LPN #2) were made aware that the treatment was not done, they (LPN #2) would have reported it to the RN supervisor. The DNS was interviewed on 9/21/2022 at 8:32 AM. The DNS stated they (DNS) were the RN supervisor on 11/8/2022 when Resident #189 required the Pleurx catheter treatments. The DNS stated that LPN #1 should have notified them (DNS) or the unit manager that they (LPN #1) could not do the Pleurx procedure. The DNS stated if they (DNS) had known that the procedure was not done, they (DNS) would have done it. The DNS stated the former DNS should have ensured that the two nurses trained to complete the Pleurx procedure were available and aware that they were responsible to complete the treatment as per the Physician's orders. RN #1 was interviewed on 9/21/2022 at 10:40 AM and stated they (RN #1) completed the Pleurx treatment on 11/5/2021 and 11/16/2021 for Resident #189. RN #1 stated that they (RN #1) sent a secure text message to the Physician on 11/5/2021 noting that 150 cubic centimeters (cc) of fluid was drained and another text message on 11/16/2021 that barely 25 ccs was drained. RN #1 stated the text messages are not part of the medical record and that the drainage should have been documented in the medical record. The physician was interviewed on 9/21/2022 at 12:22 PM and stated they (Physician) do not remember being advised the day (11/8/2021) the drainage was not done and would expect to be notified. 415.12

Based on observation and staff interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY 00279190, NY 00283964) initiated on 9/18/2022 and completed on 9/22/2022, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 3 of 3 residents units, the kitchen and the basement. Specifically, floors were soiled with litter and sticky substances, and exhausts vents contained a build-up of dust. The finding is: During a tour of the facility on 9/21/2022 to 9/22/2022, the following was observed: (1) the Kitchen Storage room located in the basement contained a sticky substance on the floor. Within the substance were 3 bugs lying on their backs. (2) In the Central Supply closet on the A Wing, plastic bottles, a box of q- tips, and litter was observed on the floor and underneath the metal storage racks (3) In the Staff Lounge, litter was observed behind and along the sides of the refrigerator (4) In the Kitchen, the corners on the floor near the range contained a build-up food, litter, and unknown particles. (5) In the Kitchen, the floor below the coffee maker contained a build-up of litter, dust, and coffee beans (6) In the Soiled utility rooms on A wing, B wing and C wing, the exhaust ducts contained a build-up of dust. In an interview on 9/21/2022 at 10:20 AM, the Director of Maintenance stated they would clean the floor. In an interview on 9/21/2022 at 10:45 AM, the Food Service Director stated there was no assigned cleaning schedule, and that they cleaned the floors and behind the stove every few days. In an interview on 9/21/2022 at 11:10 AM, the Director of Maintenance stated they would instruct the staff to clean up the storage room floor. In an interview on 9/21/2022 at 11:20 AM, the Director of Maintenance stated they would let housekeeping know to clean behind the refrigerator. In an interview on 9/21/2022 at 11:40 AM, the Corporate Environmental Coordinator stated they would check and clean all the vents. In an interview on 9/21/2022 at 2:45 PM, the Director of Maintenance stated that they oversaw both Maintenance and Housekeeping departments, but that there was a housekeeping supervisor. The Director of Maintenance further stated that each department was responsible for their own storage areas and that kitchen staff were responsible to clean the kitchen, but that Maintenance staff cleaned the laundry area and removed junk out of the basement. They further stated there was no scheduled cleaning for the areas. 10NYCRR 415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during the Recertification Survey and Abbreviated Survey (Complaint # NY00279190, NY00283964) initiated on 9/18/2022 and completed on 9/22/2022, the facility failed to maintain an effective pest control program so that the facility was free of pests. Specifically, there was evidence of bugs in the kitchen, kitchen storage room, and on the B wing. The finding is: On 9/21/2022 at 8:40 AM, a brown bug with antenna measuring 1 inch in length, was observed on the B unit between room [ROOM NUMBER] and 136. On 9/21/2022 at 10:20 AM, 3 bugs lying on their backs, were observed on the floor in the kitchen storage room. On 9/21/2022 at 10:45 AM, 2 brown bugs measuring 1/8 inch in length were observed walking on the floor below the dishwasher in the kitchen. Resident #59 was observed in the hallway on 9/18/22 at 1:20 PM. Resident #59 stated that the facility has had a lot of bugs like cockroaches and that there were mice in the facility. Resident #59 further stated that they had seen roach bait in the facility, but it was not enough to get rid of the bugs. Pest control records documented the following: - On 9/14/2022, the facility was treated for roaches in room [ROOM NUMBER], A, B, C Wings, bakery, kitchen, and gym. - On 9/7/2022, the facility was treated for roaches on the A, B, C Wings, and kitchen. - On 8/24/2022, the facility was treated for roaches on the A, B, C Wings, and kitchen. - On 8/17/2022, the facility was treated for rats and roaches on A, B, C wings, gym, bakery, and housekeeping closets. - On 8/10/2022, the facility was treated for roaches in the kitchen and dishwasher area. - On 8/3/2022, the facility was treated for roaches in the kitchen and dishwasher area. - On 7/27/2022, the facility was treated for roaches in the kitchen and the dishwasher area. An undated facility Pest Control Policy documented, it is the policy of Excel at [NAME] that an ongoing pest management program that included prevention, control of pest activity, infestation and ensures proper handling of all pesticides be in place. Additionally, the policy documented, a pest control company will be contracted to spray all areas of the facility. Services will be performed once a week for the 1st weeks of each month and as needed. Services will not be performed on the 5th week of the month if applicable. In an interview on 9/21/2022 at 2:45 PM, the Director of Maintenance (DOM) stated they oversaw both Housekeeping and Maintenance departments and stated that an exterminating company came in once a week to treat areas. The DOM further stated if there were pest sightings, staff were to enter it into a digital work order log system (TELS building management platform) or directly inform the DOM, who would log the sighting in the pest control book in the DOM office. 415.29(j)(5)