**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during an abbreviated survey (NY00337354) the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 out of 3 residents (Resident #1) reviewed for quality of care. Specifically, Resident #1 who was dependent on staff for all cares including rolling left to right acquired a Stage 3 pressure ulcer to their left hip during their stay at the facility. There was no documented physician order for turning and repositioning, and the certified nurse accountability form did not show that staff were consistently providing this care to the resident. The findings are: The facility Activities of Daily Living Total Care Policy last reviewed July 2024 documented the purpose is to establish guidelines for providing comprehensive assistance with Activities of Daily Living to residents. It aims to ensure that each individual's basic needs are met while promoting dignity, independence, and comfort. Resident #1 was admitted with diagnoses including but not limited to Dementia, Quadriplegia and Legal Blindness. A Quarterly Minimum Data Set, dated [DATE] documented the resident had severe cognitive impairment and severe impaired vision. Resident #1 had impairment to both upper and lower extremities and was dependent for all cares. The resident had an indwelling catheter and was always incontinent of bowels. Review of an admission nursing assessment dated 1/31/2024 documented Resident #1 was dependent for bed mobility and was bedbound. Resident #1 had wounds present to their coccyx, right and left buttocks and sacrum. Review of Resident #1's Braden scale assessments revealed there was no classification of the resident's risk to develop pressure ulcers. Review of Resident #1's physician's order revealed no documented evidence of an order for turning and positioning. A risk for skin impairment care plan last revised 6/21/2024 documented Resident #1 had fragile skin and decreased mobility. Interventions included moisturize skin daily, observe skin redness, swelling, or bruising with cares and resident with left hip open skin area-cleanse with normal saline, apply Hydrogel and dry protective dressing 2 times daily. Review of an activities of daily living care plan last revised 10/13/2024 documented Resident #1 was dependent on staff daily for meeting their needs. Interventions listed included monitor/document and report any changes, and potential for improvement or declines in function. Review of Resident #1's certified nurse assistant accountability for February 2024 revealed the resident required maximal assistance with rolling left and right. There was no documented evidence of direct care staff providing assistance with bed mobility on 30 occasions. Review of Resident #1's certified nurse assistant accountability for March 2024 revealed the resident required maximal assistance with rolling left and right. There was no documented evidence of direct care staff providing assistance with bed mobility on 32 occasions. Review of a Registered Nurse weekly wound rounds/team assessment note dated 3/12/2024 at 10:30 AM documented Resident #1 had developed a Stage 3 pressure ulcer to the left hip measuring 3 x 1.5 x 0.1 cm. Instructed certified nurse assistants to turn Resident #1 every 2 hours. During an interview on 12/18/2024 at 9:21 AM the Director of Nursing stated if there were orders for turning and positioning, it would be reflected on the certified nurse assistant accountability to turn and position every 2 hours. The Director of Nursing stated a completed Braden scale assessment provides the classification of the resident' risk for pressure ulcers. The resident would be ordered for turning and positioning. The Director of Nursing stated if there is no signature in the box on the certified nurse assistant accountability, it indicates the task was completed. If it is not documented, then it was not done. 10 NYCRR 415.12

Based on record review and interviews during an abbreviated survey (NY00337354, NY00337504, NY00353121, NY00334737), the facility did not ensure a facility-wide assessment was conducted to determine what resources are necessary to care for its residents competently. Specifically, the Facility Assessment did not identify individual staff assignments, systems for coordination, and continuity of care necessary to care for residents during both day-to-day operations including nights and weekends. Findings include: The Facility Assessment provided was last updated 11/7/2024 and last reviewed with the quality assurance and improvement committee on 9/18/2023. The staffing plan documented an example of the evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff is available to meet each residents needs. The table listed the position of staff by title, as well as the total number needed or average or range by position. Review of the Facility Assessment on 12/19/2024 revealed the assessment did not include the staffing plan, the requirements of number of staff needed for each unit per shift to care for residents. During an interview on 12/19/2024 at 4:40 PM, the Administrator stated their facility assessment does list the staff required to care for the residents in the facility but they were not aware that they had to include the staffing requirements by unit to meet the resident's needs, they would include this going forward. 10 NYCRR 415.26

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews during an abbreviated survey (NY00337354), the facility did not ensure the resident's right to a dignified existence. This was evident for 5 out of 6 residents (Resident #4, #12, #13, #14, #15) reviewed for dignity. Specifically, (1) During an observation on 12/13/2024, the 6th floor unit hallway had 4 residents (Resident #4, #12, #13, #14) dressed in hospital gowns; (2) During an observation on 12/13/2024 on the 5th floor dining room, Registered Nurse #1 was standing over Resident #15 while assisting them with their meal. The findings are: The Facility Resident's Rights Policy last reviewed 5/2024 documented the purpose was to provide general guidelines for resident rights while caring for the resident. Prior to having direct-care responsibilities for residents, staff must have appropriate in-service training on residents' rights including resident dignity and respect. During an observation on the 6th floor on 12/13/2024 between12:34 PM to 12:54 PM, Residents were noted to be seated along the hallways and there were 4 residents (Resident #4, #12, #13, #14) dressed in hospital gowns. 1) Resident #4 was admitted with diagnoses including but not limited to Dementia, Psychotic Disorder with Delusions and other bipolar disorders. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 3/4/2024 documented the resident had moderate cognitive impairment. No behaviors noted. The resident had impairment to the upper extremity on one side and was ambulatory. The resident required supervision for eating, moderate assistance with toileting and bed mobility and was independent for transfers. Review of an activities of daily living care plan last revised 9/3/2024 documented Resident #4 required staff assistance daily in meeting their needs due to a diagnosis of Dementia. The goal was the Resident #4's needs would be met by staff as evidenced by being well groomed and dressed appropriately daily. 2) Resident #12 had diagnoses including but not limited to Dementia, Bipolar Disorder and Persistent Mood Affective Disorder. A Quarterly Minimum Data Set, dated [DATE] documented the resident had severe cognition impairment. The resident was ambulatory and required set up assistance with eating, bed mobility and transfers, and moderate assistance with toileting. Review of an activities of daily living care plan last revised 11/18/2024 documented Resident #12 was dependent on staff for meeting their daily needs due to a diagnosis of Dementia. There were no documented interventions listed. 3) Resident #13 was admitted with diagnoses including but not limited to Personal History of Traumatic Brain Injury, Bipolar Disorder and Seizures. A Comprehensive Minimum Data Set, dated [DATE] documented the resident had moderate cognitive impairment. The resident had impairment to the upper extremity on one side. Resident #13 required supervision with eating, maximal assistance with toileting, transfers, and bed mobility. Review of an activities of daily living care plan last revised 12/3/2024 documented Resident #13 was dependent on staff daily in meeting their needs related to their history of a traumatic brain injury and seizures. Interventions listed included monitor/document/report as needed any changes, reasons for self-care deficit or decline in function. 4) Resident #14 was admitted with diagnoses including but not limited to Dementia, Cognitive Communication Deficit and Psychotic Disorder with Delusions. A Quarterly Minimum Data Set, dated [DATE] documented the resident had moderate cognitive impairment. The resident had impairment to both upper extremities. Resident #14 required maximal assistance with eating, toileting and bed mobility and was dependent for toileting. Review of an activities of daily living care plan last revised on 12/17/2024 documented the resident was dependent on staff daily for meeting their needed related to their history of Dementia and seizures. During an observation on the 5th floor dining room on 12/13/2024 at 1:07 PM, Registered Nurse #1 was standing next to Resident #15 while assisting them with their meal. 5) Resident #15 was admitted with diagnoses including but not limited to Dementia, Glaucoma and Major Depressive Disorder. A Quarterly Minimum Data Set, dated [DATE] documented the resident had moderate cognitive impairment. The resident had impairment to both upper and lower extremities. The resident required moderate assistance with eating, toileting and bed mobility, and maximal assistance with transfers. Review of an activities of daily living care plan last revised 7/31/2024 documented the resident was dependent on staff for meeting their daily needs. During an interview on 12/13/2024 at 1:10 PM, Certified Nurse Assistant #1 stated the residents on the 5th floor that are dressed in hospital gowns, either do not have clothes or it is a housekeeping issue. Certified Nurse Assistant #1 stated a lot of the residents on their unit do not have families or any clothing and sometimes when the laundry is sent down to housekeeping it does not get sent back to the correct resident. Certified Nurse Assistant #1 stated there was a housekeeping/laundry person, but they do not think they have one anymore. Certified Nurse Assistant #1 stated there is a lot of clothing that is donated to the residents in the facility, but the clothing gets misplaced, because it is not labeled for the residents. Certified Nurse Assistant #1 stated there is clothing down in the laundry room that the residents can wear, but some of the certified nurse assistants do not want to go down and get the clothing for the residents so they leave them in hospital gowns. During an interview on 12/13/2024 at 1:07 PM, Registered Nurse #1 stated they observed the other residents at the table assisting Resident #12 with their meal, so they went and tried to assist the resident. Registered Nurse #1 stated they were aware they are not supposed to stand over residents when assisting them with meals. During an interview on 12/18/2024 at 9:21 AM, the Director of Nursing stated they instructed the certified nurse assistants to inform them if a resident has no clothing, so they can get the social worker involved to provide clothing for the residents. The Director of Nursing stated the facility process when residents have no clothing will be to inform the residents' family of the need for clothing and also make them aware there is clothing for donation in the facility, and they will ask for permission to dress the resident in the donated clothing. During an interview on 12/18/2024 at 11:09 AM, Registered Nurse #2 (unit manager 2nd floor) stated some of the residents are adamant about wearing the hospital gowns. Registered nurse #2 stated a few of the residents on their unit stay in their room or go in and out of their rooms and they do not want to wear clothing. Registered Nurse #2 stated they ask the residents if they want to wear clothes, and they also have to care plan the residents for not wanting to wear clothes. During an interview on 12/18/2024 at 12:40 PM, Certified Nurse Assistant #2 stated Resident #13 came to the facility without any clothing and the clothing the resident had on when they arrived at the facility were soiled with urine. Certified Nurse Assistant #2 stated they were told there is clothing for the residents in the facility which is stored on the second floor. Certified Nurse Assistant #2 stated they weent to the second floor and there was no clothing and the staff on the staff on the second floor stated they do not know what they were talking about when they asked about cloyhing for residents. They asked one of the housekeepers about clothing and were sent to the basement and they found clothing, but it looked dirty. Certified Nurse Assistant #2 stated when they wash their residents and they do not have clothing they put a clean gown on them which they obtain from the clean utility room. Certified Nurse Assistant #2 stated they found out yesterday that they need to speak to the the Director of Housekeeping when they need clothes for their residents, and the Director of Housekeeping will them the clothing and label them for the resident. During an interview on 12/19/2024 at 10:27 AM, the Director of Housekeeping stated they have donated clothing for residents in the building. The Director of Housekeeping stated they have 2 large blue bins with shelving, designated for men and women. The Director of Housekeeping stated when a resident has no have clothing the certified nurse assistant is expected to contact them, or they meet with the resident directly with an inventory sheet to document their size and preferences for clothing. The Director of Housekeeping stated bring the resident clothing from the laundry room, and label the clothing with the resident name and the facility name. During an interview on 12/19/2024 at 4:40 PM, the Administrator stated they try to ensure there is clothing available for the residents in the facility and they receive clothing donations from the community. The Administrator stated the clothing that is donated is labeled with the resident's name after the resident makes their selection. No resident should have to be dressed in hospital gowns. 10 NYCRR 415.3(d)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during an abbreviated survey ((NY00337504, NY00353121), the facility did not ensure residents right to be free from abuse. This was evident for 6 out of 9 residents (Resident #3, #4, #5, #7, #8, #9). Specifically, (1) on 3/28/2024 Resident #2 hit Resident #5 with their walker after a verbal altercation in the hallway. Resident #5 sustained bruising to their left hand and chest area. (2) On 5/2/2024, Resident #2 and Resident #4 who resided in the same room engaged in a physical altercation. Resident #4 sustained a laceration to their chin and Resident #2 sustained a laceration to their left eyebrow. On 8/23/2024, Resident #2 was witnessed by staff hitting Resident #4 in the arm, while they were in the hallway without being provoked. Resident #4's room was changed after the 5/2/2024 incident, but they remained on the same unit as Resident #2 which increased the chance for another incident to occur; (3) On 11/2/2024, Resident #2 engaged in a physical altercation with Resident #3, witnessed by a staff member. Resident #3 sustained a superficial scratch to their forehead. (4) Resident #6 hit the back of Resident #9's head and stated, now we are even. (5) On 11/7/2024, Resident #6 reached back and hit Resident #7 on the right side of their face. On 11/22/2024, Resident #6 started to approach Resident #7 and aggressively started yelling at them, stating they will show them who they are today, and they are going to kill them. Resident #6 was redirected by staff, but attempts were unsuccessful. Resident #6 then went to Resident #7's room and aggressively and violently pushed Resident #7's belongings off their bed and bedside table to the floor. (6) Resident #6 walked over to Resident #8 and got into their face and told Resident #8 they told them to move, and they did not listen. The witness attempted to separate the residents and Resident #6 reached around with an open hand to slap Resident #8, they moved Resident #6 away from Resident #8 and stood in the middle of them. The facility did not implement any interventions to ensure the safety of the other resident in the facility from Resident #2 and Resident #6 with their known aggressive behaviors. The findings are: The facility Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Resident's Property policy last reviewed 5/2024 documented it is the policy of the facility that the resident has the right to be free from verbal and physical abuse. The facility prohibits any form of abuse or neglect consistent with the definitions of abuse and neglect of the Federal guidelines. The facility promotes any effort to prevent abuse and neglect. 1) Resident #2 admitted to the facility 12/8/2021 and last readmitted on [DATE] with diagnoses including but not limited to Dementia, Major Depressive Disorder and Anxiety Disorder. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 9/23/2024 documented the resident was cognitively intact. No behaviors documented. The resident required a walker for locomotion. The resident requires set-up for eating, supervision for toileting, bed mobility and transfers. A risk to be victimized/involved in resident-to-resident altercations care plan last revised 6/20/2024 documented the resident would be safe and free of harm by peers over the next 90 days. Interventions listed included monitor change in mood or behavior triggered by environmental factors and monitor well-being without environmental restrictions. The Facility Incident note dated 3/28/2024 and Accident report dated 3/29/2024 documented Resident #2 was witnessed on 3/28/2024 picking up their walker and hitting Resident #5 on the left hand. Staff immediately separated the residents. Both residents were assessed. Resident #5 had bruises to the left hand and left side of chest and complained of pain. Physician notified and Tylenol was administered. An Xray of the left hand was completed on Resident #5. Results of the Xray was negative. Resident #2 was transferred to the hospital and returned to the facility and assigned another unit. Resident #5 refused to go to the hospital. The facility investigation concluded that there was cause to believe resident abuse occurred. All staff will be educated to make sure residents are kept away from each other especially if they are off the unit. Review of a risk for harm from/to other care plan last revised 6/20/2024 documented the Resident #2 will not harm other residents x 92 days. Interventions listed included educate resident to report disruptive residents to staff and to not confront them, encourage participation in activities and socialization with others, offer room/floor change and review safety precautions with resident as needed. 2) Resident #5 was admitted to the facility with diagnoses including but not limited to Major Depressive Disorder, Adjustment Disorder and Left Hemiplegia. A Quarterly Minimum Data Set, dated [DATE] documented the resident was cognitively intact. No behaviors noted. The resident required a wheelchair for locomotion and moderate assistance with eating and transferring and maximal assistance with toileting and bed mobility. No behaviors noted. A resident-to-resident altercation care plan last revised 11/4/2024 documented the resident would be kept from Resident #2 at all times. Interventions listed included keep resident within viewing distance for observation as much as possible in activities, day room and nursing station, re-direct and re-focus attention and offer alternatives or engage in 1 to 1 as necessary, remove from other aggressive resident with aggression to a quiet, calm setting to avoid escalation of behavior and reduce incidents of altercation and as of 4/1/2024 resident will be kept away from Resident #2 at all times. 3) Resident #4 admitted to the facility 11/30/2023 with diagnoses including but not limited to Dementia, Psychotic Disorder with Delusions and other Bipolar Disorders. A Quarterly Minimum Data Set, dated [DATE] documented the resident had moderate cognitive impairment. No behaviors noted. The resident had impairment to the upper extremity on one side and was ambulatory. The resident required supervision for eating, moderate assistance with toileting and bed mobility and was independent for transfers. Review of an incident note dated 5/2/2024 documented Registered Nurse Supervisor was called to the unit and upon arrival observed Resident #2 standing at the doorway of their room alert, oriented and verbally responsive, no apparent distress noted. Resident #2 denied having a fall and was observed with a laceration to their left eyebrow 1 x 0.5 cm with slight bleeding. Resident #2 stated their roommate, Resident #4, accused them of stealing their cellphone and then started hitting them. Resident to Resident altercation resulting in injury to both residents. Physician made aware and 911 called. Resident #4 was moved to another room, social services to follow up. The investigation concluded that there was a cause to believe abuse occurred. Resident #4 was moved to another unit on return from the emergency room, staff would be educated to make sure that Resident #4 and Resident #2 are to always be separated especially if they are off the unit and psychiatry consult and psychology evaluations for both residents. Review of an incident/accident report dated 8/23/2024 documented Resident #2 was witnessed hitting Resident #4 on their arm without provocation in the hallway. The investigation concluded there was cause to believe resident abuse had occurred. Resident #2 hit Resident #4 for no apparent reason. The corrective actions documented staff were educated to make sure the residents are always away from each other especially when they are off the unit. Resident #4's room was changed after the 5/2/2024 incident, but they remained on the same unit as Resident #2 which increased the chance for another incident to occur. Review of a risk for potential verbal/physical abuse care plan last revised 8/26/2024 documented Resident #4 had a physical altercation with Resident #2 on 8/23/2024. Interventions listed included assess for signs and symptoms of physical abuse, encourage resident to seek out staff or assistance if having difficulties with others, ensure resident stays in room with a compatible roommate, monitor mood and behaviors and provide early interventions on any changes, provide support and encouragement for resident to express feelings and ensure resident is free from abuse. Review of risk to be victimized/involved in resident-to-resident altercations care plan last revised 3/6/2024 documented Resident #4 had impaired judgement/confusion. Interventions listed included keep resident within viewing distance for observation as much as possible in activities, day room and nursing station and monitor well-being without environmental restrictions. 4) Resident #3 admitted to the facility on [DATE] with diagnoses including but not limited to Vascular Dementia, Cerebral Infarction and Alcohol Dependence. A Quarterly Minimum Data Set, dated [DATE] documented the resident had severe cognitive impairment. No behaviors noted. The resident required a walker or a wheelchair for locomotion. The resident required set up assistance with meals, moderate assistance with toileting, bed mobility and transfers. The corrective action documented in the submission report dated 11/8/2024 documented Resident #2 will not be permitted to visit the unit of Resident #3 unescorted. Staff were educated to make sure Resident #2 and Resident #3 are always away from each other when they are off the unit. Resident #3 was discouraged to verbalize comments to peers. There was no investigative summary attached to the incident/accident file. Review of a peer-to-peer altercation care plan initiated 7/6/2024 documented Resident #3 would not have any further altercations. Interventions listed included deescalate the situation that can potentiate to an altercation, psychiatry consult, and resident relocated to another unit. There was not documented evidence of the care plan being reviewed after 7/6/2024 or revised to reflect the incident that occurred on 11/12/2023. A psychosocial well-being care plan initiated 7/9/2024 documented Resident #3 is a potential for abuse. Interventions listed included allow resident to vent feelings, of being fearful, anxious, as necessary and provided 1 to 1 support as necessary. Review of a risk to be victimized/involved in resident-to-resident altercations care initiated 12/28/2023 documented Resident #3 had impaired judgement/confusion. Interventions listed included monitor for change in mood/behavior and monitor wellbeing without environmental restrictions. Review of an incident/accident report dated 11/2/2024 documented Resident #3 and Resident #2 engaged in a physical altercation and were found by staff on the floor hitting each other. Resident #3 sustained a superficial scratch to their forehead. Resident #3 and Resident #2 were transferred to the emergency room for evaluation. 5) Resident #6 admitted to the facility 6/24/2024 with diagnoses including but not limited to Anxiety Disorder, Post-Traumatic Stress Disorder and Epilepsy. A Significant change Minimum Data Set, dated [DATE] documented the resident was cognitively intact. No behaviors noted. The resident required a wheelchair for locomotion. The resident required set up assistance with eating, maximal assistance with toileting and transferring and moderate assistance with bed mobility. A risk for harm to others/from other care plan last revised 11/22/2024 documented Resident #6 was a risk to harm others. Documented on 11/8/2024 Resident #6 had an altercation with Resident #7. On 11/22/2024 Resident #6 slapped Resident #8 on the face unprovoked and threatened Resident #7 to kill them. Interventions listed included educate resident to report disruptive residents to staff and not confront them and offer resident room/floor change and on 11/22/2024 transfer to emergency room and psychiatry consult. 6) Resident #9 admitted to the facility 3/15/2022 with diagnoses including but not limited to Dementia, Cerebral Infarction and Altered Mental Status. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 8/12/2024 documented the resident had moderate cognitive impairment. No behaviors noted. The resident used a walker and a wheelchair for locomotion. The resident required set up assistance with eating, supervision with toileting, bed mobility and transfers. Review of the incident investigation documented on 8/30/2024 at 5:45 PM Resident #7 and Resident #9 had a verbal argument and were immediately separated by staff. While the staff were wheeling Resident #9 to their room, Resident #6 suddenly hit the back of Resident #9's head and stated, now we are even. Staff immediately intervened and separated the residents. Assessments were conducted for both residents and no injuries were found. The corrective action documented the residents were kept away from each other and safety maintained on the unit. The physician ordered to send both residents to the emergency room for evaluation. Resident #9 was moved to another unit on return from the emergency room. Psychiatry and Psychology follow up in house. Review of a risk to be victimized/involved in resident-to-resident altercations initiated 9/4/2024 documented secondary to impaired judgement / confusion / aggression / behaviors. Interventions listed included monitor for changes in mood and behavior triggered by environmental factors. Review of a risk for potential verbal/physical abuse last revised 10/11/2024 documented Resident #9 was at risk secondary to Dementia. Interventions listed included assess for signs and symptoms of abuse, encourage resident to seek out staff or assistance if having difficulties, ensure resident stays in a room with a compatible roommate, provide support and ensure resident is free from abuse. 7) Resident #7 admitted to the facility 6/14/2023 with diagnoses including but not limited to Anxiety, Peripheral Vascular Disease and Acquired Bilateral Lower Extremity Above the Knee Amputations. A Quarterly Minimum Data Set, dated [DATE] documented the resident was cognitively intact. The resident exhibited verbal behaviors directed towards others. The resident had impairment to both lower extremities and required a wheelchair for locomotion. The resident required set up assistance with eating, supervision with toileting, bed mobility and transfers. Review of a risk to be victimized/involved in a resident-to-resident altercation last revised on 10/21/2024 documented Resident #7 was at risk secondary to medical and physical status. On 8/3/2024 documented Resident #7 was threatened by Resident #9. Interventions listed from 3/23/2024 documented monitor for changes in mood and behavior triggered by environmental factors. 8) Resident #8 admitted to the facility on [DATE] with diagnoses including but not limited to Personal History of Traumatic Brain Injury, Cerebral Infarction and Contracture of eft Hand. A Comprehensive Minimum Data Set (an assessment tool that measures health status) dated 9/17/2024 documented the resident was cognitively intact. The resident exhibited verbal behaviors directed towards others. The resident had impairment to the upper and lower extremities on one side and required a wheelchair for locomotion. The resident required set up assistance with eating, moderate assistance with toileting and supervision with bed mobility and transfers. Review of the investigative summary dated 11/8/2024 documented on 11/7/2024 staff witnessed Resident #7 waiting in line for the smoking session, and Resident #6 rolled ahead of Resident #7 in the line. Resident #7 made a derogatory comment to Resident #6 and Resident #6 turned around and did not say anything. When Resident #7 called Resident #6 a derogatory name again, Resident #6 reached back and hit Resident #7 on the right side of their face. Staff separated the residents immediately and maintained safety. Body checks were completed, and no injuries were noted. Resident #7 had an x-ray ordered and the result came back negative. The physician ordered to send Resident #6 to the emergency room for a psychiatric evaluation. Review of the investigation summary dated 11/25/2024 documented on 11/22/2024 at 5:30 PM Resident #7 was interacting with staff at the nurses' station, Resident #6 started to approach Resident #7 and aggressively started yelling at Resident #7, stating they will show them who they are today, and they are going to kill them. Staff immediately intervened and removed Resident #7 from the situation and Resident #6 was redirected and escorted by staff to their unit. Safety was maintained and 911 was called and police assistance requested. Resident #6 was redirected by staff, but attempts were unsuccessful. Despite multiple attempts to redirect Resident #6 by staff they went to Resident #7's room and aggressively and violently pushed Resident #7's belongings off their bed and bedside table. Resident #6 returned to their unit as the police arrived. The police interviewed both residents and then Resident #6 was transferred to the emergency room due to aggressive behavior. Resident #7 will be seen by psychiatry and psychology in house and reassurance provided. Review of an incident and accident report dated 11/22/2024 documented at 10:58 AM staff witnessed Resident #6 telling Resident #8 to move out of the way. Resident #6 then turned to the witness and stated they asked Resident #8 to move nicely and if they do not move, then they will move them. The witness told Resident #6 that they should leave Resident #8 alone because they were not in their way. Resident #6 then proceeded to walk over to the ice bucket to get ice. After Resident #6 got the ice, Resident #6 walked over to Resident #8 and got into their face. Resident #6 reached around with an open hand to slap Resident #8, they moved Resident #6 away from Resident #8 and separated. Review of a risk to be victimized/involved in a resident-to-resident altercation initiated 10/10/2023 and last updated 12/13/2024. documented Resident #8 was at risk secondary to living in a congregate setting. Interventions listed included monitor for changes in mood and behavior triggered by environmental factors. There was no documented evidence of the care plan being updated with the incident that occurred on 11/22/2024. During an interview on 12/18/2024 at 9:21 AM the Director of Nursing stated when there is a resident-to-resident incident, the residents are immediately separated. The Director of Nursing stated following a resident-to-resident incident all department heads are given a list of the residents involved and instructed to ensure the residents are kept separate. During an interview on 12/19/2024 at 4:40 PM, the Administrator stated the residents with the resident-to-resident situations are separated by unit initially. The Administrator stated they meet with the interdisciplinary team and see what interventions can be put in place and if an intervention is not working then they will change the intervention. The Administrator stated they are always educating the staff to be knowledgeable of which residents need to be closely supervised when they are near each other. The Administrator stated the resident-to-resident incidents are brought up regularly in the quality assurance and performance improvement meetings and they try to have activities on going, so that the residents are always staying busy. The Administrator stated they do their best to try and keep the residents that are more challenging safe and away from each other. 10 NYCRR 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during an abbreviated survey (NY00337504, NY00353121) the facility did not ensure the report of the results of their investigation was submitted to the New York State Department of Health in accordance with State law within 5 working days of the incident for 2 of 3 residents (Resident #2, #6) reviewed for abuse. Specifically, (1) Resident # 2 was witnessed hitting Resident #5 on their left hand with their walker on 3/28/2024. The 5-day investigative conclusion report was not submitted to the New York State Department of Health until 4/11/2024. 2)On 5/2/2024 Resident #2 engaged in a physical altercation with Resident #4 and resulted in injury to both residents. There was no documented evidence that a 5-day investigative conclusion report was submitted to the New York State department of Health. 3) On 11/2/2024 Resident #2 and Resident #3were engaged in a physical altercation and were found by staff on the floor hitting each other. Resident #3 sustained a superficial scratch to their forehead. The 5-day investigative conclusion report was not submitted until 11/8/2024. (4) Resident #6 was witnessed on 11/7/2024 hitting Resident #7 on the right side of their face. The 5-day investigative conclusion report was not submitted until 11/13/2024. 5)On 11/22/2024 Resident #6 reached around with an open hand and slapped Resident #8 in the face. The 5-day investigative conclusion report was not submitted until 12/3/2024. The findings are: 1) Resident #2 was admitted to the facility 12/8/2021 and last readmitted on [DATE] with diagnoses including but not limited to Dementia, Major Depressive Disorder and Anxiety Disorder. A Quarterly Minimum Data Set (an assessment tool that measures health status) dated 9/23/2024 documented the resident was cognitively intact. No behaviors documented. The resident required a walker for locomotion. The resident requires set-up for eating, supervision for toileting, bed mobility and transfers. Review of the accident/incident report dated 3/28/2024 at 9:10 PM documented Resident #5 sustained bruising to their left hand after Resident #2 hit them with their walker after a verbal altercation in the hallway and the investigative summary dated 3/29/2024 concluded there is cause to believe an alleged resident abuse occurred. Review of the Aspen Complaint Tracking System revealed the 5-day investigative conclusion report was not submitted until 4/11/2024. 2)A Review of the investigation conclusion dated 5/2/2024 documented a resident-to-resident altercation between Resident #2 and Resident #4. Both residents were transferred to the emergency room and psychiatric evaluation, as Resident #2 sustained a laceration to the chin and Resident #4 sustained a laceration to the left eyebrow. Review of the Aspen Complaint Tracking System revealed no submission of the 5-day investigative conclusion report for the incident that occurred on 5/2/2024. 3) A Review of an incident/accident report dated 11/2/2024 documented Resident #3 and Resident #2 engaged in a physical altercation and were found by staff on the floor hitting each other. Resident #3 sustained a superficial scratch to their forehead. Review of the Aspen Complaint Tracking System revealed the 5-day investigative conclusion report was not submitted until 11/8/2024. 4) A Review of a Facility investigative summary dated 11/8/2024 documented on 11/7/2024 staff witnessed Resident #7 waiting in line for the smoking session. Resident #6 rolled ahead of Resident #7 on the line. Resident #7 made a derogatory comment to Resident #6 and Resident #6 turned around and did not say anything. Resident #7 called Resident #6 a derogatory name again, and Resident #6 reached back and hit Resident #7 on the right side of their face. Staff separated the residents immediately and maintained safety. Body checks were completed, and no injuries were noted. Resident #7 had an x-ray ordered and the result came back negative. The physician ordered to send Resident #6 to the emergency room for a psychiatric evaluation. Review of the Aspen Complaint Tracking System revealed the 5-day investigative conclusion report was not submitted until 11/13/2024. 5) A Review of an incident and accident report dated 11/22/2024 documented at 10:58 AM staff witnessed Resident #6 telling Resident #8 to move out of their way. Resident #6 then turned to a staff (witness) and reported they asked Resident #8 to move nicely and if they do not move, they will move them. Resident #6 proceeded to walk over to the ice bucket to get ice and walked over to Resident #8 and got into their face. Resident #6 reached around with an open hand and slapped Resident #8. Resident #6 was moved away from Resident #8, and both were separated. Review of the Aspen Complaint Tracking System revealed the 5-day investigative conclusion report was not submitted until 12/3/2024. During an interview on 12/18/2024 at 9:21 AM, the Director of Nursing stated the incident that occurred on 3/28/2024 they are not sure who submitted the 5-day conclusion as it states anonymous. The Director of Nursing stated for the incident that occurred on 5/2/2024 they were not aware that a 5-day conclusion was not submitted. The Director of Nursing did not provide and explanation as to why the 5-day conclusion report was not submitted for some of the incidents and why those submitted were late. 10NYCRR 415.4(b)(1)(ii)

Based on record review and interview during an abbreviated survey (NY00334737) the facility did not ensure sufficient nursing staff to attain or maintain the well-being of each resident as determined by the facility staffing grid as necessary to meet the needs of the residents for 35-40 residents on the 3rd floor Dementia Unit. Specifically, review of the facility scheduled data sheets for January 2024, February 2024 and March 2024 revealed staffing was not adequate across various shifts based on the unit needs and Provider Average Ratio (PAR) levels documented on the staffing grid. The findings are: The facility Staffing policy last revised 5/2024 documented the facility must have sufficient nursing staff with the appropriate competencies and skill sets to: provide nursing and related services to assure resident safety. Providing care includes but is not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs. Attain or maintain the highest practicable physical, mental, and psychological well-being of each resident. As determined by resident assessments and individual plans of care. Considering the number, acuity, and diagnoses of the facility's residents' population. The Staffing Grid documented as of November 12, 2024, the certified nurse assistant Provider Average Ratio levels for the 3rd floor were as follows: Day shift: 5 certified nurse assistants, Evening shift: 4 certified nurse assistants, Night shift: 2 certified nurse assistants. Review of the facility staffing schedule for the 3rd Floor Dementia Unit for January 2024 revealed the following: Day shift-2 certified nurse assistants on 1/1/2024, 1/8/2024, 1/9/2024, 1/11/2024, 1/12/2024, 1/13/2024, 1/21/2024, 1/23/2024, 1/25/2024, 1/28/2024 3 certified nurse assistants on 1/2/2024, 1/4/2024, 1/6/2024, 1/7/2024, 1/10/2024, 1/14/2024, 1/15/2024, 1/16/2024, 1/20/2024, 1/22/2024, 1/24/2024, 1/29/2024, 4 certified nurse assistants on 1/3/2024, 1/5/2024, 1/17/2024, 1/18/2024, 1/19/2024, 1/27/2024, 1/30/2024, 1/31/2024. Evening shift-2 certified nurse assistants on 1/1/2024, 1/3/2024, 1/13/2024, 1/14/2024, 1/16/2024, 1/20/2024, 1/21/2024, 3 certified nurse assistants on 1/2/2024, 1/4/2024, 1/5/2024, 1/6/2024, 1/7/2024, 1/8/2024, 1/9/2024, 1/10/2024, 1/11/2024, 1/12/2024, 1/17/2024, 1/18/2024, 1/24/2024, 1/25/2024, 1/27/2024, 1/29/2024, 1/30/2024, 1/31/2024. Night shift-1 certified nurse assistant on 1/13/2024, 1/25/2024, 1/28/2024 Review of the facility staffing schedule for the 3rd Floor Dementia Unit for February 2024 revealed the following: Day shift-2 certified nurse assistants on 2/5/2024, 2/9/2024, 2/11/2024, 2/12/2024, 2/13/2024, 2/14/2024, 2/22/2024, 3 certified nurse assistants on 2/1/2024, 2/4/2024, 2/8/2024, 2/10/2024, 2/19/2024, 2/20/2024, 2/21/2024, 2/26/2024, 4 certified nurse assistants on 2/2/2024, 2/3/2024, 2/6/2024, 2/7/2024, 2/16/2024, 2/23/2024, 2/25/2024, 2/27/2024, 2/28/2024, 2/29/2024, Evening shift-2 certified nurse assistants on 2/4/2024, 2/9/2024, 2/11/2024, 2/17/2024, 2/18/2024, 2/23/2024, 2/26/2024, 3 certified nurse assistants on 2/1/2024, 2/3/2024, 2/6/2024, 2/8/2024, 2/10/2024, 2/12/2024, 2/13/2024, 2/14/2024, 2/18/2024, 2/20/2024, 2/21/2024, 2/24/2024, 2/25/2024, 2/27/2024, 2/28/2024. Night shift-1 certified nurse assistant on 2/3/2024, 2/4/2024, 2/16/2024, 2/22/2024, 2/25/2024 Review of the facility staffing schedule for the 3rd Floor Dementia Unit for March 2024: revealed the following-Day shift-2 certified nurse assistants on 3/16/2024, 3/17/2024, 3/18/2024, 3/21/2024, 3/26/2024, 3 certified nurse assistants on 3/2/2024, 3/3/2024, 3/4/2024, 3/5/2024, 3/7/2024, 3/10/2024, 3/25/2024, 3/31/2024, 4 certified nurse assistants on 3/1/2024, 3/6/2024, 3/8/2024, 3/9/2024, 3/11/2024, 3/12/2024, 3/13/2024, 3/14/2024, 3/15/2024, 3/19/2024, 3/22/2024, 3/23/2024, 3/24/2024, 3/27/2024, 3/28/2024, 3/30/2024, Evening shift-2 certified nurse assistants on 3/1/2024, 3/4/2024, 3/11/2024, 3 certified nurse assistants on 3/2/2024, 3/3/2024, 3/5/2024, 3/6/2024, 3/7/2024, 3/8/2024, 3/10/2024, 3/12/2024, 3/13/2024, 3/15/2024, 3/16/2024, 3/17/2024, 3/19/2024, 3/21/2024, 3/22/2024, 3/24/2024, 3/25/2024, 3/26/2024, 3/27/2024, 3/28/2024, 3/30/2024, 3/31/2024.Night shift-1 certified nurse assistant on 3/19/2024 During an interview on 12/19/2024 at 1:55 PM the Staffing Coordinator stated they have been working in the facility since March. The Staffing Coordinator stated staffing during the morning and evening shifts, have a lot of call outs and they try to have additional staff scheduled just in case, but sometimes they call out as well. The Staffing Coordinator stated if the census on a unit is 30 residents or below then they will schedule 3 certified nurse assistants. The Staffing Coordinator stated if a unit has a 1 to 1 then they schedule 3 certified nurse assistants and 1 extra. The Staffing Coordinator stated if they do have extra certified nurse assistants then they will schedule them to work on the Dementia units. Staffing for the facility is as follows as per the Staffing Coordinator: morning and evening shifts all units- 4 certified nurse assistants, night shift-2 certified nurse assistants. The Staffing Coordinator stated they also use agency staff when there is an opening and the regular or the per diem certified nurse assistants do not pick up the shift. During an interview on 12/19/2024 at 2:28 PM Certified Nurse Assistant #3 stated they have been working in the facility for a longtime and the staffing is really bad. Certified Nurse Assistant #3 stated sometimes they start the shift off with 4 certified nurse assistants on the unit and then they end up with 2 or 3 certified nurse assistants. Certified Nurse Assistant #3 stated sometimes when they arrive to the facility in the morning, there is only 1 certified nurse assistant and the nurse for the entire unit with 35 to 40 residents. That is too much for the 3rd floor dementia unit where the residents wander around. Certified Nurse Assistant #3 stated when they arrive in the morning the residents on the unit are saturated with feces and urine from head to toe. Certified Nurse Assistant #3 stated the staffing shortage occurs every week and the facility's response to them is that they reach out to agency staff, but they never come in. During an interview on 12/19/2024 at 2:37 PM Certified Nurse Assistant #4 stated they have been working in the facility since the beginning of the year. Certified Nurse Assistant #4 stated they are now assigned to the 3rd floor. They work double shifts about 2-3 times/week. Certified Nurse Assistant #4 stated the staffing in the facility is bad and there have been times when they are the only certified nurse assistant on the unit with the nurse. Certified Nurse Assistant #4 stated there have been times when there is only certified nurse assistants on the unit with no nurse. Certified Nurse Assistant #4 stated sometimes on the weekend they work with 2 certified nurse assistants on the 3rd floor, and it is not easy. This is another reason a lot of staff do not want to work on the 3rd floor. During an interview on 12/19/2024 at 2:50 PM Certified Nurse Assistant #5 stated they have been working in the facility for 27 years and the staffing has gotten better compared to earlier in the year, the staffing was bad. Certified Nurse Assistant #5 stated the facility uses agency staffing to fill gaps and now the staffing is better, but before it was horrible. During an interview on 12/19/2024 at 5:03 PM the Director of Nursing stated when they came to the facility the staffing was done according to the census and there was a back and forth about the acuity and type of residents they had. The Director of Nursing stated staffing is a challenge in the facility, with the lateness and the call outs. The Director of Nursing stated although the documented Provider Average Ratio (PAR) for the day shift is 5 certified nurse assistants, most days they have 3 or 4. The Director of Nursing stated if the residents on the units have appointments, the certified nurse assistants are pulled from the units to accompany the residents to the appointments. The Director of Nursing stated they must meet the needs of the residents and staffing has improved from where it used to be. 10NYCRR 415.13 (A)(1)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews during an abbreviated survey (NY00337354, NY00334737), the facility did not ensure the environment was functional, sanitary, and comfortable for residents, staff, and the public. Specifically, on every unit in the facility there were multiple areas of chipped paint, scuff marks, visible dirt and stains on the walls and floors, base boards chipped and coming off the wall, holes in the walls, chipped tiles, caving ceiling tiles and foul odors. The findings are: The facility Resident Environmental Quality policy last revised 10/2024 documented it is the policy of the facility to be designed, constructed, and maintained to provide a safe, functional, sanitary, and comfortable environment for resident's staff and the public. During rounds on the units on 12/13/2024 from 12:34pm to 2:41pm the following was observed: On the 2nd floor there was chipped paint on the walls along the hallway. On the 3rd floor there was a light bulb out on the high side hallway, the walls were dirty and had chipped paint. The bathroom in room [ROOM NUMBER] had visible dirt on the walls and the radiator had chipped paint. The base boards were off and peeling along the hallways in many areas. By room [ROOM NUMBER] the paint was chipped on the wall and the baseboard was coming off. On the 4th floor dining room, there was chipped paint and large scuff marks on the walls, the baseboards were chipped and coming off the walls. There was an improper ceiling tile repair, and a portion of the tile was caving. The plaster was chipped off the wall at the nurse's station. The wall behind the bed in room [ROOM NUMBER] was visibly dirty and stained. The bathroom in room [ROOM NUMBER] had a hole in the wall around the plumbing and duct tape holding the paper towel dispenser together. On the 5th floor there was chipped paint along the walls on the low side of the hallway and well as on the doorways to the rooms. The door to the medication room in the nursing station was chipped. There were some tiles coming up and cracked in the nurse's station. There were holes in the wall by room [ROOM NUMBER]. The panel under the water fountain at the end of the low side hallway had a screw missing and was protruding from the wall, the baseboard by the water fountain was chipped along the entire corner. In the dining room there was a large, scuffed area along the entire bottom section of the wall. On the 6th floor the walls had chipped paint along the hallway and visibly soiled walls and doors. Multiple areas of the base boards were chipped and coming off the walls. During an interview on 12/17/2024 at 9:45 AM, the Director of Maintenance stated they are responsible for everything that breaks down in the facility, maintaining the equipment, some engineering tasks and dealing with the boiler room. The Director of Maintenance stated they currently have 2 staff members under them, and they have a lot of experience in construction, and they have to assist their staff who are not as experienced. The Director of Maintenance stated the staff then write a note as to what repair is needed and then they complete the task and sign off and close the ticket with a note. The Director of Maintenance stated they have the app on their cellphones and the computer and daily they review to see if there are issues that need to be addressed. The Director of Maintenance stated most tasks are completed in a day but if additional items are needed to complete the task, then it may take longer and if the task cannot be completed the next day, then they try to address it within 48 hours. The Director of Maintenance stated they make environmental rounds in the morning if they are not available then they will ask their employees to make the rounds. The Director of Maintenance stated the Administrator is only on rounds if necessary or if they find something they need to have addressed. The Director of Maintenance stated they are trying their best with completing the painting and patching in the facility, the work is overwhelming at times. The Director of Maintenance stated they will patch holes and they have to go back and paint the area and they are trying to hire someone with the skills needed to repair things like painting and patching holes. The Director of Maintenance stated they have spoken with the Administrator about hiring additional staff and they are working on it and it is their responsibility to maintain the building and not to fix it. During an interview on 12/16/2024 at 9:03 AM, the Administrator stated they have been working in the facility since February 2024 and they do environmental rounds in the facility at least weekly, but they try to do rounds daily. The Administrator stated when they make rounds, they focus on making sure the hallways are free of clutter, no items on the carts, observe for chips in the paint, holes in the walls, ensure no doors are propped open and ceiling tiles are intact. The Administrator stated they also spot check to ensure the call bells are working and the resident's televisions are working. The Administrator stated if something is found they reach out to the maintenance department and if it is a nursing issue they reach out to nursing. The Administrator stated depending on the item that is being requested to work on, they timing requirement for expected repairs differs. The Administrator stated if it is a remote control then they would expect it to be addressed in an hour or two, if it is a hole in the wall then within 48 hours, they would expect it to be addressed. The Administrator stated they try to be reasonable so if they request several things at one time then they will allow them more time. The Administrator stated they do not usually use an outside vendor for cosmetic needs in the building. The administrator stated they were working on hiring more staff for maintenance. 10 NYCRR 415.29

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during abbreviated survey (NY00331536, NY0033004, NY00332489), the facility did not ensure that residents were free from abuse, neglect, and exploitation for 2 of 4 (Residents #1 and #2) reviewed for abuse. Specifically, (1) Resident #2 had multiple documented incidents of sexual/physical and verbal aggression towards staff on 12/19/2023,12/20/2023,1/12/2024 and no new interventions were put in place to prevent further reoccurrence; (2) On 1/13/2024, Resident #1 reported to their assigned Certified Nursing Assistant (Staff # 21) that they were inappropriately touched by another resident (Resident #2). Resident #2's hat was found on Resident #1's bed and Resident #2's sweater was found on the ground next to the bed. Resident #1and #2 were assessed and transferred to the Emergency Room. Resident #1 was transferred from the emergency room to a hospital for further evaluation. The facility did not notify local law enforcement. Resident #2 was arrested for alleged sexual assault of Resident #1 on 1/17/2024. The findings are: An undated facility policy titled 'Abuse, neglect, and exploitation of residents' documented it is the moral and legal responsibility of all staff members to identify, prevent and report suspected or witnessed abuse; the administrator/director is responsible to receive and investigate all alleged violations thoroughly, timely, and objectively; and for situations involving reasonable cause to suspect sexual abuse (excluding sexual harassment), serious physical injury, serious bodily injury and suspicious death, local law enforcement shall be notified immediately. Resident #1 had diagnoses including but not limited to multiple rib fractures, schizophrenia, and hypertension. Resident #1's admission Minimum Data Set (a resident assessment tool) dated 12/4/2023 documented the Resident #1 had a Brief Interview for Mental status (BIMS, used to determine attention, orientation, and ability to recall information) of 13, reflecting intact cognition, and exhibited no behaviors. Resident #2 had diagnoses including but not limited to lung carcinoma, schizophrenia, and dementia. The Quarterly Minimum Data Set, dated [DATE] documented Resident #2 had a Brief Interview for Mental status Score of 11/15, reflecting moderate cognitive impairment. Resident #2 had no impairment of upper or lower extremities and had no verbal or physical behavioral symptoms towards others. Resident #2's comprehensive care plan reviewed 10/18/2023 documented the resident demonstrated problematic behavior including wandering, wanting to go home, and banging on tables; with interventions including but not limited to monitor resident's whereabouts, anticipate resident's needs, intervene as necessary to protect rights and safety of others. A review of Resident #2's behavior notes revealed multiple acts of sexual aggression including: - On 12/19/23, Registered Nurse #1 documented Resident #2 was screaming to self and other CNA's, You want to F*** me. - On 12/20/23, Registered Nurse #39 documented Resident #2 was wandering into other resident's rooms, harassing them, and making inappropriate sexual remarks to residents and staff. Registered nurse #39 additionally documented Resident #2 attempted to strangle a nurse on the 2nd floor. - On 12/20/23, Licensed Practical Nurse #5 documented Resident #2 entered the shower room during a female resident's shower and refused to leave. - On 1/12/24, Licensed Practical Nurse #22 documented Resident #2 punched Licensed Practical Nurse #22 in their private parts and barricaded Licensed Practical Nurse #22 in their room with a wheelchair. There was no documented evidence the incidents that occurred on 12/19/2023, 12/20/2023, and 1/12/2024 were investigated, and there were no updates to Resident #2's care plan to reflect Resident #2's physical and sexually aggressive behaviors. An undated facility investigative summary report, authored by the director of nursing, documented that on 1/13/2024 at approximately 2:00 PM, Resident #1 reported that they were inappropriately touched by another male resident (Resident #2) on the unit to their assigned staff, Certified Nursing Assistant #21. The Director of Nursing Services was notified at 2:01 PM, the administrator was notified, both residents were assessed for any injury by Registered Nurse Supervisor #17 with no acute findings. Resident #1 was transferred to the emergency room for further evaluation and Resident #2 was transferred to the emergency room for behavioral management and inappropriate sexual behavior. During an interview on 1/23/2024 at 3:30PM, Certified Nursing Assistant #21 stated they were informed by Resident #1 of the alleged sexual assault, and observed Resident #2's sweater on the ground next to Resident #1's bed and Resident #2's hat on the pillow of Resident #1 Certified Nursing Assistant #21 stated they informed the nurse, the nursing supervisor called the director of nursing, then the nursing supervisor arranged for an ambulance transfer for both residents to the hospital. Certified Nursing Assistant #21 stated 911 was not called at the time of the alleged sexual assault and they do not recall police in the building on 1/13/2024. During an interview on 1/24/2024 at 10:49 AM, Detective #1 stated Resident #2 was arrested on 1/17/2024 for an allegation of sexual assault of Resident #1 and stated the police department was not notified of the sexual assault until they were alerted of the incident by the hospital emergency department staff, after Resident #1 reported to hospital staff that they had been sexually assaulted in their nursing home. During an interview on 1/24/2024 at 12:02 PM, the Director of Nursing stated they were aware of Resident #2's escalating physical/sexual behaviors and many discussions were had about them during the morning report. The director of nursing was unable to provide care-plans with specific interventions to protect staff and residents and was unable to state any plans that were put in place to protect staff and residents in the facility from Resident #2's behaviors. During an interview with Resident #1 on 1/24/2024 at 4:09 PM, Resident #1 stated Resident #2 got on top of them, tore off their incontinence brief, and put their hand in their vagina. During an interview on 1/26/2024 at 9:12 AM, Registered Nurse Unit Manager #5 stated that care plans are developed by an interdisciplinary team, that care plans are for the staff to follow when providing care to residents and are updated by them. Registered Nurse Unit Manager #5 stated they spoke to the Director of Nursing about each incident of Resident #2's escalating sexual/physical behaviors and they were always told to call the doctor and order a psychiatry consult. Registered Nurse Unit Manager #5 denies training on crisis prevention or intervention, or specific training for psychiatric de-escalation, or personal safety education. Registered Nurse Unit Manager #5 stated they do not write specific interventions on how to manage resident behaviors in the care plans because many of the staff have worked at the facility for a long time and know how to handle resident behavior needs. During an interview on 1/26/2024 at 8:55 AM, Physician #1 stated when Resident #2 misbehaves, staff report Resident #2's behavior and they order the resident be transferred to the hospital for a psychiatric evaluation. Physician #1 stated the facility has sent Resident #2 to the hospital for behavior multiple times, Resident #2's medications have been adjusted, psychiatry has been consulted, and nothing seems to work. Physician #1 stated Resident #2 is currently being held at the hospital where they are physically restrained and not allowed back to the facility because there is an active restraining order against them for Resident #1. 10 NYCRR 415.4(b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during an abbreviated survey (NY00332489) it was determined the facility did not ensure that the comprehensive person-centered care plan was implemented to meet the residents needs for safety for 1 of 9 residents reviewed for accidents (Resident #5). Specifically, Resident #5 with a known history of polysubstance abuse had suspected drug overdoses that occurred in the facility on 12/9/2023, 1/5/2024,1/10/2024, 1/18/2024, 1/23/2024, 1/29/2024, and 2/2/2024 for which Narcan (an opioid reversal agent) had to be administered by facility staff; Resident #5's comprehensive care plan did not address the resident's known substance use disorder, was not updated to reflect the suspected overdoses. No new care plan interventions were put in place to ensure Resident #5's safety and prevent recurrent overdoses. The findings are: The undated facility policy titled, Comprehensive Care Plan documented each resident's comprehensive care plan has been designed to incorporate risk factors associated with identify problems and enhance the optimal functioning of the resident by focusing on a rehabilitative program. Resident #5 was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral infarction, adult failure to thrive, and other psychoactive substance abuse (a drug that affecting the function of the mind and nervous system). The Quarterly Minimum Data Set (a resident assessment tool), dated 10/11/2023, documented Resident #5 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and the ability to recall) of 14 associated with intact cognition. Resident #5 was on a scheduled pain medication regimen and was receiving opioid medication. Resident #5's comprehensive care plan dated 10/11/2023, did not indicate the resident had a substance use disorder and did not mention the suspected overdoses that occurred on 12/9/2023, 1/5/2024, 1/10/2024, and 1/18/2024. Resident #5's comprehensive care plan dated 1/24/2024 was updated to reflect substance use after the New York State Department of Health commenced their investigation on 1/23/2024. A review of hospital emergency department summaries documented Resident #5 suffered subsequent suspected overdoses on 1/23/2024, 1/29/2024 and 2/2/2024. During an interview on 1/26/2024 at 9:12 AM, Registered Nurse Unit Manager #5 stated they are responsible for updating the resident's care plans. Registered Nurse Unit Manager #5 stated that Resident #5 has overdosed multiple times despite education provided and denies having any substances in their possession. Registered Nurse Unit Manager #5 stated they did not make a care plan for the overdoses because they did not think they are allowed to put a resident's overdose in their care plan. Registered Nurse Unit Manager #5 stated they initiated a care plan regarding illicit drugs after Resident #5 overdosed on 1/23/2024, and stated they were directed to make the care plan by the Director of Nursing because the New York State Department of Health was in the building. During an interview on 1/29/2024 at 9:23 AM, the director of nursing stated the facility began house-wide in-service education over the weekend and Resident #5's care plan was updated on 1/23/23 to reflect their substance use disorder. 415.11 (c) (1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews during an abbreviated survey (#NY00332489, NY00331536, NY00330044), the facility did not ensure that the resident's Primary Care Physician (PCP) comprehensively reviewed the resident's total program of care including the resident's current condition, progress and problems in maintaining or improving their physical, mental and psychosocial well-being and decisions about the continued appropriateness of the resident's current medical regimen for 1 of 9 residents (Resident #5) reviewed for accidents. Specifically, Resident #5 Resident #5 had suspected drug overdoses that occurred in the facility on 12/9/2023, 1/5/24,1/10/24, 1/18/24, 1/23/24, and 1/29/24 for which Narcan (an opioid reversal agent) had to be administered by facility staff. Resident #5's comprehensive care plan was not updated after episodes of overdose or illicit substance. The resident's physician (Physician #2) did not recommend new interventions including recommendations made by hospital after discharge. Resident #5 was admitted to the facility on [DATE] with diagnoses including but not limited to cerebral infarction, adult failure to thrive, and other psychoactive substance abuse (a drug that affects the function of the mind and nervous system). The Quarterly Minimum Data Set, (a resident assessment tool) dated 10/11/2023, documented Resident #5 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and the ability to recall) of 14 associated with intact cognition. Resident #5 was on a scheduled pain medication regimen and was receiving opioid medication. A review of the hospital admission and discharge summaries dated 12/9/2023 and 12/11/2023 documented Resident #5 was treated for polysubstance use drug low blood pressure that is caused by use of many illicit substances. The urine toxicology was positive for opiates, cannabinoid, and cocaine following their transfer to the hospital from the nursing home. The discharge summary documented the emergency room Physician (Physician #3) held Oxycodone 10mg every 6 hours for pain and recommended to consider referral to outpatient rehabilitation for treatment of the resident's substance use disorder. There is no documented evidence a referral was made prior to Resident #5's overdose attempt on 1/29/2024. An individual facility psychotherapy progress note dated 1/20/2024 and written by Therapist #1 documented Resident #5 will be seen 2-6 times/month for individual psychotherapy sessions for depression and adjustment disorder. The Therapy note documented Resident #5 was having difficulty adjusting to decreased physical functioning and had symptoms of pain. The note documented that Resident #5 expressed the desire to stay clean. The therapist notes mentioned overdose and issues leading to the resident's drug seeking behavior. Review of medical notes revealed no documented evidence that Physician #2, or the facility addressed Resident #5 expressed desire to 'stay clean, and no documented evidence Physician #2 addressed Resident #5's difficulty to adjusting to decreased physical functioning and pain. Resident #5's comprehensive care plan dated 10/11/23 documented the resident has a mood problem related to admission with interventions including administer medications as ordered and monitor/document for side effects and effectiveness. The comprehensive care plan does not state specific signs and symptoms for staff to observe and report to the physician. During an interview on 1/29/2024 at 11:20 AM, Physician #2 stated Resident #5 denied use of illicit substances when questioned. Physician #2 could not provide the date this conversation was held with the resident. Physician #2 was not aware Resident #5 expressed a desire to get clean during their psychotherapy session on 1/20/2024. Physician #2 stated they are surprised the facility had not provided more supervision for Resident #5 to prevent further overdoses. Physician #2 stated most facilities they had worked at in the past handled situations after the first time a resident overdose. Physician #2 stated they have not provided any referral to outpatient substance use programs and have not discussed any other adjunctive therapies for drug addiction to Resident #5. During an interview on 2/7/2024 at 9:18AM, the facility's Medical Director stated Resident #5 has not had a referral made to any types of substance use treatment programs however, there are several services the facility would be able to entertain for substance use treatment for Resident #5 going forward. The Medical Director did not provide evidence that the medical staff were actively overseeing the total plan of care for this resident or other residents at risk for drug overdose. 10 NYCRR 415.15 (b) (2) (i-iii)

Based on interview and record review conducted during abbreviated surveys (NY00331536, NY00330044, and NY00332489) between 01/22/2024 and 02/07/2024, it was determined the facility was not administrated in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the 200 licensed bed facility did not operate with a full-time social worker from 8/12/2023 to 11/2/2023. The findings are: Refer to the following tag: F850: Qualifications of Social Worker greater than 120 Beds The Facility Survey Report, dated 8/9/2023 included the question: Has your facility ensured that employees and other persons providing residents services in your facility are licensed, registered or certified in accordance with applicable laws? The answer was checked, Yes. Under the heading Director of Social Work, the facility documented they employed a full-time social worker with a master's degree in social work. During an interview on 2/2/2024 at 10:25AM, the director of nursing confirmed the facility was without a social worker from 8/12/2023 to 11/2/2023 and stated nursing had to assume many social services responsibilities in the absence of a full-time social worker. During an interview on 2/2/2024 at 10:25 AM, the Director of Human Resources confirmed the facility was without a full-time social worker from 8/12/2023 when their previous director of social work quit abruptly, until 11/2/2023 when the new director of social work began their position. The director of human resources confirmed Social Worker #1 (the facility's per-diem social worker) was per-diem status and worked less than 40 hours a week. A review of the facility's previous Quality Assurance and Performance Improvement (QAPI meeting) attendance sheet documented no director of social work or representative from the department was present during the meeting. During an interview on 2/5/2024 at 10:16 AM, the facility's former Administrator (Administrator #1) on record stated there was no full-time social worker in the facility between 8/12/2023 and 11/2/2023. 10 NYCRR 415.26

Based on record review and interviews conducted during abbreviated surveys (NY00331536, NY00330044, NY00332489), the facility with a licensed bed capacity of 200 beds was operating without a full-time social worker from 8/12/2023 to 11/2/2023. The findings are: A facility policy titled, 'Social Services', dated 2/2022, documented a facility with more than 120 beds will employ a qualified social worker on a full-time basis. The Facility Survey Report, dated 8/9/2023 included the question: Has your facility ensured that employees and other persons providing residents services in your facility are licensed, registered or certified in accordance with applicable laws? The answer was checked, Yes. Under the heading Director of Social Work, the facility documented they employed a full-time social worker with a master's degree in social work. During an interview on 2/2/2024 at 10:05 AM, the facility's Social Work Assistant #1 stated the facility did not have a full-time social worker from 8/12/2023-11/2/2023 and they assumed many responsibilities in the absence of a full-time social worker. Social Work Assistant #1 stated there was a Per-Diem Social Worker (Social Worker #1) who would come in the afternoons and assist with the Minimum Data Set submissions. Staff # stated they have been at the facility for multiple years, and they do not have a bachelor's degree. During an interview on 2/2/2024 at 10:25AM, the Director of Nursing confirmed the facility was without a social worker from 8/12/2023 to 11/2/2023 and stated that the nursing department had to assume many social services responsibilities in the absence of a full-time social worker. During an interview on 2/2/2024 at 10:25 AM, the Director of Human Resources confirmed the facility was without a full-time social worker from 8/12/2023 when their previous director of social work left abruptly, until 11/2/2023 when the new director of social work began their position. The Director of Human Resources confirmed that Social Worker #1 was per-diem status and worked less than 40 hours a week. A review of facility time sheets revealed between 8/12/2023 to 11/2/2023, Social Worker #1 was of per-diem status and consistently worked less than 40 hours per week. During an interview on 2/5/2024 at 10:16 AM, the facility's former Administrator (Administrator #1) stated there was no full-time social worker in the facility between 8/12/2023 and 11/2/2023. 10NYCRR 415.5 (g) (2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during an abbreviated survey (NY00331536 and NY00330044), the facility did not ensure that all allegations of abuse, neglect, and mistreatment were thoroughly investigated. This was evident for 4 of 4 residents (Residents #1, #2, #3, #4, #5) reviewed for Abuse. Specifically, (1) Resident #2 was accused of alleged inappropriate touching by Resident #1 on 1/13/2024 and the facility failed to call 911 or notify local law enforcement. Local law enforcement was notified of the sexual abuse allegation on 1/14/2024 by the hospital emergency room staff when Resident #1 reported the allegation to hospital staff; (2) Facility progress note documented Resident #2's aggressive physical/verbal/sexual behaviors towards staff and residents on 12/19/2023, 12/20/2023 and 1/12/2024. There was no documented evidence that the incidents were investigated by the facility; (3) the facility failed to investigate an allegation of resident-to-resident sexual abuse involving Resident #3 and Resident # 4 on 12/8/2023; (4) The facility did not initiate an investigation into Resident #5's multiple suspected drug overdoses on 12/9/2023, 1/5/2024,1/10/2024, 1/18/2024, 1/23/2024, and 1/29/2024 or update the care plan for Resident #5. The findings are: An undated facility policy titled, 'Abuse, neglect, and exploitation of residents' documented it is the moral and legal responsibility of all staff members to identify, prevent and report suspected or witnessed abuse; the administrator/director is responsible to receive and investigate all alleged violations thoroughly, timely, and objectively; and for situations involving reasonable cause to suspect sexual abuse (excluding sexual harassment), serious physical injury, serious bodily injury and suspicious death, local law enforcement shall be notified immediately. Resident #1 Resident #1 had diagnoses including but not limited to multiple rib fractures, schizophrenia, and hypertension. Resident #1's admission Minimum Data set (a resident assessment tool) dated 12/4/2023 documented the resident has a brief interview of mental status (BIMS, used to determine attention, orientation, and ability to recall information) score of 13 /15 denoting intact cognition and exhibited no behaviors. Resident #1's comprehensive care plan dated 12/4/2023 revealed no potential for being the victim of abuse. An undated facility investigative summary report, authored by the director of nursing, documented that on 1/13/2024 at approximately 2 PM, Resident #2 reported that they were inappropriately touched by another male resident (Resident #2) to Certified Nursing Assistant #21. The Director of Nursing was notified at 2:01 PM, the administrator was notified, both residents were assessed for injury by Registered Nurse #17 with no acute findings. Resident #1 was transferred to the emergency room for evaluation and Resident #2 was transferred to a different hospital for behavior management and alleged sexual behavior. A hospital history and physical examination dated 1/14/2024 documented Resident #1 was transferred to the hospital from another local hospital for a sexual assault examination (a specialized examination conducted after alleged incidents of sexual assault only performed at designated hospitals within a regional area) after a male touched the resident's breast and inserted his finger into their vagina at their nursing home. Resident #2 Resident #2 had diagnoses including but not limited to, lung carcinoma, schizophrenia, and dementia. The Quarterly Minimum Data Set, dated [DATE] documented Resident #2 had a Brief Interview for Mental status Score of 11/15, reflecting moderate cognitive impairment. Resident #2 had no impairment of upper or lower extremities and had no verbal or physical behavioral symptoms towards others. Resident #2's comprehensive care plan reviewed 10/18/2023 documented the resident demonstrated problematic behavior including wandering, wanting to go home, and banging on tables; with interventions including but not limited to monitor resident's whereabouts, anticipate resident's needs, intervene as necessary to protect rights and safety of others. Resident #2's Comprehensive care plan effective 10/18/2023 documented Resident #2 is at risk to be victimized/involved in altercations with other residents and did not address sexually aggressive behaviors. There was no documented evidence of a care plan that was put in place to ensure the safety of other residents and staff to prevent further recurrence of Resident #2's physical and sexually aggressive behaviors, no updates to Resident #2's care plan, and no documented evidence the incidents that occurred on 12/19/2023, 12/20/2023, and 1/12/2024 were investigated. During an interview on 1/23/2024 at 3:30PM, Certified Nursing Assistant #21 stated they were informed by Resident #1 of the alleged sexual assault, and observed Resident #2's sweater on the ground next to Resident #1's bed and Resident #2's hat on the pillow of Resident #1 Certified Nursing Assistant #21 stated they informed the nurse, the nursing supervisor called the director of nursing, then the nursing supervisor arranged for an ambulance transfer for both residents to the hospital. Certified Nursing Assistant #21 stated 911 was not called at the time of the alleged sexual assault and they do not recall police in the building on 1/13/2024. During the time of the onsite investigation on Resident #2 was unavailable for an interview with surveyors. During an interview on 1/24/2024 at 10:49 AM, Detective #1 stated Resident #2 was arrested on 1/17/2023 for an allegation of sexual assault on Resident #1 and stated the police department was NOT notified of the sexual assault until they were alerted of the incident by the hospital emergency department staff which was over 1 day after the alleged incident occurred on 1/13/2024. Detective #1 stated they do not know why the nursing home staff did not call 911 at the time of the incident and if they did call timely, the investigation could begin and evidence and the scene could have been secured, evaluated, and investigated. During an interview on 1/24/2024 at 12:02 PM, the Director of Nursing stated they were aware of Resident #2's escalating physical/sexual behaviors and many discussions were had about them during the morning report. The director of nursing was unable to provide care-plans with specific interventions to protect staff and residents and was unable to state any plans that were put in place to protect staff and residents in the facility from Resident #2's behaviors. The director of nursing stated they believe they informed the Nursing Supervisor #17 to call 911, send both residents to the hospital, and notify the families of both residents. The Director of Nursing stated they assumed a call to 911 would involve police and medical response. The Director of Nursing stated they did not follow up on the incident and confirmed 911 was not called at the time of the incident. The residents were sent to 2 different hospitals, and neither resident left the facility until after 6pm on 1/13/2024 (multiple hours after the alleged event). During an interview on 1/24/2024 at 3:10pm, Registered Nurse Supervisor #17 stated they work occasionally at the facility as a nursing supervisor and were the nursing supervisor on 1/13/2024, the time of the alleged sexual assault between Resident #2 and Resident #1. Registered Nurse Supervisor #17 stated they immediately called the Director of Nursing for direction at 2 pm on 1/13/2024 as soon as they were alerted by Certified Nursing Assistant #21 of the sexual assault. Registered Nurse Supervisor #17 stated the Director of Nursing informed them to send Resident #2 to a hospital for behavioral evaluation and Resident #1 to a hospital close-by for a sexual assault investigation. The Director of Nursing never instructed them to call 911. Registered Nursing Supervisor #17 stated it took multiple hours to send both residents out, and they had to call the Director of Nursing back for guidance after an ambulance company refused to take Resident #2 all the way to the hospital. Registered Nursing Supervisor #17 stated both residents left the facility after 6 pm because it was a very busy afternoon with new admissions. Registered Nurse Supervisor #17 confirmed they never called or were informed to call 911 by the director of nursing after the alleged sexual assault. During a follow-up interview on 1/24/2024 at 4:09 PM, the Director of Nursing stated they now remember communicating later in the afternoon with the nursing supervisor on 1/13/2024 about the ambulance company refusing to take Resident #2 to a hospital and had further difficulty remembering the details of the events of the day because they stated they were napping and sick at home on 1/13/2024. During an interview on 1/24/2024 at 4:09 PM, Resident #1 stated Resident #2 got on top of them, tore off their incontinence brief, and put their hand in their vagina. Resident #3 Resident # 3 had diagnoses that included Hypertension, psychotic disorder with hallucinations and dementia. The Discharge Minimum Data Set, dated [DATE] documented Resident #3 had a Brief Interview for Mental Status score of 00 which is associated with severe cognitive impairment. Resident # 3's comprehensive care plan from 11/21/2023 to discharge on [DATE] did not address behavioral problems, until after discharged when a care plan dated was created on 12/12/2023 titled Resident demonstrated problem behavior related to dementia, psychosis- hit staff-throw objects at staff verbally aggressive. A review of Resident # 3 physicians note dated 11/22/2023 at 10:54 AM documented Resident # 3 had prior history in another facility of unsafe behavior, touching other residents, and hitting staff. Resident #4 had diagnoses including but not limited to Urinary tract infection, Alzheimer's disease, unspecified dementia, psychosis disorder with hallucination due to unknown physiological condition. The Quarterly Minimum Data Set, dated [DATE], documented Resident #4 had a Brief Interview for Mental status score of 99, indicating resident was not able to complete the interview. Resident # 4's comprehensive care plan dated 6/30/2023 and revised on 11/22/2023 titled Resident having impaired cognition function/dementia or impaired though process related to dementia. Review of the facility Accident/Incident reports from 12/1/2023-12/31/2023 revealed no alleged sexual abuse incidents involving Resident # 3 and Resident #4. A review of medical records from 11/2023 to 12/2023 of Residents #3 and #4 did not reveal any documentation of sexual abuse investigation. During an interview on 1/31/2024 at 4:37 pm, Certified Nursing Assistant # 8 stated Resident #4's door was closed and when they entered the room, they saw Resident #3 with their pants down and pullup down exposing their buttocks, did not see if their penis was out. Resident # 3 was lying on top of the Resident # 4 with the sheets removed. Certified Nursing Assistant #8 stated they told Resident #3 to get out the room, then they shouted for Certified Nursing Assistant #6 to come and assist. Certified Nursing Assistant # 6 was asked to go and get Licensed Practical Nurse # 15. Certified Nursing Assistant #8 stated they informed Licensed Practical Nurse # 15 and informed the Registered Nurse Evening Supervisor # 11. Certified Nursing Assistant #8 stated they were never interviewed or asked to write a statement. During an interview on 1/23/2023 at 3:39 pm, Certified Nursing Assistant #6 stated they observed Resident # 3 sitting on Resident # 4's occupied bed, and Resident #3 had their pants unzipped. Certified Nursing Assistant #6 stated Certified Nursing Assistant #8 stayed in the room while they notified the Licensed Practical Nurse #15. They all escorted Resident # 3 out of the room and Resident #3 was not agitated. During an interview on 1/23/2024 at 3:22 PM, Licensed Practical Nurse #15 stated they were called to Resident #4's room by Certified Nursing Assistant # 6. They observed Resident #3 fully dressed; pants zipped; attempting to get in bed with Resident #4. They got Resident #4 out of the room, and they reported the incident to the Registered Nurse Evening Supervisor # 11. Licensed Practical Nurse #15 stated they only gave a verbal account of the incident. During an interview on 1/23/2024 at 1:12 pm, Registered Nurse Evening Supervisor # 11 stated when they arrived on the Unit, Certified Nursing Assistant #6 told them Resident # 3 was in Resident #4's doorway attempting to get in the room, when Certified Nursing Assistant #6 tried to stop them, Resident #3 punched Certified Nursing Assistant #6. They called 911 and Resident # 3 was sent to the hospital for being aggressive toward staff. Registered Nurse Evening Supervisor # 11 stated they verbally interviewed all staff, wrote the staff statements down and gave their investigation to the director of nursing at the facility's morning huddle meeting on 12/12/2023. During an interview on 1/24/2023 at 3:50 pm, the Director of Nursing stated there was no report or investigation given during morning meeting on 12/12/2023. They have no record of the investigation, no accident/incident report was completed, and police and Emergency Medical Service was not called. During an interview with the Clinical nutrition manager on 1/24/2024 at 9:30 AM, they stated during a morning meeting on 12/12/2023, the Registered Nurse Evening manager # 11 stated on 12/08/2023 Resident # 3 was on top of Resident # 4 with his pants down and Resident # 4 pullup off. Resident #5 had diagnoses including but not limited to cerebral infarction, adult failure to thrive, and other psychoactive substance abuse (a drug that affecting the function of the mind and nervous system). The Quarterly Minimum Data Set, dated [DATE], documented Resident #5 had a Brief Interview for Mental Status of 14 associated with intact cognition. Resident #5 was on a scheduled pain medication regimen and was receiving opioid medication. A review of the hospital admission and discharge summaries dated 12/9/2023 and 12/11/2023 documented Resident #5 was treated for polysubstance use drug low blood pressure that is caused by use of many illicit substances). The urine toxicology was positive for opiates, cannabinoid, and cocaine following their transfer to the hospital from the nursing home. A review of a hospital admission and Discharge summary dated [DATE] and 1/16/2024 indicated Resident #5 was found with a pill box that contained many different drugs which was confiscated by the emergency room staff. Resident #5 was diagnosed with altered mental state and treated for a likely drug overdose. A review of a hospital emergency room Discharge summary dated [DATE] documented Resident #5 was treated for drug overdose and provided no additional discharge treatment recommendations. There was no documented evidence that a facility investigation was initiated after the resident overdosed on 12/9/2023, 1/5/2024, 1/10/2024, 1/18/2024, 1/23/2024, and 1/29/2024. 483.12(c)(2)-(4)

Based on interviews and record review conducted during an abbreviated survey(s) (NY00331536, NY00330044 and NY00332489) the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Specifically, 1) multiple residents and staff complained about short staffing, and how it delayed care to many of the residents 2) Observations of 1 CNA for an entire nursing unit who was also assigned provide continuous monitoring of Resident # (), and 3) analysis of the actual staffing schedule for 2/2/0224 showed the facility was below the minimum levels documented on the Facility Assessment. The findings are: The Facility Assessment, last revised January 24, 2024, documented the facility's staffing plan to ensure sufficient staff to meet the needs of residents at any given time on units 2,3,4,5, and 6 calls for the following staffing plan: 7:00AM-3:00pm shift: 2 registered nurses and 5 certified nursing assistants per floor 3:00PM-11:00PM: 1 licensed practical nurse and 3 certified nursing assistants per floor 11:00PM-7:30 AM: 1 licensed practical nurse and 2 certified nursing assistants per floor A review of the staffing dated 2/2/24 documented the staff assigned to the 4th floor for the 11pm-7am shift were 1 certified nursing assistant and one registered nurse. During an interview on 2/3/2024 at 2:45 PM, Registered Nursing Supervisor #40 confirmed 1 certified nursing assistant was on the 4th floor for the 11:00pm-7:00AM shift on 2/2/24-2/3/24, and stated the floor had a census of 37 residents. Registered Nursing Supervisor #40 was unable to state how one certified nursing assistant can care for the whole floor and provide care to the residents. During an interview on 2/5/24 at 11:45 AM, Resident #11 stated every night at bedtime, they are left in a soiled incontinence brief and when they wake up, their bottom is burning. Resident #11 stated overnight there is only one CNA for the unit most of the time so many residents are stuck waiting excessively long for staff assistance. During an interview on 2/5/24 at 11:49 AM, Certified Nursing Assistant #3 stated that on morning of 2/5/24, and most mornings when they started their shift at 7: 30 AM there were not staff left on the unit. As a result, Resident #11 was in a soiled incontinence brief as are many residents on the unit. Certified Nursing Assistant #2 stated that they are often required to play catch-up for the entire shift. They stated that they often find residents congregated by the elevators asking for help. During an interview on 2/5/24 at 11:56 AM, Licensed Practical Nurse #3 stated when they came in at 7:30 AM this morning for their shift, there were no staff on the unit . Licensed Practical Nurse #3 stated there were multiple residents soiled and lined up at the elevator just asking for help. Licensed Practical Nurse #3 stated that is the situation they walk-into into on most mornings when reporting for duty. During an interview on 2/5/24 at 12:12 PM, the facility's staffing coordinator stated the facility trying to make the best effort to staff the floors to minimum ratios however, the numbers usually fall short as the facility has a staffing shortage. During an interview on 2/7/24 at 11:11 AM, the Director of Nursing stated staffing numbers are low on the weekend and the facility offers shift incentives to help increase the staff numbers. 10NYCRR 415.13 (A) (1) (i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during an abbreviated survey/s (#NY00331536, NY00330044, and NY00332489), the facility did not ensure each resident was provided the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 3 of 3 residents (Resident #2, Resident #4, and Resident #5) reviewed for abuse . Specifically, 1 )Resident #2 displayed sexually aggressive behaviors beginning in December 2023 and a plan was not developed or implemented to prevent recurrence until after an alleged incident of sexual abuse of Resident #1 that occurred on 1/13/2023; 2) Resident #5 suffered a known substance use disorder and no plan or interventions were put in place to prevent multiple hospitalizations for suspected overdoses during their stay in the facility; and 3) Resident # 4 exhibited a behavioral disturbance, and a plan was not developed or implemented to prevent reoccurrence and ensure the safety of staff and other residents. The findings are: 1) Resident #2 Resident #2 was originally admitted to the facility with diagnoses including but not limited to, lung carcinoma, schizophrenia, and dementia. The Quarterly Minimum Data Set (a resident assessment tool), dated 11/18/23, documented Resident #2 had a brief interview of mental status of 12, reflecting moderate cognitive impairment, documented Resident #2 did not have verbal or physical behavioral symptoms towards others, and had no impairment of their upper or lower extremities. Behavior notes dated 12/19/2023, 12/20/2023, and 1/12/2024 documented multiple incident s in which Resident #2 displayed sexually aggressive behaviors towards staff and/or other residents. There was no documented evidence a plan was put in place to ensure the safety of other residents and staff to prevent further recurrence of Resident #2's physical and sexually aggressive behaviors, no updates to Resident #2's care plan, and no documented evidence the incidents were investigated that occurred on 12/29/2023, 12/20/2023, and 1/12/2024. An undated facility investigative summary report, authored by the director of nursing, documented that on 1/13/2024 at approximately 2:00 PM, Resident #1 reported that their assigned Certified Nursing Assistant (CNA #1) that they were inappropriately touched by another resident (Resident #2). The Director of Nursing Services was notified at 2:01 PM, the administrator was notified, both residents were assessed for any injury by Registered Nurse on duty with no acute findings. Resident #1 was transferred to the emergency room for evaluation and Resident #2 was transferred to a different hospital for behavior management and alleged sexual behavior. During an interview on 1/24/2024 at 10:49 AM Detective #1 stated Resident #2 was arrested on 1/17/2023 for an allegation of sexual assault on Resident #1. During an interview on 1/23/2024 at 3:30pm, Certified Nursing Assistant #1 stated they and their colleagues have been telling the nurses and administration about Resident #2's escalating sexually aggressive behavior since Resident #2 was admitted to the facility, and they have done nothing. During an interview on 1/23/2024 at 3:39 PM, licensed practical nurse #1 stated Resident #1 has been violent with staff and residents for a long time, staff have been telling administration for a long time about Resident #2's behavior and administration has done nothing about Resident #2's behavior. During an interview on 1/26/2024 at 9:12 AM, Registered Nurse Unit Manager #5 stated that care plans are developed by an interdisciplinary team, that care plans are for the staff to follow when providing care to residents, and that they are responsible for updating resident care plans. Registered Nurse Unit Manager #5 stated they spoke to the Director of Nursing Services about each incident of Resident #2's escalating sexual behaviors and the Director of Nursing Services always said to call the doctor and order a psychiatry consult. Registered Nurse Unit Manager #5 stated they received training on crisis prevention or intervention, but no specific training for psychiatric de-escalation, or personal safety education. Registered Nurse Unit Manager #5 stated they do not write specific interventions manage resident behaviors in the care plans because many of the staff have worked at the facility a long time and know how to handle resident behavior needs. During an interview on 1/24/2024 at 12:02 PM, the director of nursing stated they were aware of resident #2's escalating sexual behaviors and many discussions were had about them during the morning report. The director of nursing stated the facility sends the Resident #2 to the emergency room for evaluation on days the facility staff cannot handle Resident #2's behaviors, confirmed the care plan was not updated to address the specific sexual behaviors, and confirmed that no additional plans or interventions were put in place to prevent further recurrence of events. During an interview on 1/26/2024 at 8:55 AM, Physician #1 stated when Resident #2 misbehaved, staff report this behavior and Physician #1 orders Resident #2 to be transferred to the hospital for an evaluation. Physician #1 stated the facility has sent Resident #2 to the hospital for behavior multiple times, Resident #2's meds have been adjusted, psychiatry has been consulted, and nothing seems to work. The Physician #1 stated Resident #2 is currently being held at the hospital where they are physically restrained, as they are not allowed to return to the facility because, with regard to Resident 1, there is an active restraining order against Resident #2. 2) Resident #5 A facility policy titled: Resident Possession of Illegal Substance created 3/1/2022 and revised 11/1/2023 stated to protect the health and safety of residents, the facility will provide additional monitoring, and supervision, which includes providing supervised visitation, to individuals who are suspected of bringing illegal substances into the facility. A facility policy titled, Residents with Alcohol/Drugs Substance Use Disorder, created 2/20/2022 and reviewed 1/24/2024 documented the facility will make efforts to prevent substance use through scheduled care plan meetings with resident and/or family members which may include providing substance use treatment services, such as behavioral health services, medication assisted treatment, alcoholic/narcotics anonymous and self-help groups as applicable. Resident #5 was originally admitted to the facility on [DATE] with diagnoses including but not limited to cerebral infarction, adult failure to thrive and other psychoactive substance abuse. The Quarterly Minimum Data Set, dated [DATE], documented Resident #5 had a brief interview of mental status score of 14, had an active diagnosis of 'other psychoactive substance abuse, uncomplicated', exhibited no physical or verbal behavior towards others, and no functional impairment of the upper and lower extremities. A review of a hospital admission and discharge summaries dated 12/9/2023 and 12/11/2023 respectively, documented the resident was treated for polysubstance use drug induced hypotension and urine toxicology was positive for opiates, cannabinoid, and cocaine. Recommendation was made to hold Percocet and refer the resident to outpatient rehab. A review of a hospital admission and discharge summaries respectfully dated 1/10/2023 and 1/16/2023 indicated Resident #5 was found with a pill box that contained many different drugs which was confiscated by the emergency room staff. Resident #5 was diagnosed with altered mental state and treated for a likely drug overdose. A review of a hospital emergency room Discharge summary dated [DATE] documented Resident #5 was treated for drug overdose and provided no additional discharge treatment recommendations. There was no documented evidence that a facility investigation was initiated after the resident overdosed on 1/18/24. An individual psychotherapy progress note dated 1/20/2024 documented Resident #5 expressed the desire to 'stay clean'. It did not document how the resident obtained drugs. A review of a hospital emergency room Discharge summary dated [DATE] documented Resident #5 was treated for a drug overdose. Resident #5 had a subsequent overdose on 1/29/2024. During an interview with Resident #5 on 2/1/2024 at 07:40 AM, Resident#5 stated they were previously clean from substance use for 35 years and began using illicit substances again in the facility to deal with depression. Resident #5 stated they have not made the decision whether to get clean and if they do, they will reach out to the facility. Resident #5 stated they obtain drugs through the family members of other residents in the facility when they come to visit. Resident #5 refused to provide any further details. Resident #5 stated they have not been offered treatment programs, narcotics/alcoholics anonymous meetings, or medication assisted therapies by the facility. Resident #5 stated they have not been offered any assistance from the social worker and Physician #2 (Resident #5's primary physician) has 'told him to stop doing drugs' with no further treatment options. The resident had a subsequent overdose on 02/01/24 at (add time). During an interview on 2/1/2024 at 8:25AM, Registered Nurse Unit Manager #5 stated stated that care plans are developed by an interdisciplinary team, that care plans are for the staff to follow when providing care to residents, and that they are responsible for updating resident care plans. Registered Unit Manager #5 stated prior to Department of Health (DOH) arrival on 1/22/2024, there was no care plan to address Resident #5's illicit substance use or any interventions in-place to prevent further relapse. Registered Nurse Unit Manager #5 stated staff communicated using word of mouth between staff to watch out for signs of overdose for Resident #5. Registered Nurse Unit Manager #5 stated they discussed with the Director of Nursing Services and the Administrator at morning huddle each of Resident #5 overdose events. Registered Nurse Unit Manager #5 stated facility administration was planning on not re-admitting the resident to the facility. Registered Nurse Unit Manager #5 was not aware of any further plans to address Resident #5's illicit drug use and overdoses. Registered Nurse Unit Manager #5 stated these issues had never been discussed in Resident #5's care plan meetings. During an interview on 1/29/2024 at 10:45 AM, the Director of social services stated they were never made aware of Resident #5's multiple overdoses and were unaware of any programming or programs offered to residents with substance use disorders. During an interview on 1/29/2024 at 11:20 AM, Physician #2 stated they have discussed the case with the Director of Nursing regarding Resident #5's overdoses. Resident #5 denies use of substances when questioned. Physician #2 was not aware Resident #5 expressed a desire to 'get clean' during their psychotherapy session on 1/20/2024. Physician #2 stated they are surprised the facility has not provided more supervision for Resident #5 to prevent further overdoses. The physician stated most facilities they had worked at in the past handled situations after the first time a resident overdosed. During an interview on 2/1/2024 at 10:04 AM, the Director of Nursing Services stated no previous overdoses of Resident #5 have been investigated because they did not think it is in the facility's policy to do so. The Director of Nursing Services stated on 1/18/ 2024, they spoke with Resident #5's brother regarding referring Resident #5 to a drug treatment program. The Director of Nursing Services stated the facility's plan is to offer Resident #5 a drug treatment program once they no longer require skilled nursing services. During an interview on 2/1/2024 at 5:15 PM, the facility Administrator stated they are aware of Resident #5's recent overdoses but not the extensive history details. The Administrator stated they are limited in things they can do or cannot do because of Centers for Medicare and Medicaid Services guidance. The Administrator stated the residents have rights and the facility cannot search the resident's room and are limited because of Centers for Medicare and Medicaid Services. 3 ) Resident #4 Resident #4 was admitted on [DATE] and discharged on 12/8/2023 with diagnoses that included Hypertension, psychotic disorder with hallucinations and dementia. The discharge Minimum Date Set (MDS, an assessment tool) dated 12/08/2023 documented that Resident #4had a Brief Interview for Mental status (BIMS, used to determine attention, orientation, and ability to recall information) with a score 0 which is associated with severe cognitive impairment. Resident #4 required supervision (assistance) with eating, and oral care, and one person assistance with toilet use and showers. Behavioral issues included verbal aggression 1-3 days and wandering behaviors 4-6 days, rejection of care 1-2 days. A review of Resident #4's medication orders revealed Resident #4 received quetiapine 25 mg every morning for psychosis (doctors' order 11/22/2023, Donepezil 10 mg tablet every evening for dementia doctors order 11/30/2023), and divalproex 125 mg, 4 capsule by mouth in the evening for bipolar disorder, (doctor's order 11/25/2023. A physician note dated 11/22/2023 at 10:54 documented as requested by nursing to examine resident after aggressive behavior has hit another resident and staff. The same note stated history of aggressive, extremely unsafe behavior, touching other resident, pacing hallway and hitting staff unable to be redirected. A behavioral note dated 11/25/2023 documented Resident #4 was verbally aggressive, threating, and hitting staff. A nursing progress note dated 11/29/2023 at 10:01 documented Resident #4 chasing staff with a fork and knife, supervisor psych and MD informed, psych. MD informed, and Lorazepam given. Facility Psychiatry note dated 11/29/2023 referenced the incident where Resident #4 chased the staff with a plastic knife and fork. Psychiatry notes documented, aggressive with staff nonpharmacological measure exhausted. Psychiatry ordered lorazepam 1 mg q12 hours as needed and to discuss plan of care with nursing. Care plan created by Clinical nutrition manager on 11/29/2023. There was no documented evidence Resident #4's comprehensive care plan was updated to address Resident #4's physical and sexual their physically and sexually aggressive behaviors, that a plan was put in place to prevent recurrence and to ensure the safety of other residents and staff, or that the behavior incidents involving Resident #4 were investigated a plan was put in place to ensure the safety of other residents and staff to prevent recurrence, or the incidents were investigated. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during an abbreviated survey and extended survey (NY00332489), the facility did not ensure that all nursing staff were in-serviced in behavioral health care needs of residents. Specifically, the facility was unable to provide documented evidence that they provided nursing staff education on behavioral health between1/1/23 and 12/31/23. The findings are: A request was made for the Policy and Procedure related to In-services and Staff Education but was not received prior to the exit date of 2/7/2024. A Facility Assessment last updated on 1/24/24 documented that the facility had a capacity of 200 residents. The facility assessment documented common diagnoses of residents included but were not limited to psychiatric/mood disorder and offered mental health and behavior services to residents. The facility assessment documented that nursing staff received training and competencies upon hiring and then annually. It further documented that the facility ' s behavioral health services program will ensure that staff have the adequate competencies and skills to meet the behavioral health needs of the facility ' s residents. A review was conducted of the [NAME] Gardens staff training binder which included all staff in-service education from 1/1/23 to 12/31/23. In-service sign-in records documented Abuse / Abuse Prohibition in-service trainings were conducted on dates which included 3/8/23, 7/26/23, 7/27/23, 8/26/23, 10/25/23, 11/21/23, and 12/17/23. In-service sign-in records documented Dementia Care in-service trainings were conducted on dates which included 7/10/23, 7/27/23, 8/4/23, 8/8/23, 8/11/23, 9/18/23, 12/19/23, and 12/20/23. In-service sign-in records documented Opioid Overdose in-service training was conducted on 7/18/23. There was no additional training noted on behavioral health, crisis prevention/intervention, or caring for residents with a history of substance use disorders. Staff interviews conducted on 1/24/24 revealed Licensed Practical Nurse #5 and Certified Nursing Assistant #5 have not been provided in-service education for behavioral health, crisis prevention/intervention, or care for residents with substance use disorders. Staff interviews conducted on 1/26/24 revealed Certified Nursing Assistant #21, Licensed Practical Nurse #22, Registered Nurse #1, and Registered Nurse Manager #5 have not been provided in-service education for behavioral health, crisis prevention/intervention, or care for residents with substance use disorders. During an interview on 1/29/24 at 9:23 AM, the Director of Nursing stated the facility began behavioral health training over the weekend. Previously their training focused on Abuse and Dementia Care. No specific training for behavioral health. 10NYCRR 415.5 (g) (2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #125 was admitted with diagnoses which included malnutrition, chronic obstructive pulmonary disease (COPD), and a pulmonary nodule. The MDS admission assessment dated [DATE] documented the resident had no pressure ulcers on admission. The nurse's note dated 7/12/23 documented the resident was noted with skin breakdown to the sacrum. The Supervisor was made aware, the physician was made aware and they were awaiting recommendations. The nurse's note dated 7/13/23 documented the resident was seen by the physician due to skin breakdown in the sacral area with an order to apply sulfadiazine for 2 weeks, twice a day. The physician order dated 7/13/23 documented Silver Sulfadiazine to sacrum twice a day. The physician's order dated 7/18/23 documented Medihoney to sacral area and cover with foam dressing twice a day. Weekly Wound Rounds/Team Assessments dated 7/18/23 to 8/11/23 documented stage 2 pressure ulcer, measurements, drainage, skin status, and treatments. On 8/11/23 at 10:00 AM, review of the resident's medical record documented there was no care plan in place for the resident's stage 2 sacral pressure ulcer. During an interview on 8/11/23 at 10:15 AM, when asked to locate the resident's pressure ulcer care plan, the Registered Nurse Unit Manager (RNUM) #1, RNUM stated they could not find it and they called the Wound Nurse to find it. RNUM #1 stated the Wound Nurse was responsible for initiating and updating the pressure ulcer care plans. During an interview on 8/11/23 at 11:30 AM, the Wound Nurse stated that they should have initiated the pressure ulcer care plan after completing weekly wound rounds on 7/18/23. During an interview on 8/11/23 at 12:00 PM, the Director of Nursing (DON) stated that the pressure ulcer care plan should have been initiated when the pressure ulcer was identified on 7/12/23. The DON stated that the RNUM should have initiated the pressure ulcer care plan the day the pressure ulcer was identified. §483.21(b)(1) Based on record review and interviews conducted during recertification and abbreviated (NY000320651) surveys from 8/9/23 to 8/15/23, the facility did not ensure that a comprehensive person-centered care plan (CCP) was developed and implemented to ensure services were provided to maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #73) reviewed for accidents, and for 1 of 1 resident (Resident #125) reviewed for pressure ulcers. Specifically, 1. Resident #73 did not have a plan of care to address skin assessment and treatment for a repair of laceration on their nose and 2. Resident #125 was identified with skin breakdown to the sacrum and there was no corresponding comprehensive care plan with interventions addressing the skin breakdown. The undated facility policy for Comprehensive Care Plan documents an individualized Comprehensive Care Plan that includes measurable objectives and timetables to meet the residents medical, nursing, mental and psychological needs is developed for each resident. 1. Resident #73 was admitted with Diagnoses of major depressive disorder, dysphagia, opioid dependency and Schizophrenia. The Minimum Data Set (MDS) an assessment tool indicated the resident had severe cognitive impairment, needed extensive assistance of 2 persons for bed mobility and was incontinent of bladder and bowel. According to the facility accident/incident report dated 7/20/23 the resident had a fall from bed and sustained a laceration to their nose. They were transferred to the Emergency Room(ER) for evaluation and treatment. The discharge instructions documented for stitches: keep the wound clean and dry, if you were given a bandage change it at least once a day. Also change it if it gets wet. Clean wound two times a day, pat dry. Apply thin layer of antibiotic ointment. There was no documented evidence that a plan of care was in place to address the residents repair of laceration wound on their nose after returning from the ER. During an interview with the Registered Nurse Unit Manager (RNUM) on 8/14/23 at 11:16 AM, they stated they were responsible for care plans but overlooked developing a plan for the laceration. The RNUM stated it was very important to have a plan of care to ensure the wound was assessed and treatments were performed to prevent infection.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews conducted during the Recertification Survey from 8/11/23 to 8/15/23, it was determined the facility did not ensure a resident's care plan was revised to reflect the resident's change in condition for one of one resident (Resident #102) reviewed for Incontinence of Bowel and Bladder. Specifically, when Resident #102 had a decline in continence of bowel and bladder, the care plan was not updated. Findings include: Review of the undated facility policy, Comprehensive Care Plan, revealed that the resident's care plans would be revised as changes in the resident's condition dictates. Resident #102 had diagnoses including Schizophrenia, brain cancer, and obesity. A quarterly Minimum Data Set (MDS, an assessment tool), dated December 09, 2022, documented the resident was always continent of bowel and occasionally incontinent for bladder. An annual MDS dated [DATE], documented the resident was always continent of bowel and frequently incontinent of bladder. A quarterly MDS dated [DATE] documented the resident was occasionally incontinent of bowel, and frequently incontinent of bladder. A Care Plan for incontinence of bladder dated 9/26/2022 with goals to be free from Urinary Tract Infection, and no decline in skin breakdown related to incontinence. The interventions included incontinence pad, monitor peri area for skin incontinence. The care plan was last reviewed 7/12/2023 and no revisions were made and bowel incontinence was not addressed. During an observation on 08/10/23 at 11:46 AM, a bag containing the resident's soiled underpants was observed on the floor next to the bed. During an interview on 08/11/23 at 01:44 PM, the Certified Nurse Aide (CNA) #5 stated the resident had urine leaking sometimes and they had not noticed that the resident had bowel incontinence. During an interview on 08/11/23 at 02:00 PM, the Director of Nursing (DON) stated they currently did not have anyone on a toileting program. The DON stated they expected the CNA to report changes in the residents condition the nurses. The DON stated they were not sure how they would know if the resident was having more incontinent episodes and it was up to the nurse manager to update the care plan. During an interview on 08/14/23 at 09:55 AM, Registered Nurse (RN) #7 stated they had only worked at the facility for about 1 month and did not know that the resident had increasing incontinence. During an interview on 08/14/23 at 10:00 AM, the MDS coordinator stated they reviewed the medical record and they read everything. They stated they code Section H for bowel and bladder, and would not necessarily notice a change in continence. The nurses on the unit should have identify a decline in continence and were responsible for updating the care plan. 10 NYCRR 415.11(c)(2)(i-iii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview conducted during a recertification survey and abbreviated survey conducted from 8/9/23-8/15/23(NY00315357) the facility did not provide adequate supervision to prevent elopement for 1 of 5 residents reviewed for accidents. Specifically, Resident #237 left the facility undetected by staff on 4/23/23 and was not found until 4/24/23 when the facility found the resident had been admitted to a hospital. Findings include: The Policy and Procedure titled Elopement Prevention dated 10/2018, documented the facility will utilize all possible measures to maintain the safety and well-being of all residents. The facility will have systems and tools in place to prevent unsafe wandering and or elopement. Resident #237 had diagnoses of Unspecified Dementia with Behavioral Disturbance, and Major Depressive Disorder. The Quarterly Minimum Data Set (MDS, a resident assessment and screening tool) dated 2/10/23 revealed the resident was severely cognitively impaired. The MDS documented Resident #237 had wandering behavior, required limited assistance with transfers, walking in room and corridor as well as locomotion on and off unit. An Elopement Risk assessment dated [DATE] revealed that the resident had a history of elopement and was at risk for elopement . The assessment documented the resident had attempted leaving the facility without informing staff. The resident had verbally expressed the desire to go home, often packed belongings to go home, and stayed near an exit door and also wander aimlessly. The Person-Centered Care Plan titled At Risk for Elopement was initiated on 2/6/2023, with a goal that Resident #237 would not elope from facility within the next 90 days. The interventions included approaching the resident calmly and redirecting resident. Review of the Incident report dated 4/23/2023 documented at approximately 4:08 PM Resident #237 was noted missing during a scheduled smoking period. The facility's investigation concluded the resident eloped during a supervised smoking period in the facility. During an interview on 8/14/2023 at 10 AM, the Director of Nursing (DON) stated since the 4/23/23 incident they made the smoking area more secure. Observation of the smoking area, with the DON present, revealed an enclosed area for the residents to smoke and the supply cart and the staff monitoring were located outside the smoking area. During an interview on 8/14/2023 at 10 AM, Resident #41 stated they were there when Resident #237 was smoking and disappeared. The monitor gave them their cigarettes and was outside of the smoking area. No one saw what happened and then the staff was searching for him. During an interview on 8/15/23 at 10 AM, Smoking Monitor #1 stated that on 4/23/23 Resident #237 came downstairs and was given a cigarette and went to the smoking area. The smoking monitor stated they stood outside the patio. The monitor stated that they looked for something in the supply cart and when they looked back, did not see resident. The smoking monitor stated another resident stated Resident #237 hopped the fence. The smoking monitor stated the Supervisor and Assistant Administrator were notified and a code purple was called. During an interview on 8/14/23 at 8:15 PM, LPN #1 stated resident was anxious and trying to leave the unit to go to smoke and the resident was taken to the smoking area. LPN #1 stated the CNA was asked to go check on Resident #237 and found the resident was not in the smoking area when the CNA arrived. The LPN stated they called the supervisor and Code Purple was called. During an interview on 8/14/2023 at 9:41 AM, the Nursing Supervisor RN #3 stated they were made aware on 4/23/23 at around 4:10 PM that the resident was missing and went to the smoking area to search. A Code Purple was called and we were unable to find the resident. During an interview on 8/15/2023 at 1:55 PM, the Director of Nursing (DON) stated the resident was at risk for elopement and was on enhanced supervision. Nursing was to escort him to the smoke patio he would be escorted back to the unit. During an interview on 8/15/2023 at 11:20 AM, the Assistant Administrator stated on 4/23/23 they were notified Resident #237 eloped and the Code Purple was called. They stated they drove around the area and the search was unsuccessful; 2 days later Resident #237 showed up at the hospital.

Based on observation, record review and interview conducted during a recertification survey from 8/9/23 to 8/15/23. The facility did not ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 5 residents reviewed for Medication storage. Specifically, Resident #64 had a bottle of unlabeled Mucinex at his bedside. Findings include: The Policy and Procedure titled Medication Administration revised 2/4/2020 documented medications should be administered as ordered by the physician. Only licensed Personnel are assigned responsibility preparing administering and recording medication. Resident #64 was admitted with Malignant Neoplasm of Esophagus, Dysphagia and Muscle wasting. The Quarterly Minimum Data Set (MDS, a resident assessment and screening tool) dated 5/5/23 revealed the resident had intact cognition. The MDS documented Resident #64 had no swallowing disorder and required supervision and set up help only for eating. The Care Plan dated 9/6/2022, documented Resident #64 was at risk for aspiration related to esophageal cancer. Interventions included checking for appropriate medication form, and may crush appropriate medications and mix with applesauce per physician orders, and to facilitate medication administration. During observations on 8/9, 8/10, 8/11, and 8/14/2023,a bottle of Mucinex was on resident night stand unlabeled. During an interview on 8/9/23 at 10 AM, Resident #64 stated they had a cold and took Mucinex. They stated it was helpful and not provided by the facility. A physician order dated 8/14/2023, documented Mucinex Fast-max chest congestion oral liquid, give 10 milliliters by mouth every 8 hours. During an interview on 8/15/23 at 10:17 AM, licensed practical nurse (LPN) #2 stated they were unaware the resident had the medication at the bedside and if they had noticed it, they would have removed it and gotten a physician order. During an interview on 8/15/23 at 10:15 AM, registered nurse (RN) #5 stated resident had a cough and purchased the Mucinex. RN #5 stated it should not have been at the bedside. 415.18

Based on record review and interview conducted during a recertification survey from 8/9/23 to 8/15/23, the facility did not properly establish and/or maintain an Infection Prevention and Control Program designed to provide a safe and sanitary environment. Specifically, (1) The facility could not provide evidence that a facility risk assessment was conducted annually to identify where waterborne pathogens could grow and spread in the facility water system and 2) the facility did not update the Water Management Plan since July 2017. The findings are: The facility Legionella Water Management Program dated July 2017 documented the purpose of the water management program is to identify areas in the water systems where Legionella bacteria can grow and spread. 1) The facility did not provide any documented evidence that an Environmental Assessment of Water Systems in Healthcare Settings was performed and updated annually to minimize the risk of healthcare facility associated Legionella Species according to best practice standards and regulations. 2) The facility Water Management Program was last updated July 2017. During an interview with the Director of Nursing (DON) on 8/11/23 at 11:07 AM, they stated they were not involved with the Environmental Assessment and only dealt with Legionella portion if residents were having symptoms. During an interview conducted with the Director of Maintenance (DOM) on 08/14/23 at 09:27 AM, they stated that they are in charge of Legionella, but they did not have an Environmental Assessment of Water Systems in the Maintenance binder. The DOM stated they have been at the facility for four months, did not have nursing home experience and was not familiar with the Environmental Risk Assessment or Water Management Plan in place. The DOM stated that an outside vendor does the water testing / sampling and stated the last water sampling was performed on 2/16/23 and all samples were negative. During an interview with the Administrator on 8/14/23 at 2:00 PM, they stated the DOM was being trained by the DOM from a sister facility about the Water Management Plan and Environmental Assessment. The Administrator also stated they did not know the Water Management Plan needed to be updated annually but it was important that a current plan was in place to identify problems early. The Administrator stated they started at the facility November 2022 and was still getting things together. 10NYCRR 415.19

Based on record review and interviews during a recertification survey from 8/9/23 to 8/15/23, the facility did not ensure that the Infection Preventionist (IP) completed specialized training in infection prevention and control prior to assuming the role. Specifically, the facility's designated IP who is the Director of Nursing Services (DON), did not have documented evidence of completed specialized training in infection prevention and control until 08/11/23. The findings are: During the annual survey Entrance Conference on 8/09/23 at 9:33 AM, the Director of Nursing (DON) identified themselves as the Infection Preventionist since they started at the facility in October of 2022. When asked for proof of training, they stated they could not find it. On 8/11/23 at 02:30 PM, the DON presented a document titled Training Plan Proof of Completion as of 8/11/23 and included an attached copy of course modules. One of the modules had a completion date of 8/11/23. During an interview with the DON on 8/14/23 at 10:21 AM the DON stated they have a certificate of Proof of Training effective 8/11/23 because that was the date they finished the last module and could not print a certificate until the last module was completed. The DON stated they did not realize it was incomplete all along. 10NYCRR 415.19

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey from 8/9/23 to 8/15/23, the facility did not provide a COVID-19 vaccination for 1 (Resident #110) of 5 residents reviewed for COVID-19 vaccination after screening and consent was obtained. Specifically, Resident #110 had consent from 12/7/22 but had not received the vaccine when reviewed as of 8/14/23. Findings include: The facility policy titled COVID-19 Infection Control Policy, dated 2/11/2022, documented the updated COVID-19 vaccination will be offered within 14 days of admission/readmission. Resident #110 was admitted [DATE] and had diagnoses including Dysphagia, Type II Diabetes, and Depression. The Minimum Data Set (MDS, a resident assessment tool) dated 5/10/23, documented the resident had cognitive impairment, required extensive assistance with bed mobility, transfers and toilet use and received a gastrostomy tube feeding. The resident had a Consent for the COVID-19 immunization which was obtained 12/7/22. The resident's immunization record documented the resident had consent since 12/7/22 but had not received the COVID-19 vaccine as of 8/14/23. During an interview with the Director of Nursing (DON) on 8/15/23 at 8:36 AM, they stated they were responsible for making sure residents received education and were offered updated vaccines. The resident was eligible and had a consent for the COVID-19 vaccine dated 12/7/22, but the resident was in and out of the hospital and they lost track of giving the vaccine. They stated it should have been given within 2 weeks of admission to the facility. The DON stated it was their job to make sure the vaccines were offered, ordered, and given. 10NYCRR 415.19

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review conducted during an abbreviated survey (NY00314199), the facility staff did not ensure that a resident assessment accurately reflected the resident's behavior. This was evident in 1 out of 18 residents sampled (Resident #1). Specifically, the Minimum Data Set (MDS, a resident assessment tool) dated 12/07/2022, 02/17/2023, 02/24/2023, and 03/03/2023 documented resident #1 had wandering behaviors. There was no corresponding nursing assessment / evaluation, nursing progress notes, and care plans in resident#1's medical record. Interview with the Registered Nurse/MDS Coordinator (RN/MDSC) revealed that MDS assessment was completed based solely on information gathered from the Certified Nursing Assistant (CNA) Task Documentation (CNA Accountability) and not from any nursing assessment / evaluation, progress notes and care plan. The findings are: The Facility Comprehensive Resident-Centered Care Planning Policy dated 01/16/2023 is done to develop an individualized interdisciplinary care plan for each resident based on Care Area Assessment to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan, and the residents' choices. The MDS Nurse will review the care plans during the assessment process to ensure that the care planning process is in effect and appropriate. The Facility Behavioral Assessment, Intervention and Monitoring Policy dated 01/14/2023 documented that behavioral symptoms will be identified and will be managed appropriately. The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Unsteadiness on feet, Depression, and Schizophrenia. The MDS dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 11/15, associated with moderate cognition impairment. Resident #1's MDS assessments dated 12/07/2022, 02/17/2023, 02/24/2023, 03/03/2023 identified the resident as having wandering behavior noted on the CNA task form. During an interview conducted with the RN/MDSC on 04/11/2023 at 10:09 AM, the RN/MDSC stated that they are responsible for completing the MDS assessment for the residents with a 7-day look back period. RN/MDSC stated they completed the 12/07/2022, 02/17/2023, 02/24/2023, 03/03/2023 assessment for Resident #1. The assessment was completed based on documentation from the CNA Task Documentation. The RN/MDSC stated that the CNAs report resident 's behavior to the nurse, the nurse should evaluate the resident's wandering and refer the resident to the Medical Doctor (MD). The nurse should initiate a care plan to address the issue/concern reported to them. Resident#1's wandering behavior care plan should have been initiated by the nurse. 415.11 (b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews conducted during an abbreviated survey (NY00314199), the facility did not ensure that a comprehensive person-centered care plan (CCP) was developed and implemented to ensure services were provided to maintain the residents' highest practicable physical, mental, and psychosocial well-being for 1 of 18 residents (Resident #1) reviewed for accidents. Specifically, Resident #1 was identified on several Minimum Data Set (MDS) assessments as having wandering behavior. There was no corresponding comprehensive care plan with interventions addressing the wandering behavior. On 04/05/2023 at 2:22 PM, resident #1 exited the facility through the front door unnoticed by facility staff and remains missing during the onsite investigation. The findings are: The Facility Comprehensive Resident-Centered Care Planning Policy dated 01/16/2023 is done to develop an individualized interdisciplinary care plan for each resident based on Care Area Assessment to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive resident-centered care plan, and the residents' choices. The MDS Nurse will review the care plans during the assessment process to ensure that the care planning process in in effect and appropriate. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Unsteadiness on feet, Depression, and Schizophrenia. The Minimum Data Set (MDS, an assessment tool) dated 03/03/2023 documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 11/15, associated with moderate cognition impairment. The resident required extensive 1-person assistance for dressing, toilet use and personal hygiene; supervision with setup help only for bed mobility, transfer, walk in room and corridor, locomotion on the unit, and eating. Resident #1 was identified on 4 MDS assessments dated 12/07/2022, 02/17/2023, 02/24/2023, 03/03/2023 as having wandering behavior as identified on the Certified Nursing Assistant (CNA) task form. There was no documented evidence that the resident had a care plan for wandering behavior / elopement risk. The Physician Order dated 02/22/2023 documented that the resident required ambulation in unit with Home Health Aide (HHA - CNA) and extensive assist x 1; transfer out of bed (OOB) extensive assist x 1. This order was in effect during the time of the incident. The CNA Instructions ([NAME]) from 02/21/2023 to 04/05/2023 with print date 04/10/2023 was reviewed. The resident required limited assistance with 1-person for bed mobility; extensive assistance with 1-person for transfers out of bed; can ambulate 30 feet with HHA (CNA) and extensive assistance of 1-person; the resident needs assistance / escort to activity/functions. This instruction was in effect during the time of the incident. During an interview conducted with CNA #1 on 04/12/2023 at 12:15 PM, the CNA stated that they worked on the 3rd floor (their regular floor) and was assigned to the resident on the day of the incident. CNA #1 stated that they were documenting that the resident had a wandering behavior because the resident always walks around the unit. During an interview conducted with RN Manager (RNM) on 04/12/2023 at 12:35 PM, the RNM stated that they were the manager on the unit at the time of the incident but that was not their regular floor. The RNM stated that they initiate and update care plans as well as initiate and complete investigation reports. The RNM stated that they usually update and maintain the CNA instructions based on the resident's care plan, but the instruction in place for resident #1 was incorrect. The RNM stated that the nurse who was supposed to complete the care plans does not work in the facility anymore. 415.11(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during an abbreviated survey (NY00314199, NY00288011), the facility did not maintain an environment free of accident hazard by ensuring that a resident was adequately supervised to prevent an elopement for 2 of 18 residents (Resident #1 and #18) reviewed for accidents. Specifically, (1) Resident #1 who had moderate cognition impairment and identified to have wandering behavior, exited the facility through the front door on 04/05/2023 at 2:22 PM unnoticed by facility staff. Staff became aware that resident #1 was missing at 3:09 PM, resident #1 remained missing during the onsite investigation; (2) Resident #18 who had severe cognitive impairment and was care planned as an elopement risk, exited the facility through the front door on 12/13/2021 at 12:20 PM and on 12/14/2021 at 10:30 AM unnoticed by facility staff. Resident #18 was returned by staff to the facility with no injuries on both during the two incident dates. The facility reported both incidents to NYSDOH on 12/14/2021 at 5:10 PM. Resident #18 was no longer in the facility during the onsite investigation. The findings are: The Facility Policy and Procedures on Elopement Prevention / Wandering Behavior Management effective 11/2018 last review dated 03/07/2022 was reviewed. It is the policy of this facility to utilize all possible measures to maintain the safety and well-being of all residents. To have system and tools in place to do all that is reasonable to identify and prevent unsafe wandering and/or elopement and to act quickly and prudently should ether occur. Resident #1 was admitted to the facility on [DATE] with diagnoses that included Diabetes Mellitus, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Unsteadiness on feet, Depression, and Schizophrenia. The Minimum Data Set (MDS, an assessment tool) dated 03/03/2023 documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 11/15, associated with moderate cognition impairment. The resident required extensive 1-person assistance for dressing, toilet use and personal hygiene; supervision with setup help only for bed mobility, transfer, walk in room and corridor, locomotion on the unit, and eating. Resident #1 was identified on 4 MDS assessment dated [DATE], 02/17/2023, 02/24/2023, 03/03/2023 as having wandering behavior as identified on the Certified Nursing Assistant (CNA) task form. The Elopement Evaluation dated 09/22/2022, 12/22/2022, 02/21/2023 revealed that the resident was not at risk for elopement. There was no documented evidence that the resident had a care plan for wandering behavior/elopement risk. The Physician Order documented that the resident could ambulate in the unit with a Home Health Aide (HHA) / Certified Nursing Assistant (CNA) and required extensive assist x 1; transfer out of bed extensive assist x 1 with order dated 02/22/2023. The Certified Nursing Assistant (CNA) Instructions ([NAME]) from 02/21/2023 to 04/05/2023 with print date 04/10/2023 documented that the resident required limited assistance with 1-person for bed mobility; extensive assistance with 1-person for transfers out of bed; can ambulate 30 feet with an HHA (CNA) and extensive assistance with 1-person; the resident needs assistance / escort to activity functions. The CNA Task (Accountability) from 02/21/2023 to 04/05/2023 documented that the resident was observed with wandering behavior symptoms. During surveyor onsite review of the camera footage dated 04/05/2023, surveyor observed that as the receptionist who was manning the reception desk at the facility lobby left their post at 2:21 PM and walked over towards the administrative offices, resident #1 was observed unescorted and walking out the facility towards the automatic front door of the lobby at 2:22 PM. During an interview conducted with the Front Desk Receptionist (FDR #1) on 04/11/2023 at 12:26 PM, FDR #1 stated that their responsibility was to monitor the residents in the lobby area and was not supposed to let residents leave the building. FDR #1 stated that they were familiar with resident #1's usual routine of talking with them in the lobby and smoking at the back of the building supervised by a staff member. FDR #1 stated that when resident #1 eloped, they left the reception desk to call the Administrator, they could not recall seeing resident #1 at the time or they would have stopped them from leaving the facility. During an interview conducted with CNA #1 on 04/12/2023 at 12:15 PM, the CNA stated that the 3rd floor was their regular floor and was assigned to the resident during the day of the incident. The CNA stated that the resident can verbalize their need and only required supervision. The CNA stated that the 3rd floor was a dementia/behavior unit, a locked unit, so they had to put a code on the elevator so the resident can go downstairs by themselves. The CNA stated that they were documenting that the resident had a wandering behavior because the resident always walks around the unit. The CNA stated that day the last time they saw the resident was lunch time between 12 to 1. They usually make rounds before they leave at 3:30 PM, and around 3:09 PM they noticed that the resident was not in their room. During an interview conducted with RN Manager (RNM) on 04/12/2023 at 12:35 PM, the RNM stated that they were the manager on the unit at the time of the unit but that was not their regular floor. The RNM stated that they initiate and update care plans and initiate and follows through investigation reports. The RNM stated that they usually update and maintain the CNA instructions based on the resident's care plan, but the instruction in place for resident #1 was not correct and should have been updated. Resident #18 was admitted to the facility on [DATE] with diagnoses that included Coronary Artery disease, Hypertension, Gastroesophageal Reflux Disease, Diabetes Mellitus, Hyperlipidemia, Dementia, Depression, and Schizophrenia. The Quarterly MDS dated [DATE] documented that the resident had a short term and long-term memory problems. The resident had adequate hearing, moderately impaired vision with no corrective lenses, with clear speech, sometimes makes self-understood, and sometimes understands others. Resident had no behavior exhibited. The resident required limited 1-person assistance for bed mobility, transfer, walk in room and in corridor, locomotion on and off the unit, dressing, toilet use, and personal hygiene. The resident had wandering behavior that occurred 1 to 3 days and Wander / Elopement alarm was used. The MDS dated [DATE] documented that the resident had wandering behavior that occurred daily with no documented wander/elopement alarm used. There was no documented evidence of a Wandering Assessment / Evaluation in October 2021 and November 2021. The Accident / Incident Report (A/I) dated 12/13/2021 was reviewed. The A/I documented that the resident was found walking down South Broadway outside the facility. The resident was last seen by their assigned CNA at 12:20 PM. The resident was on every 30-minute visual monitoring and had a wander guard on the left ankle. The Director of Nursing (DNS/DON) Investigation Summary documented that the resident was found by the nurse standing in front of the facility by 12:30 PM, the nurse immediately went and redirected the resident back to the facility unharmed. An elopement code was activated because the resident was found missing in the unit at 12:40 PM. The system in place did not prevent the elopement. There was no camera footage review. There was no interview of the receptionist (front desk). The DON reported to the New York State Department of Health (NYSDOH) the incident on 12/14/2021 at 5:10 PM (not reported within 24 hours) that the wander guard alert sound was low and cannot be heard by the front desk. The A/I Report dated 12/14/2021 documented that during safety check the resident was noted to be missing in the unit and a code purple was activated. The resident was observed walking towards the street outside the facility and was redirected back to the unit unharmed. The resident was on 30-minute visual checks and have a wander guard on their ankle. The DNS Investigation Summary documented that staff reported that the resident opened the alarm door (the resident knew the code) and took the stairs leading to the exit door. There was no statement about any staff member witnessing how the resident left the unit. There was no camera footage review. There was no interview of the receptionist (front desk) manning the lobby at the time. A CNA statement documented that the resident was last seen in the unit at 8:50 AM but the DNS reported to the NYSDOH that the resident was last seen at 10 AM. The system in place did not prevent the elopement. The director of maintenance (DOM) inspected the door where the resident exited, and it required repairs; a vendor was called to make necessary repairs and was scheduled on 12/15/2021. The DOM at the time does not work in the facility anymore. The Elopement Care Plan initiated on 10/22/2021 was reviewed. The resident was at risk for elopement related to verbalize a desire to leave the facility; currently is or has a history of behavior or unsafe wandering towards exit door; resident exhibits agitation, restlessness, or anger over placement in nursing home, with diagnosis of mental illness. Interventions included apply secure care bracelet (wander guard); check function of secure care bracelet (wander guard) with transmitter daily every night nursing shift (11-7) and prn; check placement of secure care bracelet (wander guard) every shift for CNA and nursing. There was no documented evidence of wander guard function and maintenance checks, and alarm function and maintenance checks / logs completed in October 2021, November 2021, and December 2021. The Treatment Administration Record (TAR) from 12/01/2021 to 12/31/2021 was reviewed. The resident had a wander guard that was being checked for placement on the right ankle by nurses. The Resident Nursing Instructions from 10/20/2021 to 07/22/2022 was reviewed. The resident was on safety precaution for elopement with wander guard (alarm) initiated on 12/13/2021. The Certified Nursing Assistant (CNA) Documentation Record from 12/01/2021 to 12/31/2021 was reviewed. There was no documented evidence that the resident was on any behavior monitoring, and or any wander guard placement checks. During a telephone interview conducted with the Director of Nursing (DON) on 04/26/2023 at 11:42 AM, the DON stated that they were not working for the facility when Resident #18 eloped. The DON stated that they could not find some of the documents pertaining to the investigation regarding the elopement incidents on 12/13/2021 and 12/14/2021 such as any camera review, interview and/or statement of the front desk person manning the lobby, interview and/or statement of staff who saw the resident open an alarmed door, and any wander guard function and maintenance checks during that time. The DON stated when Resident #1 exited the facility the resident had no wander guard in place. The DON stated that presently wander guards are checked for functioning, as well as all doors with alarms. The DON that during the onsite visit the surveyor checked the wander guards and doors with alarm. The DON stated that with regards to Resident #1's MDS assessment, the MDS Coordinator (MDSC) was in-serviced about how to complete assessments. Information needed to complete the MDS assessment include CNA documentations, comprehensive progress notes, care plans, and nursing assessments. The DON stated that the comprehensive care plans required interdisciplinary review and the MDSC must always verify that the care plans are completed accurately. 415.12(h)(a)

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure that 1 of 3 residents ( Resident #86) received care in a dignified manner. Specifically, during wound care and diaper change the resident's door was left ajar exposing the resident's private areas to public view. The findings are: Resident #86 was admitted with diagnoses including; Benign Prostatic Hypertrophy, Neurogenic Bladder and Diabetes Mellitus. The Minimum Data Set (MDS; a resident assessment and screening tool) of 4/9/19 indicated the resident was mildly cognitively impaired and was dependent on staff for personal hygiene, toileting, and dressing. During the survey the following was observed: 5/21/19 at 9:33 AM- the door to the resident's room was ajar. A nurse was transferring the resident to a wheelchair and she was observed pulling up the resident's diaper and then pulling up the residents' pants. No curtain was drawn for privacy. Later, during the dressing change the nurse left the room and the resident was left lying on his right side facing the door. The resident's genitalia and buttocks were exposed. The door was left ajar and no privacy curtain was drawn. On 5/22/19 at 10:40 AM the Registered Nurse (RN#2) was interviewed after the dressing change. He stated he did not have an explanation why the door was left open and he knew it should be closed for privacy. 415.5(a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not ensure that residents or their representatives and the ombudsman were provided with written notification of their transfer to the hospital. This was evident for 2 of 2 residents (Resident #45 and Resident #160) reviewed for hospitalizations. The findings are: 1. Resident #45 was admitted to the facility on [DATE] with diagnoses including Hypertension, Quadriplegia and Neurogenic Bladder. The clinical record documented that resident #45 was admitted to the hospital on [DATE] and returned to the facility on 5/3/19 with a diagnosis of Bacteremia. Resident #45 was also admitted to the hospital on [DATE]. He returned to the facility on 5/13/19 with a diagnosis of Artificial Opening Status of Gastronomy Tube. There was no documented evidence that written notification for both hospitalizations on 4/26/19 and 5/11/19 was submitted to the Ombudsman. 2. Resident #160 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Bipolar Disorder and Chronic Obstructive Pulmonary Disease. The clinical record documented that resident #160 was admitted to the hospital on [DATE] and she returned to the facility with a diagnosis of a Clogged Left AV Fistula. Resident #160 was also admitted to the hospital on [DATE] and returned to the facility on 5/2/19 with a diagnosis of a Clogged Left AV Fistula. There was no documented evidence that the resident's representative was notified of the hospitalization on 4/27/19 or that written notification for both hospitalizations on 4/18/19 and 4/27/19 was submitted to the Ombudsman. The Social Worker was interviewed on 05/21/19 03:43 PM. The Social Worker stated that the nursing department notified a resident's family of their transfer to the hospital and was not certain which department notified the Ombudsman. The Director of Nursing (DON) was interviewed on 05/22/19 09:36 AM. The DON stated that she did not know who was responsible for notifying the Ombudsman and deferred to the MDS Coordinator. The MDS Coordinator was interviewed on 05/22/19 09:45 AM. The MDS Coordinator stated she was not responsible for hospital notifications to the Ombudsman. 415.3(h)(i)(iii)(a-c)

Based on record review and interview conducted during the most recertification survey, the facility did not ensure that two quarterly assessments utilizing the State approved instrument were conducted for 1 of 11 residents (#59) reviewed for resident assessment. The findings are: Resident #59 was admitted in 2013 and had an annual assessment utilizing the State approved instrument, Minimum Data Set (MDS), completed on 7/30/2018. A review of the resident's clinical record revealed that no additional assessments utilizing the MDS were completed until 3/4/19 at which time an annual MDS was done. This resulted in two quarterly assessments not being done between 7/30/18 and 3/4/19. The MDS Nurse responsible for the completion of the resident's assessments was interviewed on 5/21/19 at 10:40 AM and stated she knew they were late in doing 2 quarterly assessments for Resident #59. Additionally, they had completed an annual assessment in March 2019 instead which is more comprehensive. The MDS Coordinator was interviewed on 5/22/19 at 9:43 AM. She stated that quarterly assessments are to be done every 92 days. It is late if it is done later than 92 days. 415.11(a)(4)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, the facility did not ensure the comprehensive person-centered care plan was reviewed and revised with measurable objectives, time frames and appropriate interventions for 1 of 5 residents (Resident #86) reviewed for pressure ulcers. Specifically, the care plan 1. did not address the effectiveness of treatment to a left heel pressure injury identified on admission, 2. did not reflect the development and treatment of two new pressure ulcers, and 3. did not initiate new interventions to prevent further skin breakdown. The findings are: Resident #86 was admitted on [DATE] with diagnoses and conditions including chronic viral Hepatitis C, Cerebral infarction and Diabetes Mellitus. The admission Minimum Data Set (MDS; a resident assessment tool) dated 4/5/19 documented the resident was cognitively intact, received total assist of two staff support for transfer, total assist of one staff support for toilet use and personal hygiene, extensive assist of two staff support for bed mobility, extensive assist of one staff support for eating and dressing, had a urinary catheter, was frequently incontinent of bowel, did not have any pressure ulcers, was at risk for pressure ulcers, and used a pressure reducing device when in bed. The Pressure Ulcer Injury care plan dated 4/2/19 documented potential for pressure ulcer related to Diabetes Mellitus, incontinence of bowel and impaired mobility, goal stated; no new skin breakdown, and interventions included; skin risk assessment, keep skin clean and dry, monitor skin during daily care, provide incontinence care every 3-4 hours, assess for changes in skin condition and report to Medical Doctor. Care plan note dated 4/2/19 documented: admitted [DATE] with left heel redness, started on protective dressing left heel upon admission. No further pressure ulcer care plan review or revisions were documented. Record Review revealed an admission Nursing assessment dated [DATE] documented left heel redness and Braden scale -16 (mild risk). Current May 2019 physician's orders include: Protective dressing to left heel daily for redness, ordered 3/29/19. Silvadene apply to cleansed left buttock with normal saline then cover with dry protective dressing for diagnosis; pressure ulcer of sacral region, unspecified stage, ordered 5/6/19. Additionally, an order for clean right buttock with normal saline, apply Silvadene 1% topical, cover with protective dressing was dated 5/6/19 and discontinued 5/20/19. Wound Care Medical Notes documented: 5/6/19 Right buttock stage 3 (2 x 2 x 0.1 cm); Collagenase QD prn; Left buttock stage 2 (1.5 x 1.0 x 0.1 cm); Silvadene QD and prn. 5/13/19; Right buttock wound healed, recommend observation and skin care protection. Left buttock 0.5 x 1.0 x 0.1 cm, Silvadene QD and prn. An interview with the Registered Nurse/Unit Manager (RN #1) responsible for review and revision of the residents' care plan was conducted on 5/21/19 at 2:46 PM. At that time the Pressure Ulcer Injury care plan was reviewed and the RN reported the care plan had not been reviewed and revised to address the left and right buttocks pressure ulcers. When asked about the left heel redness and treatment noted on admission of 3/29/19, the RN stated it is not being followed on wound rounds. 415.11(c)(2)(i.iii)

Based on observation, interview and record review conducted during the recertification survey the facility did not ensure that the environment was free of accident hazards and that each resident received adequate supervision and assistance to prevent accidents. This was evident for 1 resident reviewed for accident hazards. (Resident #153) The findings are: Resident #153 was admitted with diagnoses including; Diabetes Mellitus, Non-Alzheimer's Dementia and Right Above the Knee Amputation. The annual MDS (Minimum Data Set-an assessment tool) dated 1/28/19 documented that the resident is cognitively impaired and is dependent on 1 staff person for toileting, personal hygiene and dressing. Review of the comprehensive care plan initiated on admission revealed the following; Goals: Resident will be without injuries resulting from falls/Resident will have no further falls related to physical performance limitations (i.e. unsteady gait or Orthostatic Hypotension) within the next 90 days. Interventions: Anticipate needs of resident/encourage resident to seek assistance as needed/keep personal items within reach at all times/keep resident clean and dry at all times/maintain a safe environment free of any hazards at all times/make sure assistive devices are in good working condition every shift/report any finding to charge nurse/Supervisor/monitor activities of resident daily/monitor risk factors every shift/report any findings to Supervisor/charge nurse/monitor activities of resident daily/monitor risk factors every shift/place on 1/2 hour observation as indicated/provide floor mats/provide incontinent care every 3-4 hours/&prn/PT evaluation for transfer/ambulation status as needed /Reinforce education for call bell assistance. In an interview on 5/15/19 at 10:56 AM the resident stated that because the commode frame in his bathroom is in disrepair he had been using the public lavatory across the hall from his room. The resident also stated he had fallen several times in his room and once in the lavatory. Review of the nursing progress notes revealed the following; 2/6/19- the resident fell in the bathroom and was found between the toilet and his wheelchair. He had no injuries. A rehabilitation screen was ordered and performed. 2/16/19- the resident fell as he transferred himself from his wheelchair striking his head on the floor. 4/10/19- the resident was found sitting on the floor by this bed after he attempted to self- transfer. 4/16/19- resident was found on the floor next to his bed while attempting to transfer. In an interview with the maintenance worker on 5/21/19 at 11:04 AM he was asked about the missing frame on the left side of the commode and he stated a grab bar was in place on the wall. At that time he was advised that because of the resident's above the knee amputation the grab bar was not appropriate as he has to push down on each side with his hands to raise himself off the commode. The maintenance worker advised the surveyor that he will address this issue. In an interview with the Rehabilitation Director on 5/21/19 at 3:38 PM she stated she was unaware there was a problem and she will assess the situation to get the resident a full commode frame. She stated that a grab bar is not acceptable for this resident with an above the knee amputation. 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews conducted during a recertification survey, the facility did not provide the care and services in accordance with the resident's comprehensive care plan for 1 of 4 residents reviewed for accidents and 1 of 3 residents reviewed for pressure ulcers (Resident #82). Specifically, (1.) a floor mat to prevent injuries and a side rail to assist in turning and positioning was not applied to prevent further falls, and (2.) a pressure-relieving mattress was not applied to prevent further pressure ulcers and heal an existing Stage 2 gluteal pressure ulcer. The findings are: Resident #82 was readmitted to the facility on [DATE] and has diagnoses and conditions including Alzheimer's disease, Anemia and Atrial Fibrillation. The resident had a fall on 8/3/17 that resulted in fracture of the right wrist and laceration on the lip. The resident had another fall on 8/4/17 which resulted in fracture of the left hip. The Significant Change Minimum Data Set (MDS; a resident assessment tool) of 8/18/17 indicated the resident had a fall prior to admission to the facility. The 14-day scheduled MDS of 8/25/17 revealed the resident is at risk for developing pressure ulcers and has one Stage 2 pressure ulcer identified on 8/22/17. Both of these assessments revealed that the resident was totally dependent on one to two persons with most aspect of activities of daily living. a. The August 2017 care plan for falls had interventions including assistance with ambulation and transfers related to weakness, unsteady gait and balance, use of bilateral side rails, bed placed in lowest position as possible, and application of floor mats. Observations conducted on 8/31/17, 9/1/17 and 9/5/17 revealed there was no floor mat and side rail in place. The Registered Nurse manager was interviewed on 9/5/17 at 11:00 AM and stated that the side rails had been ordered and that she would check on the availability of the floor mats. b. The August 22, 2017 care plan for pressure ulcer revealed the resident is high risk for developing pressure ulcers related to poor mobility, decreased oral intake, and due to existing medical diagnoses including anemia, Alzheimer's disease, and degenerative joint disease. Interventions include skin assessment every shift, monitor oral intake, turning and positioning every two hours, and use of pressure-relieving mattress. Observations on 8/31/17 and 9/1/17 revealed there was no pressure-relieving mattress in bed. The Licensed Practical Nurse in charge was interviewed on 9/1/17 at 2:00 PM and acknowledged that the resident did not have a pressure-relieving mattress in place. She stated that is not a pressure-relieving mattress when asked to describe the mattress the resident was using at that time. 415.11(c)(3)(ii)

Based on record review and interview conducted during a recertification survey, the facility did not ensure that the pharmacy consultant's report of irregularities and recommendations to conduct testing for hemoglobin A1C (HbA1C; a test that shows the average level of blood sugar over the past 2 or 3 months) and thyroid function test for 1 of 5 residents reviewed for unnecessary medications (#192), during a medication regimen review, were not acted upon or reviewed accordingly by the attending physician or the director of nursing in order to take appropriate actions. The findings are: Resident #192 has diagnoses including Diabetes Mellitus (DM), Hypothyroidism and undergoes hemodialysis treatment. The August 2017 Physician Orders form indicated orders for Levemir (a type of insulin used in the treatment of DM) 5 units subcutaneously at bedtime and Synthroid 25 mcg. daily before breakfast. The pharmacy consultant reported that in July and August 2017, irregularities were identified during review of the resident's medication regimen. The recommendations were to conduct HbA1C and thyroid function tests. There was no documented evidence that the attending physician documented in the resident's medical record that the identified irregularities and recommendations were reviewed and what, if any, actions were taken to address it. The Licensed Practical Nurse (LPN) in charge was interviewed on 8/31/17 at 11:00 AM and stated that the above tests were never done. The attending physician was interviewed on 8/31/17 at 11:10 and stated that the tests were not ordered. The attending physician acknowledged that they should have been done and would order them. 415.18(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview conducted during a recertification survey, the facility did not consistently provide adequate maintenance services necessary to maintain an orderly and comfortable interior during a review of the facility's environment. Specifically, multiple residents' areas on the Second to the Sixth Floor units were found to be in disrepair and required ongoing maintenance care. The findings are: An initial environmental tour of the facility was conducted in the morning of 8/28/17 and on 9/1/17 at 1:00 PM. The following were observed: Second Floor: - room [ROOM NUMBER] had dirty bathroom walls; - room [ROOM NUMBER] wall behind the bed had holes; - room [ROOM NUMBER] had holes in the walls and baseboard behind the bed; - room [ROOM NUMBER] had water marks in the ceiling; - The lower part of the shower room door was broken; Third Floor: - room [ROOM NUMBER] had water marks in the ceiling, and dirty walls and radiator; - room [ROOM NUMBER] walls and closet had dirty, scraped paint areas; - room [ROOM NUMBER] had exposed plastered areas that were not painted, and dirty walls; - room [ROOM NUMBER] multiple ceiling tiles were displaced. The walls had dirty areas; - room [ROOM NUMBER] had scraped wall paint, dirty walls, and bathroom floor; - room [ROOM NUMBER] had scraped paint along the lower walls, and marks on the closet door. - room [ROOM NUMBER] had peeling paint on the walls; - room [ROOM NUMBER] had holes in the walls and doors, as well as dirty walls; - The unit's dining room had several broken ceiling panels. Fourth Floor: - room [ROOM NUMBER] bathroom had partially missing ceiling tiles, and dirty walls; - The shower room had several broken tiles; - The hallway walls had multiple areas with dirty marks, chipped, and peeling paints. Fifth Floor - - room [ROOM NUMBER] had holes in the bathroom door; - The shower room partition lower end had broken areas. Six Floor - - The dining room had missing ceiling panels near the clock; - The shower room had broken, missing tiles; - The lower part of the water fountain had peeling areas. The Director of Housekeeping (DH) was interviewed on 9/1/17 at 12:37 PM and stated that he is responsible for housekeeping and maintenance issues in the facility and that he cannot do anything without the approval of the hospital maintenance department. The DH further stated that orders for repair were placed but he was waiting for approval from the hospital's maintenance department. The facility administrator was interviewed on 8/31/17 at 1:09 PM and stated that they were aware of environmental issues that needed repairs. The Administrator stated that the facility is in the process of being sold, and once the State's approval is received, renovations will be started. 415.5(h)(2)

Based on observation, record review and interview conducted during a recertification survey, the facility did not ensure that each resident receives food at proper temperature during review of the facility's kitchen and food services. Specifically, as a result of residents' complaints, 4 out of 4 test trays conducted during a lunch meal revealed that hot and cold food was not served at proper temperature on 1 out of 5 units (5th Floor). The findings are: Confidential interviews with three residents were conducted on 8/30/17 between 10:00 AM and 1:00 PM. The residents stated that the food was never hot and most of the time it is cold. On 8/31/17, during lunch, a meal observation of food temperature check was conducted prior to tray line service and revealed that hot and cold foods were at proper temperatures. Two test trays for puree and regular consistency diets were requested and sent to the 5th floor. From 12:13 PM to 12:22 PM, together with the Nutrition Service Manager (NSM), an observation was made of the test trays of food temperatures for puree and regular consistency test trays and revealed that multiple hot foods were noted to be below 140 degrees Fahrenheit (F). This included puree consistency turkey 119 degrees F; soup 131 degrees F; mashed potato 119 degrees F and vegetable was 108 degrees F. The regular consistency food including turkey 124 degrees F and vegetable 132 degrees F. Multiple cold foods were noted to be above 40 degrees F. This included pudding 58 degrees F and milk 58 degrees F. These temperatures were confirmed by the NSM. The NSM was interviewed at that time and stated that hot food temperatures should be above 140 degrees F and cold food temperatures should be below 40 degrees F. The Food Service Director (FSD) was interviewed on 8/31/17 at 12:41 PM and stated that food temperatures were out of range more than 2 hours, and stated that paper service and lack of proper equipment to maintain proper temperatures were the issues. The FSD further stated the tray carts are not insulated and do not have separate hot/cold units. She stated that the facility tried to maintain proper temperatures and had requested proper equipment. A follow up interview of the FSD was conducted in the afternoon of 9/1/17 and was asked about the hot food temperatures of less than 140 degrees F and cold foods temps of more than 41 degrees F observed during mealtime on 8/31/17, and if any interventions other than dishwasher repair had been considered to maintain proper food temperatures during meal service. The FSD stated that in March 2017 she presented a proposal to administration with a recommendation to replace the dishwasher or to rent a dishwasher pending repairs. She stated that administration is still considering these options. The FSD further stated that lowerators used to heat plates had been purchased but were not in use due to use of disposables. 415.14(d)(1)(2)