Every finding on record at Eddy Village Green

Based on observations and interview conducted during the recertification survey, it was determined that the facility did not post nurse staffing information in an area accessible to all residents and visitors, as required by the posting requirements. Specifically, the posting of daily nurse staffing levels for staff working in the facility on each shift was displayed on one (1) resident unit, and not accessible to residents and visitors on the other resident units of the facility. This is evidenced by: During an observation from 3/25/2025 through 4/03/2025, the doorway to the administration suite was labeled with a sign documenting that no one was allowed in the building except staff. During an observation on 4/03/2025, at 11:10 AM, the daily nurse staffing postings were located on the wall by the reception desk in the administration building, which was not readily visible or accessible to all residents and visitors. There was no nurse staffing levels posted at any of the 16 residential units where residents and visitors from other units would walk through. During an interview on 4/03/2025 at 11:15 AM, Director of Nursing #1 stated that the nurse staffing postings were not posted in the residential houses, and they would expect residents and visitors to go to the administration building to see the staff posting it if they wanted to. 10 New York Codes, Rules, and Regulations 415.13

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure drugs and biologicals were labeled and stored in accordance with professional standards of practice for two (2) (House 21 and House 24) of 8 medication carts reviewed, and 8 (Houses 1, 2, 3, 4, 19, 21, 22, 24) of 8 medication rooms reviewed. Specifically, (a.) opened medications had no open and or expiration dates; (b.) one active medication had expired; (c.) medication rooms were left open and unattended; (d.) unlicensed staff had key/access code to medication rooms. This is evidenced by: The facility's Policy and Procedure Titled, Medication Administration effective [DATE] documented, each patient/resident/elder would receive medications according to provider orders and accepted professional standards. Under General Considerations, Responsibility and Procedure: The nurse is responsible for: #3: NOTE carefully the name, dose, amount of administration and expiration date. Be sure the frequency and time schedules correspond. Multidose Medications: 1. Medications with shortened expiration dates should have date opened noted. 2. Once any medication or biological package is opened, the facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. 3. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. a. Facility staff may record the calculated expiration date based on date opened on the medication container. The facility's Policy and Procedure 5.3 titled Storage and Expiration Dating of Medications and Biologicals, revised dated [DATE], documented General Storage Procedures: 1. Facility should ensure that only authorized facility staff, as defined by facility, should have possession of the keys, access cards, electronic codes, or combinations which open medication storage areas. Authorized staff may include nursing supervisors, charge nurses, licensed nurses, and other personnel authorized to administer medications in compliance with applicable law. 5. Facility should ensure all medications and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by residents and visitors. During an observation on [DATE] at 12:34 PM, House 21 Medication Room Door was wide open. Signage was posted on door that read, Please Keep Med Room Door Closed At All Times. Licensed Practical Nurse #1 was observed walking from medication room to kitchen area while leaving medication room door open. They returned approximately 10 minutes later. In the interim, Shahbaz (Certified Nurse Aide) #2 went into medication room and retrieved supplies leaving door open. During an interview on [DATE] at 12:44 PM, Licensed Practical Nurse #1 stated the Shahbaz (Certified Nurse Aides) had the access code to medication room because some of their patient care supplies, such as soap, toothpaste, deodorant, combs, etcetera are kept in the medication room. Dietary staff also had access code to enter medication room to deliver tube feeding supplies. During an observation on [DATE] at 12:55 PM, House 21 medication cabinet contained 1 Basaglar Kwik insulin pen with no open and or expiration date. It was placed in a bag dated [DATE]; 1 bottle of Carbamide Peroxide ear drops with no open and or expiration dates. 1 expired albuterol sulfate hydrofluoroalkane (HFA) inhaler dated [DATE]. During an observation on [DATE] at 1:20 PM, House #24 medication cabinet contained the following with no open and or expiration dates: 1 polyvinyl alcohol ophthalmic 1.4 percent eye drops; 1 Novolog insulin pen, and 1 fluticasone inhaler with no open and or expiration dates. During an observation on [DATE] at 3:15 PM, House #21 Medication Room contained the following stock medications: Calcium 600 milligram tablets; multivitamins; Benadryl liquid; Senna plus tablets; Guaifenesin cough syrup; Aspirin 81 milligram tablets; Tylenol 325 and 500 milligram capsules; Efferdent; Mucinex tablets; Ferrous Sulfate 325 milligrams; Ibuprofen 200 milligram tablets; Melatonin tablets; Vitamin B12 500 and 1000 micrograms; Glucose Gel; Hemorrhoid cream; Ben Gay Ointment. MiraLAX powder; Artificial Tears Eye Drops; Debrox Ear Drops; Deep Sea Nasal Spray; 4% Lidocaine Patches. The unlocked medication room refrigerator contained a six-back beer for resident use as prescribed. On top of the medication room filing cabinet there were 3 bottles of wine. During an observation on [DATE] at 3:30 PM, Medication Rooms in House 1, 2, 3, 4, 19, 21, 22, and 24 contained stock mediations as above and supplies that Shahbaz (Certified Nurse Aide) use for resident care. During an interview on [DATE] at 2:43 PM, Director of Nursing #1 stated nurse should date medication upon opening with open and expiration dates. Shahbaz (Certified Nurse Aides) had access to the medication room so that they could obtain necessary supplies for patient care. Dietary staff deliver tube feeds, central supply delivers stock medication and other stocks. Both had access to medication room. Families provided alcohol beverages unless there was a special event. In that case the facility will order alcoholic beverages to serve. The Nurse Manager kept an eye on alcoholic beverages. There was no tracking for how much alcohol was used. During an interview on [DATE] at 03:18 PM, Administrator #1 stated staff who were not certified to pass medication should not access the medication room. As of today, the Certified Nurse Aide supplies were relocated to another area, and the access code to the mediation rooms were changed and given only to licensed staff who administer medication. During an observation on [DATE] at 10:17 AM, House #19 Medication Room was wide open and unattended. At the time of observation, Certified Nurse Aide #3 stated it was their mistake, but the door was usually open anyway. 10 New York Codes, Rules, and Regulations 415.18(d)

Based on observation and interviews conducted during the recertification survey, the facility did not ensure that each resident was treated with dignity and respect, cared for in a manner, and in an environment that promotes maintenance or enhancement of their quality of life for three (3) (Resident #s 110, 136 and 145) of 36 residents reviewed for dignity. Specifically, (a.) Resident #110 was administered medications in a common area with other residents and individuals present without resident's permission; (b.) Certified Nurse Aide stood over the dining room table instead of sitting with resident, while assisting Resident #136 with their meal; (c.) Resident #145 was served meals at dining room table with the use of plastic utensils. This is evidenced by: The facility's Policy and Procedure titled Resident Rights, effective 5/28/2024, documented it is the policy to ensure residents have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. Social Work staff, in accordance with facility, New York State Department of Health, and CMS regulations, will act as the designated advocates for resident rights. New York State Manual or Nursing Home Resident Rights, 2022, documented, right to be valued as an individual, to be treated with consideration, dignity and respect in full recognition of your self-worth. o Be cared for in a manner that enhances your quality of life, free from humiliation. Privacy: Personal privacy during care and treatment. o Confidentiality concerning your personal and medical information. https://www.health.ny.gov/facilities/nursing/rights/docs/rights_booklet.pdf Resident #110 Resident #110 was admitted to the facility with a diagnoses of Parkinson's Disease (movement disorder of the nervous system that worsens over time), type 2 diabetes mellitus (when the body cannot use insulin correctly and sugar builds up in the blood), and major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). The Minimum Data Set (an assessment tool) dated 10/13/2024 documented that the resident could be understood, was understand by others, and was mildly cognitively impaired. During an observation on 3/28/2025 at 10:59 AM, Licensed Practical Nurse #4 administered a cup of prescribed medication to resident while resident was sitting in living room. In addition, Licensed Practical Nurse held conversation with Resident regarding the medications received. Two other residents were present. During an interview on 3/28/2025 at 11:05 AM, Licensed Practical Nurse #4 stated Resident #110 always took their medication in the living room, and it was okay. Therefore, they did not ask resident's permission to administer the medication in the common area. Licensed Practical Nurse #4 stated they should have asked permission since the Department of Health was observing the medication pass. Resident #136 Resident #136 was admitted to the facility with diagnoses of neurocognitive disorder with Lewy Bodies (a progressive brain disorder characterized by the accumulation of Lewy bodies, protein clumps in the brain cells, leading to cognitive decline), adjustment disorder with mixed anxiety and depressed mood (short-term mental and behavioral condition that occurs when someone has an unhealthy or excessive reaction to a stressful event or life change within 3 months), and moderate protein-calorie malnutrition (a condition resulting from insufficient intake of protein and/or energy (calories) leading to weight loss or failure to gain weight). The Minimum Data Set, dated dated dated [DATE] documented Resident had severe cognitive impairment, and usually could make themselves understood and usually understand others. During an observation on 3/26/2025 at 12:26 PM, Shahbaz (Certified Nursing Aide) #9 was standing up next to Resident #136 while the resident was seated in their wheelchair at the dining table. Shahbaz #9 was feeding the resident their lunch meal. Shahbaz #9 remained standing up until they were done assisting the resident with finishing their lunch. During an interview on 3/26/2025 at 12:26 PM, Shahbaz # 9 stated they normally sat next to residents while feeding them but because there were no chairs around for them to sit in, they stood up while feeding Resident #136. They stated they were taught to sit next to the residents when feeding them so they could observe how they were eating, but they were standing as there were no chairs available for them to sit in when feeding the resident. During an interview on 4/02/2025 at 10:09 AM, Registered Nurse #4 stated when Shahbaz is feeding a resident, they should be sitting down next to them and conversing with the resident. They should not be standing up while feeding the resident because it was a dignity concern. They stated sometimes they had to remind Shahbaz they should be sitting down while feeding residents. They stated this was the resident's home and they should be treated like they were in their home and Shahbaz should not be standing up while feeding residents. During an interview on 4/03/2025 at 12:06 PM, Director of Nursing #1 stated Shahbaz should sit down next to a resident when they are feeding the resident. There were little stools in the houses that the Shahbaz could sit on when they aided with meals. The Shahbaz should sit next to the resident when feeding them because it was a dignity concern. They did not want the resident to feel rushed or pressured through the meal and this may occur if the Shahbaz were standing over them when eating. They stated meals should be enjoyable. 48615 Resident #145 Resident #145 was admitted with the diagnoses of unspecified dementia (a decline in mental ability severe enough to interfere with daily life), morbid obesity (a severe form of obesity characterized by a significantly high body mass index), and major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities). The Minimum Data Set, dated dated dated [DATE] documented that the resident sometimes could be understood and sometimes understand others and was severely cognitively impaired. During an observation on 3/26/2025 at 12:25 PM, seven residents, including Resident #145, were given plastic utensils for their meals. During a record review on 3/26/2025 at 1:45 PM, Resident #145's Comprehensive Care Plan did not include the usage of plastic utensils at meals. 51317 During an interview on 4/01/2025 at 12:45 PM, Shahbaz #4 stated that plastic utensils may be used for safety reasons and should be in the comprehensive care plan. During an interview on 4/02/2024 at 11:35 AM, Registered Nurse #1 stated that the use of plastic utensils should be included in the comprehensive care plan for each resident who used them 10 New York Codes, Rules, and Regulations 415.3(c)(1)(i)

Based on record review and interview conducted during the recertification and abbreviated (Case #NY00358717) survey, the facility did not ensure that residents were free from neglect for four (4) (Resident #s 16, 25, 99, and 115) of five (5) residents reviewed for neglect. Specifically, Residents #s 16, 25, 99, and 115 were not provided toileting care by staff on evening and night shift of 10/27/2024. Some of these residents were left overnight in the same clothes they had been dressed in the day before, and some with their incontinence garment, clothes, and bedding saturated with urine. This is evidenced by: The Policy and Procedure titled Abuse Prevention and Investigation Policy effective 3/25/2025, neglect is defined as the failure to provide timely, consistent, safe, adequate and appropriate services treatment, and care necessary to avoid physical harm, mental anguish or mental illness. The Resident [NAME] (Resident care card followed by Certified Nurse Aide) dated 10/29/2024, documented Resident #16 required substantial/maximum assistance to get dressed. Resident #16 required substantial/maximum assistance using a gait belt and walker for transfers and was dependent on staff for toilet transfers. Resident #16 was on a toileting schedule: upon waking, before and after meals, before bed and on first and last rounds during the night. The Resident [NAME] dated 10/29/2024, documented Resident #25 required substantial/maximum assistance to get dressed. Resident #25 required touching assistance with wheeled walker for transfers and toilet transfers. Resident #25 was on a toileting schedule: upon waking, before and after meals, before bed, and on first and last rounds. The Resident [NAME] dated 10/29/2024, documented Resident #99 required substantial/maximum assistance for toilet clothing management. Resident #99 required partial/moderate assist with a gait belt to get on and off the toilet. Resident #99 was on a toilet schedule: upon waking, before meals and before bed, check on last rounds. The Resident [NAME] dated 10/29/2024, documented Resident #115 was non ambulatory and required a ceiling lift for transfers. Resident #115 required a total lift into a chair over the toilet. Resident #115 was on a toileting schedule: upon waking, before and after meals, before bed, and on first and last rounds. The Investigation Summary Form dated 10/28/2024, documented Shahbaz (Certified Nurse Aide) #1 reported that Resident #25 was still in the same clothes they had been dressed in the day before and their incontinence garment, clothes, and bedding were saturated with urine. It further documented Shahbaz #1 reported that Resident #115 was found saturated with urine on morning rounds at approximately 8:30 AM on 10/28/2024. In a written statement obtained on 10/29/2024, Shahbaz #11 stated there were residents that were not changed that should have been, specifically Residents #'s 16 and 99. Shahbaz #11 stated they also did not change Resident #25 and did not read their care card. The Investigation Summary Form dated 10/28/2024 stated surveillance footage was reviewed for the 10/27/2024 evening and overnight shift. The footage documented that (a) Resident #16 was put to bed at 7:17 PM on 10/27/2024 and their room was not entered until the arrival of the day shift on 10/28/2024, (b) Resident #25 was in their room at 7:44 PM on 10/27/2024 and no staff entered their room until the arrival of the day shift on 10/28/2024, (c) Resident #99 was put to bed at 10:30 PM on 10/27/2024 and no staff entered their room to provide care until the arrival of the day shift on 10/28/2024, and (d) Resident #115 was put to bed at 9:13 PM on 10/27/2024 and no staff entered their room to provide care until the arrival of the day shift on 10/28/2024. The Weekly Wound tracking documented Resident #16 had a deep tissue injury on the left heel with an onset date of 10/29/2024. Former Director of Nursing #1 documented an in-person interview with Shahbaz #11 that took place on 10/29/2024 at 2:00 PM. During this interview, Shahbaz #11 admitted they had not changed Resident #16 during the overnight shift and had not toileted Resident #25 and Resident #99 during the overnight shift. Former Director of Nursing #1 documented an in-person interview with Shahbaz #12 that took place on 10/29/2024 at 2:30 PM. During this interview, Shahbaz #12 admitted they had put extra incontinence pads and briefs on Resident #25 despite knowing they were not supposed to, per the resident ' s care card. During an interview on 3/31/2025 at 3:00 PM, Director of Nursing #1 stated they were not involved with the investigation but confirmed that it was required that a Shahbaz read the resident's care card and provide care as laid out in the care card. They stated that Shahbaz #11 and Shahbaz #12 were terminated for neglect after this incident. 10 New York Codes, Rules, and Regulations 415.4 (b)(1)(i)

Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure assessments were coordinated with the Pre-Admission Screening and Resident Review (PASARR) program under Medicaid for eight (8) (Resident #s 16, 22, 65, 70, 115, 130, 145, and 166) of 36 residents reviewed. Specifically, (a) Resident # ' s 22, 65, 70, and 145 received new diagnoses of mental illness and no Level I screening was done to determine if a Level II screen needed to be done and (b) Resident # ' s 16, 22, 115, 130, and 166 were admitted with diagnoses of mental illness and Level I screen was not accurately completed to indicate the need for Level II. This is evidenced by: 48413 The facility Policy and Procedure titled, Pre-Admission Screening and Resident Review (PASSAR), effective 9/10/2022, documented all individuals seeking admission would undergo a Pre-Admission Screening and Resident Review Level I screening prior to admission to determine if they have a mental illness or intellectual disability. Screening would be conducted in accordance with New York State Department of Health guidelines and Centers for Medicare and Medicaid Services regulations. Level II Evaluation: If the Level I screening indicates potential mental illness or intellectual disability, a Level II evaluation would be completed by a qualified mental health professional. The evaluation would assess the individual's needs, preferences, and the appropriateness of nursing facility placement. Resident #22 Resident #22 was admitted to the facility with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities), anxiety (feeling of fear, dread, and uneasiness), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Minimum Data Set (an assessment tool) dated 11/15/2024, documented the resident had severe cognitive impairment, could be understood, and understand others. The Screen Form dated 12/29/2017, documented under Level I Review for Possible Mental Illness-question #23: Does this person have a serious mental illness - No. A Psychiatric consultation on 8/16/2022, documented medical history of major depressive disorder, anxiety disorder (repeated episodes of sudden feelings of intense anxiety and fear or terror), and post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). 48615 Resident #130 Resident #130 was admitted to the facility with diagnosis of fracture of right femur neck (broken hip), fracture of left ulnar (broken forearm), and major depressive disorder. The Screen Form dated 7/24/2024, documented under Level I Review for Possible Mental Illness-question #23: Does this person have a serious mental illness - No. A Psychiatric consultation dated 9/05/2024, documented the following active diagnosis: adjustment disorder with mixed anxiety and depressed mood; psychotic disorder with hallucinations due to known physiological condition, and neurocognitive disorder with lewy bodies dementia. Recommendation: consider use of Galantamine for cognition and hallucinations. Continue Zoloft 100 milligrams daily for (depression/anxiety). Continue Remeron 7.5 milligrams at bedtime for Appetite Enhancement/helps with psychosis). 51317 Resident #166 Resident #166 was admitted to the facility with diagnoses of major depressive disorder, dementia, and hypertension (high blood pressure). The Minimum Data Set, dated dated dated [DATE] documented the resident was usually understood, could usually understand others, and was severely cognitively impaired. The Screen Form dated 10/22/2024 documented under Level I Review for Possible Mental Illness-question # 23: Does this person have a serious mental illness - No. During an interview on 4/01/2025 at 10:56 AM, Social Worker #3 stated the screen was completed prior to admission. They stated that a developmental disability, serious mental illness, or intellectual disability would warrant a Level II screen. They stated if a resident was diagnosed with a serious mental illness after admission, the facility should then complete a new screen then call an agency to come in and complete the Level II screen if warranted. During an interview on 4/01/2025 at 3:46 PM, Social Worker #1 stated resident #22 and resident #130 did not have any diagnosis that required a Level II screen. During an interview on 4/01/2025 at 11:06 AM, Social Worker #2 stated a Level II screen should be requested for conditions like bipolar disorder. During an interview on 4/03/2025 at 10:10 AM, Admissions Coordinator #1 stated prior to admission all resident medical and financial information was gathered, including the DOH-695 Screen. They stated the information was reviewed for completeness then given to nursing staff for admission; any subsequent changes requiring level II screen was followed up by social work. 10 New York Codes, Rules, and Regulations 415.11(e)

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure ongoing provision of programs to support each resident and their choices of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for three (3) (Resident #s 16, 22, and 25) of 36 residents reviewed. Specifically, (a.) Resident #22 was unable to make their needs known, and there were several dates with no documented activities. (b.) For Resident #s 16 and 25, there were no consistent activities planned to meet the resident's needs and/or preferences. This is evidenced by: The facility Policy and Procedure titled, Activities, effective 10/15/2021, documented: (a) the Residential Services Activities Departments provided ongoing programs of activities designed to meet, in accordance with the comprehensive resident assessment, the interest and the physical, mental and psychosocial well-being of each resident; (b) activities programs encouraged the resident's voluntary choice of activities and participation by offering a variety of programs throughout the day and week. The programming promotes and maintains the resident's sense of usefulness to self and others; (c) the coordinator of each program ensured that there was a written plan for individual, group and independent activities in accordance with the resident's needs, interests and capabilities. The plan recognized the resident's mental and physical needs and interests, as well as education and experiences. The plan was developed and prepared with the resident and their designated representatives when it was appropriate and communicated to team members; (d) a monthly activities schedule based upon individual and group needs, interactions and capabilities was developed by the coordinator; (e) upon request, the coordinator provided the Executive Director with a monthly report of the type, frequency of, and number of residents who participated in the activity programs. They also ensured that the resident's clinical record contained a quarterly assessment to the resident's degree of participation in, response to, and benefit from the activities program. Resident #22 Resident #22 was admitted to the facility with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities), anxiety (feeling of fear, dread, and uneasiness), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Minimum Data Set, dated dated dated [DATE], documented the resident had severe cognitive impairments, could be understood, and understand others. During observations on 3/26/2025 at 2:56 PM, 3/27/2025 at 10:00 AM, and 3/28/2025 at 11:30 AM, Resident #22 was noted to be the living room common area where a television was on. The resident was dozing on and off. The Comprehensive Care Plan for Activities revised 2/11/2025, documented Resident #22 would be able to participate in activities of their choice and the resident would maintain the highest quality of life possible. Record review revealed no documented evidence of activities for Resident #22 on the following dates in 2025: 1/03, 1/06, 1/08, 1/10, 1/13-1/17, 1/19-1/21, 1/23-1/25, 1/28-1/31, 2/05, 2/07, 2/08, 2/10-2/14, 2/19, 2/21, 2/22, 2/25-2/27, 3/03-3/08, 3/12-3/14, 3/19, 3/28, and 3/31/2025. Resident #25 Resident #25 was admitted to the facility with diagnoses of major depressive disorder, spinal stenosis (a narrowing of the space inside the backbone), and cardiac murmur (an extra, unusual sound heard during a heartbeat). The Minimum Data Set, dated dated dated [DATE] documented the resident was understood, could understand others, and was severely cognitively impaired. The Comprehensive Care Plan for Activities, last revised on 3/09/2025, documented the resident would continue to participate in groups and activities of choice. During an observation on 3/25/2025 at 12:16 PM, Resident #25 was in their room alone. During an observation on 3/31/2025 at 10:15 AM, Resident #25 was in their room alone with no activities or interaction. There were personal craft supplies available in the room, but they were not in reach of the resident. Resident #16 Resident #16 was admitted to the facility with diagnoses of dementia, major depressive disorder, and panic disorder (an anxiety disorder characterized by unexpected and repeated episodes of intense fear). The Minimum Data Set (an assessment tool) dated 3/15/2025, documented the resident had moderate cognitive impairment, could be understood, and understand others. The Comprehensive Care Plan for Activities, last revised on 3/09/2025, documented the resident would continue to participate in groups and activities of choice. During an observation on 3/25/2025 at 12:50 PM, Resident #16 was observed to be in their room with no staff interaction. During an observation on 3/31/2025 at 10:09 AM, Resident #16 was observed to be sitting at the dining table with no interaction or activities. Interviews: During an interview on 3/26/2025 at 12:30 PM, Ombudsman #1 stated residents had requested more activities to take place in the houses; they wanted more personalized activities that included exercise and outside trips. During an interview on 4/03/2025 at 10:14 AM, Shahbaz (Certified Nurse Aide) #1 stated that each house had activities and that the activities depended on the Shahbaz. They stated they tried to follow the activity calendar but not all staff did. During an interview on 3/31/2025 at 1:56 PM, Recreational Therapy Manager #1 stated when there were three (3) Shahbaz in the house, one should have been conducting the activity. They stated the following: The Activity Calendar was posted in the houses. Activity attendance roster was documented in electronic medical records. One-to-One activities were documented for each elder receiving 1:1 activities. Recreational Therapy Manager #1 stated a staff member from dietary held exercise groups in the houses, although it was not on a regular basis. They also stated there had been two outside trips within their 2-year tenure--One to the mall and the other to see Christmas Lights. They stated the major barrier to outside trips was securing a driver to drive the van. 48615 During an interview on 3/31/2025 at 3:18 PM, Administrator #1 stated they were reviewing current activity programs and working with Recreational Manager #1 and house staff to improve activities. They stated that they were recently made aware of needing a driver for outside trips and looking into obtaining more drivers; families had volunteered to assist in coordinating and conducting activities, such as paint and sip. They further stated that a dietary employee conducted an exercise program each month for each house. 10 New York Codes, Rules, and Regulations 415.5(f)(1)h

Based on observation, record review, and interview conducted during the recertification and abbreviated (Case #NY00347510) survey, the facility did not ensure that each resident received adequate supervision and assistance devices to prevent accidents, and did not ensure that the resident environment remained as free of accident hazards as is possible. This was evident for one (1) (Residents #146) of the 36 residents reviewed, and for House #s 10, 16, and 21. Specifically, (a.) Resident #146, who had a prior incident of being found outside of the home unsupervised, was found to have an electronic monitoring device alarm on their walker that was not functioning as it should. There was no documented evidence that the electronic monitoring device was checked daily for placement and function to prevent further accidents. Additionally, (b.) alcoholic beverages within spaces and rooms of House #s 10, 16, and 21 were observed to be open and unattended. The facility did not identify the risk and the provision of supervision to prevent accidental consumption of alcohol that was accessible to residents, staff and visitors. This is evidenced by: (a) Resident #146 Resident #146 was admitted to the facility with the diagnoses of Alzheimer ' s disease (a type of dementia that affects memory, thinking, and behavior), type 2 diabetes mellitus (a chronic condition that happens when a person has persistently high blood sugar levels), and hypertension (high blood pressure, a condition in which the force of blood against the artery walls is too high). The Minimum Data Set (an assessment tool) dated 2/21/2025 documented that the resident was severely cognitively impaired, could be understood and understand others. Policy titled Elopement and Disruptive Wandering (Exit-Seeking), effective 2/24/2023, documented that it was the policy of the facility to identify those residents at risk for elopement and disruptive wandering behavior and to take the necessary steps to ensure their safety. If a resident was determined to be at risk for elopement, the following steps would be followed: wandering device would be placed on the resident. If the resident is wearing the device, it would trigger the alarm. Battery life would be monitored and addressed within the manufacturer's recommended timeframes. Each wander device would be checked weekly for proper functioning. The placement of the wander device for each resident would be checked at every shift. The comprehensive Care Plan with a focus on safety awareness deficit related to confusion/decreased memory, dementia, history of falls, and impulsive behavior documented on 7/06/2024. Resident #146 exited the house and was found at the end of the carport by a staff member. Resident #146 was directed back into the home. The sole of the shoe was searched, and the electronic monitoring device was not present. A new electronic monitoring device was placed on Resident #146 ' s walker. Intervention initiated 7/08/24, documented Wander alert bracelet: (check function each week) on walker. A physician's order with a start date of 12/20/2023 documented the need to check the battery for the electronic monitoring device weekly and change it if needed. Directions documented that the battery should be checked every day of the shift on Wednesday. The Medication Administration Record/Treatment Administration Record, which started on 12/20/2023, documented checking the battery for the electronic monitoring device electronic monitoring device weekly and changing it if needed each day shift, every Wednesday for safety. During March 2025, the battery was checked on 3/05/2025, 3/12/2025, 3/19/2025, and 3/26/2025. Task sheet with intervention listed, check the electronic monitoring device bracelet for placement every 12-hour shift while awake. If the alarm does not sound, or the watch is missing, notify the supervisor, Nurse Manager, or House Nurse to replace the watch (place on the walker in the red box). Walk the elder past the patio door to check the function by sound. The following dates and times were listed as times this task was documented, and it was completed: 3/18/2025- 8:13PM 3/19/2025 6:59 AM 3/25/2025 8:33 PM 3/26/2025 6:54 AM 4/01/2025 10:30 AM and 9:29 PM There was no documentation that this task was completed on 3/20/2025, 3/21/2025, 3/22/2025, 3/23/2025, 3/24/2025, 3/27/2025, 3/28/2025, 3/29/2025, 3/30/2025, and 3/31/2025. During an interview and an observation on 3/31/2025 at 2:39 PM, Shahbaz (Certified Nurse Aide) #9 stated Resident # 146 had an electronic monitoring device on their walker which was in a red plastic box attached to their walker by screws. If Resident #146 approached the doors that led outside the home, an alarm would sound. When they heard the alarm, they would check to see if the resident was attempting to exit the house. Shahbaz (Certified Nurse Aide) #9 walked with Resident #146 to the home's front door to demonstrate how the alarm was activated. Resident #146 was using their walker with the electronic monitoring device attached. When they approached the front door, an alarm did not go off, indicating Resident #146 had approached the front door. Licensed Practical Nurse #6 approached Shahbaz #9 and Resident #146 at the front door, and they all walked with Resident #146 and their walker to the side door of the home to test the alarm on the side door. When Licensed Practical Nurse #6 approached the side door with Resident #146, the alarm was not triggered and did not make a sound alerting them. During an interview on 3/31/2025 at 2:52 PM, Licensed Practical Nurse #6 stated the electronic monitoring device for Resident #146 was kept in the red box screwed on to their walker because they would remove the electronic monitoring device if it were on their body or in their shoe. Resident #146 could not remove the red box from their walker. They stated that if the alarm worked properly, it would sound when Resident #146 approached the front or side door with the walker. An alert was sent to the pagers the Shahbaz (Certified Nurse Aide) ' s used and to the cell phones the Licensed Practical Nurse and Registered Nurse used that indicated the electronic monitoring device alarm was set off. They stated that during this observation on 3/31/2025, the electronic monitoring device alarm did not go off, and the Shahbaz pager and nurse's cell phone did not receive an alert that the electronic monitoring device alarm was set off. They stated the electronic monitoring device and alarm/alert system did not work as they should have, and they would call the person responsible for maintenance to fix the electronic monitoring device. During an interview on 3/31/2025 at 4:02 PM, Director of Maintenance #1 stated they checked the battery in Resident #146 ' s electronic monitoring device after the above-described observation. They stated the battery was dead, and the electronic monitoring device was not working. They programmed a new electronic monitoring device and checked it to make sure it was working, and they said it was working as it was supposed to at this time. During an interview and observation on 4/01/2025 at 12:36 PM, Shahbaz (Certified Nurse Aide) #10 stated that if they heard an alarm sound, they would check the pager they wore and each door in the home to see what could have caused the alarm to go off. They said they check Resident #146 ' s electronic monitoring device daily to ensure it works. Shahbaz (Certified Nurse Aide) #10 took Resident #146 ' s walker to the front door. The door alarm went off, and Shahbaz (Certified Nurse Aide) #10 received a notification on their pager that the electronic monitoring device had set off the alarm. Shahbaz (Certified Nurse Aide) #10 approached the side door with Resident #146 ' s walker, and the alarm went off. Shahbaz (Certified Nurse Aide) #10 received a notification on their pager that the electronic monitoring device had set the alarm off. During an interview on 4/02/2025 at 10:09 AM, Registered Nurse #4 stated Resident #146 was able to wander out of the house one time, so they now have an electronic monitoring device in a locked box on their walker to alert staff if the resident was attempting to leave the house. Registered Nurse #4 said the electronic monitoring device was checked weekly to ensure it was functioning as it should be, and the placement of the electronic monitoring device was checked daily. Registered Nurse #4 stated they did not think checking the function of the electronic monitoring device once a week was enough and that it should be checked each 12-hour shift. They stated that if the alarm were to be set off, they would hear the alarm, and the doors would automatically lock. The Shahbaz (Certified Nurse Aide) received a notification on their pager, and the nurses received a notification on their phone that the alarm was set off. Registered Nurse #4 stated they heard the alarm did not go off for Resident #146 on 3/31/2025, and on 4/01/2025, staff checked every alarm for residents that had them to ensure they were working. During an Interview on 4/03/2025 at 12:06 PM, Director of Nursing #1 stated that if a resident wearing an electronic monitoring device were to approach an exit, the system would alarm with a beeping noise, and Shahbaz (Certified Nurse Aide) received a notification on their pager. The Shahbaz (Certified Nurse Aide) should respond to the noise and check on the residents, check the exits, and redirect the residents if necessary. They stated the nurses check the batteries in the electronic monitoring device once a week, but the batteries could stop working. The batteries could be working one minute and not the next. Director of Nursing #1 stated it was not difficult to check if Resident #146 ' s electronic monitoring device was working because a Shahbaz (Certified Nurse Aide) could take the walker and bring it to the door to see if it sets the alarm off. The resident did not need to be with them as they did this. When Director of Nursing #1 saw the gaps on the task sheet to check the electronic monitoring device placement every 12-hour shift while awake, they stated that the Shahbaz (Certified Nurse Aide) were not documenting that they completed this task consistently. Director of Nursing #1 could not say the electronic monitoring device was checked to ensure it was functioning correctly on the days that were not documented. 48413 (b) Resident environment During an observation in House #16 on 3/26/2025 at 10:46 AM, the kitchen pantry contained a box of [NAME] Oktoberfest beer with three (3) bottles, labeled with the Resident #54's name. In the pantry refrigerator, two (2) bottles of the same beer were on the door shelf with no label of the resident's name. The pantry was accessible to residents, staff and visitors. During an observation in House #10 on 3/26/2025 at 11:05 AM, the unlocked medication room contained one (1) bottle of wine and two (2) bottles of hard liquor on a shelf approximately 5 feet from the ground. During an observation on 3/28/2025 at 12:34 PM, House 21 Medication Room Door was wide open. Signage was posted on door that read, Please Keep Med Room Door Closed At All Times. Four (4) wine bottles were observed within the room. Licensed Practical Nurse #1 was observed walking from medication room to kitchen area while leaving medication room door open. They returned approximately 10 minutes later. In the interim, Certified Nurse Aide #2 went into medication room and retrieved supplies leaving door open. During an interview on 3/28/2025 at 12:44 PM, Licensed Practical Nurse #1 stated the Certified Nurse Aides and dietary staff had the access code to medication room. Record review revealed some residents had a physician order to be administered an alcoholic beverage. Record review of Resident #54's care plan documented Resident #54 enjoyed a beer occasionally; staff were to offer a beer to them when having Happy Hour. Record review of physician orders revealed Resident #54 was ordered as: may have a beer nightly at dinner and may have a beer daily. During an interview on 4/02/2025 at 2:38 PM, Registered Nurse #1 stated that nurses would give Resident #54 the alcoholic beverage when requested. They indicated that they were unsure where they would document when the nurse would give the resident their beer. Registered Nurse #1 stated there was no way of documenting when Resident #54 was given a beer due to how it was entered into the system. During an interview on 3/31/2025 at 2:43 PM, Director of Nursing #1 stated Certified Nurse Aides, dietary staff, and central supply staff had access to the medication room. They further stated the Nurse Manager would keep an eye on alcoholic beverages, and there was no tracking for how much alcohol was used/distributed. There was no documented evidence that the facility identified the accessible alcoholic beverages as an environmental hazard, assessed individual resident risk of an accident, tracked consumption of alcoholic beverages ordered by a physician when administered to a resident, or identified and implemented measures to mitigate the risk of unintended alcoholic consumption. During an interview on 3/31/2025 at 3:18 PM, Administrator #1 stated staff who were not certified to pass medication should not access the medication room. They stated that as of 3/31/2025, Shahbaz (Certified Nurse Aide) supplies were relocated to another area, and the access code to the mediation rooms were changed and given only to licensed staff who administer medication. During an observation on 4/01/2025 at 10:17 AM, House #19 Medication Room door was wide open and unattended. At the time of observation, Shahbaz (Certified Nurse Aide) #3 stated it was their mistake, but the door was usually open anyway. 10 New York Codes, Rules and Regulations 415.12(h)(1)

Based on observation, record review, and interviews conducted during a recertification and abbreviated survey (Case #NY00368845), the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, (1) an analysis of the actual staffing schedule showed that on multiple occasions from 3/25/2025 through 4/02/2025, the facility was below the minimum levels required; (2) staff reported a lack of sufficient staffing; and (3) residents reported during interviews that the facility was short-staffed at times, and this resulted in call bells not being answered timely and long wait times for care to be provided. This is evidenced by: Upon entrance to the facility on [DATE], there were 170 residents residing in 16 housing units. The Facility Assessment, last reviewed on 7/31/2024, documented that the facility's bed capacity was 190. The section titled Staffing Plan documented the following: The day shift required 1 Registered Nurse for four houses, 2 Licensed Practical Nurses for two houses, and 3 Shahbaz (Certified Nurse Aide) per house. The evening shift required 1 Registered Nurse for the facility, 2 Licensed Practical Nurses for two houses, and 2 Shahbaz per house. The night shift requires one Registered Nurse for the facility, two Licensed Practical Nurses for two houses, and one Shahbaz per house. A review of staffing sheets provided by the facility from 1/19/2025 through 3/22/2025 documented that they did not meet their assessed minimum staffing on most day shifts, for the following: On 1/20/2025, during the day shift, all houses had 2.5 Shahbaz providers except for houses 7, 10, and 16, which had 1.5 Shahbaz each; houses 12 and 19, which had two Shahbaz each. On 1/28/2025, during the day shift, all houses had 2.5 Shahbaz except for house 1, which had 1.5 Shahbaz; houses 3, 10, and 12, which had two Shahbaz each. On 2/05/2025, during the day shift, all houses had 2.5 Shahbaz providers except for house 6, which had 1.5 Shahbaz. On 2/13/2025, during the day shift, all houses had 2.5 Shahbaz providers except houses 1, 2, 4, 10, and 12, which had two Shahbaz each. On 2/21/2025, during the day shift, all houses had 2.5 Shahbaz providers except for houses 1 and 4, which each had 1 Shahbaz; house 7, which had 2 Shahbaz. On 2/24/2025, during the day shift, all houses had 2.5 Shahbaz providers except for houses 5 and 22, which each had 1.5 Shahbaz; houses 1, 2, 3, 4, and 7, which had 2 Shahbaz. On 3/05/2025, during the day shift, all houses had 2.5 Shahbaz providers except for houses 1 and 12, which each had 1.5 Shahbaz; house 2, which had 2 Shahbaz; and houses 7, 21, and 24, which each had 3 Shahbaz. On 3/14/2025, during the day shift, all houses had 2.5 Shahbaz providers except for house 24, which had 2 Shahbaz; and houses 2, 7, 10, and 21, which each had 3 Shahbaz. On 3/19/2025, during the day shift, all houses had 2.5 Shahbaz providers except for house 5, which had 1 Shahbaz; houses 2, 8, and 12, which each had 2 Shahbaz. During an interview on 3/25/2025 at 10:35 AM, Resident #70 stated that the staff were sometimes late in providing care. They stated that it could take up to an hour for staff to assist in the bathroom. They also stated that the staff stated that they were always busy and unable to do certain tasks because they were busy taking care of 12 residents. During an interview on 3/25/2025 at 3:01 PM, Resident #91 stated that they were consistently short-staffed in the morning, and breakfast was usually delayed. During an interview on 3/27/2025 at 12:04 PM, Resident #19 stated that they had waited a long time to get assistance. They also stated that the call bell system did not work well, and staff sometimes ignored it. During a surveyor-led group resident meeting on 3/27/2025 at 11:35 AM, the nine (9) residents in attendance all reported insufficient staffing to meet their needs. They often had to wait after they activated their call light. They stated that the call light system was unreliable, and staff do not hear it. They stated that staff would turn off their call light and told them they would return to provide requested care, and sometimes never returned. They stated that mealtimes were when they did not get the assistance needed, as everyone was busy trying to get the residents' meals, moved, and cleaned up afterwards. During an interview on 4/01/2025 at 12:35 PM, Shahbaz (Certified Nurse Aide) #7 stated that they were often short-staffed, residents would have to wait for care, and they had no time for anything extra. During an interview on 4/02/2025 at 2:09 PM, Registered Nurse #1 stated that staffing was not great. During an interview on 4/03/2025 at 10:54 PM, Scheduler #1 stated that they had been the scheduler since December of 2024, and the schedule calls for 2.5 Shahbaz (Certified Nurse Aides) per day per house. They stated that there were two (2) Shahbaz scheduled for the 7:00 AM to 3:00 PM shift and one (1) Shahbaz from the 8:00 AM to 1:00 PM shift. They stated that the 8:00 AM shift was tough to fill and would drop that shift if needed, and work at their minimum staffing level of two (2) Shahbaz for the house. They stated that if able, they would move individuals around the campus to achieve the minimum staffing if there were call-outs. They stated that they have had to use more agency personnel lately due to staffing issues. 51317 During an interview on 4/03/2025 at 10:54 PM, Nurse Educator #1, stated they also completed scheduling and agreed with Scheduler #1 regarding the facility staffing level and minimum staffing. Nurse Educator #1 was shown the facility assessment and staffing plan, which stated that the staffing calls for a minimum of three (3) Shahbaz per resident house. They stated that they were unsure when the facility assessment was updated but indicated that it should not have been three (3) Shahbaz. Nurse Educator #1 was shown that the facility assessment was updated on 7/31/2024 by Administrator #2. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii)

Based on record review and interviews conducted during the recertification survey, the facility did not ensure each resident's drug/medication regimen was managed and monitored to promote or maintain the resident's highest practicable mental, physical, and psychosocial well-being for five (5) (Resident #s 53, 89, 145, 161, and 166) of nine (9) residents reviewed for unnecessary medications. Specifically, for Resident #s 53, 89, 145, 161, and 166, as needed psychotropic medication orders did not include end dates. This is evidenced by: The Policy and Procedure titled, Psychotropic Medication Management, effective 3/06/2024, documented as needed orders for anti-psychotic and anti-anxiety medications were limited to 14 days and could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. If the attending physician or prescribing practitioner believed that it was appropriate for the as-needed order to be extended beyond 14 days, they would document their rationale and indicate the duration for the as needed order. Resident #53 Resident #53 was admitted to the facility with diagnoses of type 2 diabetes mellitus (characterized by high blood sugar levels due to the body's inability to use insulin effectively), major depressive disorder (a common and serious mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities), and [NAME] ataxia (a neurodegenerative disorder that primarily affects the nervous system, causing impaired muscle coordination). The Minimum Data Set (an assessment tool) dated 2/11/2025, documented that the resident could be understood, understand others, and was cognitively intact. A Clinical Physician Order dated 3/27/2025, documented lorazepam (a psychotropic medication used to treat anxiety) 0.5 milligram give 1 milligram by mouth every 8 hours as needed for spasms/[NAME] ataxia. The end date was documented as indefinite. Resident #89 Resident #89 was admitted to the facility with diagnoses of hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), congestive heart failure (a weakened heart condition that causes fluid buildup in the feet, arms, lungs, and other organs), and chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe). The Minimum Data Set, dated [DATE], documented the resident was sometimes understood, usually understand others, and was cognitively intact. A Clinical Physician Order dated 12/10/2024 documented diazepam (a psychotropic medication used to treat anxiety) rectal gel 10 milligram insert 1 applicator rectally every 24 hours as needed for seizure. The end date was documented as indefinite. Resident #145 Resident #145 was admitted to the facility with diagnoses of unspecified dementia (a decline in mental ability severe enough to interfere with daily life), morbid obesity (a severe form of obesity characterized by a significantly high body mass index), and major depressive disorder. The Minimum Data Set, dated [DATE], documented that the resident was sometimes understood, sometimes understand others, and was severely cognitively impaired. The Clinical Physician Order dated 3/17/2025, documented clonazepam 0.5 milligram by mouth two times a day for anxiety and give 0.5 milligram every 12 hours as needed for anxiety or agitation. The as-needed order end date was documented as indefinite. Resident #161 Resident #161 was admitted to the facility with diagnosis of hyperlipidemia (high level of cholesterol in the blood), hypertension (high blood pressure), and dementia. The Minimum Data Set, dated [DATE], documented the resident was rarely/never understood by others, rarely/never understood others, and was severely cognitively impaired. The Clinical Physician Order dated 3/11/2025, documented lorazepam oral tablet 0.5 milligram give 0.5 milligram orally every 6 hours as needed for anxiety/crying. The end date was documented as indefinite. Resident #166 Resident #166 was admitted to the facility with diagnoses of hypertension, non-rheumatic aortic valve stenosis (a pathological constriction that can occur above, below, or at the aortic valve), and atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow). The Minimum Data Set, dated [DATE], documented the resident was usually understood by others, could usually understand others, and was severely cognitively impaired. The Clinical Physician Order dated 12/06/2024, documented lorazepam oral tablet 0.5 milligram give 1 tablet by mouth every 8 hours as needed for anxiety/restlessness. The end date was documented as indefinite. During an interview on 3/31/2025 at 10:00 AM, Medical Director #1 stated they were aware of the regulation regarding as needed psychotropic medication and end dates. They felt medical providers should have discretion when ordering medications including applying end dates to as-needed medications. During an interview on 3/31/2025 at 2:43 PM, Director of Nursing #1 stated psychotropic medications ordered on an as needed basis should have an end date. 10 New York Codes, Rules, and Regulations 415.18 (c)(2)

Based on observation, record review, and interviews conducted during the recertification survey, the facility did not ensure food was stored in accordance with professional standards for food service safety for four (4) of 16 resident central kitchens. Specifically, (a.) bulk food items were not labeled for their contents; (b.) bulk food items and outside items were not date-labeled after opening or labeled with an expiration date; (c.) appliances were not cleaned and had dirt, grime, and unknown substances within them; and (d.) chicken was improperly being thawed. This is evidenced by: An undated policy titled Food Safety Labeling Procedure documented that all food or beverage items stored, opened, prepared, or leftover in our kitchens/storage areas and/or delivered to areas such as Nursing Stations or pantries would be clearly identified by the item name/product, the production or opened date, and the use-by date. A document titled Important Foodservice and Sanitation Guidelines described that any prepared food that was opened or stored must be labeled and dated for discard within three days. Any beverage or dairy product must be labeled with its opening date. Items must be discarded within seven days of being opened or by the manufacturer's use-by date, whichever comes first. Any condiment-type item that must be refrigerated after opening must be labeled with the opened date, and items must be discarded within 30 days of being opened. House #5 During an observation on [DATE] at 10:27 AM, uncooked chicken was in a Ziploc bag placed in a metal bowl in the kitchen sink, with water from the faucet running over it. The bag was labeled ,d+[DATE] dinner. At 11:23 AM, the same bag of chicken was observed in the metal bowl filled with water in the same sink. The bag of chicken was sitting in the bowl filled with water, and the faucet was turned off. During observations on [DATE] from 10:35 AM to 12:35 PM, the following was noted within the main kitchen area for Houses #10, 12, 14, and 16: House # 10 A) Eight (8) items did not have labels describing what they were or what they contained: Frozen French fries located within a freezer Frozen scones located within a freezer Frozen cookies located within a freezer Frozen sausage patties located within a freezer Frozen fish fillets located within a freezer Frozen peas located within a freezer Frozen dinner rolls located within a freezer Frozen broccoli located within a freezer B) Two (2) items lacked a label or writing of when they were opened: A bag of Ruffles chips Package of cookies C) The appliances had the following findings: Seals on the freezer and refrigerator were covered with dirt and grime The freezer had old fallen labels dating back to 2019 The freezer bottom had substance on the bottom of the freezer The interior of the oven had unknown substances on the glass doorway The microwave oven was covered with an unknown substance within the appliance House # 12 A) Eight (8) items did not have labels describing what they were or what they contained: Frozen waffle fries located within a freezer Frozen hot dogs located within a freezer Frozen hamburgers located within a freezer Two (2) packages of frozen sausage patties located within a freezer Four (4) packages of frozen sausage patties located within a freezer Frozen fish fillets labeled as sausage located within a freezer Frozen corn located within a freezer Frozen cinnamon rolls labeled as dinner rolls located within a freezer Frozen broccoli located within a freezer Frozen berry mix located within a freezer B) Two (2) items lacked a label or writing of when they were opened: Two (2) packages of wheat bread Package of cookies C) The appliances had the following findings: Seals on the freezer and refrigerator were covered with dirt and grime The freezer had old fallen labels dating back to 2021 The freezer bottom had substance on the bottom of the freezer The interior of the oven had unknown substances on the glass doorway The microwave oven was covered with an unknown substance within the appliance House #14 A) Eight (8) items did not have labels describing what they were or what they contained: Frozen French fries located within a freezer Frozen scones located within a freezer Frozen cookies located within a freezer Frozen sausage patties located within a freezer Frozen fish fillets located within a freezer Frozen peas located within a freezer Frozen dinner rolls located within a freezer Frozen broccoli located within a freezer B) Four (4) items lacked a label or writing of when they were opened: A bag of Ruffles chips Package of cookies Package of Cinnamon Toast Crunch bars Package of Oatmeal Bars C) The appliances had the following findings: Seals on the freezer and refrigerator were covered with dirt and grime The freezer had old fallen labels dating back to 2019 The freezer bottom had substance on the bottom of the freezer. The interior of the oven had unknown substances on the glass doorway The microwave oven was covered with an unknown substance within the appliance House #16 A) Eight (8) items did not have labels describing what they were or what they contained: Frozen hamburgers located within a freezer Frozen scones located within a freezer Frozen cookies located within a freezer Frozen sausage links located within a freezer Frozen fish fillets located within a freezer Frozen corn located within a freezer Frozen dinner rolls located within a freezer Frozen broccoli located within a freezer B) Two (2) items lacked a label or writing of when they were opened: Two (2) packages of wheat bread Package of cookies C) The appliances had the following findings: Seals on the freezer and refrigerator were covered with dirt and grime The freezer had old fallen labels dating back to 2019 The freezer bottom had substance on the bottom of the freezer The interior of the oven had unknown substances on the glass doorway The microwave oven was covered with an unknown substance within the appliance Interviews: During an interview on [DATE] at 10:44 AM, Shahbaz (Certified Nurse Aide) #4 stated that staff should have properly labeled and discarded the expired item. They stated that the labels did not always stick in the freezer and fell off. During an interview on [DATE] at 10:54 AM, Shahbaz #5 stated all staff needed to be more diligent in labeling and tracking item dates and labeled when identified. During an interview on [DATE] at 11:49 AM, Shahbaz #1 stated that all Certified Nurse Aides were responsible for looking at items and determining if they needed to be discarded by the date. During an interview on [DATE] at 11:08 AM, Registered Nurse #1 stated that food and kitchen activities were ultimately the staff's responsibility. All staff in the kitchen area should have checked the items regularly for resident safety. Registered Nurse #1 stated that it was the daily routine of the Shahbaz (Certified Nurse Aides) to maintain the cleanliness of the kitchen areas. They stated that there was a daily cleanliness checklist for them to follow. They further stated that they would periodically meet with the food service division to review the items found. During an interview on [DATE] at 2:15 PM, Director of Nursing #1 stated that the Food Service Director oversaw the food at the facility. However, it was a joint staff effort to check the food and food items daily for potential expiration dates. They further stated that the facility's distribution manager and Shahbaz (Certified Nurse Aides) were to check the items regularly, with them opened and labeled per policy. 10 New York Codes of Rules and Regulations 415.14(h)

Based on observation, record review, and interview conducted during the recertification survey, the facility did not maintain medical records in accordance with accepted professional standards and practices, as accurately documented and completed for one (1) (Resident #54) of the 36 residents reviewed. Specifically, for Resident #54, the physician's ordered alcohol administration was not documented in the Medical Administration Record. This is evidenced by: Resident #54 was admitted to the facility with diagnoses of Friedreich Ataxia (a progressive neurodegenerative disorder that primarily affects the nervous system, causing impaired muscle coordination), gastro-esophageal reflux disease (occurs when stomach contents persistently flow back into the esophagus, causing symptoms like heartburn), and essential hypertension (a condition characterized by persistently high blood pressure without an identifiable underlying cause). The Minimum Data Set (an assessment tool) dated 2/14/2025 documented that the resident could be understood and usually understand others and had intact cognition for daily living decisions. During an observation in House #16 on 3/26/2025 at 10:46 AM, the kitchen pantry contained a box of [NAME] Oktoberfest beer with three (3) bottles, labeled with the Resident #54's name. In the pantry refrigerator, there were two (2) bottles of the same beer on the door shelf with no label of the resident's name on them. During a record review of Resident #54's care plan on 3/28/2025, it was documented that Resident #54 enjoyed a beer on occasion, and staff were to offer this to them during Happy Hour. During a record review of physician orders on 3/28/2025, it was documented that Resident #54 may have a beer nightly at dinner and may have a beer daily. Record review of the March 2025 Medication Administration Record and Treatment Administration Record revealed no documentation of when Resident #54 was given an alcoholic beverage. Record review revealed no documented evidence on a process for staff to document in the medical record when a resident was given an alcoholic beverage. Record review revealed no documented evidence of policies regarding resident consumption of alcoholic beverages. During an interview on 4/02/2025 at 2:38 PM, Registered Nurse #1 stated that nurses were to give the resident the alcoholic beverage when they requested it. They indicated that they were unsure where they would document when the nurse gave the resident their beer. Registered Nurse #1 looked at the physician's orders and agreed that there was an order for the resident to receive a beer. They stated that there was no way of documenting when Resident #54 was given a beer due to the way it was entered into the system. Registered Nurse #1 stated that there should be something in the electronic records to track and record when the resident was given the beverage. 10 New York Code of Rules and Regulations 483.70 (h)(2)(ii)

Based on interviews and record review conducted during the recertification survey, the facility did not ensure that it made prompt efforts to resolve a grievance and to keep the resident appropriately apprised of progress towards resolution for one (1) (Resident #28) of 36 residents reviewed. Specifically, Resident #28 and their representative did not receive prompt resolution when a grievance was filed regarding missing hearing aids on 2/19/2025. The facility did not follow up with this grievance until 4/01/2025. This is evidenced by: Resident #28 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs resulting in swelling and irritation inside the airways that limit airflow into and out of the lungs), hypertensive heart disease (a condition arising from prolonged high blood pressure), and dependence on supplemental oxygen. The Minimum Data Set (an assessment tool) dated 1/03/2025 documented that the resident could be understood, could understand others, and had moderately impaired cognition. Facility policy titled, Complaints and Grievances, effective 1/2016, documented the facility provided a method to promptly deal with complaints and recommendations made by residents, their next of kin and/or their designated representative. The Social Worker was the grievance official or the person responsible for addressing complaints. Residents who wished to make a complaint were scheduled to be seen by the Social Worker or designee or would have the responsibility of presenting the complaint in writing to the Social Worker. Social Services would advise the Administrator of all complaints within 2 days of receipt. A response would be made to the resident, next of kin, or designated representative within 21 days of the day the complaint was made. Grievance Complaint/Follow Up Form, documented a grievance was received on 2/19/2025 and filed by Family Member #1. The form documented Resident #28 was missing two of their hearing aids. Staff were able to locate one of them, but the other hearing aid was still missing. The grievance form documented Social Worker #2 completed the form and an email was sent to the Administrator on 2/19/2025. Follow up notes on this form documented the Administrator spoke with Family Member #1 on 4/01/2025 and stated Family Member #1 said the prior administrator had agreed to reimburse the lost hearing aid prior to their departure from the facility, but to date they have not received reimbursement. Follow up notes were signed by Administrator #1. During an interview on 3/25/2025 at 10:46 AM, Family Member #1 stated Resident #28's hearing aids were missing and they looked everywhere but were not able to find them. Family Member #1 stated they told a nurse about the missing hearing aids and filed a grievance with the Social Worker. They stated this happened a few weeks ago but was unsure of the date and had not received a resolution for the filed grievance. During an interview on 3/31/2025 at 1:47 PM, Shahbaz #8 (Certified Nurse Aide) stated Resident #28 had a hearing aid for each ear. If a hearing aid was missing, they would notify the nurse. Shahbaz #8 stated they could not recall if they notified the nurse that Resident #28's hearing aids were missing. They stated by the time they realized the hearing aids were missing, they thought the nurse already knew about it. During an interview on 3/31/2025 at 2:08 PM, Licensed Practical Nurse #5 stated they were not aware of Resident #28's missing hearing aids or what was done to attempt to find them. They stated they may have been off for a few days when the hearing aids went missing. If they knew they were missing, they would write a note and tell the nurse manager or the nursing supervisor. During an interview on 4/02/2025 at 10:09 AM, Registered Nurse #4 stated they had no knowledge of Resident #28's missing hearing aids. They stated they spoke with Family Member #1 on the afternoon of 4/01/2025 and this was when Registered Nurse #4 learned the hearing aids were missing. They stated Family Member #1 told them about the missing aids and that there was no follow up on the grievance. Registered Nurse #4 stated there have been a lot of changes with nurse managers and it could have gotten lost in the shuffle, but they would communicate and make sure there was follow through on this grievance. During an interview on 4/01/2025 at 11:13 AM, Social Worker #2 stated when they got a complaint from a family member, they filled out a grievance form and they notified the Administrator or the Director of Nursing. The Administrator was the grievance officer. They worked together to figure out how to move forward on the complaint and come to a conclusion. They stated Family Member #1 filled out a grievance form regarding Resident #28's missing hearing aid on 2/19/2025. Social Worker #2 gave this form to the former administrator. Social Worker #2 stated there was a disconnect with follow up on this grievance. During an interview on 4/03/2025 at 12:15 PM, Administrator #1 stated a family member, or a resident could report a grievance, and an investigation would be completed. If the incident was reportable, they would report it, but if it was not reportable, they would come up with a solution to resolve the grievance for the family member/resident. They would expect the grievance to be resolved within 21 days but if the grievance was regarding missing items, it could take longer. 10 New York Code Rules and Regulations 415.3(d)(1)(ii)

Based on observations, record review, and interviews conducted during the recertification survey, the facility did not ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice for two (2) (Resident #s 28 and 89) of three (3) residents reviewed. Specifically, (a.) Resident #28 order for continuous oxygen was not administered. The oxygen nasal cannula was placed on the resident, but the oxygen concentrator was off, therefore not delivering oxygen to the resident; (b.) Resident #89's order for 2 liters of oxygen were not followed consistently. This is evidenced by: The facility Policy and Procedure titled, Oxygen Management, effective 5/13/2024 documented, it was policy to administer oxygen per provider order in a safe manner. Responsibility of Licensed Nursing Staff: Procedure: (1) Review orders; (2) Identify resident and explain procedure; (3) Plug in power cord; (4) Keep concentrator at least 12 inches from walls, draperies and avoid confined spaces; (5) Connect humidifier (if needed); (6) Attach oxygen tubing from the humidifier bottle to oxygen outlet connector on the concentrator. If humidification is not being utilized place adaptor on the outlet connector and attach oxygen tubing directly to the adaptor; (7) Press power switch on; (8) Turn the flow meter to the prescribed flow rate setting. (9) Follow manufacturer's recommendations on filter changes or additional required maintenance. Resident #28 was admitted to the facility with diagnoses of chronic obstructive pulmonary disease (an ongoing lung condition caused by damage to the lungs resulting in swelling and irritation inside the airways that limit airflow into and out of the lungs), hypertensive heart disease (a condition arising from prolonged high blood pressure), and dependence on supplemental oxygen. The Minimum Data Set (an assessment tool) dated 1/03/2025, documented the resident had moderate cognitive impairments, could be understood, and understand others. The Comprehensive Care Plan with focus, Potential/Actual Impaired Breathing related to Chronic Obstructive Pulmonary Disease, effective 1/17/2023, last revised 1/01/2025, documented Resident #28 was to receive 2 liters of oxygen via nasal cannula continuously. May increase as needed. Physician order initiated 5/07/2024 and revised monthly, documented apply continuous oxygen 2 liters via nasal cannula; titrate as needed to keep oxygen saturation greater than 88 percent. During an observation and interview on 3/26/2025 at 10:46 AM, Resident #28 was in their room, seated in a recliner. They were wearing a nasal cannula that was attached to an oxygen concentrator (a device that draws air from the surrounding environment and delivers a concentrated, purified stream of oxygen). The oxygen concentrator was turned off. Resident #28 was not receiving continuous oxygen. Family Member #1 stated Resident #28 was brought back to their room after eating breakfast. When they ate breakfast in the dining area, Resident #28 used a portable oxygen tank attached to their wheelchair to supply oxygen, and when Resident #28 was in their room the concentrator was used to supply oxygen. Family Member #1 stated the concentrator was not turned on when Resident #28 was returned to their room. Family member #1 turned on Resident #28's oxygen concentrator. They stated Resident #28 was supposed to receive supplemental oxygen continuously. During an interview on 3/31/2025 at 1:47 PM. Shahbaz (Certified Nurse Aide) #8 stated Resident #28 always used supplemental oxygen. When they were in their room, Resident #28 used the concentrator to supply oxygen and during meals or activities they used a portable tank to supply the oxygen. During an interview on 3/31/2025 at 2:08 PM, Licensed Practical Nurse #5 stated Resident #28 should have received supplemental oxygen continuously. Residents may need to be checked on to make sure they were receiving supplemental oxygen. During an interview on 4/02/2025 at 10:09 AM, Registered Nurse #4 stated they were not sure if Resident #28 was to receive continuous oxygen, but if a resident had orders for continuous oxygen, they should have received oxygen at all times. Resident #89 Resident #89 was admitted to the facility with diagnoses of hemiplegia (paralysis on one side of the body) following a stroke (a loss of blood flow to part of the brain, which damages brain tissue), congestive heart failure (heart cannot pump blood well enough to meet your body's needs), and chronic obstructive pulmonary disease. The Minimum Data Set, dated dated dated [DATE], documented the resident was cognitively intact, could be understood, and understand others. The Comprehensive Care Plan for Cardiac Function initiated 10/24/2024, revised 1/18/2025, documented actual alteration in cardiac function, as manifested by cardiac arrhythmia, edema, unstable vital signs. Interventions include: (a) assess lung sounds as needed and report changes to Medical Doctor; (b.) oxygen as ordered. During an observation on 3/26/2025 at 12:14 PM, Resident #89 was at the dining room table, oxygen concentrator in place, set at 5 liter per minute via nasal cannula. During an observation on 4/01/2025 at 10:57 AM, Resident #89 was sitting in the recliner in their room, oxygen concentrator in place, set at 3 liters per minute via nasal cannula. The physician order dated 10/24/2024, renewed 3/01/2025 documented Oxygen 2 liters per minute via nasal cannula as needed. Notify medical doctor if increased flow rate and/or continued use as needed for shortness of breath. During an interview on 4/03/2025 at 11:30 AM, Director of Nursing #1 stated nursing staff were to check and follow oxygen orders as prescribed. The concentrator may be used in or out of the room. If the resident is on a lower flow, they may use a tank or a portable oxygen delivery system if away from the concentrator. Certified Nurse Aides could make sure the cannula is in and turn the machine on or off but could not adjust flow of oxygen. 51317 During an interview on 4/03/2025 at 12:06 PM, Director of Nursing #1 stated if a resident had orders to receive continuous oxygen, they should have oxygen on all the time. Director of Nursing #1 stated if a resident was wearing a nasal cannula attached to an oxygen concentrator, but the concentrator was turned off, the resident was not receiving supplemental oxygen. 10 New York Codes, Rules, and Regulations 415.12(k)(6)

Based on observation, record review and interview conducted during the recertification survey, the facility did not ensure that one (1) (Resident # 130) of four (4) residents reviewed for hospitalization received notice of the bed-hold policy and return prior to or within 24 hours of an emergency transfer. Specifically, Resident #130 was not given written notice of the bed hold policy prior to or within 24 hours of transfer to the hospital on 1/18/2025. This is evidenced by: The Facility's Policy and Procedure titled Bed Hold Policy, effective 6/27/2023 documented facility support the resident's right to retain their bed when they are hospitalized or take a therapeutic leave. The policy promotes continuity of care and ongoing psychosocial support for residents. Procedure, The Bed Hold Policy Summary form must be provided to the resident, or resident's representative, at the time of transfer, or in cases of emergency transfer within 24 hours. a. Facility would document multiple attempts to reach the resident's representative in cases where the facility was unable to contact the representative. When a resident residing in a skilled nursing facility (SNF) under their Medicare benefit is hospitalized or takes therapeutic leave, Medicare would not pay to hold the bed. The Facility policy allows for the resident to pay privately to hold the bed if so desired. Facilities must make all residents, regardless of payor source, aware in writing of their policies related to holding beds during absences from the facility. Resident #130 was admitted to the facility with diagnoses fracture of femur neck (broken hip), fracture of ulnar (broken forearm), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest). The Minimum Data Set (an assessment tool) dated 11/22/2024, documented resident had mild cognitive impairment, could be understood and understand others. Nursing progress note dated 1/18/2025 documented Resident #130 was found on the floor. A subsequent x-ray revealed a right hip fracture. An order was obtained to transfer Resident #130 to the hospital via ambulance at 10:30 AM. Family aware. There was no documented evidence of Bed Hold Transfer Notice. During an interview on 4/02/2025 at 10:41 AM, Social Worker #2 stated when a resident was transferred to a hospital and was admitted for greater than 24 hours, social work mailed a notice of transfer to family along with bed hold. Social work then would notify the Ombudsman via email of the transfer with copy of the envelope with stamp sent to family. Afterwards, documents were uploaded to the electronic medical record. During an interview on 4/02/2025 at 4:05 PM, Social Worker #1 stated they were aware of facility Bed Hold Policy, but did not follow the policy and did not send Bed Hold/Transfer Notice for this admission. They stated they believed this was a weekend admission that was overlooked. During an interview on 4/03/2025 at 10:10 AM, Admission's Coordinator #1 stated Bed Hold policy was reviewed upon admission with residents. Transfers thereafter were handled by Social Work. 10 New York Codes, Rules, and Regulations 415.3(h)(4(i)(a)

Based on observation, record review, and interview conducted during the recertification survey, the facility did not ensure residents could safely self-administer medication when clinically appropriate for one (1) (Resident #84) of one (1) resident reviewed for medication administration. Specifically, Resident #84 was observed with a medicine cup of pills while eating breakfast in the dining area on 3/26/2025 and independently taking the pills. There was no documented evidence that Resident #84 was assessed to determine their ability to safely self-administer medications, or physician orders for self-administration of medications. This is evidenced by: Resident #84 was admitted to the facility with diagnoses of hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (occurs when blood flow to the brain is disrupted, leading to tissue death due to lack of oxygen and nutrients) affecting a dominant side, atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and osteoporosis (a condition in which bones become weak and brittle). The Minimum Data Set (an assessment tool) dated 2/15/2025, documented the resident usually made themselves understood, usually understand others, and had moderate cognitive impairment The facility policy, Self-Administration of Medications, dated 6/19/2023, documented it was the facility's policy to honor a resident's request to self-administer medication unless the interdisciplinary team determined the practice was unsafe. As part of the admission process, the nurse would determine if a resident wished to self-administer medications. If they did, the resident would be evaluated for self-administration of medications and the assessment would be completed and reviewed by the interdisciplinary team. If the assessment concluded the resident was able to self-administer medications, a written order would be obtained from the attending physician. The residents ability to self-administer medications would be reviewed on any readmissions, quarterly, and with significant changes. During an observation on 3/26/2025 at 10:23 AM, Resident #84 was sitting in the dining area by themselves at the table eating their breakfast. There was a plastic medicine cup with their morning medications to the side of their plate. Resident #84 poured the pills onto their plate and took them with yogurt. There was no nurse supervising Resident #84 while they independently took their medications. There was no documented evidence in Resident #84's medical record that they could self-administer their medications. There was no documented evidence of physician order for Resident #84 to self-administer their medication. During an interview on 3/28/2025 at 3:17 PM, Licensed Practical Nurse #5 stated they put Resident #84's medications in a plastic cup and left them for Resident #84 to take with their yogurt. They stated they would leave Resident #84 alone while they took their medication, and they would come back to check on Resident #84 to make sure they took all their medication. They further stated they were not aware that Resident #84 was not formally assessed to take their medication independently. During an interview on 4/02/2025 at 10:09 AM, Registered Nurse #4 stated if a resident self-administered medication, an assessment for self-administration should have been completed. Registered Nurse #4 stated they did not think Resident #84 had an assessment for self-administration of medications and this resident should not have medications left for them to take independently. During an interview on 4/03/2025 at 12:06 PM, Director of Nursing #1 stated if a resident wanted to self-administer medications, an assessment would be completed, and the interdisciplinary team would need to agree that the resident was able to self-administer their medications. They stated Resident #84 did not have an evaluation for self-administration of medication and their medication should not have been left in a medicine cup for them to take independently. 10 New York Codes, Rules, and Regulations 415.3(e)(1)(vi)

Based on record review and interview conducted during an abbreviated survey (NY00373673), the facility did not ensure the environment remained as free of accident hazards as possible for 1 (Resident #1) of 1 resident reviewed for accident hazards. Specifically, for Resident #1 the facility did not ensure the resident's bed was positioned away from the heating unit resulting in a second degree burn to the resident's arm. This is evidenced by: Resident #1 was admitted to the facility with diagnoses of Alzheimer's Disease (a degenerative neurological disease-causing memory loss), peripheral vascular disease (disorder of the blood vessels), and psychotic disorder with delusions (mental health condition in which a person can't tell what's real from what's imagined). The Minimum Data Set, dated [DATE] documented the resident could usually understand, could be understood, and was severely cognitively impaired. The Care Plan dated 2/15/2024 and titled, Safety awareness deficit related to confusion/decreased memory, decreased strength/endurance, Dementia, history of falls, Impulsive behaviors, Limited mobility, documented the bed was to be positioned against the wall on the left side near the window. In a written statement Licensed Practical Nurse #1 documented they entered the resident's room on 3/02/2025 at 9:45PM to find the resident lying in bed sideways with left arm and shoulder on heater. The resident's left arm had burn marks and was hot to touch. A Hospital Discharge summary dated [DATE] documented the resident presented with first and second degree burns of the left lateral humeral area from contact with a heater. Patient denied pain and declined pain medication. Antibiotic ointment and dressing applied. No additional care is needed for the burn. During an observation on 3/06/2025 at 11:20AM, all beds in House 12 were observed to be positioned away from the heat source. Resident #1 was in bed, lying sideways with one foot on the floor. During an interview on 3/6/2025 at 11:30AM Certified Nurse Aide #2 stated they were not here at the time of the incident but was told about it and told to make sure all beds are always away from the heaters. Reports resident moves around in bed a lot and likes to have one foot on the floor most of the time. During an interview on 3/6/2025 at 11:45 AM Certified Nurse Aide #3 stated they were aware of incident and were told to keep beds away from heaters. Has never noticed any of the heaters feeling too hot and not aware of any other incidents like this. During an interview on 3/6/2025 at 11:35AM Resident #1 stated they were comfortable in the bed and feeling good. Resident was asked about the incident and stated they were fine, nothing happened. During an interview on 3/6/2025 at 2:30PM Senior Maintenance Manager #1 stated a heating company came in to check all heating units and found a faulty valve in Resident #1's heater and two others in the facility. The valves were replaced. During an interview on 3/6/2025 at 2:30PM Maintenance Manager #1 checked the temperature all heating units in the facility, and all were at or below 160 degrees as they should be. They are looking into whether this is a safe temperature and if it can be adjusted and still maintain comfortable room temperatures. Past Non-compliance -F689 Based on the following corrective action taken, there was sufficient evidence the facility corrected the noncompliance and was in substantial compliance for this specific regulatory requirement at the time of this survey. - Appropriate first aid and medical care were provided to the resident. - The incident was reported appropriately to the State Survey Agency - A thorough investigation was completed. - Education was provided to all staff regarding following positioning beds near heat sources. - The resident's Care Plans were updated to reflect the proper bed position. - An outside vendor was brought in to inspect all heat sources in the facility for malfunctioning and correct identified issues. - Maintenance staff have checked all heat source temperatures and will continue to audit to maintain safety. At the time of survey, there were no additional injuries identified as resulting from beds being placed near heat source. 10 New York Code Rules and Regulations 415.12(h)(1)

Based on record review and interviews during an abbreviated survey (Case #s NY00370986, NY00359919, NY00359950, and NY00360114), the facility failed to ensure all allegations of abuse were thoroughly investigated for three (3) (Resident #'s 1, 2, and 3) of four (4) residents reviewed for abuse investigation. Specifically, (1.) video surveillance footage revealed Shahbaz (Certified Nurse Aide) #1 pushed Resident #1 to the floor on 2/02/2025 at 5:03 PM. There was no documented evidence the facility initiated an investigation on 2/02/2025 (2.) Resident #2 was left unattended in the bathroom by Shahbaz #5 for one hour and twenty minutes on 11/04/2024. Resident #2 attempted to get themselves off of the toilet and subsequently fell and suffered an injury to their right shoulder. (3.) On 11/05/2024, Resident #3 attempted to stand from the table after finishing their meal; Shahbaz #5 yelled at the resident to sit the F*** down. This resulted in Immediate Jeopardy and substandard quality of care to resident health and safety with the likelihood to affect all 177 residents in the facility. The immediate Jeopardy was lifted on 2/13/2025. This is evidenced by: Cross-referenced to: F600: Abuse Prohibition, F609: Reporting. Review of the facility Abuse Prevention & Investigation Policy, dated 10/14/2022, documented the following: - Residents have the right to be free from verbal, sexual, physical, and mental abuse; neglect, mistreatment, corporal punishment, involuntary seclusion, exploitation, and misappropriation of property (thereafter abuse shall be understood to include all of the above). - All employees have an obligation to report such abuses when they have reasonable cause to believe that such an incident has occurred. The facility shall follow guidelines as outlined in federal/state regulations, Dear Administrator Letters (DALs), Centers for Medicaid and Medicare State Operations Manual Appendix PP, and [NAME] Health/St. Peter's Health Partners policies and procedures. The staff shall report any incident or allegation/suspicion of abuse as outlined above to the Administrator, Director of Nursing Services or their designee immediately. In cases where a crime is suspected, the facility leadership is expected to report the same to local law enforcement under the Elder Justice Act. Resident #1 Resident #1 was admitted with diagnoses of non-Alzheimer's dementia (decline in mentation), osteoporosis, (bone weakness), and anxiety. The Minimum Data Set (an assessment tool) dated 11/29/2024 documented the resident was cognitively impaired, could be understood, and understand others. Video surveillance footage revealed that on 2/02/2025 at 5:00 PM, Shahbaz #1 pushed Resident #1 and walked away. Resident #1 fell and sustained a fractured (broken) hip. Nursing progress note dated 02/02/2025 at 6:13 PM, completed by Registered Nurse #1, documented that Registered Nurse #1 was called to House 16 for a witnessed fall. It documented the following: Shahbaz #1 reported that they were taking Resident #1 to their room when Resident #1 let go of the side rail and fell to the floor. Upon arrival, Resident #1 was observed sitting on the floor in the dining room. On assessment, Resident #1 was observed to be in pain with some guarding to their right thigh and was unable to stand. Resident #1 was assisted off the floor with a mechanical lift and two-person assist, then placed in a wheelchair. Physician was made aware and ordered an x-ray of the right hip, pelvis and femur. The x-ray was ordered to be completed by a Mobile / portable, bedside unit Resident #1's family was notified and came in to visit. Vital Signs: Temperature 97.8, Pulse 83, Respirations 20 per minute, Blood Pressure 160/84. Record review of Mobile X-ray imaging report of Resident #1's right hip, dated 02/02/2025 at 6:45 PM, revealed Resident #1 sustained a fracture of the right femur (long leg bone located from hip to knee) that suggested subacute timing (that indicated it had recently occurred). There was no documented evidence the facility initiated an investigation on 2/02/2025 to rule out abuse. Additionally, there was no documented evidence the facility completed a thorough investigation of the alleged violation, and no documented evidence that the facility informed law enforcement. Facility 5-day Investigation Report created 02/07/2025 and changed 02/11/2025 documented the following: There was reasonable cause to believe that abuse, neglect, or mistreatment occurred on 02/02/2025. Resident representative was reported of the incident on 02/05/2025 at 1:30 PM (three days later). Summary of interview(s) with staff responsible for oversight and supervision of the location where the alleged victim resides listed as, ' NA. ' Summary of interview(s) with staff responsible for oversight and supervision of the alleged perpetrator, if staff or a resident, listed as, ' NA. ' The facility corrective action noted only the termination of employment for Shahbaz #1. During an interview on 02/11/2025 at 9:01 AM, Assistant Director of Nursing #1 stated Resident #1 had a fall with an injury on 02/02/2025, and video of the incident was reviewed with Guide #1 on 02/03/2025 at 10:50 AM, when abuse was discovered. They stated that Shahbaz #1 was interviewed by telephone and suspended when their recounting of the events that occurred did not match the actual events documented in the video recorded on 02/02/2025 at 5:00 PM. Assistant Director of Nursing #1 stated they then reported it to New York State Department of Health. During an interview on 02/11/2025 at 9:05 AM, Administrator #1 stated that they became aware of the incident on 02/03/2025 at 10:50 AM, when Assistant Director of Nursing #1 notified them that abuse had occurred, and the investigation was not started on 2/02/2025. During an interview on 02/11/2025 at 2:17 PM, Shahbaz #2 stated they were afraid and intimidated by Shahbaz #1. Shahbaz #2 stated they saw Shahbaz #1 grab Resident #1 and pull them away from the table. Shahbaz #2 stated that they thought Shahbaz #1 was taking the resident to their room and did not intervene. They stated that they heard Resident #1 talk loudly and heard Resident #1 fall but did not see it. The resident fell hard; I didn't report it until later because I was scared; I reported it to Licensed Practical Nurse #2 later that night on 02/02/2025 when they arrived at 7:00 PM. The Shahbaz said that Licensed Practical Nurse #2 called the Assistant Director of Nursing #1 and insisted I tell them I had concerns about the fall, and thought they should look at the video because something was not right. During an interview on 02/11/2025 at 11:35 AM, Guide #1 stated they were contacted by Assistant Director of Nursing #1 at approximately 9:30 PM on 02/02/2025 about a fall in the house where Resident #1 resided and where Shahbaz #1 worked. Guide #1 stated Assistant Director of Nursing #1 wanted to know if Shahbaz #1 was working on 02/03/2025. Guide #1 stated they informed Assistant Director of Nursing #1 that Shahbaz #1 was not working the next day, and both decided to not review the video until 02/03/2025. Guide #1 stated they and Assistant Director of Nursing #1 reviewed the video on 02/03/2025 at approximately 10:30 AM and found that Shahbaz #1 had abused Resident #1. Guide #1 further stated that they interviewed Shahbaz #1 about the incident by phone; the account given by Shahbaz #1 was not consistent with the video. Guide #1 stated Shahbaz #1 was suspended pending the outcome of the investigation and subsequently terminated. There was no documented evidence the facility took measures to prevent further potential abuse by Shahbaz #1 on 02/02/2025. Based on observations, interview and record review cross referenced, when Shahbaz #2 heard the incident as it unfolded, they did not intervene and did not share the status of what had happened with responding staff (Licensed Practical Nurse # 1, Registered Nurse #1, and Shahbaz #3) while the resident was on the ground. Video surveillance footage revealed that after the fall, Resident #1 was animated whenever Shahbaz #1 approached the resident. Shahbaz #1 was allowed to provide continued assistance with staff when Resident #1 was removed from the floor. During an interview on 02/11/2025 at 1:00 PM, Assistant Director of Nursing #1 stated Licensed Practical Nurse #1 called them on 02/02/2025 at 7:39 PM, to report that Resident #1 had fallen, had a fracture (bone break), and was being transferred to the hospital. Assistant Director of Nursing #1 stated they were aware Shahbaz #1 had completed their shift and left for the day, and Guide #1 confirmed with them via text message on 02/02/2025 that Shahbaz #1 was not scheduled to work on 02/03/2025 (the next day). Assistant Director of Nursing #1 stated that they (Assistant Director of Nursing #1) did not come into the facility on [DATE] and had not reported the incident to Administrator #1 or started an investigation until 02/03/2025. They stated that the video of the 02/02/2025 incident was not reviewed until 02/03/2025 because they were unable to access the video from home. They further stated that Shahbaz #1 was not suspended on 02/02/2025 because they had no concerns of abuse. During a telephone interview on 02/12/2025 at 6:49 AM, Registered Nurse #1 stated they did not assess or perform range of motion on Resident #1 prior to telling staff to transfer the resident off the floor. Registered Nurse #1 stated that they documented their progress note of Resident #1 being transferred off the floor for this incident was not accurate because they had written it as staff were actively moving Resident #1 off of the floor, and they had thought staff were using the hoyer lift as they instructed. They stated they had not corrected their documentation/progress note on the incident since recording it on 02/02/2025. Registered Nurse #1 stated Shahbaz #1 had been one of the staff members assisting the resident off the floor. There was no documented evidence the facility took corrective action for other staff members involved in the incident including but not limited to Licensed Practical Nurse #1, Registered Nurse #1, Guide #1, and Assistant Director of Nursing #1 following the verification of the allegation. Resident #2 Resident #2 was admitted with diagnoses of non-Alzheimer's dementia (mental decline), end stage renal disease (loss of kidney function), and depression. The Minimum Data Set, dated [DATE], documented resident could usually be understood and could usually understand others with severely impaired cognition for activities of daily living. Review of a Facility Reported Incident received by the New York State Department of Health on 11/08/2024 revealed the following: Resident #2 was placed on the toilet on 11/04/2024 at 6:05 PM by Shahbaz #5 and never checked on until 7:25 PM when the resident was found to have fallen on the floor. Shahbaz #5 stated that they placed Resident #2 on the toilet and left them for approximately 10 minutes, however, video camera footage did not corroborate this recounting. The facility determined this when they reviewed surveillance camera footage three (3) days later on 11/07/2024 at 2:50 PM. Shahbaz #5 was placed on suspension pending continued investigation of potential neglect, and Administrator #1 was notified of the event. Facility investigation dated 11/07/2024 documented the following: Shahbaz #5 left Resident #2 unattended on the toilet for 1 hour and 20 minutes on 11/04/2024 and supported by review of the video surveillance footage that the facility viewed three days after the event on 11/07/2024 at 02:50 PM. It identified Shahbaz #5 ' s recounting of the fall was not consistent with the times they were observed going in and out of the resident's room on the evening of the event. Resident #2's Comprehensive Care Plan documented the resident was a fall risk and the resident ' s care card documented Resident #2 required assistance with toileting to and from the bathroom, was unreliable with using a call bell or pendant for safety, and required all needs to be anticipated. The resident sustained an injury to the right shoulder that resulted in a permanent injury and pain. There was no documented evidence the facility took measures to prevent further potential abuse by Shahbaz #5 on 11/04/2024. Additionally, there was no documented evidence of a Facility 5-day Investigation Report submittal to the New York State Department of Health. Resident #3 Resident #3 was admitted with diagnoses of non-Alzheimer's dementia (mental decline), osteoporosis (decreased bone density), and anxiety. The Minimum Data Set, dated [DATE] documented resident could usually be understood and usually understand others with severely impaired cognition for daily decision making. Review of a Facility Reported Incident received by the New York State Department of Health on 11/08/2024 revealed the following: On 11/05/2024 at 7:30 PM, Resident #3 was sitting at the dining room table, stood up from the chair, and Shahbaz #5 stated Can you just sit the f*** down. It further documented that staff were first made aware of the incident on 11/07/2024 at 4:00 PM. There was no documented evidence the facility took measures to prevent this verbal abuse by Shahbaz #5 on 11/05/2024 after the 11/04/2024 allegation of abuse (see Resident #2). Additionally, there was no documented evidence of a Facility 5-day Investigation Report submittal to the New York State Department of Health. Facility Investigation dated 11/07/2024, documented the following: On 11/05/2024, verbal abuse to Resident #3 by Shahbaz #5 was not conclusive. Shahbaz #3 reported verbal abuse had occurred to Resident #3 by Shahbaz #5. Director of Nursing #1 deemed the allegation to be likely. During an interview on 02/19/2025 at 4:07 PM, Shahbaz #4 stated they reported verbal abuse of Resident #3 by Shahbaz #5 on 11/05/2024. They stated that when Resident #3 tried to stand up from the dining table, Shahbaz #5 yelled at them saying, Could you sit the F*** down. They stated that they reported the verbal abuse to Guide #1 on 11/05/2024, but it was days later before Assistant Director of Nursing #1 interviewed them. They further stated that Shahbaz #5 was not removed from resident care while the investigation was ongoing. During an interview on 2/24/2025 at 12:07 PM, Director of Nursing #1 stated there had been an ongoing investigation regarding abuse and neglect of another resident by Shahbaz #5 when the verbal abuse was reported. They felt it could not be supported, and the investigation of neglect was the reason Shahbaz #5 was terminated. The video of the incident for Resident #3, demonstrated the Shahbaz was interacting with Resident #3 but no sound was recorded. During an interview on 2/24/2025 at 12:26 PM, Licensed Practical Nurse #3 stated they reported concerns to Administration and was told to report concerns to the Guide, Administration did not interview Licensed Practical Nurse #3 regarding allegations of abuse by Resident #2 or Resident #3 regarding Shahbaz #5. During an interview on 02/24/2025 at 3:38 PM, Guide #1 stated after the investigation was completed, they were informed Shahbaz #5 was to be terminated for abuse and neglect. They stated that per facility procedure, Guides would inform the Shahbaz if/when they were terminated. They further stated that Human Resources had notified them (Guide #1) of the need to terminate Shahbaz #5. There was no documented evidence the facility took corrective action for other staff members involved in the incident including but not limited to Licensed Practical Nurse #3 and Guide #1 following the verification of the allegation. 10 New York Codes, Rules and Regulations 415.4(b)(2)

Based on record review and interviews during an abbreviated survey (Case #'s NY00370986, NY00359919, NY00359950, and NY00360114), the facility failed to ensure the residents' right to be free from abuse and neglect for four (4) (Resident #'s 1, 2, 3, and 4) of four (4) residents reviewed for abuse and neglect, which included physical, verbal and mental abuse. Specifically, (1.) Video footage documented Resident #1 was pushed to the floor on 2/02/2025 at 5:03 PM by Shahbaz (Certified Nurse Aide) #1, transferred off the floor by Licensed Practical Nurse #1 without an assessment by a Registered Nurse, and suffered a broken hip. (2.) Resident #2 was left unattended in the bathroom by Shahbaz #5 for one hour and twenty minutes on 11/04/2024. Resident #2 attempted to get themselves off the toilet and subsequently fell and suffered an injury to their right shoulder. (3.) On 11/05/2024, Resident #3 attempted to stand from the table after finishing their meal; Shahbaz #5 yelled at the resident to sit the F*** down. (4.) On 11/08/2024 at 3:00 AM, Resident #4 used their call bell requesting assistance, Shahbaz #6 entered the room and pushed the resident down on the pillow. This resulted in Immediate Jeopardy and substandard quality of care to resident health and safety and had the potential to affect all 177 residents in the facility. The immediate Jeopardy was lifted on 2/13/2025. This is evidenced by: Cross-referenced to: F609: Reporting, F610: Investigate/Prevent/Correct Alleged Violations. Review of the facility Abuse Prevention & Investigation Policy, dated 10/14/2022, documented the following: - Residents have the right to be free from verbal, sexual, physical, and mental abuse; neglect, mistreatment, corporal punishment, involuntary seclusion, exploitation, and misappropriation of property (thereafter abuse shall be understood to include all of the above. - All employees have an obligation to report such abuses when they have reasonable cause to believe that such an incident has occurred. The facility shall follow guidelines as outlined in federal/state regulations, Dear Administrator Letters (DALs), Centers for Medicaid and Medicare State Operations Manual Appendix PP, and [NAME] Health/St. Peter's Health Partners policies and procedures. The staff shall report any incident or allegation/suspicion of abuse as outlined above to the Administrator, Director of Nursing Services or their designee immediately. In cases where a crime is suspected, the facility leadership is expected to report the same to local law enforcement under the Elder Justice Act. Resident #1 Resident #1 was admitted with diagnoses of non-Alzheimer's dementia (decline in mentation), osteoporosis (bone weakness), and anxiety. The Minimum Data Set (an assessment tool) dated 11/29/2024 documented the resident had severely impaired cognition and could usually be understood and could usually understand others. Review of video surveillance footage on 02/11/2025 at 4:00 PM revealed that on 02/02/2025 at 5:00 PM: 1. Shahbaz #1 was with Resident #1 in the hallway. 2. Resident #1 was ambulating with their hands behind their back, without the need of an assistive device. Resident #1 walked over to the dining table and was stopped by Shahbaz #1, who blocked the resident from going to the table, pushing the resident in a backward motion. 3. Shahbaz #1 grabbed Resident #1 by the arm. Resident resisted, and Shahbaz #1 placed their hands on the resident's arms, spun the resident by pulling them around, and pushed the resident backward while the resident was trying to prevent the Shahbaz from grabbing them. 4. Once Resident #1 was up against the wall in a backward position, the resident attempted to steady themselves by grabbing for the handrail but was unable to hold on to the rail. 5. Shahbaz #1 let go of Resident #1 with a push, and the resident began to fall to the ground. 6. Shahbaz #1 made no attempts to stop or break the resident's fall. 7. Resident #1 fell against the wall; resident's legs appeared to buckle or twist. The resident reached for the handrail again but could not hold on to it and fell on their right hip. 8. Shahbaz #1 looked at Resident #1, who had fallen, and walked away from the resident. Resident #1 was then alone on the floor as Shabazz #1 transported other residents to the dining table. 9. Resident #1 was transferred off the floor by Licensed Practical Nurse #1, Shahbaz #1 and Shahbaz #3 without the use of a mechanical lift. Record review of an undated facility document titled Termination revealed the following: on 02/03/2025, the facility investigated a resident fall that resulted in a fracture (bone break) and hospitalization. The investigation produced credible evidence to support Shahbaz #1 physically abused and neglected the resident. Camera review showed Shahbaz #1 held Resident #1's hands while they proceeded to move them away from the table by pushing and pulling them across the hallway towards the handrail, approximately 10-15 feet. Shahbaz #1 pushed Resident #1 against the wall, their body leaning, and their gait unsteady, then they let go of the resident's hands, causing the resident to fall backwards. The undated facility document noted that based on the video footage, it was uncertain whether the resident was pushed; Shahbaz #1 proceeded to walk away from Resident #1 and left them on the floor until the nurse responded to evaluate Resident #1. The document noted Shahbaz #1 was terminated, and the document was signed by Guide #1 (Guides oversee the Shahbaz in the homes) and Assistant Director of Nursing #1 with no date or time. Termination of Shahbaz #1 was documented as being done verbally by telephone. Nursing progress note dated 02/02/2025 at 6:13 PM, completed by Registered Nurse #1, documented that Registered Nurse #1 was called to House 16 for a witnessed fall. It documented the following: Shahbaz #1 reported that they were taking Resident #1 to their room when Resident #1 let go of the side rail and fell to the floor. Upon arrival, Resident #1 was observed sitting on the floor in the dining room. On assessment, Resident #1 was observed to be in pain with some guarding to their right thigh and was unable to stand. Resident #1 was assisted off the floor with a mechanical lift and two-person assist, then placed in a wheelchair. Physician was made aware and ordered an x-ray of the right hip, pelvis and femur. Mobile imaging was called to be in. Resident #1's family was notified and came in to visit. Vital Signs: Temperature 97.8, Pulse 83, Respirations 20 per minute, Blood Pressure 160/84. Record review of Mobile X-ray imaging report of Resident #1's right hip, dated 02/02/2025 at 6:45 PM, revealed Resident #1 sustained a fracture of the right femur (long leg bone located from hip to knee) that suggested subacute timing (that indicated it had recently occurred). During an interview on 02/11/2025 at 9:01 AM, Assistant Director of Nursing #1 stated Resident #1 had a fall with an injury on 02/02/2025, and video of the incident was reviewed with Guide #1 on 02/03/2025 at 10:50 AM, when abuse was discovered. They stated that Shahbaz #1 was interviewed by telephone and suspended when their recounting of the events that occurred did not match the actual events documented in the video recorded on 02/02/2025 at 5:00 PM. Assistant Director of Nursing #1 stated they then reported it to New York State Department of Health. During an interview on 02/11/2025 at 1:00 PM, Assistant Director of Nursing #1 stated Licensed Practical Nurse #1 called them on 02/02/2025 at 7:39 PM, to report that Resident #1 had fallen, had a fracture (bone break), and was being transferred to the hospital. Assistant Director of Nursing #1 stated they were aware Shahbaz #1 had completed their shift and left for the day, and Guide #1 confirmed with them via text message on 02/02/2025 that Shahbaz #1 was not scheduled to work on 02/03/2025 (the next day). Assistant Director of Nursing #1 stated that they (Assistant Director of Nursing #1) did not come into the facility on [DATE] and had not reported the incident to Administrator #1 or started an investigation until 02/03/2025. They stated that the video of the 02/02/2025 incident was not reviewed until 02/03/2025 because they were unable to access the video from home. They further stated that Shahbaz #1 was not suspended on 02/02/2025 because they had no concerns of abuse. During an interview on 02/11/2025 at 9:05 AM, Administrator #1 stated that they became aware of the incident on 02/03/2025 at 10:50 AM, when Assistant Director of Nursing #1 notified them that abuse had occurred, and the investigation was not started on 2/02/2025. During an interview on 02/11/2025 at 11:35 AM, Guide #1 stated they were contacted by Assistant Director of Nursing #1 at approximately 9:30 PM on 02/02/2025 about a fall in the house where Resident #1 resided and where Shahbaz #1 worked. Guide #1 stated Assistant Director of Nursing #1 wanted to know if Shahbaz #1 was working on 02/03/2025. Guide #1 stated they informed Assistant Director of Nursing #1 that Shahbaz #1 was not working the next day, and both decided to not review the video until 02/03/2025. Guide #1 stated they and Assistant Director of Nursing #1 reviewed the video on 02/03/2025 at approximately 10:30 AM and found that Shahbaz #1 had abused Resident #1. Guide #1 further stated that they interviewed Shahbaz #1 about the incident by phone; the account given by Shahbaz #1 was not consistent with the video. Guide #1 stated Shahbaz #1 was suspended pending the outcome of the investigation and subsequently terminated. During an interview on 02/11/2025 at 2:17 PM, Shahbaz #2 stated they were afraid and intimidated by Shahbaz #1. Shahbaz #2 stated they saw Shahbaz #1 grab Resident #1 and pull them away from the table. Shahbaz #2 stated that they thought Shahbaz #1 was taking the resident to their room and did not intervene. They stated that they heard Resident #1 talk loudly and heard Resident #1 fall but did not see it. The resident fell hard; I didn't report it until later because I was scared; I reported it to Licensed Practical Nurse #2 later that night on 02/02/2025 when they arrived at 7:00 PM. The Shahbaz said that Licensed Practical Nurse #2 called the Assistant Director of Nursing #1 and insisted I tell them I had concerns about the fall, and thought they should look at the video because something was not right. Shahbaz #2 stated that the resident could be easily redirected but that was not the way Shahbaz #1 dealt with Resident #1. They stated Shahbaz #2 had reported Shahbaz #1 for bullying them in the past, and this had been reported to both Guide #1 and the Assistant Director of Nursing #1, but nothing was done. Shahbaz #2 reported feeling intimidated because of this and did not stop what they felt was abuse. They stated Shahbaz #1 could be rough with the residents and had done things the way they wanted to, and that Shahbaz #1 worked at the facility a long time. Shahbaz #2 stated no investigation had been started at the time of the fall by Registered Nurse #1 and that they (Shahbaz #2) were interviewed on 02/03/2025 by Assistant Director of Nursing #1. During an interview on 02/11/2025 at 2:42 PM, Licensed Practical Nurse #1 stated they saw Resident #1 on the floor on 02/02/2025 after being called to respond to House #16 for a fall. Licensed Practical Nurse #1 stated they called Registered Nurse #1, who arrived at the house at 5:00 PM on 02/02/2025. Licensed Practical Nurse #1 stated Registered Nurse #1 did not assess the resident and instructed Licensed Practical Nurse #1 to use a mechanical lift to pick Resident #1 up off the floor. Licensed Practical Nurse #1 stated that with the help of Shahbaz #3, they lifted Resident #1 off the floor without using the mechanical lift and could see the resident's leg was injured. They stated Resident #1 was placed in a wheelchair and taken to the office where Registered Nurse #1 was located. They stated Registered Nurse #1 called the physician and completed paperwork. They stated they called the family and when the family arrived, they brought the resident to their room and placed the resident in their bed using a gait belt (a belt used to assist with ambulating). Licensed Practical Nurse #1 further stated that Registered Nurse #1 never went to the room to perform any further evaluation of the resident. During an interview on 02/11/2025 at 3:37 PM, Medical Director #1 stated Resident #1 should have been assessed prior to being picked up; they also stated what a proper assessment was and how a resident should be handled after a fall which would help to prevent further injury to a resident and that abuse needed to be investigated and reported. During a telephone interview on 02/11/2025 at 5:11 PM, Licensed Practical Nurse #2 stated they arrived for their 02/02/2025 7:00 PM shift and were given report of Resident #1's fall by Licensed Practical Nurse #1. They stated that no abuse was reported until Shahbaz #2 told them that they (Shahbaz #2) were afraid and that things were 'not right.' During a telephone interview on 02/12/2025 at 6:49 AM, Registered Nurse #1 stated they did not assess or perform range of motion on Resident #1 prior to telling staff to transfer the resident off the floor. They stated that upon receiving the x-ray report on 02/02/2025 prior to the resident being transferred to the hospital, they became concerned with Shahbaz #1's accounting of the fall. They stated that they were not present when the fall occurred, but Shahbaz #1 was still interacting with the resident. Registered Nurse #1 stated they called Assistant Director of Nursing #1 to verbalize concerns, and requested the video be reviewed to determine what happened and ensure the resident hadn't hit their head, as neurological checks had not been done and abuse needed to be ruled out. They stated that they felt something did not seem right. Registered Nurse #1 stated that Assistant Director of Nursing #1 relayed to them that Shahbaz #1 had worked at the facility for a long time, they had no concerns that Shahbaz #1 would abuse a resident, but they would look at the video. Registered Nurse #1 stated that Assistant Director of Nursing #1 dismissed the concerns. Registered Nurse #1 stated they were interviewed by Assistant Director of Nursing #1 and asked about assessing Resident #1 when they responded to the incident on 02/02/2025. They stated that the video demonstrated no range of motion or full assessment of Resident #1 had been done prior to Resident #1 being lifted from the floor. Registered Nurse #1 stated they were not aware that the leg was fractured; that a full assessment including range of motion should have been done; and that they had not asked or interviewed anyone about the fall other than Shahbaz #1. They stated that Shahbaz #1 worked their regular schedule from 02/02/2025 until they were suspended as of 02/11/2025. Registered Nurse #1 stated that their progress note of Resident #1 being transferred off the floor for this incident was not accurate because they had written it as staff were actively moving Resident #1 off of the floor, and they had thought staff were using the hoyer lift as they instructed. They stated they had not corrected their documentation/progress note on the incident since recording it on 02/02/2025. Registered Nurse #1 stated Shahbaz #1 had been one of the staff members assisting the resident off the floor. During an interview on 02/18/2025 at 3:45 PM, Shahbaz #3 stated Registered Nurse #1 and Licensed Practical Nurse #1 told them to help get Resident #1 off the floor. The resident was crying and holding their right leg, they appeared to be in pain. They stated that Resident #1 was assisted up by Shahbaz #1 and Shahbaz #3 while Licensed Practical Nurse #1 got a wheelchair. They stated that Registered Nurse #1 was not present when the staff got the resident off the floor without using the mechanical lift. They further stated that Shahbaz #1 had been sometimes aggressive with staff members, but Shahbaz #3 had not seen Shahbaz #1 abuse residents. During a telephone interview on 2/20/2025 at 9:08 AM, Guide #1 stated they had been aware of staff concerns with Shahbaz #1; a counselling meeting was provided to Shahbaz #1 in December 2024 after a staff confrontation. During an interview on 2/24/2025 at 3:38 PM, Guide #1 stated after the investigation was completed, Human Resources informed them that Shahbaz #'s 2, 3 and 5 were all terminated. Several attempts to reach Shahbaz #1 from 02/13/2025 to 02/24/2025 by telephone were unsuccessful. Resident #2 Resident #2 was admitted with diagnoses of non-Alzheimer's dementia (mental decline), end stage renal disease (loss of kidney function), and depression. The Minimum Data Set, dated [DATE], documented resident could usually be understood and could usually understand others, with severely impaired cognition for daily decision making. Review of a Facility Reported Incident received by the New York State Department of Health on 11/08/2024 revealed the following: Resident #2 was placed on the toilet on 11/04/2024 at 6:05 PM by Shahbaz #5 and never checked on until 7:25 PM when the resident was found to have fallen on the floor. Shahbaz #5 stated that they placed Resident #2 on the toilet and left them for approximately 10 minutes, however, video camera footage did not corroborate this recounting. The facility determined this when they reviewed surveillance camera footage three (3) days later on 11/07/2024 at 2:50 PM. Shahbaz #5 was placed on suspension pending continued investigation of potential neglect, and Administrator #1 was notified of the event. Facility investigation dated 11/07/2024 documented the following: Shahbaz #5 left Resident #2 unattended on the toilet for 1 hour and 20 minutes on 11/04/2024 and supported by review of the video surveillance footage that the facility viewed three days after the event on 11/07/2024 at 02:50 PM. It identified Shahbaz #5's recounting of the fall was not consistent with the times they were observed going in and out of the resident's room on the evening of the event. Resident #2's Comprehensive Care Plan documented the resident was a fall risk and the resident's care card documented Resident #2 required assistance with toileting to and from the bathroom, was unreliable with using a call bell or pendant for safety, and required all needs to be anticipated. The resident should not have been left unattended on the toilet, and Shahbaz #5 was terminated. The resident sustained an injury to the right shoulder that resulted in a permanent injury and pain. A nursing progress note dated 11/04/2024 at 9:35 PM documented the following: Resident #2 was found on the floor that day and had a full range of motion to all extremities. Registered Nurse Supervisor #3 was called, and using a mechanical lift, Resident #2 was moved off the floor and placed in a wheelchair. The supervisor and family were notified and note of the event placed in the Medical Director's log. A nursing progress note dated 11/04/2024 at 9:32 PM documented the following: Registered Nurse Supervisor #3 documented they were called to House #12 for a resident fall. Resident #2 was laying on their left side in the bathroom. The Physician and family were notified. A nursing progress note dated 11/05/2024 at 9:06 AM documented the following: Resident #2 reported experiencing pain in their right arm and right leg following a fall. The resident was unable to lift their right arm in front of them. X-rays were ordered and were pending. The resident had no memory of the fall. A medical provider progress note dated 11/06/2024 at 11:08 AM documented further x-rays were requested to follow up on the right shoulder and clavicle (neck) areas because of pain and bruising on the chest. A rehabilitation progress note dated 11/06/2024 at 12:28 PM documented that the resident was no longer able to feed themselves as a result of the fall. Staff reported the resident was right-handed, and staff had begun assisting with feeding for Resident #2 during meals. Resident #3 Resident #3 was admitted with diagnoses of non-Alzheimer's dementia (mental decline), osteoporosis (decreased bone density), and anxiety. The Minimum Data Set, dated [DATE] documented resident could usually be understood and usually understand others, with severely impaired cognition for daily decision making. Review of a Facility Reported Incident received by the New York State Department of Health on 11/08/2024 revealed the following: On 11/05/2024 at 7:30 PM, Resident #3 was sitting at the dining room table, stood up from the chair, and Shahbaz #5 stated Can you just sit the f*** down. It further documented that staff were first made aware of the incident on 11/07/2024 at 4:00 PM. Record review revealed Shahbaz #5 continued to work on 11/05/2024, and that this incident occurred one day after Shahbaz #5 had left Resident #2 unattended on the toilet for 1 hour and 20 minutes on 11/04/2024. In an email dated 11/12/2024 at 8:27 AM, Director of Nursing #1 documented the following to Human Resource officer regarding abuse and neglect allegations against Shahbaz #5: We are asking for termination since there was definite neglect and even though we were unable to substantiate the profanity, it probably did happen. During an interview on 02/19/2025 at 4:07 PM, Shahbaz #4 stated they reported verbal abuse of Resident #3 by Shahbaz #5 on 11/05/2024. They stated that when Resident #3 tried to stand up from the dining table, Shahbaz #5 yelled at them saying, Could you sit the F*** down. They stated that they reported the verbal abuse to Guide #1 on 11/05/2024, but it was days later before Assistant Director of Nursing #1 interviewed them. They further stated that Shahbaz #5 was not removed from resident care while the investigation was ongoing. During an interview on 02/24/2025 at 12:07 PM, Director of Nursing #1 stated the following: When the verbal abuse was reported, there had been an ongoing investigation regarding abuse and neglect towards another resident by Shahbaz #5. On 02/11/2025, Shahbaz #5 had not been truthful about the neglect of Resident #2 and gave a different recounting of the events which was proven false by watching the video. The video of the incident for Resident #3 demonstrated Shahbaz #5 was interacting with Resident #3 and could not hear as no sound was recorded. They stated that they didn't know why audio was not recorded, and none of the videos record sound. They further stated that Shahbaz #4 had reported what they heard but had not seen the incident. Resident #4 Resident #4 was admitted with diagnoses of coronary artery disease (narrowing of the arteries in the heart), end stage renal disease (loss of kidney functioning), and anxiety (nervousness). The Minimum Data Set, dated [DATE], documented resident could be understood and understand others with intact cognition. Review of a Facility Reported Incident received by the New York State Department of Health on 11/11/2024 revealed the following: Resident #4 reported to a staff member on 11/09/2024 at 11:00 AM that Shahbaz #6 pushed them down hard onto the bed and left without providing help on 11/08/2024 at 3:00 AM. It documented Administrator #1 was first made aware of the incident on 11/11/2024 at 11:25 AM. An email dated 11/10/2024 at 12:08 PM, sent to Guide #1 from Licensed Practical Nurse #3, documented they received a complaint from Resident #4 concerning Shahbaz #6 who turned off the call bell at approximately 11/08/2024 at 3:00 AM and did not assist them. The second time the call bell was turned on, Shahbaz #6 came in, turned off the light and pushed the resident down on the bed hard. The resident reported Shahbaz #6 left without providing any help and that Resident #4 sat up for two hours worried about it. Resident #4 stated they were old but knew what they were talking about and would not make this up. Licensed Practical Nurse #3 assured the resident it would be addressed with Shahbaz #6's supervisors. Investigation dated 11/11/2024 at 11:20 AM, documented the following: Verbal abuse and neglect had occurred by Shahbaz #6. This was determined through interviews with Resident #4, that Shahbaz #6 had abused the resident and was terminated. This was supported by review of the video that identified Shahbaz #6's accounting of the events was not consistent with the times they were observed going in and out of the resident's room on the evening of the event (night shift 11/07/2024 PM into 11/08/2024 AM). The Investigation documented Guide #1 was notified via email by Licensed Practical Nurse #3 on 11/10/2024 at 12:00 PM that Resident #4 had reported abuse by Shahbaz #6. The investigation was initiated on 11/11/2024 by Assistant Director of Nursing #1. During the investigation, other residents reported concerns with Shahbaz #6 and care they received. During surveillance camera review of the investigation, Shahbaz #6 was noted to be sitting for large portions of their shift, did not provide resident care, and did not enter seven (7) resident rooms on their shift that night. During an interview on 02/24/2025 at 12:07 PM, Director of Nursing #1 stated that in the facility's Greenhouse Models (a specific living environment), the Guide is the one who would address concerns with the Shahbaz and would bring it to administration's attention. During an interview on 02/24/2025 at 12:26 PM, Licensed Practical Nurse #3 stated during morning medication pass on 11/10/2024, Resident #4 reported they had been abused by Shahbaz #6 during care given during the night shift. They stated that Resident #4 was worried about being cared for by Shahbaz #6. They stated that they (Licensed Practical Nurse #3) sent an email to Guide #1 immediately. They stated that there was no interview or investigation done regarding the reported abuse of Resident #4 by Shahbaz #6 until 11/11/2024, when they were interviewed by Assistant Director of Nursing #1. During an interview on 02/24/2025 at 3:38 PM, Guide #1 stated after the investigation was completed, they were informed Shahbaz #5 was to be terminated for abuse and neglect. They stated that per facility procedure, Guides would inform the Shahbaz if/when they were terminated. They further stated that Human Resources had notified them (Guide #1) of the need to terminate Shahbaz #5. New York Codes, Rules and Regulations 415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (Case #s NY00370986, NY00359919, NY00359950, and NY00360114), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 4 (Resident # ' s 1, 2, 3 and 4) of 4 residents reviewed for abuse and neglect. Specifically, (1) an allegation of abuse of Resident #1 – overheard by staff and that resulted in a broken leg – on 02/02/2025 at 5:00 PM was not reported to the New York State Department of Health until 02/03/2025 at 12:55 PM. (2) An allegation of abuse of Resident #2 – that resulted in a broken shoulder – on 11/04/2024 was not reported to the New York State Department of Health until 11/08/2024. (3) An allegation of verbal abuse on Resident #3 that was witnessed by staff on 11/05/2024 was not reported to the New York State Department of Health until 11/08/2024. (4) An allegation of physical abuse on Resident #4 that was first made known to staff on 11/09/2024 was not reported to the New York State Department of Health until 11/11/2024. This is evidenced by: Cross-referenced to: F600: Abuse Prohibition, F610: Investigate/Prevent/Correct Alleged Violations. Review of facility Abuse Prevention & Investigation Policy dated 10/14/2022, documented the following: - Residents have the right to be free from verbal, sexual, physical, and mental abuse; neglect, mistreatment, corporal punishment, involuntary seclusion, exploitation, and misappropriation of property (thereafter abuse shall be understood to include all of the above). - All employees have an obligation to report such abuses when they have reasonable cause to believe that such an incident has occurred. The facility shall follow guidelines as outlined in federal/state regulations, Dear Administrator Letters (DALs), Centers for Medicaid and Medicare State Operations Manual Appendix PP, and [NAME] Health/St. Peter's Health Partners policies and procedures. The staff shall report any incident or allegation/suspicion of abuse as outlined above to the Administrator, Director of Nursing Services or their designee immediately. In cases where a crime is suspected, the facility leadership is expected to report the same to local law enforcement under the Elder Justice Act. - a. A report to the New York State Department of Health must be made immediately, but no later than 2 hours after forming the suspicion that an allegation meets the following criteria: Serious bodily injury occurred (regardless of infraction type, e.g., neglect, exploitation, misappropriation, etc.) and/or if there is suspicion that abuse has occurred. b. A report to the New York Department of Health must be made no later than 24 hours after forming the suspicion that an allegation has occurred that: Serious bodily injury did NOT occur, and the allegation involves neglect, exploitation, mistreatment, and misappropriation that does not result in serious bodily injury. c. Failure to report such incidents is considered a violation of regulations and policies governing resident abuse and compromises the facility ' s ability to provide a safe and secure environment for residents. Resident #1 Resident #1 was admitted with diagnoses of non-Alzheimer's dementia (decline in mentation), osteoporosis, (bone weakness), and anxiety. The Minimum Data Set (an assessment tool) dated 11/29/2024 documented the resident could usually be understood and could usually understand others with severely impaired cognition. Video surveillance footage revealed that on 02/02/2025 at 5:00 PM, Shahbaz #1 pushed Resident #1 and walked away. Resident #1 fell and sustained a fractured (broken) hip. Record review of Mobile X-ray imaging report of Resident #1's right hip, dated 02/02/2025 at 6:45 PM, revealed Resident #1 sustained a fracture of the right femur (long leg bone located from hip to knee) that suggested subacute timing (that indicated it had recently occurred). During a telephone interview on 2/12/2025 at 6:49 AM, Registered Nurse #1 stated upon receiving the report of the x-ray on 2/02/2025, they became concerned with Shahbaz #1's accounting of the fall. They stated they had not been present when the fall occurred, but Shahbaz #1 was interacting with the resident. Registered Nurse #1 stated they called the Assistant Director of Nursing #1 to verbalize concerns, and requested the video be reviewed. Registered Nurse #1 stated they did not interview any staff. During an interview on 02/11/2025 at 1:00 PM, Assistant Director of Nursing #1 stated Licensed Practical Nurse #1 called them on 02/02/2025 at 7:39 PM, and they (Assistant Director of Nursing #1) did not come into the facility on [DATE] and had not reported the incident to Administrator #1 or started an investigation until 02/03/2025. During an interview on 2/13/2025 at 4:08 PM, Administrator #1 stated the complaint with abuse that occurred on 2/02/2025 to Resident #1 was reportable and had not been investigated or reported per regulation by Assistant Director of Nursing #1. They further stated Assistant Director of Nursing #1 had not notified them and had not followed the procedure in place to protect the resident; Reporting should have been completed on 2/02/2025 two hours after it the allegation was made that abuse was suspected; The video should have been viewed when the concern was raised by the staff especially given the serious injury. There was no documented evidence that the facility notified law enforcement. Record review revealed the facility submitted the Reportable Incident to the New York State Department of Health one day after the event, on 02/03/2025 at 12:55 PM. Resident #2 Resident #2 was admitted with diagnoses of non-Alzheimer's dementia (mental decline), end stage renal disease (loss of kidney function), and depression. The Minimum Data Set, dated [DATE], documented resident could usually be understood and could usually understand others with severely impaired cognition for activities of daily living. Review of a Facility Reported Incident received by the New York State Department of Health on 11/08/2024 revealed the following: Resident #2 was placed on the toilet on 11/04/2024 at 6:05 PM by Shahbaz #5 and never checked on until 7:25 PM when the resident was found to have fallen on the floor. Shahbaz #5 stated that they placed Resident #2 on the toilet and left them for approximately 10 minutes, however, video camera footage did not corroborate this recounting. The facility determined this when they reviewed surveillance camera footage three (3) days later on 11/07/2024 at 2:50 PM. Shahbaz #5 was placed on suspension pending continued investigation of potential neglect, and Administrator #1 was notified of the event. Facility investigation dated 11/07/2024 documented the following: Shahbaz #5 left Resident #2 unattended on the toilet for 1 hour and 20 minutes on 11/04/2024 and supported by review of the video surveillance footage that the facility viewed three days after the event on 11/07/2024 at 02:50 PM. It identified the resident sustained an injury to the right shoulder that resulted in a permanent injury and pain. During a telephone interview on 2/20/2025 at 9:08 AM, Guide #1 stated videos were to be reviewed if there was a fall or injury or any questionable situation immediately, and that was not being done. Guide #1 further stated investigations and reporting were done by the Assistant Director of Nursing, Director of Nursing, or Administration. Resident #3 Resident #3 was admitted with diagnoses of non-Alzheimer's dementia (mental decline), osteoporosis (decreased bone density), and anxiety. The Minimum Data Set, dated [DATE] documented resident could usually be understood and usually understand others with severely impaired cognition for daily decision making. Review of a Facility Reported Incident received by the New York State Department of Health on 11/08/2024 revealed the following: On 11/05/2024 at 7:30 PM, Resident #3 was sitting at the dining room table, stood up from the chair, and Shahbaz #5 stated Can you just sit the f*** down. It further documented that staff were first made aware of the incident on 11/07/2024 at 4:00 PM. During an interview on 02/19/2025 at 4:07 PM, Shahbaz #4 stated they reported verbal abuse of Resident #3 by Shahbaz #5 on 11/05/2024. They stated that when Resident #3 tried to stand up from the dining table, Shahbaz #5 yelled at them saying, Could you sit the F*** down. They stated that they reported the verbal abuse to Guide #1 on 11/05/2024, but it was days later before Assistant Director of Nursing #1 interviewed them. They further stated that Shahbaz #5 was not removed from resident care while the investigation was ongoing. Resident #4 Resident #4 was admitted with diagnoses of coronary artery disease (narrowing of the arteries in the heart), end stage renal disease (loss of kidney functioning), and anxiety (nervousness). The Minimum Data Set, dated [DATE], documented resident could be understood and understand others with intact cognition for daily decision making. Review of a Facility Reported Incident received by the New York State Department of Health on 11/11/2024 revealed the following: Resident #4 reported to a staff member on 11/09/2024 at 11:00 AM that Shahbaz #6 pushed them down hard onto the bed and left without providing help on 11/08/2024 at 3:00 AM. During an interview on 02/24/2025 at 12:26 PM, Licensed Practical Nurse #3 stated during morning medication pass on 11/10/2024, Resident #4 reported they had been abused by Shahbaz #6 during care given during the night shift. They stated that Resident #4 was worried about being cared for by Shahbaz #6. They stated that they (Licensed Practical Nurse #3) sent an email to Guide #1 immediately. They stated that there was no interview or investigation done regarding the reported abuse of Resident #4 by Shahbaz #6 until 11/11/2024, when they were interviewed by Assistant Director of Nursing #1. During an interview on 2/13/2024 at 5:45 PM, Director of Nursing #1 stated the reporting and investigating of complaints had not been completed timely by Assistant Director of Nursing #1. New York Codes, Rules and Regulations 415.4(b)(1)(i)

Based on record review, video review, and interviews during an abbreviated survey (Case #s NY00245312, NY00293887, and NY00306925), the facility did not ensure the resident had the right to be free from abuse for 1 (Resident #2) of 5 residents reviewed for abuse. Specifically, the facility did not ensure that Certified Nurse Aide (CNA) #8 followed the facility's Fall Standard of Care document on 4/2/2022 on the night shift. A security video reviewed for the night of 4/2/2022, showed the following; Resident #2 sitting on the floor near the doorway of their room; a staff member (CNA #8) walked to the resident's room; put their arms under the resident's arms; lifted them up a little; and dragged them backward into their room. This was evidenced by: A document titled, Fall Standard of Care for all Residents revised on 6/1/2018, documented if a fall occurred a Registered Nurse (RN) must be notified and an assessment completed prior to moving the resident. All unwitnessed falls required neuro checks with the exception of the alert and oriented resident who can state they did not hit their head. Resident #2 Resident #2 was admitted to the facility with diagnoses of dementia with behavioral disturbance, Parkinson's disease, and history of falling. The Minimum Data Set (MDS- an assessment tool) dated 2/19/2022, documented the resident had severe cognitive impairment, could rarely/never be understood, and could usually understand others. The Policy and Procedure titled, Abuse Prevention and Investigation Policy dated 10/14/2022, documented residents had the right to be free from physical abuse. A review of undated, untimed security video on 6/21/2023 at 8:32 AM, showed 16 minutes (min.) 5 seconds (sec.) into the video, Resident #2's leg became visible in their doorway. At 16 min. 19 sec. the resident was fully visible in the doorway of their room. At 18 min. 42 sec. Certified Nurse Aide (CNA) #8 walked toward Resident #2. As CNA #8 approached Resident #2, the CNA was shaking their finger at them. At 18 min. 44 sec. they were at the resident's doorway, walked behind them, bent over, placed their hands under the resident's arms, lifted the resident slightly, and dragged them backward into their room. At 18 min. and 52 sec., CNA #8 exited the room. The facility document titled, Investigation Summary Form dated 4/5/2022, documented on 4/5/2022 at 5:47 PM, Licensed Practical Nurse (LPN) #1 reported to the Assistant Director of Nursing (ADON) that Resident #2 had a bruise on their right outer thigh of unknown origin. A prior investigation for abrasions on the right side of the resident's neck and back of their head was closed on 4/5/2022 due to the facility determining the cause was the resident's fingernails and the abrasions were self-inflicted. Because of the bruise on the resident's right thigh, there was cause for suspicion of abuse and the investigation was reopened on 4/6/2022. Surveillance camera footage was viewed by the Director of Nursing (DON) and the ADON from 4/1/2022 at 7:00 AM- 4/2/2022 at 5:00 AM. The footage showed that on 4/2/2022 at 4:52 AM, the resident was seen scooching on their bottom to the doorway of their room. CNA #8 was then seen going behind the resident, placed their arms underneath both of the resident's arm, and pulled the resident across the carpeted floor into their room and then left the room. A Health Status Note dated 4/2/2022 at 3:35 PM, documented LPN #1 went into Resident #2's room to check out a report by CNA #8 that the resident had scratched a scab on their head, and it had bled a little. The resident had an abrasion on the right back side of their head that was caked with dried blood. There was a hard lump the under abrasion that measured 5 centimeters in diameter. There was a scratch on the right side of the resident's neck. The resident's pajama top collar had a large stain of dried blood on it. The front and back of their pillow had several fresh blood spots on it. ADON was notified. A Health Status Note dated 4/2/2022 at 8:16 AM, documented LPN #1 reported to Registered Nurse Supervisor (RNS) #3 the resident was found to have bright red blood on both sides of their pillow and bedding. Night CNA #8 reported the resident had picked a scab. The RNS assessment documented Resident #2 had an abrasion with a lump on the right back side of their head. Their hair was matted with dried blood and there was dried blood on their forehead and neck with an abrasion on the right front side of their neck. The resident's fingernails were clean and absent of blood. The resident had cognitive impairment and was unable to report what occurred. There were no changes in the resident's neurological status. A Health Status Note dated 4/5/2022 at 5:47 PM, documented the resident was observed to have a bruise on their right outer thigh. The cause was unknown. During an interview on 5/23/2023 at 12:28 PM, Registered Nurse Manager (RNM) #1 stated the video (4/2/2022 on the night shift) showed the resident was on the floor and CNA #8 put their hands under Resident #2's arms and pulled the resident backward into their room. RNM #1 stated the resident had a bump and some dried blood on their head following the incident and LPN #1 called them to report it. The resident had been incontinent and had not been changed by CNA #8, the only CNA working the night shift in the resident's house. The RNM told LPN #1 to call the DON. During an interview on 5/24/2023 at 11:05 AM, LPN #1 stated sometime between 7:00 AM and 7:30 AM on 4/2/2022, CNA #11 was making rounds with CNA #8. CNA #8 reported to them that Resident #2 had picked scabs on their head and that was why there was blood on the resident's pillowcase. When CNA #11 was helping the resident, they observed dried blood on the resident's forehead and on their hands, but not under their nails. There was blood on the back of the resident's neck, blood on the neck of their pajamas in the back, and the resident had quite a large lump on the back of their head. LPN #1 stated CNA #11 called for them to go to the resident's room. The LPN stated they checked the resident over very thoroughly then called RNS #3 who came to the house and assessed the resident. The ADON was notified. During an interview on 5/24/2023 at 11:44 PM, CNA #11 stated about 7:30- 8:00 AM (on 4/2/2022), they went to get Resident #2 up for the day. They stated they found blood, a bump, and a cut on the back of their head. The person (CNA #8) they were doing rounds with stated the resident had picked a scab. CNA #11 stated there was no blood under the resident's fingernails. They immediately called LPN #1 to the room. LPN #1 looked at the resident's head and hands then called RNS #3 who came to the house to assess the resident. The day before, CNA #11 stated they had brushed the resident's hair, and there were no injuries to their head. During an interview on 6/20/2023 at 11:09 AM, the ADON stated they were notified by LPN #1 (on 4/5/2022) Resident #2 had a fairly large bruise on their right thigh of unknown origin. A couple of days prior (4/2/2022), the resident was found in bed and had abrasions to the right back side of their head and their right neck. The ADON stated the resident's fingernails were jagged and they had blood under their fingernails. It was believed the abrasions were self-inflicted. The ADON stated in view of that, they felt suspicious that something else may have occurred when the bruise was observed, so they reopened the investigation. They stated they started watching the surveillance video for a few days prior to the discovery of the bruise. When they watched the (4/2/2022) video, they viewed the resident on the floor scooching toward the doorway of their room. Prior to that the resident was in bed so they assumed they either got themselves out of bed or fell out of bed. They stated they watched CNA #8 put their arms under the resident's arms, lifted on the resident and dragged them back into their room. They stated they could not see CNA #8 put the resident in bed because the camera angle did not show the resident's bed. The ADON stated CNA #8 did not report the resident had fallen out of bed and they did not follow protocol for a fall which was that a fall was supposed to be reported to a nurse who reported it to RNS who then will do an assessment for injuries. During an interview on 6/20/2023 at 1:55 PM, CNA #8 stated they had no recall of the incident. The scenario portrayed in the security video was explained to CNA #8 and it showed they had dragged the resident, who was on the floor, backward into their room in April 2022. The CNA maintained they had no recall of such an occurrence and stated they worked at a lot of places. The video was reviewed a second time and the CNA continued to state they did not recall such an incident. CNA #8 stated they did not remember the facility either. During an interview on 6/20/2023 at 2:06 PM, the DON stated they viewed the video and Resident #2 was seen by the entrance of their room door on the floor. The resident either fell or placed themselves on the floor. CNA #8 grabbed the resident under their arms and dragged them back into their room. If a resident fell , staff were supposed to notify a nurse. The nurse would then notify the RNS who would come do an assessment. That did not happen. 10 NYCRR 415.4(b)(1)(i)

Based on observation, record review and interviews during an abbreviated survey (Case # NY 565) completed on 2/2/2022, the facility failed to implement the comprehensive person-centered care plan for 1 (Resident #3) of 5 residents reviewed for care plan implementation. Specifically, for Resident #3, the facility did not ensure the intervention for close supervision documented on the resident's care plan for Alteration in Mobility was implemented resulting in serious injuries sustained in a fall that required hospitalization . This resulted in actual harm to Resident #3 that was not immediate jeopardy. This was evidenced by: Resident #3 was admitted to the facility with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (an assessment tool) dated 9/10/2021, documented the resident had severe cognitive impairment, could sometimes be understood, and could usually understand others. The Comprehensive Care Plan for Alteration in Mobility revised on 12/10/2020, documented the resident was to have close supervision and use a wheeled walker when ambulating (walking) on the unit for up to 125 feet. The Policy and Procedure (P&P) titled, Falls Management Policy dated May 2018, documented residents who were at risk for falls, would have an individualized care plan developed that identified interventions to reduce fall risk. The P&P titled, Care Card (Kardex) dated 8/2/2019, documented the care cards/Kardex contained basic safety interventions. Staff were to refer to the care card to obtain information pertinent to care delivery. The Physical Therapy Discharge Summary dated 12/10/2020 at 3:31 PM, documented the discharge recommendation was for the resident to have close supervision on the unit with transfers and ambulation. An undated document titled, Assist Levels, documented close supervision meant the resident performed tasks while the caregiver was standing next to the resident, within arm's length, with their full attention on the task. The Certified Nurss's Aide (CNA) Kardex as of 9/21/2021, documented the resident was to have close supervision for locomotion (walking) on the unit for up to 125 feet. A Fall Note dated 9/20/2021 at 7:59 PM, documented the Registered Nurse (RN) received report that Resident #3 fell while self-ambulating and they found the resident face down on the floor next to the dining room table. There was noticeable injury, with the resident's face, head and floor covered in blood. The resident's dentures were close by and broken in several pieces. The resident was cyanotic (blue), but their color improved, and they become more alert with the administration of oxygen and removal of large blood clots from their airway. The RN assessed the resident and the resident reported neck discomfort, and bilateral rib pain. There were visible bleeding lacerations to their head, face, mouth, and nose area, as well as possible alteration in head structure, which was difficult to fully assess due to the bleeding and swollen areas on the resident's face, head, nose, and mouth. The resident's head and neck were supported while the Medical Doctor (MD) was called, and an order received to send the resident to the hospital. Before the ambulance arrived, the resident started having difficulty breathing. Another large blood clot was removed from the resident's airway and the resident was able to breathe easier. When the ambulance arrived, the Emergency Medical Technicians took over care and the resident started vomiting a large amount of blood. Staff reported the fall was unwitnessed when questioned. The family was notified. The Facility Investigation Summary for the incident on 9/20/2021 documented that Resident #3 had a significant history of falls and fractures and was unable to be independent with their mobility. The resident required close supervision for transfers and ambulation with their wheeled walker and lack of safety awareness. On 9/20/2021 at 6:01 PM, Resident #3 got up from the dining room table, first ambulating toward the kitchen counter, then turning to go to a different table. The resident picked up a dirty dish from that table, and when the resident turned around without using their walker and the plate in their hand, the resident fell forward onto the floor face first. There was significant bleeding and injury to the resident's face. The security video footage showed that CNA #1 was standing at the kitchen sink washing dishes and was able to view the resident standing independently with their walker and the resident proceeding to ambulate to one of the tables. CNA #1 did not leave the kitchen until the resident was on the floor at 6:05 PM. It documented that upon separate interviews, CNA #1, and CNA #2 both verbalized the resident required close supervision for transfers and ambulation and that was not provided. On 1/26/2022 at 3:08 PM, a video of incident was reviewed by the DOH Surveyor with the Director of Nursing (DON) and the Administrator. On 9/20/2021 at 6:01 PM, Resident #3 got up from their chair at the table, and using their walker, started to walk away from the table initially standing at the kitchen counter near the sink. CNA #1 was washing dishes at the sink and could see the dining room. CNA #2 entered the dining area, approached Resident #3 who was still standing at the counter, hugged the resident, then walked away to take care of another resident, and was seen wheeling that resident out of the dining room. Resident #3 walked away toward the living room, stopped at another table, picked up a dirty plate and turned around without their walker. When the resident turned, the resident fell forward onto the floor. As the resident was falling, the plate was in their right hand and their arm was flexed at the elbow. Their left arm was at their side. The resident did not attempt to break the fall, landing on their face with their right arm under them and their left arm at their side. During an interview on 1/26/2021 at 3:43 PM, the Director of Nursing (DON) stated both CNA #1 and CNA #2 knew Resident #3 was close supervision for ambulating. CNA #1 was at the sink and CNA #2 hugged the resident and then walked away. The DON stated CNA #2 stated they thought CNA #1 was going to go over to the resident and CNA #1 stated they thought CNA #2 was going to stay with the resident. The DON stated Resident #3's care plan was not followed. During an interview on 1/28/2022 at 1:31 PM, CNA #2 stated the fall (9/20/2021) occurred at dinner time. CNA #2 stated they were coming into the dining room area and Resident #3 was standing by the kitchen counter. CNA #2 stated they hugged the resident and then went to provide care to another resident. CNA #2 stated they asked Resident #3 to sit down, but the resident stated they did not want to, so they made sure the resident had their walker and told CNA #1 to watch Resident #3 because they had to care for the other resident. While in the resident's room providing care, CNA #2 stated they heard a loud bang and went to see what happened. CNA #2 stated Resident #3 was on the floor. CNA #2 stated they went over to the resident to check on them and the resident was unresponsive at first. CNA #2 stated CNA #1 just stood there so they told CNA #1 to call the nurse. CNA #2 stated the resident was bleeding and when the nurse arrived, the nurse rolled the resident over. CNA #2 stated it appeared the resident may have broken their nose and saw their dentures were broken in their mouth. The resident went to the hospital by ambulance. CNA #2 stated Resident #3 would walk around by themselves a lot without their walker and they would take the resident's walker to them and remind them to use it. CNA #2 stated the CNA Kardex documented the resident was not supposed to walk alone. CNA #2 stated close supervision meant you needed to be with a resident when they were walking. During an interview on 1/28/2022 2:09 PM, the Director of Physical Therapy (DPT) stated the resident was close supervision for transfers and ambulation. Close Supervision meant the staff were to be within hand's reach of the resident when the resident was walking in case the resident started to lose their balance so they could grab them. The DPT stated if the care plan/CNA Kardex documented close supervision for transfers/ambulation the care plan had to be followed. For example, if a resident was eating a meal, and the resident got up from the table staff should be there within hand's reach to walk with the resident. During an interview on 2/2/2022 at 11:29 AM, the Assistant Director of Nursing (ADON) stated they interviewed each CNA separately regarding the 9/20/2021 incident. The ADON stated CNA #1 told them that Resident #3 needed supervision when they were walking and stated that meant someone had to be right with the resident when they were walking. The ADON stated CNA #1 (who was washing dishes at the sink) told them they saw the resident get up from the table and it looked like they were dancing while holding their walker. CNA #1 told the resident to sit down. Then CNA #1 saw CNA #2 walking toward the resident and thought they were going to have the resident sit down at the table. The ADON stated CNA #1 should have looked to see if resident sat or not or if CNA #2 was walking with the resident. CNA #1 did not do that. The ADON stated the next thing CNA #1 knew, they saw the resident with the plate and without their walker. The ADON stated CNA #1 did not leave the sink until after the resident fell . The ADON stated when they interviewed CNA #2, the CNA stated Resident #3 needed guided assist and when asked to clarify, CNA #2 stated, the resident required supervision with assistance, and when asked to clarify that, CNA #2 stated it meant the resident needed to have someone with them and CNA #2 stated they usually had their hand on resident's back when the resident was ambulating. CNA #2 stated it meant someone needed to be right next to the resident. CNA #2 stated they saw the resident standing in front of the kitchen counter, gave the resident a hug and asked the resident to sit down. CNA #2 stated they were not sure if the resident sat down or not. The ADON stated CNA #2 then proceeded to take another resident to their room. CNA #2 heard a loud bang, ran out of the room, and found Resident #3 lying on the floor face first. The ADON stated when CNA #2 left the resident after they hugged them, CNA #1 should have stayed with the resident until the resident decided where they wanted to sit down for the evening. During an interview on 2/2/2022 at 2:53 PM, the Medical Doctor (MD) stated Resident #3 walked with a walker and needed close supervision when walking. The MD stated the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 10 NYCRR 415.11(c)(1)

Based on observation, staff interview, and medical record review during a Abbrieviated Survey (Case #NY 234) the facility did not ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistive devices to prevent accidents for one (Resident #1) of two resident's reviewed. Specifically, Resident #1 was identified by the facility as a high risk for falls and a "safety challenge" since her admission 4/8/14. Resident #1 had several care planned interventions to assist in preventing falls and/or injury with falls, which included a chair alarm. On 7/31/14, Resident #1 had a fall which resulted in a right hip fracture. Upon review of the house cameras and staff interview it was found that Resident #1's chair alarm was not in use at the time of her fall according to her plan of care (POC). It was also confirmed that staff did not attempt to place the chair alarm. Furthermore, the facility's fall investigation had not identified that facility staff had not followed this resident's careplanned intervention regarding use of a chair alarm to prevent falls and/or injury with falls. This resulted in actual harm that is not immediate jeopardy. This was evidenced by: Resident #1 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] assessed the resident as having a Brief Interview of Mental Status (BIMS) score of 4, or severely impaired cognition. The Comprehensive Care Plan (CCP) dated 4/8/14 and revised 4/14/14 documented that Resident #1 had a safety awareness deficit and a chair alarm was used for safety (elder does remove at times/refuses-use for safety when elder accepts). An additional intervention was documented 6/3/14, dycem (no-slip, rubber-like plastic material used to stabilize) above and below chair alarm pad. Dycem must be securely taped to chair alarm to minimize elder's ability to remove. The Physical Therapy (PT) Evaluation dated 5/23/14 documented that an evaluation was requested secondary to Resident #1's increase in falls. It documented, based on this evaluation, it has been determined that falls are being caused by behaviors of the elder as each fall she is attempting to transfer herself in or out of bed or her wheelchair. She also has impaired safety awareness and history of aggression with staff related to assistance with mobility. Due to these impairments, skilled PT intervention will not prevent falls at this time. Elder has a history of ignoring education from staff on safety and asking for assistance when she wants to get up and chooses to get up on her own resulting in falls. The Care Card (a document used by staff to determine what care the resident required) dated 7/18/14 documented provide chair alarm: check placement and function every shift; check that dycem is taped to both sides of chair alarm for safety. The Resident Accident & Incident Report dated 7/31/14 at 5:00 pm documented that Resident #1 was found on the floor laying on her right hip/side. Right upper lip and under right eye have abrasions. Under the Fall Related Information section it documented "N/A" or not applicable to the question; Personal alarm in place & working? The Post Fall Huddle Form (facility staff meet immediately post fall to discuss fall and record findings) dated 7/31/14 documented viewed on camera and care plan followed. Sent to emergency room after x-ray done, positive hip fracture, admitted to hospital. The Morning Meeting Form dated 7/31/14 documented camera reviewed and POC was being followed. Elder got up from chair in LR (living room) and fell in office 30 seconds later. Shahbaz (Certified Nursing Assistant) responded within 10 seconds of elder rising but could not reach her before fall. In the Employee Statement dated 7/31/14 Shahbaz #1 documented that she did not witness the fall with Resident #1. She documented that she sat Resident #1 down and walked away to get dinner rolls out of the oven. She stated she turned around and did not see Resident #1 where she had been sitting. She stated she heard Resident #1 yell out and she went looking for her. She found Resident #1 on the floor in the nursing office. The Investigation Summary Form dated 7/31/14 documented that Resident #1 was sitting in the living room in a recliner while the shabaz was preparing dinner meal and watching her from the kitchen. Shabaz comes to Resident #1's side twice to address her restlessness and moving up and down from her chair. Shabaz talks to Resident #1 for one minute and then goes back to kitchen. One minute later, Resident #1 stands up and heads to the office. Ten seconds later shahbaz notices she is not in her chair and begins to look for her. Thirty seconds after Resident #1 gets up from her chair she is in the office and turns to leave when there is no one there and loses her balance and falls to the floor landing on her right side. Five seconds later shahbaz enters the office and comforts Resident #1 and then calls for help. It further documented Resident #1 has been a safety challenge since her admission as demonstrated by her 42 falls leading up to her fractured right hip. Bed, chair, and floor mat alarms were used but Resident #1 was able to disable all alarms and she would pull the pad out from under her making them limited in effectiveness. During an observation on 9/29/14 at 11:35 am the videos from the facility's house cameras were viewed. The video started approximately 15 minutes prior to Resident #1's fall and provided two views: one of the living room and one of the nursing office in which Resident #1 ambulated to and fell in. At the beginning of the video Resident #1 is viewed sitting in the living room in a recliner. Her wheelchair is next to her. There is no chair alarm in place beneath the resident. The resident is observed standing up twice, but does not ambulate far as the shabaz intervenes and sits the resident back down. During this time there is no chair alarm observed. The shahbaz is not observed attempting to place a chair alarm underneath the resident. Approximately one minute later, while the shahbaz is in the kitchen area with her back to the resident, Resident #1 gets up and begins ambulating toward the nursing office. Approximately 20-25 seconds later, the shahbaz turns around and notices Resident #1 is no longer in her chair and begins to look for the resident. Approximately 10 seconds after that, the shahbaz locates the resident on the floor in the nursing office. While viewing the video with the Director of Nursing (DON) present, the surveyor asked the DON where Resident #1's chair alarm was as it was not in the chair the resident was sitting in. The DON stated that she did not know, perhaps it was shut off as the shahbaz was monitoring Resident #1 closely. During an interview on 10/14/14 at 9:24 am Shahbaz #1 stated that she was in the kitchen preparing biscuits for dinner. She stated Resident #1 was sitting in the living room. She stated she had assisted Resident #1 in sitting down a couple of times as she was getting up on her own. She stated she did not attempt to place the chair alarm underneath Resident #1, she thinks it was in the resident's wheelchair. When asked to clarify this, she stated Resident #1 had not refused or removed the chair alarm, but rather, she did not attempt to place it under the resident at all. She stated she returned to the kitchen after assisting Resident #1 sit back down. She stated she was tending to biscuits in the oven for dinner. She stated she turned around and noticed Resident #1 was no longer seated in her chair. She heard Resident #1 yell, and found her lying on the floor in the nursing office. During an interview on 10/14/14 at 11:57 am the Registered Nurse (RN) Supervisor stated she was called to the house as Resident #1 was found on the floor. She stated she did not know if the resident's chair alarm was in place at the time of the fall, that is something she would not investigate. She stated she assessed the resident at the time and obtained an x-ray, however the fall would be reviewed the following day in morning meeting and it would be determined if the care plan was followed and if any new interventions were necessary. During an interview on 10/14/14 at 12:32 pm the RN Guide (manager) stated that she reviewed the film the day following Resident #1's fall and staff was in compliance with her POC. When asked where Resident #1's chair alarm was at the time of her fall, she stated she did not know, but the resident would peel the alarm apart at times. She stated she did not know if the shahbaz had attempted to place the alarm, there was no audio in the video so she did not know the exchange, but during the 15 minutes prior you did not see the shabaz attempt to place the alarm. She stated the shahbaz should have attempted to place the alarm if the resident was not refusing. She stated they had discussed removing the chair alarm, however staff felt it was an effective intervention at times. During an interview on 10/16/14 at 12:56 pm the LPN stated she was called to the house as Resident #1 was found on the floor. She stated she believed Resident #1 was supposed to have a chair alarm, however she did not know if it was in place the evening of her fall. She stated she was not made aware the resident was refusing any interventions, and if she was, the shahbaz would let her know. She further stated if Resident #1 was refusing interventions the Shahbaz would document this in the medical record for appropriate follow up. There was no documented evidence in Resident #1's record that she was non-compliant with the chair alarm the evening of her fall. During an interview on 10/23/14 at 8:34 am Shahbaz #2 stated it was her and Shahbaz #1 in the house that evening. She stated Shahbaz #1 was caring for Resident #1 at the time of her fall. She stated she did not witness the fall and was providing care to another resident in their room when it occurred. She stated she did not usually work in that house and was unaware if Resident #1 had a chair alarm or not. She stated if a resident was refusing interventions they would try to deal with them and notify the Licensed Practical Nurse (LPN). She further stated they had access to progress notes and could document this kind of behavior in the resident's medical record. During an interview on 10/23/14 at 8:55 am the DON stated that Resident #1 was care planned for a chair alarm when she accepted it, or in other words, when she did not refuse it or remove it. She stated they had discussed possibly discontinuing the chair alarm, however felt it was useful if staff had to step out; it was one other tool to keep Resident #1 safe. She stated the chair alarm was not in place at the time of Resident #1's fall, however this was not addressed in the facility's investigation as it was under the discretion of the shahbaz whether or not to use it. She stated that she did not feel it would have made a difference if the chair alarm was in place or not, but perhaps the shahbaz would have heard it and turned around faster if it was. 10 NYCRR 415.12(h)(1)