Every finding on record at New York State Veterans Home At Montrose

Based on observations, interviews, and record review conducted during survey (2695131), the facility failed to ensure that a resident received supervision and devices necessary to prevent accidents for one (1) (Resident #6) of three (3) residents reviewed for accidents. Specifically, Resident #6 had eight (8) falls between 10/06/2025 and 03/17/2026. On 03/17/2026 Resident #6 fell and sustained a laceration to the back of their head requiring six (6) stitches. This resulted in actual harm to Resident #6 that was not Immediate Jeopardy.The findings are:The undated facility policy titled Accident and Incident Reporting documented fall risk assessments were completed by registered nurses quarterly, annually, upon significant change, and after a fall. All falls will be reviewed at the designated accident and incident review meeting with the interdisciplinary team and any additional team members deemed necessary. Resident #6 had diagnoses of Parkinson's (a degenerative neurological disorder) and depression. The Minimum Data Set 3.0 (a resident assessment tool) dated 09/17/2025 documented Resident #6 had mild cognitive impairments, required partial to moderate assistance with toileting, personal hygiene, and bathing, was independent in transfers in and out of bed, and had no falls since their last assessment. The Comprehensive Care Plan related to falls initiated 03/24/2025 documented Resident #6 had a history of falls, had impaired mobility related to their Parkinson's diagnosis, and was noncompliant with safety teachings. Interventions to prevent falls included gradually changing the resident's position to prevent postural hypotension, gradual dose reduction as per doctor's order, monitor for side effects of psychotropic medication, and psychiatric consultation as needed. The care plan was updated on 09/05/2025 to reflect Resident #6 had been given a fall risk identifier. Physician Orders as of 03/16/2026 documented Resident #6 was ordered to receive Ativan 0.5mg every eight (8) hours as needed and at 9:00PM as needed for anxiety. Resident #6 was also ordered to receive trazodone 50mg at 9:00PM for insomnia. The Nursing Note dated 10/06/2025 documented Resident#6 fell in their room while trying to stand and turn. No injury was noted. The Accident/Incident Report dated 10/06/2025 documented Resident #6 fell in their room and the statement provided by Certified Nurse Aide #8 documented Resident #6 had reported their genital area hurt, causing the resident to get out of bed. A 10/07/2025 Care Plan intervention included Physical Therapy evaluation (a refresh of a 03/24/2025 intervention) and Resident #6 educated to use call bell for assistance. The Medical Doctor Note dated 10/08/2025 documented Resident #6's pelvis x-rays were negative for fracture. Nursing Notes and Accident/Incident Reports dated 10/18/2025 documented Resident #6 fell and hit their head while trying to ambulate to the bathroom. The Fall Risk assessment dated [DATE] documented Resident #6 was at high risk for falls. Care Plan note dated 10/18/2025 documented Resident #6 sustained a six (6) centimeter round hematoma to left forehead with a two (2) centimeter open area with scant blood. Resident transferred to the hospital for evaluation. There is no documented evidence of updated interventions to the resident's care plan. Nursing Notes and Accident/Incident Report dated 10/31/2025 documented Resident #6 fell from a chair in their room. Care Plan note dated 10/31/2025 documented Resident #6 sustained an abrasion to the left knee and small skin tear to the left upper thigh with no bleeding. Intervention for neuro checks for 48 hours and every 15-minute checks for 72 hours. There is no documented evidence of long-term interventions to assist in helping to prevent additional falls. The Minimum Data Set 3.0 dated 12/18/2025 documented Resident #6 had short term memory deficits and was independent in decision making. Resident #6 had falls within the last two (2) to six (6) months. Resident #6 required partial/moderate assistance with toileting, showering, and personal hygiene. Resident #6 required assistance with eating and dressing. Resident #1 was independent in ambulating up to 100 feet and chair-to-bed transfers. Nursing Notes dated 12/22/2025 documented Resident #6 fell in the unit hallway while walking back to their room. No injury was noted. The Accident/Incident Report dated 12/22/2025 documented Resident #6 fell while ambulating back to their room. The Falls Risk assessment dated [DATE] documented Resident #6 was at high risk for falls. The Comprehensive Care Plan related to falls was revised on 12/23/2025 to include interventions for staff to assure hygiene cares were provided promptly to Resident #6, comfortable positioning, possessions were within reach, and the resident's bed was at proper height to promote out of bed transfers. Resident #6 was provided with non-skid socks while in bed, was encouraged to use their call bell to call for staff assistance, and they would receive hourly visual checks by staff. The Nursing Note and Accident/Incident Report dated 01/02/2026 documented Resident #6 was observed sitting on the floor by the housekeeper. No injury was noted. There was no documented evidence that a Fall Risk Assessment was completed, or that the care plan related to Resident #6's falls was revised to address the resident's fall on 01/02/2026. The Nursing Note and Accident/Incident Report dated 01/05/2026 documented Resident #6 self-reported to nursing staff that they fell in their room and were able to pick themselves up from the floor.A Fall Risk assessment dated [DATE] documented Resident #6 was at high risk for falls. Care Plan Note dated 01/05/2026 documented resident fell with no injury. Intervention for neuro checks and every 15-minute checks for 48 hours. On 01/06/2026 hip protectors (padded briefs designed to prevent hip fractures) were provided. On 01/07/2026 Resident #6 to be reminded to use call bell for staff assistance (a refresh of a 12/23/2025 intervention). The Nursing Note and Accident/Incident Report dated 02/07/2026 documented Resident #6 fell out of bed while reaching for a personal item in their bedside dresser drawer. No injury was noted. The Falls Risk assessment dated [DATE] documented Resident #6 was at high risk for falls. Regarding Resident #6's fall on 02/07/2026 there was no documented evidence that the care plan related to falls was revised with interventions to address falls. There was an intervention for neuro checks for 48 hours and every 15-minute checks for 72 hours. On 03/11/2026 at 4:15PM, Resident #6 had their room door closed and refused to have visitors in the room or to be interviewed. The Nursing Note dated 03/15/2026 documented nursing staff were made aware that Resident #6 fell while out on pass with family, but the family reported the resident did not hit the floor and did not sustain any injury. Nursing Notes dated 03/17/2026 documented the nurse answered Resident #6's call bell and found the resident kneeling on their bedroom floor with Certified Nurse Aides #10 and #11 standing next to them. Certified Nurse Aide #10 reported Resident #6 fell and hit their head. Resident #6 was observed with a 6.6-centimeter laceration (cut) and bleeding to the back of their head. The family and doctor were made aware, and Resident #6 was transferred to the hospital for evaluation. The Accident/Incident Report dated 03/17/2026 documented Resident #6 reported they fell backwards in their room and hit their head on a bedside table drawer. A witness statement from Certified Nurse Aide #10 documented Resident #6 was walking around their room and telling the aide not to touch them while Certified Nurse Aide #10 told the resident to sit down. The witness statement documented Resident #6 refused to sit down and fell, hitting their head on their nightstand. A witness statement from Certified Nurse Aide #11 documented they were in Resident #6's room asking the resident to sit down and put their pants on when Resident #6 spun around to tell the aides not to touch them and fell, hitting their head on a nightstand. Regarding Resident #6's fall on 03/17/2026 there was no documented evidence that the care plan related to falls was revised with interventions to address falls. The Nursing Note dated 03/18/2026 documented Resident #6 returned from the hospital with six (6) stitches towards the right side of the back of their head. The Medical Doctor Note dated 03/18/2026 documented Resident #6 was walking with their walker and reaching for their wheelchair when they fell backward hitting their head on 03/17/2026. Resident #6 had gait (pattern of walking) disorder and an acute laceration to the scalp. During a telephone interview on 03/20/2026 at 12:27 PM, Complainant #1 stated the facility has not had any meaningful care plan meetings with both the family and Resident #6 in attendance to discuss the resident's fall risk and prevention plan. Resident #6 fell again on 03/17/2026 and sustained a painful injury to the back of their head requiring stitches. Complainant #1 stated they asked facility staff about using floor mats or other environmental alterations for safety but were not aware of any changes made to the resident's room or furniture. During an interview on 03/20/2026 at 3:35 PM and 03/23/2026 at 1:02 PM, Medical Doctor #1 stated Resident #6 was at high risk for falls and fell frequently. Medical Doctor #1 stated they evaluated Resident #6's medication regime to determine any contributing factors to fall risk. Resident #6 received several of Parkinson's medications that the resident inconsistently was compliant with taking. Resident #6 did receive Ativan to treat their anxiety, but it was prescribed on as needed basis and Resident #6 has only had one (1) administration of this medication in the last 30 days. Medical Doctor #1 stated staff on the unit were aware Resident #6 was at high risk for falls and frequently monitored the residents. Medical Doctor #1 was unable to specify how frequently staff monitored and rounded on Resident #6. Medical Doctor #1 stated Resident #6 fell on [DATE] resulting in a laceration to the back of their head requiring six (6) stitches. Resident #6 was transferred to the hospital and returned on 03/18/2026. Stitches should be removed in a week. Medical Doctor #1 stated this fall resulted in a painful and harmful injury for Resident #6; however, the resident should be able to recover from it within a few weeks. Certified Nurse Aide #8 was interviewed on 03/23/2026 at 12:15 PM and stated they were aware that Resident #6 fell while out on pass with their family and then fell in their room on 03/17/2026. Certified Nurse Aide #8 stated they were working and present on the unit that day and heard that two (2) other certified nurse aides were in the room with Resident #6 when the resident attempted to turn around and then fell. Certified Nurse Aide #8 stated they were instructed to ensure Resident #6 had their bed in the lowest position and to ensure proper technique and positioning when assisting the resident with transferring out of bed. Certified Nurse Aide #8 stated they frequently checked on Resident #6 because the resident frequently used the call bell and needed assistance. Certified Nurse Aide #8 stated they were also instructed to answer Resident #6's call bell promptly to prevent the resident from trying to get up unassisted. During an interview on 03/23/2026 at 12:31 PM, Registered Nurse #9 stated Resident #6 was at high risk for falls and fell last week resulting in stitches to the back of their head. Resident #6 has been weaker since that incident and now requires staff assistance to get out of bed. Resident #6 previously was able to walk in the hallway with their walker but didn't look like they were able to ambulate without staff assistance now. Registered Nurse #9 stated they made sure to round frequently on all the residents on their side of the unit. They were not aware of any special fall prevention or rounding instructions for Resident #6. During an interview on 03/23/2026 at 1:32 PM, the Acting Director of Nursing stated residents were assessed by a Registered Nurse following a fall and interventions to prevent another fall were immediately put in place. Resident falls were discussed in the next morning meeting with the interdisciplinary team and the team determined whether any further interventions should be added to the resident's falls prevention care plan. All residents were placed on 15-minute visual checks for 48 hours following a fall incident. The Acting Director of Nursing stated Resident #6 had several falls and current interventions to prevent future falls included proper positioning of the resident's bed, keeping items within reach, and answering the call bell promptly. Resident #6 was also on hourly visual rounds but all residents regardless of fall risk were on hourly visual rounds. There have not been any recent interdisciplinary team meetings with the family and Resident #6 to discuss the resident's fall risk and prevention plan. The Acting Director of Nursing stated they were unsure what devices the physical therapy recommended for Resident #6 and were unsure whether the resident was provided with a reacher (a mobility aid to pick up objects out of reach). The Acting Director of Nursing stated they were unaware of whether Resident #6 was appropriate for floor mattresses and stated they would need to follow up on whether an environmental assessment was done to determine safety of Resident #6's room and furnishings. During an interview on 03/23/2026 at 3:32 PM, the Administrator stated they plan to foster better communication and collaboration with Resident #6 and their family to ensure the resident's plan of care included effective and individualized interventions to keep the residents safe. The interdisciplinary team would ensure an environmental assessment was done to maximize resident safety. The Administrator stated Resident #6 did sustain a painful and injurious fall on 03/17/2026 and the team were looking for ways to address Resident #6's unique challenges from their Parkinson's diagnosis and other comorbidities. 10 New York Codes, Rules, and Regulations 415.12(h)(1)

Based on observations, interviews, and record review conducted during the abbreviated survey from 03/11/2026 to 03/23/2026, the facility did not ensure the resident's right to resolve grievances. This was evident for two (Resident #1 and #6) of four residents reviewed for resident rights. Specifically, 1) Resident #1's Representative was not provided with an opportunity to file a written grievance in relation to concerns with the resident's medication regime and care received, and 2) Resident #6's Representative was not provided the opportunity to file a written grievance in relation to concerns with medication regime and care received. The findings are:The facility policy titled Resident [NAME] of Rights dated 09/2022 documented residents had the right to voice grievances about care or services and could expect the facility to promptly investigate and try to resolve their concerns.1) Resident #1 had diagnoses of Alzheimer's dementia and diabetes mellitus.The Minimum Data Set 3.0 (an assessment) dated 12/08/2025 documented Resident #1 was severely cognitively impaired, their family participated in the assessment, and their family provided information related to Resident #1's discharge status.The Medical Doctor dated 12/29/2025 documented Resident #1 was evaluated by Psychiatry with recommendations to continue Klonopin use while Resident #1's Representative requested that Klonopin use be discontinued.The Social Work Note dated 12/29/2025 documented Resident #1's Representative attended the resident's initial care plan meeting and expressed concerns related to medication administration. Nursing staff and the Medical Doctor would address the Representative's concerns.The Social Work Note dated 01/23/2026 documented Resident #1's Representative attended a care plan meeting with the interdisciplinary team in attendance. Medical Doctor and Psychiatry recommendations were explained to Resident #1's Representative and the Administrator informed the Representative that Resident #1 would receive the recommended care of the clinicians at the facility while a resident of the facility.There was no documented evidence Resident #1's Representative was offered the opportunity to file a grievance in writing for care and medication concerns expressed to facility staff.During an interview on 03/11/2026 at 6:06 PM, Resident #1's Representative stated they communicated concerns to the facility staff related to the resident's medication regime, missing dentures, and ensuring Resident #1 was kept in areas under video surveillance for safety. Resident #1's Representative stated they emailed with Social Worker #1 and the facility's administration but were not offered the opportunity to file a grievance for any of these concerns and, although they met with facility staff on multiple occasions, felt as though these concerns were unresolved.2) Resident #6 had diagnoses of Parkinson's disorder and depression. The Minimum Data Set 3.0 dated 12/18/2025 documented Resident #6 had short term memory deficits and was independent in decision making. Resident #6 had falls within the last two to six months. Resident #6 required partial/moderate assistance with toileting and was required supervision or was independent with all other activities of daily living.The Nursing Note dated 12/21/2025 documented Resident #6 requested not to have a specific Certified Nurse Aide assigned to them due to their skin color. The Social Work Note dated 12/23/2025 documented Resident #6 had an incident where the resident demanded their latanoprost eye drops be administered at their request which differed from the Medical Doctor Order.There was no documented evidence Resident #6, or their Representative, was offered the opportunity to file a grievance for any of their unresolved concerns with care and medication.During a telephone interview on 03/20/2026 at 1:05 PM, Resident #6's Representative stated they expressed concerns related to Resident #6's medication regime and the resident's number of falls in the facility and did not feel as though their concerns have been addressed or resolved.During an interview on 03/23/2026 at 10:55 AM, Social Worker #1 stated they were assigned to Resident #1 and Resident #6. The interdisciplinary team met with both Representatives of Resident #1 and Resident #6, sometimes with facility Administration present, and they were aware that both Representatives had concerns regarding medication administration. Social Worker #1 stated they believed the Representatives' concerns were being addressed through the care plan meetings and did not think to file a written grievance for Resident #1 or Resident #6 related to any of their care concerns.During an interview on 03/23/2026 at 3:30 PM, the Administrator stated the grievance process allowed residents and families to have their concerns investigated and receive a resolution in writing. The Administrator stated they were present at care plan meetings held with Resident #1's Representative and believed all the Representatives concerns were being addressed; therefore, filing a grievance did not seem necessary. The Administrator stated they intended to foster better communication and collaboration with Resident #6 and their family and stated filing a written grievance to address their concerns would have been appropriate. The Administrator stated that there were no grievance investigations on file for both Resident #1 and Resident #6.10 NYCRR 415.3(d)(1)(ii)

Based on observations, interviews, and record reviews conducted during the abbreviated survey from 03/11/2026 to 03/24/2026, the facility did not ensure the resident's right to self-determination. This was evident for one (1) (Fair Haven Unit) of six(6) resident units reviewed for resident rights. Specifically, on 03/07/2026 and 03/08/2026 the Fair Haven Unit (which is also the memory care unit with residents with impaired cognitive abilities) Day room, needed to undergo repairs. The day room had a sensory room and two bathrooms. The twenty (20) residents on the Fair Haven Unit including Resident #3, #4, and #5, were placed in the dining room causing an interruption of their daily routine and how the residents spent their leisure time before and after lunch and dinner on 03/07/2026 and 03/08/2026. There was no documented evidence that resident representatives were notified prior or were involved in choosing how the residents spent their leisure time during the repairs. The findings are:The facility policy titled Resident [NAME] of Rights dated 09/2022 documented the resident had the right to participate in planning of care and services.Resident #4 had diagnoses of Alzheimer's dementia and chronic kidney disease. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #4 was severely cognitively impaired and had their family participate in the assessment.Resident #5 had diagnoses of dementia and anxiety disorder. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #5 was severely cognitively impaired and had their family participate in the assessment.Resident #3 had diagnoses of Alzheimer's dementia and hypertension.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #3 was severely cognitively impaired and had their significant other participate in the assessment.The facility Grievance and Resolution Form dated 03/09/2026 documented a grievance investigation was in progress related to reports of Fair Haven Unit residents being kept in their dining room over the weekend.The facility Census List dated 03/11/2026 documented there were 20 residents on the Fair Haven Unit including Resident #3, #4, and #5. During an interview on 03/11/2026 at 6:37 PM, Resident #3's Representative stated the 20 Fair Haven Unit residents were displaced from their unit dayroom and common area due to a heating repair issue on 03/07/2026 and 03/08/2026. Some residents were upset and distraught at the disruption to their daily routine as the alternatives provided did not include an area to descalate such as the sensory room as all the residents have significant cognitive impairments. The families were not notified or involved in the facility decision/plan to move the residents into the dining room for the entire weekend. During an interview on 03/23/2026 at 3:01 PM, the Deputy Administrator stated the 20 Fair Haven Unit residents did have a change in their daily routine on 03/07/2026 and 03/08/2026. The Deputy Administrator stated they became aware of a malfunctioning heater in the Fair Haven dayroom on 03/06/2026 and directed staff to place residents in the Fair Haven dining room for leisure time throughout the day. Staff were directed to also bring activities and a television for residents to use while in the dining room. The Deputy Administrator stated they did not inform families and representatives of the Fair Have Unit residents prior to the disruption in daily routine and residents and their representatives were unable to choose how the residents spent their leisure time in before and after lunch and dinner on 03/07/2026 and 03/08/2026. 10 NYCRR 415.5(d)(1)(2)

Based on observations, interviews, and record review conducted during the survey, the facility failed to ensure a resident's right to be free from physical abuse. This was evident for one (1) (Resident #1) of four (4) residents reviewed for abuse. Specifically, on 03/01/2026 Certified Nurse Aide #1 is observed on video surveillance that was provided by Resident #1's representative, in Resident's #1 room striking the resident on the top of their head with a broom, grabbing Resident #1 by the neck and placing them in a reclining back wheelchair, and using their left hand to strike Resident #1 on the left side of their neck. Facility staff confirmed they observed recorded video footage on 03/02/2026 of Certified Nurse Aide #1 striking Resident #1 on the left side of their neck on 03/01/2026. This resulted in psychosocial harm to Resident #1 that is not immediate jeopardy.The findings are:The facility policy titled Abuse Prohibition, last reviewed 08/2016 documented the facility shall train all staff at orientation and ongoing about appropriate interventions to deal with aggressive residents and how to recognize signs of burnout, frustration, and stress that may lead to abuse.Resident #1 had diagnoses of Alzheimer's dementia and diffuse traumatic brain injury (damage throughout the brain from a sudden impact) with less than 30 minutes of loss of consciousness. The Minimum Data Set (an assessment tool) dated 12/15/2025, documented Resident #1 was severely cognitively impaired, independent in ambulation, required supervision with transfers, and was dependent on staff for toileting, showering, and personal hygiene.The Comprehensive Care Plan related to abuse was created 12/29/2025 and documented Resident #1 was at risk for being the victim of abuse related to their aggressive behavior and would be monitored to ensure their safety. The Nursing Note dated 02/28/2026 documented Resident #1 was readmitted from the hospital at 4:45 AM and was placed on one-to-one supervision. Resident #1 became agitated later in the day and wandered the unit cursing loudly.The Nursing Note dated 03/01/2026 documented Resident #1 was calm and cooperative during care in the morning and became agitated at 12:40 PM, cursing at the nurse, wandering the unit, and refusing medication.The Nursing Note dated 03/02/2026 at 6:57 AM documented Resident #1 was observed sleeping in bed and was cooperative with care when they woke up at 5:00 AM.The Nurse Practitioner Note dated 03/02/2026 at 10:20 AM documented Resident #1 became agitated and attempted to strike staff and another resident. Resident #1 was transferred to the hospital for a psychiatric evaluation.The Nurse Practitioner Note dated 03/03/2026 at 12:09 AM documented Resident #1 returned to the facility from the hospital at approximately 10:30 PM. On 03/02/2026, the resident's Representative showed facility staff camera surveillance footage of an incident involving Resident #1 and facility staff that occurred in Resident #1's room on 03/01/2026 at approximately 4:15 PM. The Administrator was immediately made aware.The Facility Reported Incident created 03/02/2026 at 11:26 PM documented Resident #1's Representative showed Registered Nurse #4 a hidden camera surveillance footage on their phone of Certified Nurse Aide #1 striking Resident #1 with their left hand on the left side of their neck on 03/01/2026 at approximately 4:15 PM.The facility Resident Accident Report dated 03/03/2026 documented Licensed Practical Nurse #3 and Registered Nurse #4 provided written statements confirming hidden camera surveillance footage from Resident #1's room which showed Certified Nurse Aide #1 using their hand to strike the left side of Resident #1's neck. Certified Nurse Aide #1 provided a written statement that they raised their hand to defend against Resident #1 who was swinging their arms and fists. Certified Nurse Aide #1 was immediately removed from the schedule. The facility determined staff to resident contact did occur and facility is pursuing termination from employment for Certified Nurse Aide #1.During an interview on 03/05/2026 at 10:14 AM, the Assistant Administrator stated the facility's surveillance footage of the hallway outside of Resident #1's room showed Head [NAME] #5 obtaining a broom and dustpan from a hallway closet and handing it to Certified Nurse Aide #1, who is off camera inside the doorway to Resident #1's room. Per Head [NAME] #5, they were not aware of an incident occurring nor did they hear anything from the hallway outside Resident #1's room. Resident #1's Representative had their own hidden camera surveillance footage of the incident between Resident #1 and Certified Nurse Aide #1; however, the facility has not obtained a copy for purposes of their own investigation. Certified Nurse Aide #1 was hired in May 2025 and received orientation that included abuse prevention training. Certified Nurse Aide #1 had no prior allegations of abuse from any other residents in the facility. Certified Nurse Aide #1 was not scheduled to work on 03/02/2026 and they were removed from the facility schedule and placed on administrative leave on 03/03/2026 pending completion of investigation. The facility filed a report with local law enforcement on 03/03/2026 and reported the incident to the New State Department of Health on 03/02/2026. During an interview on 03/05/2026 at 11:24 AM with Resident #1's Representative, they stated they placed the hidden camera in Resident #1's room to determine triggers for the resident's behavior and frequent hospitalizations. The camera surveillance footage from 03/01/2026 at 4:15 PM revealed Resident #1 was struck by Certified Nurse Aide #1 on the left side of their neck. Resident #1's Representative stated this interaction with staff would have caused Resident #1 to be fearful and increasingly agitated and aggressive if they were cognitively intact.During an interview on 03/05/2026 at 1:12 PM, Head [NAME] #5 stated they were assigned as the second staff member responsible for constantly supervising and monitoring Resident #1 on 03/01/2026. Head [NAME] #5 stated they were not clinical staff and did not enter Resident #1's room when Certified Nurse Aide #1 brought the resident in there to provide care. Head [NAME] #5 stated they were stationed in the hallway outside Resident #1's room on 03/01/2026 at around 4:15 PM and Certified Nurse Aide #1 opened the door and asked for a broom from the hallway closet. Head [NAME] #5 stated they did not hear any commotion, altercation, yelling, or noise from Resident #1's room after they brought the broom to Certified Nurse Aide #1.An interview was conducted on 03/05/2026 at 2:08 PM with Licensed Practical Nurse #3 and they stated they observed camera surveillance footage on the personal cell phone of Resident #1's Representative on 03/02/2026 and saw Certified Nurse Aide #1 strike Resident #1 on the left side of their neck.Registered Nurse #4 was interviewed on 03/06/2026 at 11:10 AM and stated they and Licensed Practical Nurse #3 viewed the camera surveillance footage presented by Resident #1's representative and saw Certified Nurse Aide #1 striking Resident #1. They immediately reported the incident to the Administrator. Resident #1 was assessed with no physical injury noted.Medical Doctor #1 was interviewed on 03/06/2026 at 10:43 AM and stated Resident #1 is severely cognitively impaired and did not appear to recall the incident when they assessed the resident on 03/03/2026; however, if Resident #1 were cognitively intact, the facility would expect to monitor for adverse effects and reactions like agitation and fearfulness that could potentially arise after the resident was a victim of staff abuse.An interview was conducted on 03/06/2026 at 12:32 PM with the Acting Director of Nursing and they stated their investigation determined that physical contact did occur between Certified Nurse Aide #1 and Resident #1 as reported by Licensed Practical Nurse #3 and Registered Nurse #4 after viewing camera surveillance footage shown by Resident #1's Representative. As a result, the facility determined that abuse did occur, and that Certified Nurse Aide #1 would be terminated from employment.At a meeting with Resident#1's Representative on 03/11/2026 at 6:06 PM, Resident #1's Representative used their personal cell phone to show hidden camera surveillance footage of Resident #1's room with a date and timestamp from 03/01/2026 between 4:11 PM to 4:20 PM. The footage revealed at 4:17 PM Certified Nurse Aide #1 raised a small black broom in their right-hand above Resident #1 and struck Resident #1 on the top of their head once with the end of the broom. Resident #1 responded by saying Ouch and continued to pace in their room. At 4:19 PM, Certified Nurse Aide #1 grabbed Resident #1 by the neck and roughly placed the resident into a reclining back wheelchair. Certified Nurse Aide #1 moved to the front of Resident #1's wheelchair. Resident #1 used their arms to shove Certified Nurse Aide #1 away from them. Certified Nurse Aide #1 used their left hand to strike Resident #1 on the left side of their neck. Both Resident #1 and Certified Nurse Aide #1 move out of camera view and Resident #1 was heard yelling Ow three times and cursing. Certified Nurse Aide #1 then positioned Resident #1 in camera view again with the wheelchair tilted back preventing Resident #1 from getting up without staff assistance. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interview conducted during the Recertification and Abbreviated surveys (NY 00350287) from 05/28/25 to 06/04/25, the facility did not ensure there was sufficient nursing staff to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, on 3 of 21 days from 7/15/24 through 8/4/24 and 2 of 31 days from 5/1/25 through 5/31/25 the facility did not meet minimum staffing requirements for Certified Nurse Aides as documented in the Facility Assessment. The findings included: The Facility Assessment, revised 1/2025, documented the following minimum requirements. Day shift: five Registered Nurses, one Licensed Practical Nurse, and twenty-two Certified Nurse Aides. Evening shift: three Registered Nurses, three Licensed Practical Nurses, and seventeen Certified Nurse Aides. Night shift: four Registered Nurses: two Licensed Practical Nurses and twelve Certified Nurse Aide. Daily staff sheets from 7/15/2024 through 8/5/2024 documented during the day shift on 7/20/24 there were 18/22 Certified Nurse Aides, 7/21/2024 there were 14/22 Certified Nurse Aides, and 7/28/2024 there were 19/22 Certified Nurse Aides. Daily staff sheets from 5/1/2025 through 5/31/2025 documented during the day shift on 5/24/25 and 5/25/25 there were 19/22 Certified Nurse Aides. During the Resident Council Meeting on 5/20/25 at 1:49 PM, Resident #1 stated they felt degraded when they need to utilize an adult brief for bowel movements because the unit was short-staffed and staff were not available to assist them to the bathroom. Resident #101 stated they required assistance with oxygen approximately two months ago during the night shift and staff were not available to assist due to assisting other resident and not enough staff. They stated they rang the call bell which was not answered for an extended length of time. During an interview on 5/30/25 at 1:42 PM, Certified Nurse Aide #9 stated their unit usually had between three and five Certified Nurse Aides, with three occurring frequently. They stated when three Certified Nurse Aides were assigned to the unit, cares were rushed and stressful. They stated residents frequently complained of long wait times for cares. They stated they were frequently asked to accept overtime due to callouts and were also assigned to other units to assist with coverage. During an interview on 05/30/25 at 1:58 PM, Licensed Practical Nurse #5 stated the facility has reduced Nursing staffing in the last year. They stated optimal staffing for Certified Nurse Aides on the unit was four to five Certified Nurse Aides during day and evening shifts, however, the unit frequently only had three due to last minute callouts. They stated reduced number of Certified Nurse Aides causes delays in cares. They stated residents and family representatives frequently complain of short staffing and delays in care. During interview and observation on 5/30/25 at 1:47 PM and 6/2/25 at 1:57 PM, the Staffing Coordinator stated they were aware the facility did not meet minimum staffing requirements on some dates between 7/15/24 through 8/4/24 and 5/1/25 through 5/31/25 and 7/15/24. They stated they were aware of facility minimum staffing guidelines which were updated (lowered) 7/15/24. They stated the goal was to meet or exceed daily minimum staffing numbers. When the minimum staffing numbers were not met, staff were distributed throughout units by Nursing Supervisors. They stated the main reason for not meeting minimum staffing requirements was due to staff call-outs. They stated they were not allowed to overstaff to cover callouts. During an interview on 06/02/25 at 02:36 PM, the Director of Nursing stated Certified Nurse Aides were redistributed to units based on census when minimum staffing numbers were not met. They stated staff turnover was relatively low, but some Certified Nurse Aides leave their position due to making more money working for staffing agencies. 10 NYCRR 415.13(a)(1)(i-iii)]

Based on record review and interviews conducted during the Recertification and Abbreviated Survey NY 00331181 from 5/28/25 to 6/4/25 the facility did not ensure residents received adequate supervision to prevent accidents for one (1) of four (4) residents (Resident #254) reviewed for accidents. Specifically, a two (2) person assist during transfers was not provided as per care plan which resulted in Resident # 254 sustaining two (2) skin tears to their right upper arm and a 1 cm by 1 cm abrasion to their head. The findings include: Resident #254 was admitted to the facility with diagnoses including Parkinson's Disease, Anxiety, and Vascular Dementia. The 12/7/23 Quarterly Minimum Data Set (resident assessment tool) documented Resident #254 had severe cognitive impairment and required dependent assistance with transfers. The Activities of Daily Living Care Plan updated 4/13/23 documented Resident #254 required total body lift with assist of two staff. The January 2024 Certified Nurse Aide instructions were unavailable as Resident #254 was discharged from the facility/electronic medical record. The 1/7/24 Resident Accident Report documented two (2) skin tears to the resident's right arm and a 1 cm by 1 cm abrasion to their head. The Certified Nurse Aide stated they transferred the resident using the sit to stand lift and the sling rubbed against the resident's arm. The resident was assessed and first aid was administered, the physician, wound team, and health care proxy were made aware. The 1/7/24 Registered Nurse #1 statement documented Certified Nurse Aide #2 reported they transferred Resident #254 using the Sit to Stand Lift and the sling rubbed against his arm. The 1/7/2024 Certified Nurse Aide #2 statement documented that when they assisted Resident #254 with transferring back to bed, the resident became agitated and scratched his right arm. During an interview on 5/30/25 at 1:04 PM, the Assistant Director of Nursing stated that on 1/7/24 at 4:50 PM, Registered Nurse #1 observed skin tears to Resident #254's right upper arm, and an abrasion to their head, and interviewed Certified Nurse Aide #2 who stated the sling rubbed against the resident's arm. During an interview on 5/30/25 at 1:17 PM, the Director of Nursing stated the resident had required a 2-person assist with a total body lift with transfers. They stated they interviewed Certified Nurse Aide #2 the following morning (1/8/24), and Certified Nurse Aide #2 stated they transferred the resident without assistance. During an interview on 5/30/25 at 4:05 PM, the Director of Nursing stated they could not access Certified Nurse Aide instructions because Resident #254 was discharged from the electronic medical record system. They stated documentation of the assistance Resident #254 required was documented on the Care Plan. During an interview on 6/01/25 at 2:15 PM, Registered Nurse #1 stated on 1/7/24, Certified Nurse Aide #2 told them they transferred Resident #254 without asking for assistance. Registered Nurse #1 stated they had been administering medications in the same hallway and could easily have assisted Certified Nurse Aide #2 with the transfer if asked. Registered Nurse #1 further stated Certified Nurse Aide #2 had asked them for assistance on prior days and they expected Certified Nurse Aide #2 would ask for assistance if needed. They stated the resident's transfer status had not changed recently. Registered Nurse #1 stated if the Resident's transfer status had changed recently, they would have reported the change to the Certified Nurse Aides when they came in. They stated the change of shift report given by the nurse to the Certified Nurse Aides included whatever changes had occurred on the previous shifts. Registered Nurse #1 stated Certified Nurse Aides were responsible for checking the computer for resident transfer status or ask the nurse if they were unsure. They stated when they asked, Certified Nurse Aide #2 denied checking the CNA instructions prior to transferring the resident. During an interview on 6/02/25 at 8:51 AM, the Director of Nursing stated for transfers, Resident #254 required 2-person assistance with total body lift starting on 4/13/2023. The Director of Nursing stated the care plan was documented on the Certified Nurse Aide Touch, (Certified Nurse Aide instructions). During a review of the ADL (Activities of Daily Living) Data Report, the Director of Nursing stated Certified Nurse Aide #2 provided care to Resident #254 thirteen (13) days prior to the 1/7/24 incident, on 12/23/23 and 12/24/23, and had documented providing 2-person assistance with transfers on those dates. The Director of Nursing stated on 1/8/24, Certified Nurse Aide #2 stated they transferred Resident #254 by themselves. During an interview on 6/02/25 at 10:49 AM, Certified Nurse Aide #2 stated on 1/7/2024, they transferred Resident #254 without assistance. They stated they were aware Resident #254 required 2-person assistance. They stated they were made aware of how to transfer residents from either the Certified Nurse Aide Touch (Certified Nurse Aide instructions) or from the nurse. They stated they received verbal report if there were changes in the resident's status. 10 NYCRR 415.12(h)(2)

Based on record review and interviews during an abbreviated survey (NY00375411) the facility did not ensure that the resident was free from chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for one (1) out of three (3) residents (Resident #1) reviewed for restraints. Specifically, on 3/15/2025 the facility staff administered intramuscular anti-psychotic medication to Resident #1. Resident #1 was seen on a surveillance camera wandering on the unit and going in and out of other resident's rooms. Resident #1 was observed on surveillance camera being held against the wall by four (4) staff members (Certified Nurse Aide #2, Licensed Practical Nurse #1, Security Officer #1 and Registered Nurse #2) and administered the intramuscular injection. Resident #1's medication list did not include any anti-psychotics on admission. In addition, Resident #1 had no documented medical symptom or appropriate assessment for the use of the antipsychotic medication. This resulted in the use of a chemical restraint to subdue the resident which had the potential for serious harm/injury that is not immediate jeopardy The findings are: The Facility Restraints-Use of Chemical or Physical Restraints policy last revised 9/2023 documented the facility shall provide its residents with considerate and respectful care designed to promote the resident's independence, dignity and safety in the least restrictive environment commensurate with resident's preference, physical and mental status. The facility is generally a restraint free facility. The purpose is to ensure resident's safety and maintain optimum levels of physical and emotional functioning when in restraints. Physical or chemical restraints are not used at the facility. Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to Parkinsonism (brain conditions that cause slowed movements, rigidity (stiffness) and tremors), anxiety disorder, and Depression(mood disorder that causes persistent feeling of sadness and loss of interest in things and activities once enjoyed) . An Admission Minimum Data Set, dated dated dated [DATE] documented Resident #1 was cognitively intact. Review of a psychosocial well-being care plan dated 3/13/2025 documented Resident #1's well-being as positively able to verbalize needs, engages in conversation with others, and has a supportive family who visits. Resident #1 is negatively impacted by increase in confusion, sundowning (a collection of behaviors such as difficulty sleeping, anxiety, agitation, and restlessness that occurs from dusk through night), and declining health status. Interventions listed included to monitor effectiveness of approaches, provide support and show interest in well-being through verbalization and supportive techniques, identify conflicts and apply appropriate approaches for resolution. There was no documented evidence of any specific approaches documented on the care plan. Review of a mood care plan dated 3/13/2025 documented Resident #1 had potential for mood issues related to diagnoses of anxiety, sundowning and Parkinson's disease. Resident #1 expressed feeling down, depressed or hopeless, feeling tired or having little energy, poor appetite and having trouble falling asleep or staying asleep, or sleeping too much. Interventions listed included assess and monitor resident to determine onset of mood problem, assist resident in managing feelings by having staff available during upset episodes, encourage to verbalize concerns, try to get resident to identify unmet needs, do not negate residents' feelings and let it be known that efforts will be made to relieve anxieties and concerns. Acknowledge difficulty adjusting to facility, establish foundation for trust and support and involve significant individuals in life as support while dealing with mood issues. Review of the Facility Surveillance Camera Recording dated 3/15/2025 revealed at 5:42 AM Resident #1 is observed standing in the hallway of the unit, wearing a T-shirt, briefs and tennis shoes. At 5:50 AM Resident #1 is seen wandering around the unit and enters another resident's room. Registered Nurse #1 is observed trying to redirect Resident #1. Resident #1 comes out of the room, goes to the nursing cart and began writing on a piece of paper. Registered Nurse #1 attempted to grab Resident #1's wrist and then quickly let go and began removing items off the top of the nursing cart. At 6:09 AM Resident #1 was seen wandering the hallway with staff following behind. Resident #1 sat in a recliner in the common area. At 6:11AM Registered Nurse #1 and Certified Nurse Aide #3 enter the common area attempting to administer some oral medication to Resident #1. The resident refuses. At 6:13 AM Licensed Practical Nurse #2 was seen attempting to give Resident #1 some oral medication, and the resident swung their hand at Licensed Practical Nurse #2 and Licensed Practical Nurse #2 handed the medication back to Registered Nurse #1. At 6:27 AM Licensed Practical Nurse #1 is seen holding Resident #1 by the left arm, Registered Nurse #2 is standing to the right of the resident, Certified Nurse Aide #2 is standing behind the resident putting on gloves. Licensed Practical Nurse #1 proceeds to grab both of Resident #1's wrist, while holding the resident against the wall in the hallway. Certified Nurse Aide #2 and Registered Nurse #2 proceed to grab Resident #1's right arm and Registered Nurse #1 is seen administering an injection to Resident #1. During an interview on 3/26/2025 at 12:35 PM, the Administrator stated they felt by the time the staff intervened physically, Resident #1 appeared to be calm, and staff should have left the resident and not attempted to administer the medications. The Administrator stated they would have let Resident #1 be and ensured everyone was safe. During an interview on 3/27/2025 at 9:27 AM, Certified Nurse Aide #2 stated Resident #1 sat in a chair in the common area, and they refused to get up. Registered Nurse #1 then called for the resident to get some medication. Certified Nurse Aide #2 stated after the medication Resident #1 was still disruptive and the staff brought Resident #1 back to their own unit. During a telephone interview on 3/27/2025 at 10:34 AM, Attending Physician #1 stated they received a call from the facility on 3/15/2024 at around 5:00 AM informing them there was a new admission who was agitated, paranoid and felt staff were trying to hurt them. Attending Physician #1 stated it was reported to them that Resident #1 was going in and out of other resident's rooms and was being physically combative with staff. Attending Physician #1 stated they were called multiple times, and they first recommended that Resident #1 be give oral Ativan (sedative). Attending Physician #1 stated they were then informed that Resident #1 spit the medication out and was still agitated and paranoid, so they ordered intramuscular Haldol (antipsychotic) to be administered. Attending Physician #1 stated following the administration of the Haldol Resident #1 was still reportedly agitated, so they ordered to send the resident out to the hospital for further evaluation. Attending Physician #1 stated Haldol and Ativan are the only two behavioral drugs available on hand at the facility. Attending Physician #1 stated if Resident #1 was only being verbally aggressive or in distress, they would have recommended other interventions such as placing the resident on a one-to-one monitoring or redirection should be attempted first. Attending Physician #1 stated that it was explained to them that other interventions were tried and did not work. Attending Physician #1 stated they did not have the opportunity to view the surveillance camera footage of what took place on 3/15/2025. During an interview on 3/28/2025 at 11:10 PM, Security Officer #1 stated the nurses tried to give Resident #1 some medication and the resident knocked it out of the nurse's hand. Security Officer #1 stated the nurses gave Resident #1 an injection while the staff were holding the resident so the injection could be administered. During an interview on 3/28/2025 at 1:05 PM Licensed Practical Nurse #1 stated when they arrived at the facility on 3/15/2025 at 6:30 AM, Registered Nurse #2 and another nurse (unable to recall name of nurse) were talking about Resident #1 being aggressive. Licensed Practical Nurse #1 stated Registered Nurse #2 asked Registered Nurse #1 to call Attending Physician #1 and they heard Registered Nurse #2 say that the resident needed an injection of Haldol. Licensed Practical Nurse #1 stated the staff were trying to get Resident #1 in the wheelchair before administering the injection because they were not sure how the resident would react to the injection. During an interview on 3/28/2025 at 1:22 PM, Registered Nurse #2 stated during the incident, Resident #1 entered another resident's room, the other resident was awake and asked Resident #1 to leave their room. Resident #1 tried to close the door while in the room, and Registered Nurse #2 tried to keep the door open. Registered Nurse #2 stated after a few minutes Resident #1 came out of the room. They asked Registered Nurse #1 to check the orders for Resident #1 to see if they had any as needed medication orders for the resident, as they were a new admission. Registered Nurse #2 stated Registered Nurse #1 checked the orders for Resident #1 and saw there was an as needed order for oral Ativan. Registered Nurse #2 stated Resident #1 was wandering around the unit at that time and raising their fists. Registered Nurse #1 gave the resident the oral medication and they spit it out, so Registered Nurse #1 called Attending Physician #1 (who was on call) and got an order for intramuscular Haldol. Registered Nurse #2 stated Resident #1 was still on the adjacent unit going into other resident's rooms. Registered Nurse #2 stated Registered Nurse #1 then came and administered the Haldol injection, but they do not recall how the injection was given. All they could remember was that Resident #1 was standing up fighting and resisting Registered Nurse #1 from giving the injection. 10 NYCRR 415.4(a)(1) and 415.3(d)(1)(vii)

Based on record review and interviews during an abbreviated survey (NY00375411), the facility did not ensure that a resident is free from physical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms for one (1) of three (3) residents (Resident #1) reviewed for restraints. Specifically, on 3/15/2025 Resident #1 was seen on Facility Surveillance Camera Footage wandering the hallway to the adjacent unit. Resident #1 was seen going in and out of other resident's rooms. Security Officer #1 was observed grabbing Resident #1 by their wrist to keep the resident in one place. Resident #1 is observed on surveillance camera footage in a wheelchair and trying to propel themselves away from the staff. Resident #1 was seen with all four of their extremities held by four staff members (Certified Nurse Aide #2, the Security Officer #1, Licensed Practical Nurse #1 and Registered Nurse #2), preventing the resident's movement. Staff was seen wheeling the resident back to their room holding on to all four extremities. This resulted in psychosocial harm to Resident #1 and the potential for serious injury that is not immediate jeopardy. The findings are: The Facility Restraints-Use of Chemical or Physical Restraints last revised 9/2023 documented the facility shall provide its residents with considerate and respectful care designed to promote the resident's independence, dignity and safety in the least restrictive environment commensurate with resident's preference, physical and mental status. The facility is generally a restraint free facility. The purpose is to ensure resident's safety and maintain optimum levels of physical and emotional functioning when in restraints. Physical or chemical restraints are not used at the facility. Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to Parkinsonism (brain condition that causes slow movement, tremors, rigidity), anxiety disorder and Depression. An Admission Minimum Data Set, dated dated dated [DATE] documented Resident #1 was cognitively intact. Review of a psychosocial well-being care plan dated 3/13/2025 documented Resident #1's well-being as positively able to verbalize needs, engages in conversation with others, and has a supportive family who visits. Resident #1 is negatively impacted by increase in confusion, sundowning (a collection of behaviors such as difficulty sleeping, anxiety, agitation, and restlessness that occurs from dusk through night), and declining health status. Interventions listed included to monitor effectiveness of approaches, provide support and show interest in well-being through verbalization and supportive techniques, identify conflicts and apply appropriate approaches for resolution. No specific approaches were documented on the care plan. Review of a mood care plan dated 3/13/2025 documented Resident #1 had potential for mood issues related to diagnoses of anxiety, sundowning (a collection of behaviors such as difficulty sleeping, anxiety, agitation and restlessness) that occurs from dusk through night) and Parkinson's disease. Resident #1 expressed feeling down, depressed or hopeless, feeling tired or having little energy, poor appetite and having trouble falling asleep or staying asleep, or sleeping too much. Interventions listed included assess and monitor resident to determine onset of mood problem, assist resident in managing feelings by having staff available during upset episodes, encourage to verbalize concerns, try to get resident to identify unmet needs, do not negate residents' feelings and let it be known that efforts will be made to relieve anxieties and concerns. Acknowledge difficulty adjusting to facility, establish foundation for trust and support and involve significant individuals in life as support while dealing with mood issues. Review of the Facility Surveillance Camera Recording dated 3/15/2025 revealed at 5:42 AM Resident #1 was standing in the hallway of the unit, wearing a T-shirt, briefs and tennis shoes. At 5:50 AM Resident #1 is seen wandering around the unit and enters another resident's room. Registered Nurse #1 is observed trying to redirect Resident #1. At 5:51 AM Security Officer #1 is seen in the hallway grabbing Resident #1 by both wrists and attempting to keep Resident #1 in one place. Registered Nurse #2 is seen witnessing the incident. At 5:52 AM Resident #1 broke free from Security Officer #1 and walked down the hallway. Security Officer #1 and Registered Nurse #2 are seen following the resident. At 6:03 AM Resident #1 is seen getting up from a chair and walking down the hallway with Registered Nurse #2 walking closely behind. Resident #1 continues to wander the hallway to another unit. Registered Nurse #2 is seen trying to redirect the resident. At 6:07 AM Certified Nurse Aide #2, Licensed Practical Nurse #1, Security Officer #1 and Registered Nurse #2 show up with a wheelchair and they were seen trying to get Resident #1 to sit down in the wheelchair. At 6:09 AM Resident #1 was seen wandering the hallway with Registered Nurse #2, Security Officer #1 and Certified Nurse Aide #2 following behind. Resident #1 sat in a recliner in the common area. Security Officer #1 and Certified Nurse Aide #1 are seen standing in front of the seated resident. At 6:11 AM Registered Nurse #1 was seen attempting to administer oral medication to Resident #1, which they refused. At 6:13 AM Licensed Practical Nurse #2 tries to administer the oral medication, and the resident appears to swing at Licensed Practical Nurse #2. Between 6:13 AM and 6:19 AM, Certified Nurse Aide #2 and Security Officer #1 are observed standing in the common area with Resident #1. Between 6:21 AM and 6:23 AM, Certified Nurse Aide #2 leaves and Resident #1 stands from the chair and sits back down. At 6:26 AM, Resident #1 gets up from the chair and Security Officer #1 was attempting to stop the resident by blocking their path with a wheelchair. At 6:27 AM four (4) staff members (Certified Nurse Aide #2, Security Officer #1, Licensed Practical Nurse #1 and Registered Nurse #2) were observed assisting with sitting Resident #1 in a wheelchair. Resident #1 attempts to propel the wheelchair with their hands and legs and Certified Nurse Aide #2 , Security Officer #1, Licensed Practical Nurse #1 and Registered Nurse #2 each grab Resident #1 by their extremities. Resident #1 is then seen swinging their arms and attempting to get free from the restraint of the staff members. Resident #1 is seen kicking at Registered Nurse #1 and attempted to remove Security Officer #1's hand from their wrist. Resident #1 continues to kick and attempt to remove the staffs' hold of their arms. At 6:27 AM Licensed Practical Nurse #1 is seen holding Resident #1 by the left arm, Registered Nurse #2 is standing to the right of the resident, Certified Nurse Aide #2 is standing behind the resident putting on gloves. Licensed Practical Nurse #1 proceeds to grab both of Resident #1's wrist, while holding the resident against the wall in the hallway. Certified Nurse Aide #2 and Registered Nurse #2 proceed to grab Resident #1's right arm and Registered Nurse #1 is seen administering an injection to Resident #1. At 6:29 AM Certified Nurse Aide #2, Security Officer #1, Licensed Practical Nurse #1 and Registered Nurse #2 are seen moving Resident #1 down the hall while physically restraining the resident's extremities. Registered Nurse #1 is seen following behind. Resident #1 was brought back to the unit and into the resident's room. Review of an undated Facility Incident Report submitted on 3/18/2025 at 12:30 PM documented the incident occurred on 3/15/2025 at 6:27 AM and the Administrator was made aware of the incident on 3/18/2025 at 10:00 AM. Resident #1 was walking around their unit in a shirt and brief on 3/15/2025 at approximately 5:43 AM. Resident #1 was not able to be re-directed by the nurse and entered another resident's room. Security and the supervisor were called for assistance. Resident #1 went to the adjoining unit and entered at least two other resident's rooms. At some point Resident #1 attempted to close the door of another resident's room on the supervisor's arm. Orders were received for oral Ativan and Haldol intramuscularly. Resident #1 spit out the oral Ativan and the Haldol was administered intramuscularly. Resident #1 was placed in a wheelchair and attempted to propel the wheelchair with their arms. Two staff members held onto Resident #1's arms and the resident placed their feet down. Two additional staff members held onto the resident's legs. Resident #1 was brought back to their room via the wheelchair with staff members holding onto each limb. Resident #1 was transported to the hospital via ambulance a short time later. Resident #1 returned to the facility at 2:00 PM on 3/15/2025. The root cause analysis documented that according to statements obtained from staff, several attempts were made to keep Resident #1 safe (after they had received Haldol injection ordered by the medical provider), including assisting them to a wheelchair for transport back to their room. The investigation summary initiated on 3/18/2025 provided to surveyors during the onsite survey, did not include a conclusion. Review of the facility investigative summary submitted to the New York State Department of Health on 3/21/2025 at 1:26 PM documented Resident #1 shared with their family, after the incident, that they were forcibly placed in a wheelchair and restrained. The summary documented that Resident #1 has noted on several occasions since the incident that they were restrained by a group of people. Resident #1 was moved to a private room two days after the incident. Medication adjustments were made with collaboration with Resident #1's neurologist. During an interview on 3/26/2025 at 12:35 PM, the Administrator stated they felt by the time the staff intervened physically, Resident #1 appeared to be calm, and staff should have left the resident and not even attempted to administer the medications. The Administrator stated they would have let Resident #1 be and ensured everyone was safe. During an interview on 3/27/2025 at 9:27 AM, Certified Nurse Aide #2 stated that together with Registered Nurse #2, the Security Officer #1, Registered Nurse #1, and possibly Licensed Practical Nurse #2, they placed Resident #1 in a wheelchair on the day of the incident. Because the resident was fussing and kicking, they each took a limb, and they brought Resident #1 back to their unit and put the resident in bed. Certified Nurse Aide #2 stated as the staff were placing Resident #1 in the bed, the resident kicked Licensed Practical Nurse #1 on the side. During a telephone interview on 3/27/2025 at 10:34 AM, Attending Physician #1 stated they received a call from the facility on 3/15/2024 at around 5:00 AM informing them that there was a new admission who was agitated, paranoid and felt staff were trying to hurt them. Attending Physician #1 stated it was reported to them that Resident #1 was going in and out of other resident's rooms and was being physically combative with staff. Attending Physician #1 stated they did not have the opportunity to view the surveillance camera footage of what took place on 3/15/2025. Attending Physician#1 stated they gave orders for Ativan by mouth and Haldol intramuscularly. During an interview on 3/28/2025 at 11:10 PM, the Security Officer #1 denied touching Resident #1 on 3/15/2025 during the incident. They stated the staff forced Resident #1 into the wheelchair and escorted the resident back to their unit. The Security Officer #1 stated Resident #1 was trying to stop the staff by grabbing the wheelchair and placing their feet under the wheelchair, but the staff held the resident back in the wheelchair. The Security Officer #1 stated three (3) to four (4) staff members held Resident #1's legs, to prevent the resident from sticking their legs under the wheelchair, and they held the resident back into the wheelchair. The Security Officer #1 stated they do not know why the staff continued to push Resident #1 into the wheelchair. During an interview on 3/28/2025 at 1:05 PM, Licensed Practical Nurse #1 stated when they arrived at the facility on 3/15/2025 at 6:30 AM, Registered Nurse #2 and Registered Nurse #1 (they cannot remember their name) were talking about Resident #1 being aggressive. Licensed Practical Nurse #1 stated Registered Nurse #2 told the nurse to call Attending Physician #1 and they heard them say Resident #1 needed an injection of Haldol. Licensed Practical Nurse #1 stated they were there waiting to start their shift when the nurse got the order, and they were asked to give support. Licensed Practical Nurse #1 stated they walked from Resident #1's unit to the other unit and when they got to the unit they saw Resident #1 walking with no assistive device. Licensed Practical Nurse #1 stated Resident #1 asked how they were, and they placed their self-next to the resident, to make sure the resident did not fall. Licensed Practical Nurse #1 stated they were trying to get Resident #1 to go back to their unit and the resident stated the staff were trying to kill them. Licensed Practical Nurse #1 stated they asked Resident #1 to come with them and they refused. Licensed Practical Nurse #1 stated they cannot recall if anyone was holding Resident #1 or not during the injection of the Haldol, but after the injection the resident kept trying to hit them with a sharpie marker they had in their hand, so they took the marker from Resident #1, and the resident was hitting them in the arm. Licensed Practical Nurse #1 stated the staff wanted to get Resident #1 in the wheelchair because they did not know how the resident would react to the injection. During an interview on 3/28/2025 at 1:22 PM, Registered Nurse #2 stated they recall assisting Resident #1 into a wheelchair with other staff including the Security Officer, Certified Nurse Aide #2 and Licensed Practical Nurse #1 on the day of the incident. They wanted to move Resident #1 to their room so the resident could be safe. Registered Nurse #2 stated they were on Resident #1's left side holding their left leg, Certified Nurse Aide #2 was also on the residents left side and Licensed Practical Nurse #1 assisted as well. Registered Nurse #2 stated Resident #1 was aggressive, and that is why they moved the resident back to their unit. 10 NYCRR 415.4(a)(2-7)

Based on record review and interviews during the abbreviated survey (NY00365964), the facility did not ensure that all allegations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated for 1 of 3 residents (Resident #3) reviewed for abuse. Specifically, Resident # 3 sustained a skin tear to left hand on 12/17/2024 that was not thoroughly investigated by the facility. Findings include: The Facility Abuse Prohibition policy last revised 9/2023 documented the home shall prohibit abuse through the following: training of employees (new employees and ongoing training of all employees), identification of possible incidents or allegations which need investigation, investigation of incidents and allegations and reporting of incidents, investigations as well as the home's response to the results of the investigations. When dealing with situations where abuse is alleged to have occurred any person who has reasonable cause to believe that any situation of resident abuse has occurred is responsible to immediately notify his/her supervisor, circumstances to be reported may include, but are not limited to, a statement that physical abuse has occurred, the supervisor is to immediately notify the Administrator/designee, the supervisor will complete the appropriate form (Accident/Incident Report form, Investigation Form, Abuse Allegation Investigation Form) and initiate the investigation. Resident # 3 was admitted to the facility with diagnosis that included but not limited to Dementia, Atrial Fibrillation, Congestive Heart Failure, and Muscle Wasting. An admission Minimum Data Set, dated dated dated [DATE] documented Brief interview of Mental Status score of 4 with physical behavior symptoms directed towards others, and wandering. The resident has no impairment on upper and lower extremities, uses a walker and wheelchair for locomotion, requires set up or clean up assistance for eating, independent with bed mobility and transfers, occasionally incontinent of bladder and always continent of bowel. A review of a nursing progress note dated 12/17/2024 at 6:34pm documented open purpura to left hand. Skin tear protocol in place. No c/o pain. A review of the medical progress note dated 12/19/2024 documented that on 12/18/2024 the resident was seen for follow up on recent admission with dementia, agitation, wandering, confusion. Noted with insomnia, wandering on the unit, exiting on the unit, exit seeking. Non-compliant and with physical aggression to staff. Resident medical history reviewed. Medications list reviewed. Skin: No rash A review of the medical progress notes dated 12/20/2024 documented seen for follow up of left-hand ecchymosis on exam. Ecchymosis present at base of 1st and 2nd fingers. Skin tear with scab present, normal range of motion of fingers, wrist. No tenderness of digits, wrist or hands. No further treatment needed. There was no documented evidence of any incident report or any skin assessment or any resident refusals pertaining to the resident's skin tear on 12/17/2024. During an interview on 3/28/2025 at 11:41am, the Assistant Administrator stated they do not have an incident report on Resident # 3 because they were only in the facility for a week, and there were no skin assessments completed for the resident pertaining to the incident on 12/17/2024. During an interview on 3/28/2025 at 2:24 PM, Licensed Practical Nurse #3 stated Resident # 3 wanted to go home after their admission. The resident went to the main door of the unit and the Certified Nursing assistant # 4 told them that the resident hit them with their walker and the resident was bleeding from the purpura opening. Licensed Practical Nurse #3 treated the resident's hand, initiated the skin protocol order, and documented a behavior note in the residents electronic medical record. Licensed Practical Nurse #3 could not recall if the physician was notified, but they stated the called the resident's family member. Licensed Practical Nurse #3 stated it was brought to their attention that they did not write a note that they contacted the family; therefore, there made a late entry note after the resident was discharged . During an interview on 3/28/2025 at 2:32 PM, Social Worker # 1 stated Resident # 3 had an incident that was reported during the morning meeting on 12/18/2024.The report was that the resident was wandering out of the unit and the staff followed him and the resident hit the staff with the walker. Social Worker #1 stated Resident #3's family representative informed them that Resident # 3 had a mark on their hand. Social Worker # 1 stated they went to see Resident # 3, and they saw a scar on the resident's hand but Resident # 3 Family Representative wanted to take the resident home because they alleged that someone hit the resident. Social Worker # 1stated they reported the allegation to the Director of Nursing and the Administrator. Resident #3's Family Representative took the resident out of the facility Against Medical Advice but refused to sign the form. During an interview on 3/28/2025 at 3:09 PM, the Director of Nursing stated there should not have been an incident report for the resident because the incident was observed and the skin tear was over purpura, and the purpura was opened because it was hit by the walker. Director of Nursing stated Resident # 3 refused to have a skin assessment upon admission and multiple attempts were made but they refused. The refusals and ongoing attempts to complete a skin assessment should have been documented in a nursing progress note. If the resident was found with an unwitnessed skin tear, then they would do an incident report. Director of Nursing reviewed the Nursing Progress notes and acknowledged that they do not see anything in the notes documenting a skin assessment was refused. Director of Nursing stated at that time Resident #3's Family Representative was informed that the facility tried to contact her regarding the incident. Resident # 3 Family Representative was upset that they were not notified and stated that they would be taking Resident # 3 home. Against Medical Advice. Family representative was informed Resident # 3 had a behavior of smashing his walker on the floor and at people/thing During a telephone interview on 4/2/2025 at 3:30pm, Resident # 3's Family Representative stated they went to visit their family on 12/19/2024 and heard a story about how Resident # 3 attempted to leave out of a door. The nurse tried to stop their family member from leaving and it was reported that the resident was injured. Resident # 3's Family Representative stated the facility did not attempt to call them when the incident occurred. Resident # 3 Family Representative stated they requested for the facility to show them the incident report, but the facility denied this request on 12/19/2024. Resident # 3's Family Representative stated they thought someone may have abused the resident and brought it to the facility's attention. They decided to take Resident # 3 out of the facility because they were injured. The facility asked them to sign an Against Medical Advice form, and they refused to sign. 10 NYCRR 483.12(c)

Based on record review and interviews during an abbreviated survey (NY00375411) the facility did not ensure the resident was free from abuse for 1 out of 3 residents (Resident #1) reviewed for abuse. Specifically, on 3/15/2025 Resident #1 was seen on Facility Surveillance Camera Footage wandering the hallway to the adjacent unit. Resident #1 was seen going in and out of other resident's rooms. Security Officer #1 was observed grabbing Resident #1 by their wrist to keep the resident in one place. Licensed Practical Nurse #1 was observed grabbing both of Resident #1's wrists and Certified Nurse Assistant #2 and Registered Nurse #2 grabbed Resident #1's right arm while Registered Nurse #1 was seen administering an injection to the resident while staff hold the resident in place against the wall in the hallway. Resident #1 is observed on surveillance camera footage in a wheelchair and trying to propel themselves away from the staff. Resident #1 was seen with all four of their extremities held by four staff members (Certified Nurse Aide #2, the Security Officer #1, Licensed Practical Nurse #1 and Registered Nurse #2) preventing the resident's movement. Staff was seen wheeling the resident back to their room holding on to all four extremities The findings are: The facility Abuse Prohibition policy last revised 9/2023 documented the facility shall take actions to prevent abuse by identifying, correcting and intervening in situations in which abuse is more likely to occur. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse may be verbal, sexual, physical or mental. Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to Parkinsonism, Anxiety Disorder and Depression. An Admission Minimum Data Set, dated dated dated [DATE] the resident was cognitively intact. The resident required a walker and a wheelchair for locomotion, set up assistance with eating and bed mobility, moderate assistance with toileting and independent with transfers. There was no Abuse care plan initiated by the facility prior to the incident Review of a psychosocial well-being care plan dated 3/13/2025 documented Resident #1's well-being as positively able to verbalize needs, engages in conversation with others, and has a supportive family who visits. Resident #1 is negatively impacted by increase in confusion, sundowning (a collection of behaviors such as difficulty sleeping, anxiety, agitation, and restlessness that occurs from dusk through night), and declining health status. Interventions listed included to monitor effectiveness of approaches, provide support and show interest in well-being through verbalization and supportive techniques, identify conflicts and apply appropriate approaches for resolution. No specific approaches were documented on the care plan. Review of a mood care plan dated 3/13/2025 documented Resident #1 had potential for mood issues related to diagnoses of anxiety, sundowning (a collection of behaviors such as difficulty sleeping, anxiety, agitation and restlessness) that occurs from dusk through night) and Parkinson's disease. Resident #1 expressed feeling down, depressed or hopeless, feeling tired or having little energy, poor appetite and having trouble falling asleep or staying asleep, or sleeping too much. Interventions listed included assess and monitor resident to determine onset of mood problem, assist resident in managing feelings by having staff available during upset episodes, encourage to verbalize concerns, try to get resident to identify unmet needs, do not negate residents' feelings and let it be known that efforts will be made to relieve anxieties and concerns. Acknowledge difficulty adjusting to facility, establish foundation for trust and support and involve significant individuals in life as support while dealing with mood issues. Review of the Facility Surveillance Camera Recording dated 3/15/2025 revealed at 5:42 AM Resident #1 was standing in the hallway of the unit, wearing a T-shirt, briefs and tennis shoes. At 5:50 AM Resident #1 is seen wandering around the unit and enters another resident's room. Registered Nurse #1 is observed trying to redirect Resident #1. At 5:51 AM Security Officer #1 is seen in the hallway grabbing Resident #1 by both wrists and attempting to keep Resident #1 in one place. Registered Nurse #2 is seen witnessing the incident. At 5:52 AM Resident #1 broke free from Security Officer #1 and walked down the hallway. Security Officer #1 and Registered Nurse #2 are seen following the resident. At 6:03 AM Resident #1 is seen getting up from a chair and walking down the hallway with Registered Nurse #2 walking closely behind. Resident #1 continues to wander the hallway to another unit. Registered Nurse #2 is seen trying to redirect the resident. At 6:07 AM Certified Nurse Aide #2, Licensed Practical Nurse #1, Security Officer #1 and Registered Nurse #2 show up with a wheelchair and they were seen trying to get Resident #1 to sit down in the wheelchair. At 6:09 AM Resident #1 was seen wandering the hallway with Registered Nurse #2, Security Officer #1 and Certified Nurse Aide #2 following behind. Resident #1 sat in a recliner in the common area. Security Officer #1 and Certified Nurse Aide #1 are seen standing in front of the seated resident. At 6:11 AM Registered Nurse #1 was seen attempting to administer oral medication to Resident #1, which they refused. At 6:13 AM Licensed Practical Nurse #2 tries to administer the oral medication, and the resident appears to swing at Licensed Practical Nurse #2. Between 6:13 AM and 6:19 AM, Certified Nurse Aide #2 and Security Officer #1 are observed standing in the common area with Resident #1. Between 6:21 AM and 6:23 AM, Certified Nurse Aide #2 leaves and Resident #1 stands from the chair and sits back down. At 6:26 AM, Resident #1 gets up from the chair and Security Officer #1 was attempting to stop the resident by blocking their path with a wheelchair. At 6:27 AM four (4) staff members (Certified Nurse Aide #2, Security Officer #1, Licensed Practical Nurse #1 and Registered Nurse #2) were observed assisting with sitting Resident #1 in a wheelchair. Resident #1 attempts to propel the wheelchair with their hands and legs and Certified Nurse Aide #2 , Security Officer #1, Licensed Practical Nurse #1 and Registered Nurse #2 each grab Resident #1 by their extremities. Resident #1 is then seen swinging their arms and attempting to get free from the restraint of the staff members. Resident #1 is seen kicking at Registered Nurse #1 and attempted to remove Security Officer #1's hand from their wrist. Resident #1 continues to kick and attempt to remove the staffs' hold of their arms. At 6:27 AM Licensed Practical Nurse #1 is seen holding Resident #1 by the left arm, Registered Nurse #2 is standing to the right of the resident, Certified Nurse Aide #2 is standing behind the resident putting on gloves. Licensed Practical Nurse #1 proceeds to grab both of Resident #1's wrist, while holding the resident against the wall in the hallway. Certified Nurse Aide #2 and Registered Nurse #2 proceed to grab Resident #1's right arm and Registered Nurse #1 is seen administering an injection to Resident #1. At 6:29 AM Certified Nurse Aide #2, Security Officer #1, Licensed Practical Nurse #1 and Registered Nurse #2 are seen moving Resident #1 down the hall while physically restraining the resident's extremities. Registered Nurse #1 is seen following behind. Resident #1 was brought back to the unit and into the resident's room. Review of an undated Facility Incident Report submitted on 3/18/2025 at 12:30 PM documented the incident occurred on 3/15/2025 at 6:27 AM and the Administrator was made aware of the incident on 3/18/2025 at 10:00 AM. Resident #1 was walking around their unit in a shirt and brief on 3/15/2025 at approximately 5:43 AM. Resident #1 was not able to be re-directed by the nurse and entered another resident's room. Security and the supervisor were called for assistance. Resident #1 went to the adjoining unit and entered at least two other resident's rooms. At some point Resident #1 attempted to close the door of another resident's room on the supervisor's arm. Orders were received for oral Ativan and Haldol intramuscularly. Resident #1 spit out the oral Ativan and the Haldol was administered intramuscularly. Resident #1 was placed in a wheelchair and attempted to propel the wheelchair with their arms. Two staff members held onto Resident #1's arms and the resident placed their feet down. Two additional staff members held onto the resident's legs. Resident #1 was brought back to their room via the wheelchair with staff members holding onto each limb. Resident #1 was transported to the hospital via ambulance a short time later. Resident #1 returned to the facility at 2:00 PM on 3/15/2025. The root cause analysis documented that according to statements obtained from staff, several attempts were made to keep Resident #1 safe (after they had received Haldol injection ordered by the medical provider), including assisting them to a wheelchair for transport back to their room. The investigation summary initiated on 3/18/2025 provided to surveyors during the onsite survey, did not include a conclusion. Review of a psychiatric diagnosis evaluation dated 3/20/2025 documented Resident #1 felt traumatized by their recent conflict with staff. Review of the investigative summary submitted to the New York State Department of Health on 3/21/2025 at 1:26 PM documented Resident #1 did share with their family representatives that they were forcibly placed in a wheelchair and restrained after the incident occurred. Resident #1 has noted on several occasions since the incident that they were restrained by a group of people. During an interview on 3/28/2025 at 11:10 PM, the Security Officer #1 stated they work the overnight shift in the facility. The Security Officer #1 stated Resident #1 was acting out of character and refused to put their pants on. The Security Officer #1 stated they went up to the unit to talk to Resident #1 to see if they would put their clothes on and Resident #1 refused, so they left the resident alone. The Security Officer #1 denied touching Resident #1 on 3/15/2025 during the incident. They stated the staff forced Resident #1 into the wheelchair and escorted the resident back to their unit. The Security Officer #1 stated Resident #1 was trying to stop the staff by grabbing the wheelchair and placing their feet under the wheelchair, but the staff held the resident back in the wheelchair. The Security Officer #1 stated three (3) to four (4) staff members held Resident #1's legs, to prevent the resident from sticking their legs under the wheelchair, and they held the resident back into the wheelchair. The Security Officer #1 stated they do not know why the staff continued to push Resident #1 into the wheelchair. During an interview on 3/26/2025 at 11:30 AM Resident #1 stated about two weeks ago there was an incident, but they do not want to comment on th incident and that there was an incident report on file regarding the incident. Resident #1 stated they felt safe in the facility as long as they had the one on one monitoring. The Surveyors asked Resident #1 if they were afraid of retaliation and they stated they were not afraid of anyone in the facility. Resident #1 stated they would like the surveyors to call their family representative for an account of what happened. Resident #1 stated they had a bruise from the incident but would not allow surveyors to look at the bruise when asked. During an interview on 3/26/2025 at 12:35 PM the Administrator stated Resident #1's representative sent an email to the Admissions Director on 3/16/2025, stating they wanted to review the surveillance video footage. The Administrator stated they received the email the morning of 3/17/2025, where Resident #1's representative wrote that Resident #1 was assaulted. The Administrator stated they spoke about the email during the morning meeting on 3/17/2025 at 9 AM. Staff reported Resident #1 had three behavioral episodes including the morning of the incident but there was no mention of the interventions that applied by staff during the incident. The Administrator stated Registered Nurse #2 was contacted to determine what time the incident occurred and the location in order to review the surveillance camera footage. The Administrator stated they did not hear back from Registered Nurse #2 until 8pm on 3/17/2025 and they reviewed the surveillance video footage on 3/18/2025 between 9 AM and 10 AM. The Administrator stated they felt by the time the staff intervened physically, Resident #1 appeared to be calm, and staff should have left the resident and not even attempted to administer the medications. The Administrator stated they would have let Resident #1 be and ensured everyone was safe. During an interview on 3/27/2025 at 9:27 AM Certified Nurse Assistant #2 stated Resident #1 sat in a chair and they could not get them to get up and the nurse then called for the resident to get some medication. Certified Nurse Assistant #2 stated after the medication Resident #1 was still disruptive and the staff did not leave Resident #1 there because they did not belong on that unit. Certified Nurse Assistant #2 stated Resident #1 did not willing take the medication and they held the resident's hands down. Certified Nurse Aide #2 stated that together with Registered Nurse #2, the Security Officer #1, Registered Nurse #1, and possibly Licensed Practical Nurse #2, they placed Resident #1 in a wheelchair on the day of the incident. Because the resident was fussing and kicking, they each took a limb, and they brought Resident #1 back to their unit and put the resident in bed. They wanted to protect other residents During a telephone interview on 3/27/2025 at 10:07 AM, Resident #1's representative stated on 3/15/2025 they got a phone call from Resident #1 stating they were assaulted and were at the hospital. Resident #1's representative stated Resident #1 stated their leg was bleeding and that the staff had restrained them. Resident #1's representative stated Resident #1 stated they were in another resident's room, because they were trying to get away from the staff. Resident #1's representative stated Resident #1 reported the staff were trying to kick their legs so that they would sit down in the wheelchair. Resident #1's representative stated they have been trying to get a copy of the incident reports, and the facility would not provide them nor be transparent with them. Resident #1's representative stated Resident #1 informed them of the staff involved in the incident and described a restraint situation at one point. During an interview on 3/27/2025 at 10:47 AM the Director of Nursing stated they reviewed the surveillance camera footage and saw the staff sat Resident #1 down in the wheelchair. The Director of Nursing stated once they sat Resident #1 in the wheelchair the resident began to resist, so the staff took their hands off the wheelchair, and then the resident started to kick. The Director of Nursing stated the staff should have left Resident #1 alone and assigned someone to observe them. The staff should have allowed Resident #1 to leave the unit and just had someone stay with them. During an interview on 3/28/2025 at 1:05 PM Licensed Practical Nurse #1 stated the Security Officer had the wheelchair sitting behind Resident #1 and they could not remember if the resident was willing and sat in the wheelchair. Licensed Practical Nurse #1 stated Resident #1 continued to kick and fight while in the wheelchair and was been pushed too their room. Licensed Practical Nurse #1 stated to get Resident #1 to stay in the wheelchair they lifted the resident's legs and arms. Licensed Practical Nurse #1 stated Certified Nurse Assistant #2, Registered Nurse #2 and the Security Officer #1 were present and the staff took Resident #1 back to their unit to their room. During an interview on 3/28/2025 at 1:22 PM, Registered Nurse #2 stated they recall assisting Resident #1 into a wheelchair with other staff including the Security Officer, Certified Nurse Aide #2 and Licensed Practical Nurse #1 on the day of the incident. They wanted to move Resident #1 to their room so the resident could be safe. Registered Nurse #2 stated they were on Resident #1's left side holding their left leg, Certified Nurse Aide #2 was also on the residents left side and Licensed Practical Nurse #1 assisted as well. Registered Nurse #2 stated Resident #1 was aggressive, and that is why they moved the resident back to their unit. The surveyor asked Registered Nurse #2 several times what threat Resident #1 was posing, and they continued to respond they just wanted the resident to be safe. 10 NYCRR 415.4(b)(1)(i)

Based on record review and interviews during an abbreviated survey (NY00375411) , the facility did not ensure that all alleged violations involving abuse were reported immediately, but not later than 24 hours if the events that cause the allegation do not result in serious bodily injury, to the administrator of the facility for 1 out of 3 residents (Resident #1) reviewed for abuse. Specifically, on 3/17/2025 Resident #1's representative emailed the facility and informed them Resident #1 stated they were assaulted by staff on 3/15/2025 and requested to view the surveillance camera footage. The Administrator was not informed of the alleged incident that occurred on 3/15/2025 until 3/17/2025. The Administrator reviewed the video surveillance footage on 3/18/2025 and the incident was reported to the New York State Department of Health on 3/18/2025. The findings are: The facility Abuse Prohibition policy last revised 9/2023 documented the home shall prohibit abuse through the following: training of employees (new employees and ongoing training of all employees), identification of possible incidents or allegations which need investigation, investigation of incidents and allegations and reporting of incidents, investigations as well as the home's response to the results of the investigations. When dealing with situations where abuse is alleged to have occurred any person who has reasonable cause to believe that any situation of resident abuse has occurred is responsible to immediately notify his/her supervisor, circumstances to be reported may include, but are not limited to, a statement that physical abuse has occurred, the supervisor is to immediately notify the Administrator/designee, the supervisor will complete the appropriate form (Accident/Incident Report form, Investigation Form, Abuse Allegation Investigation Form) and initiate the investigation. Resident #1 admitted to the facility with diagnoses including but not limited to Parkinsonism, Anxiety Disorder and Depression. An Admission Minimum Data Set, dated dated dated [DATE] documented the resident was cognitively intact. The resident exhibited physical and verbal behaviors the significantly interfere with the resident's care and impact others. The resident required a walker and a wheelchair for locomotion. The resident set up assistance with eating and bed mobility, moderate assistance with toileting and independent with transfers. The resident was occasionally incontinent with urine and frequently incontinent of bowels. The resident was on as needed antipsychotic. Review of the Facility Incident Report submitted to the New York State Department of Health on 3/18/2025 at 12:30 PM documented the incident occurred on 3/15/2025 at 6:27 AM and the Administrator was made aware on 3/17/2025 via email and reviewed the video surveillance on 3/18/2025 at 10:00 AM. Resident #1 was walking around their unit in a shirt and brief on 3/15/2025 at approximately 5:43 AM. Resident #1 was not able to be re-directed by the nurse and entered another resident's room. Security and the supervisor were called for assistance. Resident #1 went to the adjoining unit and entered at least two other resident's rooms. At one point Resident #1 attempted to close the door of another resident's room on the supervisor's arm. Orders were received for oral Ativan and Haldol intramuscularly. Resident #1 spit out the oral Ativan and the Haldol intramuscularly was administered. Resident #1 was placed in the wheelchair and was attempting to propel the wheelchair with their arms. Two staff members held onto Resident #1's arms and the resident then put their feet down. Two additional staff members held onto the residents' legs. Resident #1 was transported back to their room via the wheelchair with staff members holding onto each limb. Resident #1 was transferred to the hospital via ambulance a short time later. Resident #1 returned to the facility before 2 PM on 3/15/2025. During an interview on 3/26/2025 at 12:35 PM, the Administrator stated Resident #1's representative sent an email to the Admissions Director, the night of 3/16/2025, stating they wanted to review the surveillance video footage. The Administrator stated they received the email the morning of the 3/17/2025, with Resident #1's representative stating Resident #1 was assaulted. The Administrator stated they spoke about the email received during the morning meeting on 3/17/2025 at 9 AM. The Administrator stated the incident was reported as Resident #1 having three behavioral episodes including the morning of th eincident. There was no mention of the physical interventions applied by staff. Registered Nurse #2 was contacted so they would know what time the incident occurred and the location in order to view on the surveillance camera footage. The Administrator stated Registered Nurse #2 did not call back until 8 PM on 3/17/2025. The review of the surveillance video footage was done on 3/18/2025 between 9 AM and 10 AM. The Administrator stated they were labeling the situation as a behavior and did not label it as an incident. The Administrator stated the proper protocol would be for the supervisor to reach out to the Director of Nursing immediately. They do not know why the supervisor did not report the incident to the Director of Nursing immediately. The Administrator stated they did not initiate the investigation and report to the New York State Department of Health because they were informed Resident #1 had behaviors. The Administrator stated they could have initiated the report, but they did not because the information provided att the meeting was related to Resident #1's behaviors. During an interview on 3/27/2025 at 10:47 AM, the Director of Nursing stated they found out about the incident that occurred on 3/15/2025, during the morning meeting on 3/17/2025. The Director of Nursing stated the Administrator informed them that an email was forwarded from Resident #1's representative stating Resident #1 informed their representative that they were restrained by staff. The Director of Nursing stated they were asked by the Administrator to find out where the incident occurred and who was involved. The Director of Nursing stated they started the investigation by talking to the day supervisor, who informed them the incident occurred on the night shift over the weekend. The Director of Nursing stated they called Registered Nurse #2 throughout the day on 3/17/2025 and did not get a response. Since they could not contact Registered Nurse #2, they sent them a text message and email. The Director of Nursing stated later that night on their way home, they received a call from Registered Nurse #2. The Director of Nursing stated the Administrator wanted to view the surveillance camera footage to determine what happened. During an interview on 3/28/2025 at 1:22 PM, Registered Nurse #2 stated they did not complete an incident report because they felt it was just a behavior and they gave report to the oncoming nurse about the situation but did not report this to any of the administrative staff. Registered Nurse #2 stated they were trained to report falls with injury, neglect, abuse or anything that they would need more assistance with. 10NYCRR 415.4(b)(1)(ii)

Based on record review and interviews during the Recertification Survey the facility did not ensure that Comprehensive Care Plans were reviewed and revised by the interdisciplinary team. This was identified for 1 (Resident # 30) of 6 residents reviewed for unnecessary medications. Specifically, Resident # 30's psychotropic care plan was not revised to reflect that the resident's brother refused psychiatric follow up and there was no documented evidence of a plan for psychiatric follow up. The finding is: Resident # 30 was admitted to the facility on [DATE] with diagnoses including Non-Alzheimer's Dementia, Seizure Disorder, Bipolar Disorder, and Psychotic disorder. The Quarterly Minimum Data Set (MDS an assessment tool) dated 7/5/23 documented resident had modified independence in cognition, and there were no mood or behaviors changes noted. The physician order dated 11/4/21 documented Abilify 2 mg, 1 tablet once a day for bipolar. The physician order dated 11/4/21 documented Venlafaxine HCL ER 150 mg, 1 capsule once a day for bipolar and depressive disorder. The Psychotropic care plan created 10/3/22 documented resident had a potential for adverse reactions associated with psychotropic medications. The interventions documented to monitor for changes in mood or behavior, psychiatry follow up as needed and administer abilify and venlafaxine as ordered. There were no revisions made to this care plan to reflect that the resident's brother refused psychiatric follow up including no documented evidence of a plan for psychiatric follow up. During an interview with registered nurse supervisor (RN) #1 on 7/25/23 at 3:24 PM, RN #1 stated the registered nurses (RN's) are able to initiate care plans. RN # 1 stated RNs and licensed practical nurses (LPNs) are able to update or revise the care plans. RN #1 stated residents who are receiving psychotropic medications are to be seen for psychiatry follow up. RN #1 stated when the brother decided to refuse psychiatric follow up on 2/3/22, RN # 1 stated the primary medical doctor (MD) would be notified and MD would evaluate and determine whether there were side effects or symptoms from and whether resident would need a gradual dose reduction (GDR). RN #1 reviewed the resident's history and physical and stated the MD was following the resident and documented the resident was doing well on current meds and power of attorney (POA) is refusing psychiatry consults. RN #1 stated they were not sure if MD could provide psychiatry follow up. RN #1 stated the psychotropic care plan and progress notes had no documentation for psychiatric follow up. During an interview with Director of Nursing (DON) on 7/25/23 at 3:47 PM, DON stated residents are supposed to have a psychiatry consult but residents' brother is refusing psychiatry. The plan was for the medical director or attending to decide on psychiatric follow up. Not sure if the MD is allowed to take on the follow up for psychiatry. When DON reviewed the psychotropic care plan, DON stated they did not find documentation of a plan for psychiatry follow up after resident's brother refused psychiatry consults. During an interview with a medical doctor (MD) #1 on 7/25/23 at 4:04 PM, MD #1 stated in February of 2022 put in an order for a psychiatry consult and the brother requested that they do not decrease residents' meds and did not want any psychiatry consults. MD #1 stated a gradual dose reduction (GDR) was done in 2018 and resident became agitated and taking other residents' food, as a result of this a GDR is currently contraindicated. and would not recommend a GDR as a result. MD stated that they would see the resident for ongoing psychiatry follow up. Since the resident is no longer being seen by psychiatry, MD stated the resident has been stable. 415.11 (c)(2)(i-iii)

Based on observations, interviews and record reviews conducted during the recertification survey, from 7/20/2023-7/27/2023 it was determined that for 1 of 38 residents reviewed for Comprehensive Care Plans (CCP), the facility did not ensure that each resident had a CCP that included measurable objectives and interventions to meet the resident's medical and nursing needs to attain or maintain the resident's highest practicable well-being. Specifically, there was no care plan for anticoagulants (blood thinner) for Resident #172. This is evidenced by the following: Resident # 172 had diagnosis including but not limited to coronary artery disease, colostomy, and atrial Fibrillation The Quarterly Minimum Data Set (MDS) an assessment tool dated 6/8/2023 documented Resident # 172 had severely impaired cognition. There was no documented evidence in the electronic medical record of a care plan related to the use of Eliquis. A review of the Care Plan dated 3/19/2023 titled At Risk for Bleeding was resolved on 6/12/2023 A review of the Physician orders documented Eliquis 5mg 2 tablets BID (twice a day) start 7/19/2023 end 7/21/2023 and Eliquis 5 mg one tablet BID to start on 7/21/2023 During an interview on 07/25/23 at 03:17 PM with Registered Nurse (RN) #1. the RN # 1 stated that an RN initiates the care plan. A resident who starts on a new medication should have a care plan initiated with goals and interventions for that medication. Eliquis or coumadin are always put on the cardiac care plan but additionally, they should have a risk for bleeding care plan. During an interview with the Director of Nursing (DON) on 07/25/23 at 03:47 PM The DON stated any resident receiving an anticoagulant should have a care plan, if the resident is on Eliquis they should have a risk for bleeding care plan as well. 415.11(c)(1)]

Based on record review and interview during a recertification and abbreviated survey (# NY00303218) conducted from 7/20/2023-7/6/2023 the facility did not ensure the resident representative was notified, provided education and given an opportunity to consent or decline prior to changing the residents pain medication regime for 1 (Resident #184) of 1 resident reviewed for notification of change. Specifically,the resident representative was not notified when a scheduled dose of Roxanol was changed to an as needed administration schedule. This was evidenced by: Resident # 184 had diagnosis of dementia, atrial fibrillation, and thyroid cancer A review of the Significant Change Assessment Minimum Data Set (MDS) dated [DATE] documented the resident had severely impaired cognition. A review of the physician orders documented 6/21/23 Roxanol 5 mg q 2 hours as needed for pain. Additionally, an order on 6/21/2022 for Roxanol 5mg three times a day (9am, 1pm, and 5PM) was discontinued on 6/22/2022. A review of the Medication Administration Record documented Roxanol was not administered on 6/23/2022. A review of the medical record 6/23/2022 nurse note documented the son was in to visit, and preferred their dad to be comfortable only with administration of Morphine under his tongue when needed. During an interview on 07/23/23 at 02:47 PM the resident representative voiced concerns regarding not being notified regarding the standing order for Roxanol was discontinued without him being notified. The resident representative felt the resident suffered because the medication was stopped. During an interview with License Practical Nurse (LPN)#1 on 07/26/23 at 03:40 PM the LPN stated they did not remember why the schduled Roxanol was stopped or if the son was notified During an interview with the Director of Nursing (DON) on 07/27/23 at 09:14 AM The DON stated the resident was on Roxanol it was not stopped, it was changed to as needed (PRN). 415.3

Based on observation, interview, and record review conducted during a recertification survey and abbreviated survey (NY00301732), the facility did not consider the views of the family council and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility. Specifically, the facility did not ensure that members of the family council, including new admissions were notified of an upcoming quarterly meeting scheduled for 6/22/22. The findings are: The Policy and Procedure (P&P) titled Family Council last revised 10/2022 documented the policy is to facilitate the establishment of a family council created by resident's family members, friends or representatives for purposes of representing the interests of the membership. Additionally, the policy documented upon request the family council may meet privately in a common meeting room of the facility as agreed upon by its members, without facility participation, and at least quarterly with representatives of the facility. The president shall work with the facility liaison on the development of meeting schedules and agenda. A review of a family council flyer documented meeting to be held June 22, 2022, at 12 noon via zoom in the administrative conference room. A review of an email from ombudsman dated 6/21/22 documented the folowing, have the families been notified about tomorrow's meeting as the family council requested? Notification to families is required as noted. Please let me know that notification has been sent. A review of an email from Assistant Administrator dated 6/22/22 documented it was an oversight on the homes part as traditionally it would put the date of the next family council meeting with administration on the minutes from the previous meeting. Additionally, the email documented they were informed that family council member (FC) #1 sent out an email as they have done in the past. On 7/27/23 at 8:51 AM there was a request for documentation of emails that showed the facility notified the family council members of the upcoming June 22, 2022, meeting, additionally requested was evidence the new admissions for June 2022 were notified as well. Facility was unable to provide the emails that the family council members and new admissions were notified for the June 2022 meeting. During an interview with Assistant Administrator (AA) on 7/25/23 at 4:45 PM, AA stated the family council is run by the resident's families, during pandemic they did a zoom meeting instead of a meeting at the facility and stated the family council sends the link to join.The facility will post a flyer on the bulletin board when the next family council meeting is. AA stated they send an email to remind the members of family council meeting and that the facility has an active only email list that is used to invite families. Upon admission they are given the admission packet and there is information about family council and the contact information for family council. AA stated administration sends emails quarterly to family council members when the next meeting will take place. When asked why they did not send the email notification of the next quarterly family council meeting in June 2022, AA stated the family council was the scheduling the zoom meetings and would send the facility the link for the zoom meeting that was being scheduled. AA stated family council members were sending the emails for the meetings. AA attends the quarterly family council meetings. During an interview with family council member (FC) #2 on 7/26/23 at 11:13 AM, FC #2 stated they asked for the facility to email family council members about the meetings being scheduled and stated the administrator took responsibility for not sending email. FC #2 stated they felt the facility was with family council meetings. FC #2 stated communication preferences need to be understood. During an interview with Director of Social Work (DSW) on 07/27/23 10:47 AM, DSW stated at one time they were the liaison for the family council until they requested that DSW to be removed in June 2022. During an interview with the Administrator on 7/27/23 at 12:43 PM, Administrator stated they did not get involved in the family council. Administrator stated prior to the pandemic they had a loose family council meeting. Administrator stated following that the admissions director was facilitating the meetings for about 1 year. During the pandemic they set up a weekly zoom call for the families that was informational but not a family council meeting. Towards the end of the pandemic the informational weekly zoom meeting turned into an informal family council.Then after that they formed a family council and appointed whoever they wanted to be founder and president of the family council. 415.5(c)(6)

Based on observations, interviews, and record reviews conducted during the recertification survey from 7/20/23 to 7/27/23, it was determined that the facility did not ensure that drugs and biological's were securely stored. Specifically, 2/6 medication carts reviewed (Both carts located on the Bear Mountain Unit) were discovered with unlocked internal narcotic medication lock boxes. The findings are: A review of a facility policy effective 7/2009 and last revised 9/2018 titled 'Medication Storage' stated Schedule II-IV controlled medications are stored separately from other medications in a double- locked drawer or compartment designated for that purpose. On 7/25/23 at 12:28 PM, 2 medication carts on the Bear Mountain unit were observed with their inner narcotic lock boxes unsecured/unlocked. During an interview on 7/25/23 at 12:30pm, Licensed Practical Nurse (LPN) #1 stated they did not push the narcotic drawer fully closed on their medication cart and that both the interior and exterior locks on the medication cart should be secured at all times. During an interview on 7/25/23 at 12:30pm, Registered Nurse (RN) #5 stated they must have forgot to fully close the inner narcotic lock box drawer on their medication cart. During an interview on 07/27/23 at 10:21 AM the Director of Nursing stated controlled substances are expected to always be secured by two locks, and the exterior and interior controlled substance lock boxes on the medication carts are expected to be locked at all times. 415.18(e)(1-2)

Based on record review and interview during the 7/20/23-7/27/23 recertification survey, the facility did not ensure that a facility-wide assessment was conducted and documenetd to thoroughly assess the needs of its residents and to determine the required resources to provide the care and services to its residents both during its day-to-day operations and during emergencies. The assessment include, but are not limited to, evaluation of diseases, conditions, physical, functional or cognitive status and acuity of its resident population. The findings include: The Facility Assessment provided to the survey team on 7/2023 with a last updated date of 7/24/23 did not document the needs of a resident requiring dialysis (Resident #30) and a resident requiring the care associated with a laryngectomy (Resident #5). During an interview on 07/25/23 at 4:20 PM, the facility's administrator stated the facility assessment should accurately reflect the residents in the facility and the document provided to the survey team on 7/20/23 was not accurate.The administrator stated the facility assessment was their responsibility. 415.26

Based on observations, record review and interviews during the recertification survey from 7/20/2023 - 7/27/2023, the facility did not ensure a safe, functional, sanitary, and comfortable environment for all residents, staff, and the public. This was evident for one resident (Resident #180) . Specifically, 1. the control unit for the resident's alternating mattress was on the floor, and 2. the cord to the resident's alternating mattress control unit extended beyond the left, lower side of the bed to a wall outlet, which created an accident hazard. Findings include: A policy and procedure dated 3/2023 and titled Repair Requisitions - Preventative Maintenance Program documented The home shall maintain all essential mechanical, electrical, and resident care equipment in safe and operating condition, and all staff members are required to use repair requisitions to report any item in need of repair. Procedures documented Any problem which is considered to have the potential to cause a severe safety hazard to a resident or staff member shall be called in immediately and followed with a written acquisition order. An Environmental Rounds Tools form used by the Plant Superintendent and other disciplines documented monitoring of infection control issues including cleanliness of all surfaces and equipment. 1) During observations on 07/20/2023 at 4:15 PM and 7/24/2023 at 3:50 PM Resident # 180's alternating mattress control unit was sitting on the floor. In an interview on 7/24/2023 at 4:02 PM the Registered Nurse (RN) #2 stated that the alternating mattress control unit should not have been on the floor, it was an infection control issue. In an interview on 7/24/2023 at 4:06 PM the lead housekeeper stated that the alternating mattress control unit should not have been on the floor, it should have been attached to the end of the bed frame, it was an infection control issue. 2) During observations conducted on 7/21/23 at 8:57 AM and 7/24/23 at 3:50 PM, the cord for Resident # 180's alternating mattress control unit extended approximately 2+ feet beyond the left, lower side of the resident's bed to a wall outlet, which created an accident hazard. In an interview on 07/24/2023 at 4:15 PM the plant superintendent stated the cord extending from the bed to the outlet was a fall risk, they make environmental rounds, and no one had reported the issue. 415.29

Based on observation, record review and interview during the recertification survey conducted 7/20/2023 - 7/27/2023, the facility did not ensure food was stored in accordance with professional standards for food safety to ensure prevention of foodborne illness. Specifically, 1 (Bear Mountain) of 4 resident refrigerators used for storing nourishments and food brought in by the resident's families contained multiple outdated perishable food items. The finding is: A policy and procedure dated 3/2023 and titled Guidelines for Proper Food Storage for Meals/Foods Brought in by Family Members documented the policy was to provide guidelines for the safe handling and storage of food brought in by family members/friends. Procedures documented that perishable/cooked food will be labeled with the resident name and room number and dated to be discarded in 2 days of being brought into the facility. During an inspection of the Bear Mountain resident refrigerator on 7/26/2023 at 1:03 PM three (3) perishable food items were found in the refrigerator (2 containers of Italian style foods, and one cardboard container of soup.) The food items were all labeled 7/23. A sign on the refrigerator door documented to date foods and discard within 2 days. In an interview conducted at that time the unit Registered Nurse (RN) #3 stated that the outdated food should have been discarded and proceeded to discard the three food items. 415.14(h)

Based on record reviews and interviews during an Abbreviated Survey (#NY 854), it could not be ensured that the facility notified residents' representatives when an accident involving a resident which resulted in injury and has the potential for requiring physician intervention, for 1 of 3 residents reviewed for accidents. Specifically, Resident #1's representative was not notified when Resident #1 was observed with a skin laceration to the right eyebrow. The findings are: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the quarterly Minimum Data Set (MDS; a resident assessment tool) dated 9/30/2020, Resident #1 required extensive assistance of one person with bed mobility and personal hygiene; extensive assistance of two persons with transfers, dressing and toilet use. Review of Resident #1's Advanced Directive which was executed on 3/16/2016, showed that Resident #1's daughter is her Health Care Proxy. Resident #1's daughter is also identified as having Power of Attorney/Financial as of 3/16/2016. Resident #1's face sheet also listed her daughter as the emergency contact. Review of Resident #1's Comprehensive Care Plan (CCP) titled, Risk for Alteration in Skin Integrity Related to Fragile Skin, Dementia, h/o Senile [CONDITION(S)] [CONDITION(S)], Impaired Independent Mobility was initiated on 7/14/2020. The CCP has been reviewed and revised with a goal that Resident #1 will maintain good skin integrity in 90 days. The documented interventions include that Resident #1 will have 1) her skin observed every shift with cares, 2) notification made to the MD/Dietary of any abnormal findings, 3) protective skin care applied at every incontinent change and 4) her finger nails kept filed and free form rough/jagged edges. Resident Accident Report dated 10/28/2020 documented that on 10/24/2020, a CNA notified Registered Nurse (RN #1) that Resident #1 was noted scratching her right eyebrow resulting in a linear abrasion measuring 4mm to the right eyebrow area. A scant amount of blood was noted on Resident #1's fingernails. Resident was also observed rubbing both eyes. No signs and symptoms of pain/discomfort noted. Resident #1 was also noted picking at her face. Area was washed and lotion applied for comfort. Skin protocol initiated. Resident #1's nails were filed. Resident's daughter notified by phone on 10/28/20 at 3:55pm. During an interview with RN #1 on 11/18/2020 at 10:50am, she stated that on 10/24/2020 between 9am and 10am, CNA #1 brought Resident #1 to her. CNA #1 reported a scratch to Resident #1's right eyebrow. RN #1 said that she did not complete an incident report because it was only a little skin irritation. She also stated that she forgot to call Resident #1's daughter. During in an interview with the facility Administrator on 11/18/2020 at 12:30pm, she stated that Resident #1's daughter called her after a window visit. Resident #1's daughter explained that she had found a scratch mark on her mother's face. The facility Administrator said that she explained to the daughter that facility staff neglected to call her about the scratch mark and apologized. The facility Administrator went on to say that RN #1 was given disciplinary action for failing to notify Resident #1's representative about the scratch mark on her face. During in an interview on 11/18/2020 at 3:15pm with the DON, she stated that the Unit Manager is responsible for notifying the families of any resident's change of condition. During an interview on 11/18/2020 at 3:25pm with the Unit Manager (UM #1), she stated that they call the families for almost everything like orders for antibiotics, new diagnoses, chest x-rays, or COVID testing for example. She explained that for a little skin scratch like what Resident #1 had sustained, the facility does not even call the MD as they have a standing protocol. If there are 2 nurses and if they are busy, UM #1 stated that she would notify the residents' families. That day, 10/24/20, Unit Manager was working with RN #1 who reported the scratch. UM #1 said that RN #1 told her that she was not going to call Resident #1's representative because the scratch was too small. UM #1 said that any nurse could call the family. She further said that it is ultimately her responsibility as a UM to ensure that residents' families are notified of any change of a resident's condition. There was no documented evidence available for review that Resident #1's representative was notified on 10/24/2020 of the linear laceration to her right eyebrow. 483.10(g)(14)(i)-(iv)