Every finding on record at St Patrick's Home

Based on observation, record review, and interviews, the facility failed to ensure sufficient nursing staff were available to provide nursing and related services to assure resident safety to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing of each resident. Specifically, interviews with residents, resident representatives, and staff members indicated that there were staffing concerns in the facility. Additionally, a review of staffing from 11/02/2024 -12/08/2024, from 01/01/2026-03/31/2026, and from 06/22/2026 -06/29/2026 indicated multiple dates where the facility did not ensure sufficient nursing staffing based on their facility assessment's staffing levels. The Payroll Based Journal Staffing Data Report for 01/01/2026-03/31/2026 triggered for One Star Staffing Rating and excessively low weekend staffing.The findings are:The policy titled Staffing Hours-Clinical last revised on 08/27/2025 documented that the facility provides sufficient staffing to provide care and services for the facility resident population in accordance with State and Federal Regulations.The New York State Department of Health intake #709142 dated 12/05/2024 documented received a complaint from a resident representative who requested that the resident remain anonymous. The representative alleged that the call bells on the unit were not answered in a timely manner. The representative reported that the residents waited up to three hours for assistance with toileting and that the anonymous resident remained in bed until approximately 2:00PM. The representative further alleged that only two certified nursing assistants were working on the unit and stated these concerns were recurring on the weekends.The New York State Department of Health intake #3011806 dated 05/12/2026 documented received a complaint from Resident #146's resident representative who reported on 05/10/2026 they observed residents lined up in the hallway on the locked dementia unit. When the resident representative asked staff why the residents were sitting in the hallway without activities, staff reportedly indicated there were only three staff members caring for 44 residents on the dementia unit. The resident representative further also stated that due to the staffing shortage, they had to provide feeding assistance for Resident #146. The Facility Assessment last updated 11/2025 documented the following par levels for the facility:Day Shift (7:00 AM - 3:00 PM):3rd Floor (bed capacity of 44): 2 Licensed Practical Nurse/Registered Nurse, 4-7 Certified Nursing Assistants4th Floor (bed capacity of 44): 2 Licensed Practical Nurse/Registered Nurse, 4-6 Certified Nursing Assistants5th Floor (bed capacity of 44): 2 Licensed Practical Nurse/Registered Nurse, 4-7 Certified Nursing Assistants6th Floor (bed capacity of 44): 2 Licensed Practical Nurse/Registered Nurse, 4-7 Certified Nursing Assistants7th Floor (bed capacity of 44): 2 Licensed Practical Nurse/Registered Nurse, 4-6 Certified Nursing Assistants8th Floor (bed capacity of 44): 2 Licensed Practical Nurse/Registered Nurse, 4-6 Certified Nursing AssistantsEvening Shift (3:00 PM - 11:00 PM):3rd Floor (bed capacity of 44): 2 Licensed Practical Nurse/Registered Nurse, 4-6 Certified Nursing Assistants4th Floor (bed capacity of 44): 2 Licensed Practical Nurse/Registered Nurse, 4-5 Certified Nursing Assistants5th Floor (bed capacity of 44): 2 Licensed Practical Nurse/Registered Nurse, 4-6 Certified Nursing Assistants6th Floor (bed capacity of 44): 2 Licensed Practical Nurse/Registered Nurse, 4-7 Certified Nursing Assistants7th Floor (bed capacity of 44): 2 Licensed Practical Nurse/Registered Nurse, 4-5 Certified Nursing Assistants8th Floor (bed capacity of 44): 2 Licensed Practical Nurse/Registered Nurse, 4-5 Certified Nursing AssistantsNight Shift (11:00 PM - 7:00 AM):3rd Floor (bed capacity of 44): 2 Licensed Practical Nurses/Registered Nurse, 2-3 Certified Nursing Assistants4th Floor (bed capacity of 44): 1 Licensed Practical Nurse/Registered Nurse, 2-3 Certified Nursing Assistants5th Floor (bed capacity of 44): 1 Licensed Practical Nurse/Registered Nurse, 2 Certified Nursing Assistants6th Floor (bed capacity of 44): 1 Licensed Practical Nurse/Registered Nurse, 2-3 Certified Nursing Assistants7th Floor (bed capacity of 44): 1 Licensed Practical Nurse/Registered Nurse, 2 Certified Nursing Assistants8th Floor (bed capacity of 44): 1 Licensed Practical Nurse/Registered Nurse, 2 Certified Nursing Assistants Review of the actual staffing schedules from 11/02/2024 through 12/08/2024 documented the following:On 11/02/2024 on the day shift, the 5th Floor was short of one nurse and one Certified Nursing Assistant, and the 6th, 7th, and 8th Floors were short of one nurse.On 11/02/2024 on the evening shift, the 3rd Floor and 4th Floors were short of one nurse, 5th, 6th, 7th, and 8th Floors were short of one nurse and one Certified Nursing Assistant.On 11/03/2024 on the day shift, the 4th, 6th, 7th, and 8th Floors were short of one nurse.On 11/03/2024 on the evening shift, the 3rd Floor and 8th Floors were short of one nurse, and the 4 th, 5th, 6th, and 7th Floors were short of one nurse and one Certified Nursing Assistant. On 11/09/2024 on the evening shift, the 4th and 8th Floors were short of one nurse, the 3rd Floor was short of one Certified Nursing Assistant, and the 5th, 6th, and 7th Floors were short of one Nurse and one Certified Nursing Assistant.On 11/10/2024 on the day shift, the 3rd Floor was short of one Certified Nursing Assistant.On 11/10/2024 on the evening shift, the 4th, 6th, and 7th Floors were short of one nurse, and the 8th Floor Unit was short of one Certified Nursing Assistant. On 11/16/2024 on the day shift, the 4th Floor Unit was short of one nurse.On 11/16/2024 on the evening shift, the 4th, 6th, and 7th Floors were short of one nurse, and the 5th Floor and 8th Floors were short of one nurse and one Certified Nursing Assistant.On 11/17/2024 on the day shift, the 4th, 5th, 7th, and 8th Floors were short of one nurse.On 11/17/2024 on the evening shift, the 3rd and 6th Floors were short of one Certified Nursing Assistant, and the 5th, 7th, and 8th Floors were short of one nurse and one Certified Nursing Assistant.On 11/24/2024 on the day shift, the 5th Floor Unit was short of one nurse and one Certified Nursing Assistant.On 11/24/2024 on the evening shift, the 3rd Floor Unit was short of one Certified Nursing Assistant, 6th Floor Unit was short of one Nurse, the 5th and 8th Floors were short of one nurse and one Certified Nursing Assistant and the 7th Floor was short of one nurse and two Certified Nursing AssistantsOn 11/30/2024 on the day shift, the 6th Floor Unit was short of one nurse and one Certified Nursing Assistant, and the 8th Floor was short of one Certified Nursing Assistant.On 11/30/2024 on the evening shift, the 6th Floor was short of one Certified Nursing Assistant, the 3rd and 5th Floors were short of two Certified Nursing Assistants, and the 7th and 8th Floors were short of one nurse and one Certified Nursing Assistant.On 12/01/2024 on the day shift, the 3rd Floor was short of one Certified Nursing Assistant, the 5th Floor was short of one Nurse, and the 6th, 7th, and 8th Floors were short of one nurse and one Certified Nursing Assistant.On 12/01/2024 on the evening shift: the 3rd Floor was short of one Certified Nursing Assistant, the 4th, 5th, 6th, 7th, and 8th Floors were short of one nurse and one Certified Nursing Assistant.On 12/07/2024 on the day shift, the 6th Floor was short of one nurse.On 12/07/2024 on the evening shift, the 5th Floor was short of one Certified Nursing Assistant.On 12/08/2024 on the day shift, the 7th and 8th Floors were short of one nurse.On 12/08/2024 on the evening shift, the 5 th and 6th Floors were short of one nurse and one Certified Nursing Assistant, the 7th Floor was short of one Certified Nursing Assistant, the 8th Floor was short of one Nurse.Review of the actual staffing schedules from 01/01/2026 through 03/31/2026 documented the following:On 01/03/2026 on the evening shift, the 3rd, 4th, 6th, and 8th Floors Unit were short of one Certified Nursing Assistant.On 01/04/2026 on the day shift, the 4th, 6th, and 7th Floors were of one nurse and the 5th Floor was short of one nurse and one Certified Nursing Assistant.On 01/04/2026 on the evening shift, the 5th and 7th Floors were short of one nurse and one Certified Nursing Assistant, and the 6th and 8th Floors were short of one nurse.On 01/10/2026 on the day shift, the 5th, 6th, 7th, and 8th Floors were short of one nurse and one Certified Nursing Assistant, and the 4th Floor Unit was short of one nurseOn 01/10/2026 on the evening shift, the 5th Floor and 7th Floors were short of one Certified Nursing Assistant, and the 6th and 8th Floors were short of one nurse. On 01/11/2026 on the day shift, the 4th, 6th, 7th, and 8th Floors were short of one nurse.On 01/11/2026 on the evening shift, the 4th, 5th, and 6th Floors were short of one Nurse, and the 7th and 8th Floors were short of one nurse and one Certified Nursing Assistant.On 01/17/2026 on the day shift, the 5th Floor Unit was short of one Certified Nursing Assistant.On 01/17/2026 on the evening shift, the 8th Floor Unit was short of one Certified Nursing Assistant, and the 5th and 7th Floors were short of one nurse.On 01/18/2026 on the day shift, the 3rd and 6th Floors were short of one Certified Nursing Assistant, the 7th Floor Unit was short of one nurse, and the 8th Floor Unit was short of one nurse and one Certified Nursing Assistant.On 01/18/2026 on the evening shift, the 3rd and 7th Floors were short of one Certified Nursing Assistant, the 8th Floor was short of one nurse and two Certified Nursing Assistants, and the 6th Floor was short of one nurseOn 01/24/2026 on the day shift, the 3rd and 4th Floors were short of one Certified Nursing Assistant, the 5th, 7th, and 8th Floors were short of one nurse and one Certified Nursing Assistant, and the 6th Floor Unit was short of one nurse.On 01/24/2026 on the evening shift, the 5th Floor was short of one Certified Nursing Assistant, and the 7th and 8th Floors were short of one nurse. On 01/25/2026 on the day shift, the 4th, 5th, 6th, 7th and 8th Floors were short of one nurse.On 01/25/2026 on the evening shift, the 5th, 6th, and 7th Floors were short of one nurse, and the 8th Floor was short of one nurse and one Certified Nursing Assistant.On 01/25/2026 on the night shift, the 3rd Floor Unit was short of one nurse.On 01/31/2026 on the day shift, the 5th and 8th Floors were short of one nurse and one Certified Nursing Assistant, and the 4th and 7th Floors were short of one nurse.On 01/31/2026 on the evening shift, the 3rd and 5th Floors were short of one nurse.On 02/01/2026 on the day shift, the 5th, 7th, and 8th Floors were short of one nurse and one Certified Nursing Assistant, and the 4th Floor Unit was short of one nurse.On 02/01/2026 on the evening shift, the 7th and 8th Floors were short of one nurse.On 02/07/2026 on the day shift, the 5th, 6th, 7th and 8th Floors were short of one nurse.On 02/07/2026 on the evening shift, the 5th Floor was short of one Certified Nursing Assistant, the 8th Floor was short of one nurse and one Certified Nursing Assistant, and the 7th Floor was short of one nurse.On 02/08/2026 on the day shift, the 4th, 5th, 6th, and 8th Floors were was short of one nurse, and the 7th Floor was short of one Nurse and one Certified Nursing Assistant.On 02/08/2026 on the evening shift, the 4th and 6th Floors were short of one nurse, and the 5th and 7th Floors were short of one nurse and one Certified Nursing Assistant.On 02/14/2026 on the day shift, 5th and 7th Floors were short of one nurse and one Certified Nursing Assistant, and the 4th, 6th and 8th Floors were short of one nurse.On 02/14/2026 on the evening shift, the 7th Floor was short of one nurse and one Certified Nursing Assistant.On 02/14/2026 on the night shift, the 3rd Floor was short of one nurse.On 02/15/2026 on the day shift, the 6th, 7th, and 8th Floors were short of one nurse.On 02/15/2026 on the evening shift, the 6th Floor was short of one nurse, and the 7th and 8th Floors were short of one nurse and one Certified Nursing Assistant.On 02/15/2026 on the night shift, the 3rd Floor Unit was short of one nurse.On 02/21/2026 on the day shift, the 5th Floor was short of one Nurse and one Certified Nursing Assistant, and the 6th, 7th, and 8th Floors were short of one nurse.On 02/21/2026 on the evening shift, the 8th Floor was short of one Certified Nursing Assistant, the 7th Floor was short of one nurse and one Certified Nursing Assistant, and the 4th and 6th Floors were short of one nurse.On 02/21/2026 on the night shift, the 3rd Floor Unit was short of one nurse.On 02/22/2026 on the day shift, the 5th, 6th, 7th, and 8th Floors were short of one nurse.On 02/22/2026 on the evening shift, the 4th and 8th Floors were short of one nurse and one Certified Nursing Assistant, and the 5th, 6th, and 7th Floors were short of one nurse.On 02/22/2026 on the night shift, the 3rd Floor was short of one nurse.On 02/28/2026 on the day shift, the 5th and 7th Floor was short of one nurse and one Certified Nursing Assistant, and the 8th Floor was short of one nurse. On 02/28/2026 on the evening shift, the 6th Floor Unit was short of one nurse and two Certified Nursing Assistants, and the 7th Floor Unit was short of one Certified Nursing Assistant. On 03/01/2026 on the day shift, the 4th, 6th, and 8th Floor s were short of one nurse, and the 7th Floor Unit was short of one nurse and two Certified Nursing Assistants.On 03/01/2026 on the evening shift, the 4th and 5th Floors were short of one nurse, and the 6th and 7th Floors were short of one nurse and one Certified Nursing Assistant.On 03/01/2026 on the night shift, the 3rd Floor was short of one nurse, and the 4th Floor Unit was short of one Certified Nursing Assistant.On 03/07/2026 on the day shift, the 4th, 6th, and 7th Floors were short of one nurse, and the 5th and 8th Floors were short of one nurse and one Certified Nursing Assistant.On 03/07/2026 on the evening shift, the 4th and 6th Floors were short of one nurse, and the 5th, 7th, and 8th Floors were short of one nurse and one Certified Nursing Assistant.On 03/08/2026 on the day shift, the 5th, 6th, 7th, and 8th Floors were short of one nurse and one Certified Nursing Assistant.On 03/08/2026 on the evening shift, the 5th, 7th, and 8th Floors were short of one nurse and one Certified Nursing Assistant, and the 4th and 6th Floors were short of one nurse.On 03/14/2026 on the day shift, the 4th, 5th, 6th, 7th, and 8th Floors were short of one nurse.On 03/14/2026 on the evening shift, the 4th Floor was short of one nurse and one Certified Nursing Assistant, and the 7th and 8th Floors were short of one nurse.On 03/14/2026 on the night shift, the 3rd Floor Unit was short of one nurse.On 03/15/2026 on the day shift, the 3rd, 4th, 5th, and 6th Floors were short of one nurse, and the 7th and 8th Floors were short of one nurse and one Certified Nursing Assistant. On 03/15/2026 on the evening shift, the 4th, 5th, and 6th Floors were short of one nurse, and the 7th Floor and 8th Floors were short of one nurse and one Certified Nursing Assistant.On 03/15/2026 on the night shift, the 3rd Floor was short of one nurse.On 03/21/2026 on the day shift, the 7th Floor was short of one Nurse, and the 8th Floor was short of one nurse and one Certified Nursing Assistant.On 03/21/2026 on the evening shift, the 6th and 7th Floors were short of one nurse, and the 8th Floor was short of one nurse and one Certified Nursing Assistant. On 03/22/2026 on the day shift, the 6th and 7th Floors were short of one nurse, and the 8th Floor was short of one nurse and one Certified Nursing Assistant. On 03/22/2026 on the evening shift, the 4th Floor Unit was short of one Certified Nursing Assistant, the 5th and 7th Floors were short of one Nurse and one Certified Nursing Assistant, and the 6th and 8th Floors were short of one Nurse.On 03/22/2026 on the night shift, the 3rd Floor Unit was short of one nurse.On 03/28/2026 on the day shift, the 7th and 8th Floors were short of one nurse.On 03/28/2026 on the evening shift, the 7th and 8th Floors were short of one Nurse. On 03/28/2026 on the night shift, the 3rd Floor was short of one Nurse.On 03/29/2026 on the day shift, the 8th Floor was short of one Certified Nursing Assistant, the 5th and 7th Floors were short of one nurse and one Certified Nursing Assistant, and the 4th and 6th Floors were short of one nurseOn 03/29/2026 on the evening shift, the 3rd Floor was short of one Certified Nursing Assistant, the 5th, 6th, and 8th Floors were short of one nurse and one Certified Nursing Assistant, and the 7th Floor Unit was short of one nurse.On 03/29/2026 on the night shift, the 3rd Floor Unit was short of one nurse, and the 4th and 7th Floor had no nurse. Review of the actual staffing schedules on 05/10/2026 documented the following:On 05/10/2026 on the day shift, the 4th Floor was short of one nurse and one Certified Nursing Assistant.On 05/10/2026 on the evening shift, the 4th Floor Unit was short of one nurse. Review of the actual staffing schedules from 06/22/2026 through 06/29/2026 documented the following:On 06/22/2026 on the day shift, the 6th Floor Unit was short of one nurse and one Certified Nursing Assistant. On 06/22/2026 on the evening shift, the 4th Floor, 7th, and 8th Floors were short of one nurse.On 06/22/2026 on the night shift, the 3rd Floor was short of one nurse.On 06/23/2026 on the evening shift, the 5th and 8th Floors were short of one nurse.On 06/23/2026 on the night shift, the 3rd Floor Unit was short of one nurse.On 06/24/2026 on the day shift, the 6th, 7th, and 8th Floors were short of one nurse.On 06/24/2026 on the evening shift, the 6th, 7th, and 8th Floors were short of one nurse.On 06/25/2026 on the day shift, the 4th, 7th, and 8th Floors were short of one nurse.On 06/25/2026 on the evening shift, the 4th, 5th, 6th, and 8th Floors were short of one nurse.On 06/26/2026 on the day shift, the 4th, 5th, and 7th Floors were short of one nurse.On 06/26/2026 on the evening shift, the 7th and 8th Floors were short of one nurse.On 06/26/2026 on the night shift, the 3rd Floor was short of one nurse.On 06/27/2026 (Saturday) on the day shift, the 5th Floor was short of one Certified Nursing Assistant, the 6th Floor was short of one nurse and one Certified Nursing Assistant, and the 4th and 7th Floors were short of one nurse.On 06/27/2026 on the evening shift, the 4th, 5th, 6th, 7th, and 8th Floors were short of one nurse.On 06/28/2026 (Sunday) on the day shift, the 7th Floor was short of one nurse, and the 8th Floor was short of one nurse and one Certified Nursing Assistant.On 06/28/2026 on the evening shift, the 6th Floor Unit was short of one Certified Nursing Assistant, and the 4th, 7th, and 8th Floor were short of one nurse.On 06/29/2026 on the day shift, the 5th, 7th and 8th Floors were short of one Certified Nursing Assistant and the 4th Floor Unit was short of one nurse.On 06/22/2026 at 9:56 AM, Housekeeper #5 was interviewed and stated the facility is consistently short staffed and that call bells ring without being answered. Housekeeper #5 also stated that, upon arrival at 7:00 AM, residents are sometimes walking in the hallway holding their wet incontinent briefs and the unit smells of urine.On 06/23/2026 at 11:15 AM, Resident #156 was interviewed and stated sometimes on weekends there were only two to three certified nursing assistants working on the unit due to call outs. Resident #156 also stated recently there was no regular nurse assigned to their unit, and the nursing supervisor was covering on the floor.On 06/23/2026 at 11:56 AM, Resident #278 was interviewed and stated that the facility was short staffed this past weekend, and during the night. Resident #278 also stated it took up to two hours waiting for staff to respond after they rang the call bell.On 06/24/2026 at 9:14 AM, [NAME] #1 was interviewed and stated that there is sometimes a foul odor on the unit. [NAME] #1 also reported that call bells are not always answered promptly and that residents have asked the porter to notify the nurse because they needed assistance. [NAME] #1 stated these issues have been observed on various days of the week.On 06/24/2026 at 11:03 AM, Certified Nursing Assistant #10 was interviewed and stated that on the weekends the unit is sometimes short-staffed, with only two to three Certified Nursing Assistants assigned. Certified Nursing Assistant #10 also stated that when staffing is low some residents remain in bed. Certified Nursing Assistant #10 further stated that call bells may ring for extended periods before staff are able to answer them.On 06/25/2026 at 11:14 AM, Resident #193 was interviewed and stated they press their call light and have to wait a long time especially at night. Resident #193 also stated they need help to get to the bathroom, but staff do not come in time, and they end up being incontinent while waiting.On 06/26/2026 at 9:51 AM, Registered Nurse #1, who is a supervisor, was interviewed and stated that the facility is sometimes short staffed, most often on weekends, but also during the week. Registered Nurse #1 also stated that certified nursing assistants frequently call out on short notice. Registered Nurse #1 further stated that having only three certified nursing assistants is difficult given the resident census of 44. Registered Nurse #1 stated that when staffing is short, some residents remain in bed longer because of insufficient staff available to assist them.On 06/26/2026 at 10:18 AM, Resident #117 was interviewed and stated on the night shift they do not always receive a clean incontinent brief due to limited staffing. Resident #117 also stated the certified nursing assistants state they are short staffed, with only one or two aides working and doing their best, and when care is requested around 8:00 AM, certified nursing assistants may say they will return later due to staffing shortages. Resident #117 further stated this occurs on all days not just on the weekends.On 06/26/2026 at 10:45 AM, Certified Nursing Assistant #8 was interviewed and stated that they work every Monday and Saturday. Certified Nursing Assistant #8 also stated that staffing varies and there are sometimes only three Certified Nursing Assistants assigned. Certified Nursing Assistant #8 further stated when there are only three Certified Nursing Assistants working, some residents do not receive their scheduled showers and call bells are not answered as quickly. Certified Nursing Assistant #8 stated that when there are only three Certified Nursing Assistants, they have 15 residents to care for.On 06/26/2026 at 4:24 PM, Licensed Practical Nurse #8 was interviewed and stated that staffing shortages occur frequently, and typically one nurse is assigned per floor, which can be challenging given the residents' behavioral needs. Licensed Practical Nurse #8 also stated there are occasions when only three aides are present, and they do the best they can under those circumstances. At times residents may not receive a shower and instead a bed bath due to limited staffing. Licensed Practical Nurse #8 further stated they work some overnights and there have been occasions when there was only one aide on the floor requiring the nurse to assist them with care. Licensed Practical Nurse #8 stated residents have complained about call lights not being answered timely.On 06/29/2026 at 10:32 AM, the Staffing Coordinator was interviewed and stated that orientation is conducted every two weeks in an effort to recruit and onboard new employees. The Staffing Coordinator also stated there is frequent turnover, noting that some new hires attend orientation for only about one week before leaving. The Staffing Coordinator further stated there are recurring last-minute callouts, especially on the weekends, and they overstaff to mitigate these call outs. The facility maintains a list of per diem and regular staff who can be contacted to fill shifts. The Staffing Coordinator stated nursing supervisors assist them with calling employees in when needed. The Staffing Coordinator stated they are not aware of any specific incentives to attract or retain staff. Long term employees are highly reliable and new employees are more likely to call out. The Staffing Coordinator also stated registered nurse supervisors occasionally cover shifts when a licensed practical nurse calls out, and several nurses are currently on leave. The Staffing Coordinator further stated they meet daily with the Director of Nursing and the Administrator to review staffing issues and escalate concerns as needed.On 06/29/2026 at 12:08 PM, the Director of Nursing was interviewed and stated that the facility PAR staffing level is two licensed practical nurses however there are times when only one licensed practical nurse is present. The Director of Nursing also stated that staffing is affected by call outs, employee illness, and staff taking time off to care for family members. The Director of Nursing further stated that the facility typically staffs five certified nursing assistants on day and evening shifts and aims for a minimum of three certified nursing assistants for the night shift. When call outs occur, the Registered Nurse supervisor also provides coverage and support. Staff may be asked to stay beyond their scheduled shift as well. Agency staff are utilized when necessary to address staffing shortages. The Director of Nursing stated there are ongoing recruitment efforts, including posting positions on hiring websites, and additional certified nursing assistants and licensed practical nurses are expected to be hired soon. The Director of Nursing further stated that the Staffing Coordinator meets with them weekly on Thursdays to review staffing levels to ensure adequate weekend coverage, and the facility attempts to maintain PAR staffing levels despite call outs causing scheduling changes.On 06/29/2026 at 1:09 PM, the Administrator was interviewed and stated the interdisciplinary team meetings are held annually to assess and determine the facility's staffing needs. The Administrator also stated that the facility has recently hired a significant number of nurses and certified nursing assistants and has actively recruited through multiple employee hiring websites. The Administrator further stated during staff call-outs the facility implements an all hands on deck approach. When multiple call outs occur, staff may be asked to remain on duty, come in early, or pick up additional shifts. The Administrator stated that incentive bonuses are offered to encourage staff coverage during staffing shortages, and the facility utilizes at least two staffing agencies as well. The Administrator also stated that they meet with the staffing coordinator and the Director of Nursing daily to review staffing levels and address any identified concerns.10 New York Codes, Rules and Regulations 415.13(a)(1)(i-iii)

Based on observations, record review, and staff interviews, the facility failed to ensure that a person-centered comprehensive care plan was developed and implemented to address the residents' medical, physical, mental, and psychosocial needs. This was evident for two of five residents (Resident #3, #191) reviewed for Unnecessary Medications, one of one resident (Resident #277) reviewed for Bladder Incontinence, and one of one resident (Resident #51) reviewed for Respiratory Care out of a sample of 38 residents. Specifically, 1). A comprehensive care plan was not developed and implemented for Resident #3 who was receiving anticoagulant treatment, 2). A comprehensive care plan was not created for Resident #277 who has indwelling urinary catheter, 3). A comprehensive care plan was not created for Resident #51 who is receiving oxygen treatment and 4). A comprehensive care plan was not created for Resident #191 who is receiving diuretic medication. Number of residents sampled: 7Number of residents cited: 4 The findings are: The facility's policy and procedure titled Care Plans - Comprehensive reviewed 03/02/2026 documented a comprehensive person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. Resident #3 was admitted to the facility with diagnoses including deep vein thrombosis (condition where a blood clot forms in a deep vein), pulmonary embolism (blockage in a lung artery, typically caused by a blood clot) and depression (mood disorder that causes persistent sadness, loss of interest, and physical fatigue). The Quarterly Minimum Data Set (an assessment tool) dated 05/08/2026 documented Resident #3 had intact cognition and received anticoagulant medication in the last seven days. The Physician Order initiated 04/26/2026 renewed 06/18/2026 documented Apixaban 5 milligrams tablet every 12 hours for Atrial Fibrilization, Prophylaxis of Deep Vein Thrombosis, Treatment of Deep Vein Thrombosis/Pulmonary Embolism Prophylaxis. There was no documented evidence a comprehensive care plans had been created for anticoagulant use. 2. Resident #277 was admitted to the facility with diagnoses including cerebrovascular accident (condition where blood flow to a part of the brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients), colostomy (a surgical procedure that creates a new path for waste to leave the body) and malignant neoplasm (an abnormal mass of cells that grows uncontrollably and invades surrounding healthy tissues). The admission Minimum Data Set (an assessment tool) dated 06/02/2026 documented Resident #277 had an indwelling catheter. The Hospital Visit Summary dated 05/20/2026 documented Resident #277was seen by urology, noted with urinary retention, Foley catheter was placed. Recommended to follow up in three weeks, change Foley catheter within four weeks. The Registered Nurse assessment dated [DATE] documented Resident #277 returned from urology appointment, noted with urinary retention as per bladder scanned. Foley catheter was placed during visit. The Physician Orders initiated 05/20/2026 discontinued 06/02/2026 (due to hospitalization) documented Foley Catheter Care every shift, as needed, Irrigate Indwelling Catheter with 30 milliliters of Normal Saline as needed for blockage, and Record Output. The Physician Orders initiated 06/17/2026 documented Indwelling Cather to Down Drain: Balloon 10 French 16 Change as Needed, Irrigate Urinary Catheter with 30 cubic centimeters Normal Saline Solution as needed, Record Output every shift, and Catheter Care every shift. The Urology Consultation dated 06/17/2026 documented to keep indwelling catheter, change monthly and follow up in three weeks. There was no documented evidence that a care plan was created for the care of Resident #277's indwelling urinary catheter. On 06/26/2026 at 09:30 AM, Registered Nurse #4 stated Resident #3 has been on anticoagulant medication for some time and Resident #277 had Foley catheter was placed during their urology visit on 05/20/2026 as per their record review. Registered Nurse #4 stated they could not locate the care plan created for Resident #3's anticoagulant medication nor Resident #277's Foley catheter management in their record. Registered Nurse #4 could not explain why they were not in place and acknowledged that it should be initiated when anticoagulant was initiated and when catheter was placed. On 06/29/2026 at 09:15 AM, Registered Nurse #3 stated Resident #277 was admitted [DATE] and during their urology visit, had Foley catheter placed on 05/20/2026 as per record review. Registered Nurse #3 stated the care plan was initiated when orders are initiated but it was probably not reinitiated when Resident #277 returned after being hospitalized from [DATE] to 06/10/2026. Registered Nurse #3 stated that admitting nurse will initiate all orders/care plans upon admission and Registered Nurse #3 will review on following day to ensure accuracy. Upon reviewing the record, Registered Nurse #3 stated Resident #3's anticoagulant use should have been implemented in the care plan for their risk of bleeding/bruising, and Resident #277's Foley catheter should have been initiated in their plan of care. 3. Resident #191 was admitted to the facility with diagnoses that include hypertension (high blood pressure), and Schizophrenia (a chronic and severe mental illness that affects how a person thinks), and edema (swelling caused by excess fluids trap in body tissues). The Quarterly Minimum Data Set (an assessment tool) dated 05/28/2026 documented Resident #191's cognition as intact, and the resident receives diuretics. A physician's order dated 02/26/2026 last revised on 03/27/2026 documented Furosemide Tablet 40 milligrams (medication to remove excess fluids from the body), one tablet by mouth, once daily, for bilateral lower extremity edema. The Medication Administration Record dated 06/01/2026 to 06/29/2026 documented Furosemide 40 milligrams were administered as ordered. There was no documented evidence that a comprehensive care plan was created to address the use of Furosemide and the bilateral lower extremities edema. During an interview on 06/29/2026 at 11:57 AM, Registered Nurse #5, who is also the supervisor, said they complete a basic care plan for medications and medical diagnoses for new admissions. Registered Nurse #5 also stated they initiate a care plan when a new medication is ordered. Resident #191 is on Furosemide 40 milligrams daily for bilateral lower extremity edema, and there is no care plan for furosemide use. Registered Nurse #5 further stated that the registered nurse supervisors are responsible for implementing the care plan, and a care plan for furosemide use should have been initiated to address the edema. During an interview on 06/29/2026 at 2:01 PM, the Director of Nursing stated that there was no care plan for Furosemide or the residents' edema, and that there should have been a care plan in place to address the medication's use. The Director of Nursing also stated that the nursing supervisors are responsible for implementing the residents' care plans and initiating care plans for medications and diagnoses. The Director of Nursing further stated that they are responsible for ensuring that care plans are in place. 4. Resident #51 was admitted to the facility with diagnoses that included coronary artery disease (a common type of heart disease that affects the main blood vessels that supply blood to the heart), hypertension (a chronic condition in which the force of blood pushing against artery walls is consistently too high), pneumonia (an infection that inflames the air sacs in one or both lungs, which can fill with fluid or pus). The Quarterly Minimum Data Set (an assessment tool) dated 06/02/2026 documented Resident #51 had moderate impairment in cognition and was receiving oxygen therapy. A Physician's order dated 01/28/2026 documented supplemental oxygen via 2-4 Liter/minute to maintain oxygen saturation greater than 90%. There was no documented evidence that a care plan was developed or implemented for safe use of oxygen therapy. On 06/23/2026 at 9:38 AM, Resident #51 was observed in their room, receiving oxygen via nasal canula. On 06/25/2026 at 11:59 AM, Registered Nurse #1 was interviewed and stated that Resident #51 has been on oxygen therapy since admission for shortness of breath. Registered Nurse #1 also stated that there was respiratory care plan in place for Resident #51, but there has not been a specific care plan for oxygen use. Registered Nurse #1 could not explain why a care plan for oxygen therapy was not initiated/implemented for Resident #51. On 06/25/2026 at 1:22 PM, the Director of Nursing was interviewed and stated that once there is doctor's order for oxygen use, there must be a care plan for oxygen therapy to ensure that the resident's use of oxygen is properly monitored and documented to prevent complications of oxygen use. The Director of Nursing also stated that the Nursing Supervisors are responsible for initiating and updating residents' care plans. The Director of Nursing further stated that they were not aware that a care plan had not been created for Resident #51's use of oxygen. 10 New York Code, Rules and Regulations 415.11(c)(1).

Based on observations, record reviews and interviews, the facility failed to ensure that residents are treated with respect and dignity and cared for in a manner and in an environment that promotes maintenance or enhancement of their quality of life, recognizing each resident's individuality. This was evident for one of two residents (Resident #36) reviewed for Dignity, and two residents (Resident #226 and Resident #95) observed during the Dining observation. Specifically, 1. Resident #36 was observed on multiple occasions in a malodorous, unclean room with multiple flies hanging from a fly trap, and 2). Staff were observed standing while feeding Resident #226 and Resident #95 in the dining room. Number of residents sampled: 4Number of residents cited: 3 1. The facility policy titled Home Like Environment last reviewed 3/2026 documented residents are provided with a safe, clean, comfortable environment and encouraged to use their personal belongings to the extent possible. The facility policy titled Resident Rights last reviewed 5/2026 documented residents will have a dignified existence. The facility policy titled Quality of Life/Dignity last reviewed 5/2026 documented each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Resident #36 was admitted to facility with diagnoses that included pain, history of falls, muscle weakness, and Non-Alzheimer's Dementia (a pattern of mental decline caused by different diseases or conditions). The Quarterly Minimum Data Set (an assessment tool) dated 05/26/2026 documented Resident #36 had intact cognition, with no signs and symptoms of delirium. The Minimum Data Set also documented Resident #36 required supervision for eating, transfers, oral care and personal hygiene, partial moderate assistance for toileting and showers, and rejected care on one to three days of the review period. On 06/22/2026 at 10:41 AM, Resident #36's room was observed with the door closed and there was a strong urine odor coming from the room which was detected from the hallway. When the State Surveyor entered the room, the urine smell was stronger, and the floor was sticky. An un-emptied urinal that was a quarter-filled was observed at the bedside. On 06/25/2026 at 9:43 AM, Resident #36's was observed to have a strong urine odor. A white three drawer storage container had built-up dirt on the container, and the base of bedside lamp on top of the container was soiled. A fly sticker was hanging from the roof with multiple large dead flies stuck to it. An uncovered urinal which was quarter filled was at the bedside. On 06/29/2026 at 9:15 AM, Resident #36 was observed sitting on the bed in their room in which a strong urine odor persisted. The comprehensive care plan titled Resident has impaired cognition created 08/22/2025 and last reviewed 06/04/2026 including interventions of ask yes or no questions to determine the resident's needs, communicate with the resident and or resident representative regarding capabilities, and explain to resident what staff is doing. The comprehensive care plan titled Resident exhibits behaviors such as refusing showers, hoarding, refusing care was created 05/06/2024 and last reviewed on 06/04/2026 and included interventions of acknowledge resident feelings/encourage to express their feelings, educate/encourage appropriate behavior, and re-approach resident for care/toileting/medication administration/treatments and other needs when resident is more agreeable. The Physician orders last reviewed 06/21/2026 documented monitor Resident #36 behaviors of refusing showers, hoarding, refusing care every shift. Document interventions and outcome. The Medication Administration Record dated documented behaviors of refusing showers, hoarding, and care on 01/21/2026, 02/22/2026, 03/31/2026, 04/23/3036, 04/29/2026, and 06/22/2026. The Interdisciplinary meeting progress note dated 06/09/2025 documented resident representative in attendance, resident invited and decline. Resident #36 continues to be encouraged to allow staff to clean their room and allow staff to shower, clean clothes and allow staff to clean room. Resident #36 has hoarding tendency. The Interdisciplinary meeting progress note dated 12/02/2025 documented Resident #36 refused to attend and representative was in attendance. Staff continue to encourage Resident #36 to allow staff to clean resident's room, showering and personal care. The Medical progress note dated 06/01/2026 documented positive memory loss with resistance to care. Assist with bathing and dressing, incontinence care as needed, one assist with transfers, behaviors including rejection of care, feeds self after setting up, anticipate further functional and cognitive decline with progression of Dementia, continue routine psychiatry follow up. The Psychiatric consults dated 01/23/2026, 003/19/2026 and 6/11/2026 documented continue non-pharmacological interventions and environmental management to minimize factors contributing to confusion. The facility failed to ensure that Resident #36, who's diagnoses included Dementia, had an environment that maintained their quality of life, respect, and dignity. During an interview via phone on 06/30/2026 at 9:44 AM, Resident #36's Representative was interviewed and stated the facility did not inform them of the condition of Resident #36's room and they were not aware the room had flies, was dirty, and had strong odor of urine as they had not gone to the facility to visit lately. During an interview on 06/29/2026 at 2:43 PM, the Director of Nursing stated staff attempted to clean Resident #36 room, and at times refused to let anyone go in the room. During an interview on 06/29/2026 at 12:05 PM, Social Worker #1 stated the team does encourage Resident #36 to accept care and to keep their room clean. Social Worker #1 also stated Resident #36 refuses to change clothing at times and has to be encouraged to change clothing and can be resistant at times depending on how they are approached. Social Worker#1 further stated they are aware of flies and odor in the room. During an interview on 06/29/2026 at 10:43 AM, Psychiatric Nurse Practitioner #4 stated Resident #36 has hoarding behavior and they have spoken to the team and Resident #36 multiple times about cleaning the room. Psychiatric Nurse Practitioner #4 stated they are aware of the smell and odor in Resident #36's room but the resident will threaten staff when they try to clean the room, and they will not clean room. Psychiatric Nurse Practitioner #4 further stated they are aware that Resident #36 cannot stay in such condition and the environment needs to be clean. During an interview on 06/29/2026 at 9:46 AM, the Director of Housekeeping and Laundry Services stated they are aware of the condition of Resident #36's room but they must follow what Resident #36 wants. The Director of Housekeeping and Laundry Services also stated they are making an appointment with the nursing staff to get Resident #36 out of the room to clean and will clean up the entire room, but within two days the room is smelling of the urine, because Resident #36 throws the urine on the floor. The Director of Housekeeping and Laundry Services stated the room is checked at least two times daily or at least three times daily by housekeeping staff, and the mattress has been changed at least six times, and every time it ends up soiled. The Director of Housekeeping and Laundry Services stated the smell can be detected from the hallway even when the room door is closed, and housekeeping staff tried to keep up with the cleaning of the room. During an interview on 06/25/2026 at 10:49 AM, Licensed Practical Nurse #3 stated aware the equipment in the room is dirty, the room has odor, and is aware there are big flies in the room and that is why there is a fly sticker in the room to trap the flies. Licensed Practical Nurse #3 also stated Resident #36 refuses everything, and hoards everything. During an interview on 06/25/2026 10:45 AM, Certified Nursing Assistant #6 stated Resident #36 refuses to come out of the room and staff must make an appointment to do anything as Resident #36 may only come out of the room occasionally. Certified Nursing Assistant #6 also stated Resident #36 will refuse to have linens changed daily, refuse to come out of the room, refuse to change clothing and at times will wear dirty clothing. Certified Nursing Assistant #6 further stated they are aware of the conditions in the room, and nothing was done to the room because Resident #36 does not want to get out of the room. 2. The facility policy titled Quality of Life/Dignity dated 09/2014 and updated 05/2026 stated that each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. The policy also stated residents should be treated with dignity and respect at all times. On 06/22/2026 between 12:20 PM and 12:44 PM, Certified Nursing Assistant #1 and Certified Nursing Assistant #2 were observed standing while feeding Resident #226 and Resident #95 respectively. Registered Nurse #1 was observed moving in and out of the two dining rooms on the unit during the residents' meals. On 06/22/2026 at 12:41 PM, Certified Nursing Assistant #2 was interviewed and stated that they found it awkward sitting down feeding Resident #95. Certified Nursing Assistant #2 also stated that it feels weird feeding resident when sitting, it seems uncomfortable, it as if they have 2 left hands when sitting down to feed Resident #95. On 06/22/2026 at 12:44 PM, Certified Nursing Assistant #1 was interviewed and stated that they know they need to sit but it is uncomfortable sitting down when feeding the resident. On 06/22/2026 at 12:52 PM, Registered Nurse #1 was interviewed, and stated that it was disappointing seeing Certified Nursing Assistant #2 feeding Resident #95 while standing. Registered Nurse #1 also stated Certified Nursing Assistant #2 has worked in the facility for a long time and has been received many in-services on resident's care and dignity and Certified Nursing Assistant #1 is relatively new and is still under training and may not really know the basics of what is to be done. Resident Nurse #1 further stated that the Licensed Practical Nurse that was covering the side of dining room is expected to monitor the residents and staff to ensure that the staff are providing residents with necessary care. On 06/25/2026 at 1:22 PM, the Director of Nursing was interviewed and stated the Certified Nursing Assistants should know better that they are not supposed to be standing when feeding the residents. The Director of Nursing also stated that it is hard to explain why the staff were observed standing over the residents when feeding them despite the training and ongoing in-services being given to the staff. On 06/29/2026 at 10:07 AM, the Administrator was interviewed and stated that they just cannot explain why the staff should be standing feeding residents when they have been educated on the proper way to feed the residents. 10 New York Code, Rules and Regulations 415.3(c)(1)(i).

Based on record review and staff interview, the facility failed to ensure that the resident and the resident representative were promptly notified when there was a need to alter treatment significantly (that is, a need to adjust an existing medication, and to commence a new form of treatment). This was evident for one of one resident (Resident #33) reviewed for Notification of Change out of a sample of 36 residents. Specifically, the facility failed to notify Resident #33's representative when medication was discontinued. Number of residents sampled: 1Number of residents cited: 1.The findings include:The facility policy titled Notification dated 04/2019, last revised 02/2026 stated the facility must consult with the resident immediately if the resident is competent and notify the resident's physician and designated representative when there is a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment). Resident #33 was admitted to the facility with diagnoses that included Alzheimer's disease, Non-Alzheimer's Dementia, (brain disorders that cause cognitive and behavioral decline) and depression (a common, serious mood disorder that causes persistent sadness, loss of interest, and physical fatigue). The Quarterly Minimum Data Set, dated [DATE] documented Resident #33 had severe impairment in cognition and required supervision or touching assistance of staff for most activities of daily living.The comprehensive care plan titled Cardiovascular dated 12/01/2023, last updated 5/17/2026 documented resident has an alteration in cardiovascular function related to hypotension and had a goal which included resident will maintain current cardiac output as evidenced by no or decreased edema, shortness of breath, or other related symptoms by review date. Interventions included administer medications as prescribed, monitor blood pressure and vital signs as ordered, and monitor lab values and notify physician of abnormal findings. The comprehensive care plan titled Impaired Cognition dated 12/20/2023, last updated 3/13/2026 documented resident has impaired cognition related to Alzheimer's Dementia had a goal of resident will maintain current level of functioning through next review date. Interventions included ask yes/no questions in order to determine resident's needs, engage resident to participate in simple, structured activities, and provide activities that accommodate resident's abilities. On 06/22/2026 at 1:20 PM, the Complainant was interviewed and stated that the major issue they had was that the facility took Resident #33 off medications they needed to survive without telling the family. The Complainant also stated that they only found this out when they requested a list of Resident #33's medication and noted that the medications for dementia and low blood pressure had been stopped and they had not been informed of the reason.A Physician's order dated 11/27/2024 reviewed documented that Resident #33's Namenda 10 mg by mouth 2 times daily was discontinued.A Medical Progress note dated 11/27/2024 documented Namenda 10mg will be discontinued due to its low benefit and contributes to polypharmacy.There were no notes documenting that Midodrine 10mg will be discontinued.Review of progress notes dated November 2024 to June 2025 revealed no documented evidence that Resident #33's representative was notified of the change in medication during this period. On 06/25/2026 at 9:55 AM, Licensed Practical Nurse #1 was interviewed and stated that Resident #33's Namenda and Midodrine were discontinued in November 2024 by the former Unit Physician Assistant that is no longer in the facility. Licensed Practical Nurse #1 also stated that there was no documentation noted in the chart that Resident #33's family was notified of the change in medication.On 06/25/2026 at 1:22 PM, the Director of Nursing was interviewed and stated that when there is any change in a resident's condition or a change in the resident's medication, the family is supposed to be notified. The Director of Nursing also stated the physician that made the decision to stop the medication should have notified the family and documented the reason for stopping the medications. The Director of Nursing further stated that they were not aware that the family was not notified by the physician when Resident #33's medications were discontinued. On 06/29/2026 at 9:38 AM, Registered Nurse #2 was interviewed and stated that they coordinate care plan meetings with social services, and rehab if indicated. Registered Nurse #2 also stated that when the list of medications was read to Resident #33's family during the care plan meeting held in June 2025, it was noted by the family that some medications were missing from the list, which included Namenda. Registered Nurse #2 further stated when Resident #33's chart was further reviewed, they observed the medication was discontinued, and they realized that Resident #33's family was not notified by the Physician. Registered Nurse #2 stated that the standard of practice is that whoever discontinued the medications and/or picks up the order should have notified the family. On 06/29/2026 at 10:38 AM, the Medical Director was interviewed and stated that a lot of times when there is change in resident's order, we communicate with the nurses to communicate with the family and sometimes the physician also communicates with the family directly. The Medical Director also stated that they believed they had met with Resident #33's family before to get the issue resolved, and the Physician Assistant that discontinued the medications without informing the family is no longer here because the facility was not happy with the quality of work being done. 10 New York Code, Rules and Regulations 415.3(e)(2)(ii)(a)

Based on the observations, record review, and interviews, the facility did not ensure that necessary housekeeping/maintenance services were provided to maintain a safe, clean, comfortable, and homelike environment. This was evident on two (Floors 7 and 3) of six resident care floors. Specifically, 1). A resident room on the 7th Floor was observed with a strong urine odor which was detected even when the door was closed, unemptied urinals, fly sticker with multiple dead flies, a soiled storage container and a sticky floor, and 2). Resident rooms on the 3rd Floor were observed with sagging, unhooked privacy curtains, scuffed areas on walls and floors, and detached baseboards. The findings are: The facility policy titled Home Like Environment last reviewed 3/2026 documented residents are provided with a safe, clean, comfortable environment and encouraged to use their personal belongings to the extent possible. 1. On 06/22/2026 at 10:41 AM, the door to room [ROOM NUMBER] was observed closed and a strong odor of urine could be smelled when standing in the hallway in front of the room. When the door was opened, there was an intense foul odor. When the State Surveyor entered the room, the floor was sticky and an unemptied urinal was observed at the bedside. On 06/25/2026 at 9:43 AM, room [ROOM NUMBER] was observed with a strong urine odor. A white three drawer storage container had built-up dirt on the container, and the base of bedside lamp on top of the container was soiled. A fly sticker was hanging from the roof with multiple large dead flies stuck to it. An uncovered urinal which was 1/4 filled was at the bedside. On 06/29/2026 at 9:15 AM, a strong urine was detected coming from room [ROOM NUMBER]. During an interview on 06/25/2026 9:30 AM, Housekeeper #3 stated they are responsible for cleaning the rooms Unit 7, and room [ROOM NUMBER] is cleaned daily, when they are on duty. Housekeeper #3 also stated that when cleaning the room they mop the floors, clean the bathroom, empty the garbage, and do other general cleaning every day. Housekeeper #3 further stated they are not sure what the odor is in the room but they ensure the room is cleaned daily. During an interview on 06/26/2026 at 9:18 AM, Housekeeper #4 stated they were assigned to strip and clean room [ROOM NUMBER] today. Housekeeper #4 also stated that despite cleaning the room today, the odor will be there tomorrow and they are not sure why this is. Housekeeper #4 further stated the resident who resides in room [ROOM NUMBER] refuses to let staff clean the room. During an interview on 06/29/2026 9:46 AM, the Director of Housekeeping and Laundry Services stated they are aware of the condition of room [ROOM NUMBER] and that the odor can be detected from the hallway, however once the room is cleaned within two days the room is smelling of the urine, as the resident throws urine on the floor. The Director of Housekeeping and Laundry Services also stated the room is checked at least two or three times daily by housekeeping staff. The Director of Housekeeping and Laundry Services further stated the mattress in the room has been changed at least six times, and each time it ends up soiled. During an interview on 06/29/2026 at 12:05 PM, Social Worker #1 stated they were aware of the flies and odor in room [ROOM NUMBER], however the resident who resides in that room can be resistant at times and nursing, housekeeping, psychiatry, the exterminator and social worker are working with the resident to keep the room clean. On 06/29/2026 at 2:43 PM, the Director of Nursing stated staff have attempted to clean room [ROOM NUMBER], however the resident who resides in the room refused to let anyone go in the room. 2. The facility's policy and procedure titled Maintenance Services reviewed 02/2026 documented that the function of maintenance personnel may include maintaining the building in good repair and free from hazards. During observations conducted on Unit 3 from 06/22/2026 to 06/29/2026, the following concerns were observed but not limited to: In room [ROOM NUMBER], there was a sagging window curtain with missing hooks, and there were black scuff marks on the wall/bathroom door. In room [ROOM NUMBER], there was a partially missing vinyl baseboard exposing unplastered wall, chipped/damaged wall corners near the closet, and black scuff marks on the wall/bathroom door. In room [ROOM NUMBER], there was a hole with fragments crumbling, chipped wall corners, loose baseboard next to the closet, and black scuff marks on the wall/bathroom door. In room [ROOM NUMBER], there was a sagging window curtain missing several hooks, black scuff marks on the wall/bathroom door. In room [ROOM NUMBER], there was a broken window curtain cord pulley, a sagging privacy curtain which had several missing hooks, and a loose wall cable cord plate with cord protruding from the side of the wall plate. In room [ROOM NUMBER], there was a detached vinyl baseboard left on the floor, exposing unplastered wall, and black scuff marks on the wall/bathroom door. The Engineering Repair Request Forms from 06/01/2026 to 06/24/2026 contained no documentation regarding any of the above concerns. On 06/29/2026 at 09:01 AM, Housekeeper #2 was interviewed and stated they are responsible for doing detailed cleaning of five rooms per day which include high dusting, disinfecting wheelchairs and furniture, cleaning and replacing bed sheets and privacy curtains if they appear dirty. Housekeeper #2 also stated curtains were not hung properly because of the broken and missing hooks which they have reported to the maintenance department verbally for a few months. During an interview on 06/29/2026 at 09:15 AM, Registered Nurse #3 stated they report any maintenance concerns affecting residents and their daily care such as beds, call bells, television, heating/cooling unit, and toilets. Registered Nurse #3 also stated common issues reported are malfunctioning beds, televisions, remote controls, toilet issues, etc. Registered Nurse #3 further stated concerns are placed on the form for the maintenance staff to repair when they are doing their daily rounds. Registered Nurse #3 stated they were not aware of these concerns because it did not affect residents directly or staff doing care. During an interview on 06/29/2026 at 09:52 AM, the Director of Engineering stated they make daily visits to all the floors to check oxygen tanks for proper functioning, adequate supply and to do repairs requested by unit nursing staff. The Director of Engineering also stated they currently do not have routine inspections focusing on structural damage in resident rooms, therefore, any maintenance concerns noted in the room should be reported to the maintenance department. The Director of Engineering further stated they used to be notified of any empty rooms to inspect and address these concerns but currently this is not going on, and repairing walls, painting, fixing structural damage in the room also takes a longer time, usually three consecutive shifts. The Director of Engineering stated they had to cut down the staffing level from seven to five employees covering the various shifts, and currently there are two maintenance staff scheduled during the day shift and one maintenance staff working in the evening. The Director of Engineering also stated there are no overnight staff, and they are on call during the overnight shift. During an interview on 06/29/2026 at 11:05 AM, the Administrator stated they were not aware of these concerns found in the rooms 10 New York Codes, Rules, and Regulations 415.5(h)(4)

Based on record review and staff interviews, the facility failed to ensure that residents and their representatives received a written summary of the baseline care plan. This was evident for one (Resident #206) of six residents reviewed for Activities of Daily Living out of 38 total sampled residents. Specifically, there was no evidence Resident #206 or their representative received a copy of the baseline care plan.The findings include:The facility policy and procedure titled Care Plan-Baseline, last revised in February 2026, documented that a baseline plan of care to meet the resident's needs shall be developed for each resident within 48 hours of admission. The Interdisciplinary Team will review the healthcare practitioners' orders and implement a baseline care plan to meet the residents' immediate care needs. The residents and their representatives will receive a copy of the baseline care plan. The facility will document receipt of information from the family, whether in the form of a signed acknowledgment or a note in the resident's clinical record.Resident #206 was admitted to the facility with diagnoses that include hypertension (high blood pressure) and dementia (a pattern of mental decline caused by different diseases or conditions). The admission Minimum Data Set assessment dated [DATE] documented Resident #206's cognition as severely impaired. The Baseline Care Plan dated 04/17/2026 for Resident #206 did not include the signatures of the interdisciplinary staff. There was no signature acknowledgment from Resident #206's family representative.There was no documented evidence that Resident #206's or their representative was provided with a written copy of the baseline care plan.During an interview on 06/29/2026 at 1:06 PM, Resident #206's representative stated that they did not receive a copy of the baseline care plan. Resident #206's representative also stated that the facility staff reviewed the information with them during the care plan meeting, but they did not receive a copy.During an interview on 06/29/2026 at 11:18 AM, Social Worker #1 stated that they did not know whether Resident #206's family representative had received a copy of the baseline care plan. Social Worker #1 also stated that the facility policy requires nursing staff to give a copy of the baseline care plan to the resident or their representative during the initial care plan meeting. Social Worker #1 further stated that Resident 206's representative participated in the initial care plan meeting by phone, but there are no notes indicating they received a copy of the baseline care plan.During an interview on 06/29/2026 at 12:09 PM, Registered Nurse #5, a supervisor, stated that the baseline care plan is supposed to be completed within 24-28 hours of admission. Registered Nurse #5 also stated that during the initial care plan meeting, if the resident or a family member requests a copy of the baseline care plan, they will provide one. Registered Nurse #5 further stated that they did not know whether Resident #206's representative received a copy of the baseline care plan, as there was no note indicating they had. Registered Nurse #5 stated that either nursing or social services is responsible for providing the baseline care plan, and they give it to the residents or representatives if they are present at the initial care plan meeting.During an interview on 06/29/2026 at 1:32 PM, the Director of Social Services stated that the baseline care plan is completed by nursing, and that if the family is present, nursing or social services provides them with a copy. The Director of Social Services also stated that they did not know whether Resident #206's representative had received a copy of the resident's baseline care plan.During an interview on 06/29/2026 at 1:54 PM, the Director of Nursing stated that the baseline care plan is completed 48 hours after admission and that a copy is provided to the resident or the resident's representative. The Director of Nursing also stated that the unit manager or the social worker is responsible for giving the baseline care plan to the residents or their representatives. The Director of Nursing further stated they are unsure whether the resident's family representative received a copy of the baseline care plan.10 New York Codes, Rules and Regulations 415.11 (c)

Based on observations, record review, and interviews, the facility failed to ensure a resident who needs respiratory care, including oxygen therapy care was provided with such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals. This was evident for one of one resident (Resident #51) reviewed for Respiratory care out of 38 sampled residents. Specifically, there was no documented evidence that the oxygen tubing provided for Resident #51 was changed as per professional standards of care. Number of residents sampled: 1Number of residents cited: 1.The findings include:The facility policy and procedure titled, Oxygen Therapy Administration dated 01/2015, last revised 09/2025, documented the following: document oxygen therapy administration in the clinical record. Clean and disinfect the oxygen delivery device following manufacturer's instructions when visibly soiled. Replace oxygen tubing, nasal canula, face mask, when visibly soiled and as needed. The policy did not specify guidelines for changing of oxygen tubing. Resident #51 was admitted to the facility with diagnoses that included coronary artery disease (a common type of heart disease that affects the main blood vessels that supply blood to the heart), hypertension (a chronic condition in which the force of blood pushing against artery walls is consistently too high), pneumonia (an infection that inflames the air sacs in one or both lungs, which can fill with fluid or pus).The Quarterly Minimum Data Set (an assessment tool) dated 06/02/2026 documented Resident #51 had moderate impairment in cognition received oxygen therapy.On 06/23/2026 at 9:38 AM, Resident #51 was observed in their room, receiving oxygen via nasal canula. There was no date noted on the oxygen tubing. Resident #51 was interviewed and stated that they have been using oxygen for a while, but they do not know when the tubing was last changed.A Physician's order dated 01/28/2026 documented supplemental oxygen via nasal canula at 2-4 Liter per minute to maintain oxygen saturation greater than 90%.There was no Physician's order regarding changing of oxygen tubing for Resident #51. On 06/25/2026 at 11:59 AM, Registered Nurse #1 was interviewed and stated that Resident #51 has been on oxygen therapy since admission for shortness of breath. Registered Nurse #1 also stated oxygen tubing is changed on Sunday and Wednesday by night shift. Registered Nurse #1 further stated that the new policy states that the tubing should not be dated when changed and their physician had not been giving a separate order for oxygen tubing change.On 06/25/2026 at 12:09 PM, Family Nurse Practitioner #2 was interviewed and stated that if residents are on continuous oxygen, it is part of the protocol that the tubing should be changed. Family Nurse Practitioner #1 also stated that there is no need to give a separate order for oxygen tubing change as the nurses should know that the tubing should be changed when a resident has order for oxygen therapy.On 06/25/2026 at 1:22 PM, the Director of Nursing was interviewed and stated that once there is doctor's order for oxygen use, there should be a separate physician's order to change the oxygen tubing in the resident's chart. The Director of Nursing also stated that it should be documented in Medication Administration Record or Treatment Administration Record when the oxygen tubing is changed as per Physician's order. The Director of Nursing further stated that the protocol change does not take away the physician order for the oxygen tubing change. 10 New York Code, Rules and Regulations 415.12(k)(5)(4)

Based on observation, record review, and interviews, the facility failed to ensure each resident receives and they provided food and drink that is palatable, attractive and at a safe and appetizing temperature. This was evident for two of two residents (Resident #117 and Resident #138) reviewed for Food out of 38 sampled residents. Specifically, the food served at lunch on Resident #117 and Resident #138's unit was at suboptimal temperatures and was not appetizing or palatable.The findings include, but are not limited to:The facility policy and procedure titled Food Temperatures, last revised on 05/28/2025, documents that foods sent to remote kitchens, such as meals, snacks, nourishment, and oral supplements, will be transported to and delivered to the kitchen to maintain a temperature at or below 41 degrees Fahrenheit for cold foods and at or above 140 degrees Fahrenheit for hot foods. 1. The facility's meal delivery record indicated that lunch was scheduled to be delivered to Unit 8 at 1:00 PM.Resident #117 was admitted to the facility with diagnoses that include heart failure (when heart muscles are too weak) and hypertension (high blood pressure).The Quarterly Minimum Data Set (an assessment tool) dated 03/23/2026 documented Resident #117 had intact cognition and required supervision assistance with eating. On 06/22/2026 at 9:51 AM, during the initial tour, Resident #117 stated that they eat in their room and the food is on the cool side. Resident #117 also stated sometimes they get their food late as yesterday, they receive supper at 7:00 PM, and they do not know whether the problem was in the kitchen or on the floor. On 06/23/2026 at 9:30 AM, Resident #117 said that yesterday, lunch arrived late at 1:30 PM instead of 1:00 PM, and it was cool. 2. Resident #138 was admitted with diagnoses that include respiratory failure ( a life-threatening condition where the lungs cannot get enough oxygen into the blood) and seizure disorder (uncontrollable shaking or convulsions), The Annual Minimum Data Set assessment dated [DATE] documented Resident #138's had intact cognition and required partial assistance with eating. On 06/23/2026 at 12:22 PM, during the lunch meal, Resident #138's Representative stated that they would like the food to improve, as Resident #138 receive only two to three chunks of meat and it is served cold.During the dining observation on 06/25/2026 from 1:04 PM to 1:46 PM, food trucks were delivered to Unit 8 at 1:04 PM, and staff delivered lunch trays to residents in the dining room and residents' rooms. At 1:46 PM, test trays were conducted on Unit 8 and the food temperature was as follows:a).Puree diet meal consisted of pureed fish at 128.6 degrees Fahrenheit, pureed carrots at 118.6 degrees Fahrenheit, pureed soup at 127 degrees Fahrenheit, mashed potatoes at 127.4 degrees Fahrenheit, milk at 53.2 degrees Fahrenheit.b). Regular diet meals consisted of fish sticks at 119 degrees Fahrenheit, rice and beans at 121.1 degrees Fahrenheit, chicken noodle soup at 125.6 degrees Fahrenheit, and milk at 52.8 degrees Fahrenheit.During an interview on 06/25/2026 at 1:46 PM, the Food Service Supervisor stated that the tray line temperatures were in the 149-degree Fahrenheit range. The Food Service Supervisor also stated they expected the hot food to be 135 degrees Fahrenheit or above and the cold food to be 40 degrees Fahrenheit or lower. The Food Service Supervisor further stated the first truck was delivered to Unit 8 at 1:04 PM, but it is now 1:46 PM, 35 minutes past the serving time, so maybe the issue might be due to the serving time.During an interview on 06/29/2026 at 1:54 PM, the Director of Nursing stated that they were unaware of the cold food issue and would follow up to ensure the food is delivered on time to residents in their rooms.During an interview on 06/29/2026 at 9:24 AM, the Administrator stated that they usually do not have an issue with the food temperatures on the unit. The Administrator also stated that late delivery can cause issues with cold food on the unit, and that all staff are required to ensure that the food is delivered on time. 10 New York Codes, Rules and Regulations 415.14(d)(1)1(2)

Based on observations and interviews, the facility did not ensure the environment was functional, sanitary, and comfortable for residents, staff, and the public. Specifically, the elevator floors were noted with cracks and discolored.The findings are: The facility's policy and procedure titled Maintenance Services reviewed 02/2026 documented that the function of maintenance personnel may include maintaining the building in good repair and free from hazards. During observation conducted from 06/22/2026 to 06/29/2026, the floor in Elevator #1 was observed chipped, with fragments broken off from the edge at the elevator entrance area causing a slight dip and uneven surface. The floor was also noted with uneven tone and discolored areas. The floor in Elevator #2 had patched up areas that appeared to be lifting off. On 06/29/2026 at 09:52 AM, the Director of Engineering was interviewed and stated they are aware of the cracks found on the elevator floors, and a company came to patch and repair the cracks about six months ago and there have been more cracked areas since then. The Director of Engineering also stated the elevator floors were changed about 10 years ago and they do not know about any plans for new flooring.On 06/29/2026 at 11:05 AM, the Administrator stated they are aware of the flooring issues observed in the elevators and they have contacted the company for the repair. 10 New York Code, Rules and Regulations 415.29

Based on observation, record reviews, and interviews during survey, the facility failed to ensure that a resident was free from physical abuse. This was evident for one (Resident #1) of four residents reviewed for abuse. Specifically, on 05/27/2025 at 10:10 PM, Resident #1 reported that Certified Nursing Assistant #1 hit them on their nose and grabbed their hand. Registered Nurse Supervisor #1 assessed Resident #1 and noted Resident #1 had a 2-centimeter skin tear on the left arm and a swollen nose bridge. Resident #1 received Tylenol 650 milligrams for pain and was transferred to the hospital on [DATE] at 12:00 AM for evaluation. Resident #1 did not return to the facility. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.The findings are: The facility policy and procedure titled Abuse Policy with a review date 06/01/2024 documented the facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends and residents of the facility. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. Resident #1 was admitted to the facility with diagnoses of spinal stenosis (narrowing of the spaces within the spine), depression and dementia (decline in cognitive function). The Minimum Data Set (a resident assessment tool) dated 04/11/2025, documented Resident #1 had moderate impairment in cognition. Resident #1 required one person assistance with bed mobility and toileting hygiene. A nursing progress notes by Licensed Practical Nurse #1 dated 05/27/2025 at 10:38 PM, documented Resident #1 sustained a skin tear to the left arm when Certified Nursing Assistant #1 was trying to provide care to them. Certified Nursing Assistant #1 called Licensed Practical Nurse #1 immediately. Licensed Practical Nurse #1 cleaned the wound to stop bleeding and applied a dressing. Resident #1 complained of generalized pain of 4/10 on pain scale. Pain medication was administered as per physician's order. A nursing progress note by Registered Nurse Supervisor #1 dated 05/28/2025 at 12:08 AM, documented Licensed Practical Nurse #1 reported that Resident #1 stated Certified Nursing Assistant #1 hit and scratched their arm. Resident #1 was assessed and observed to have a 2-centimeter skin tear at the area of a purpura (purple-colored spots or patches on the skin caused by blood that just is under the skin surface) on their left arm and about 1-centimeter swelling over the nose bridge with no skin break. Resident #1 stated they (Certified Nursing Assistant #1) hit them on the nose and grabbed their hand. Resident #1 was immediately assigned to another staff and placed on one-to-one supervision. Nurse Practitioner #1 and the Director of Nursing and family were notified. Nurse Practitioner #1 ordered to transfer Resident #1 to the hospital for further evaluation. Resident #1 left the facility at 12:00 AM on 05/28/2025. A medical progress note by the on-call Nurse Practitioner #1 dated 05/28/2025 at 1:52 AM, documented Registered Nurse Supervisor #1 initiated a telehealth call and stated Resident #1 reported Certified Nursing Assistant #1 hit them on the bridge of their nose and scratched their left arm. A physical examination assisted by Registered Nurse Supervisor #1, revealed left arm skin abrasion and swelling to the bridge of Resident #1's nose, Tylenol 650 milligram medication ordered and to transfer Resident #1 to the hospital for further evaluation. The facility's Investigation form dated 06/01/2025 documented on 05/27/2025 at approximately 10:10 PM, Certified Nursing Assistant #1 stated they answered Resident #1's call bell and Resident #1 asked to be changed. Certified Nursing Assistant #1 stated they turned Resident #1 on their right side and while they were cleaning, Resident #1 turned on their back and started to hit and kick them. Resident #1 suddenly sat up in bed and continued to swing and hit them. Certified Nursing Assistant #1 then held Resident #1's arms to prevent injury to both. Certified Nursing Assistant #1 was able to demonstrate how they held Resident #1 and the way Resident #1 moved their arms in all directions. Certified Nursing Assistant #1 let them go and saw the skin tear. Resident #1 had a plastic identification band and the assigned Certified Nursing Assistant #1 had on a silver metal bracelet. Registered Nurse Supervisor #1 was notified and assessed Resident #1. Resident #1 reported that Certified Nursing Assistant #1 hit them and scratched their arm. Nurse Practitioner #1, Director of Nursing, Administrator and Resident Representative were notified. Resident #1 was sent to the hospital for further evaluation. The Resident Representative stated that Resident #1 had a linear fracture on their nose and was admitted to the hospital. Interview with other staff members stated Resident #1 mentioned that Certified Nursing Assistant #1 did not hang their clothes but folded them and put their knitting items on the low shelf instead of the high shelf drawer. Certified Nursing Assistant #1 was suspended pending investigation. Local police arrived on 05/28/2025 at 2:05 PM and did not give a report. The incident was not witnessed and Resident #1's roommate did not hear any noise that disturbed them. Certified Nursing Assistant #1 may not have been aware of the preferences, which could be the trigger for Resident #1's behavior that was not at their baseline. Based on their investigation there is insufficient evidence to conclude that abuse, neglect or mistreatment may have occurred on the part of the facility. During an interview on 05/29/2026 at 9:25 AM, Certified Nursing Assistant #1 stated they were assigned to Resident #1 on 05/27/2025 on the evening shift (3:00 PM-11:00 PM). Certified Nursing Assistant #1 stated they introduced themself to Resident #1 and served them dinner with no issues. Certified Nursing Assistant #1 stated at approximately 10:10 PM, they answered the call light of Resident #1, and they requested, to be changed. Certified Nursing Assistant #1 stated they asked Resident #1 what side they preferred to be turned on and Resident #1 chose their right side. Certified Nursing Assistant #1 stated Resident #1 observed to be full of feces and they started cleaning them, and while cleaning them, Resident #1 suddenly started yelling and kicking. Certified Nursing Assistant #1 stated they used a soft cleaning cloth because the resident has delicate skin. Certified Nursing Assistant #1 stated they do not know why Resident #1 suddenly had an outbreak. Certified Nursing Assistant #1 stated Resident #1 turned on their back, sat up in bed and continued to swing their arms hitting them (Certified Nursing Assistant #1). Certified Nursing Assistant #1 stated they used the palm of their hands to hold Resident #1's wrist trying to calm the resident down, while telling them they were not there to hurt them. Certified Nursing Assistant #1 stated they did not scratch the resident's arm, did not touch nor hit the resident's nose. They did not hurt Resident #1 at all. Certified Nursing Assistant #1 stated they stayed with the resident and called for the nurse. During an interview on 05/28/26 at 12:24 PM, Registered Nurse Supervisor #1 stated Licensed Practical Nurse #1 reported to them on 05/27/2025 (unsure of time) that Certified Nursing Assistant #1 hit Resident #1's nose and scratched their arm. Registered Nurse Supervisor #1 stated they assessed Resident #1 and observed a 2-centimeter skin tear over the purpura area of their left forearm and a 1-centimeter swelling over the bridge of their nose. Registered Nurse Supervisor #1 stated Resident #1 complained of pain (unable to recall the pain scale) and was given pain medication with relief. Registered Nurse Supervisor #1 stated they placed Resident #1 on one-to-one supervision. Registered Nurse Supervisor #1 stated they notified Nurse Practitioner #1 (on call), Director of Nursing, Administrator and family. Registered Nurse Supervisor #1 stated they removed Certified Nursing Assistant #1 from the unit and from the schedule pending investigation outcome, however Certified Nursing Assistant #1 did not return and was terminated from the facility. Registered Nurse Supervisor #1 stated Resident #1 was sent to hospital for further evaluation and did not return to the facility.During an interview on 05/29/2026 at10:53 AM, Certified Nursing Assistant #2 stated they worked on 05/27/2025 on the 3:00 PM-11:00 PM shift. Certified Nursing Assistant #2 stated they observed a call light on in Resident #1's room and went to check. Certified Nursing Assistant #2 stated they observed Resident #1 agitated and crying and they asked Resident #1 what happened, and the resident reported that they asked Certified Nursing Assistant #1 to put their knitting supplies in their closet and not to put them in the bottom drawer and Certified Nursing Assistant #1 did not hang their clothes but instead folded them on the bed. Certified Nursing Assistant #2 stated Resident #1 has a special way of how they want their stuff (clothes etc.) to be in place. Certified Nursing Assistant #2 stated if the items are not placed how the resident wants them, it could trigger the resident to get upset. During an interview on 05/29/26 11:14 AM, the Director of Nursing stated they were notified of the incident on 05/27/2025 (unsure of time) by Registered Nurse Supervisor #1. The Director of Nursing stated Resident #1 became combative during care and Certified Nursing Assistant #1 held Resident #1's hands to prevent them from hurting each other. The Director of Nursing stated Certified Nursing Assistant #1 should have stopped when Resident #1 became aggressive and called the nurse. They stated Certified Nursing Assistant #1 should not have held Resident #1's hands. The Director of Nursing stated that Certified Nursing Assistant #1 took care of Resident #1 and transferred them to bed without any issues prior to the incident. The Director of Nursing stated based on their investigation there was not enough evidence to confirm Certified Nursing Assistant #1 intentionally hit Resident #1. The Director of Nursing stated that Resident #1 was transferred to the hospital and the family member reported that Resident #1 sustained a linear fracture to their nose. The Director of Nursing stated the cause of fracture could have been done by Resident #1 when they were moving their hands back and forth. The Director of Nursing stated Certified Nursing Assistant #1 had short nails and a pair of silver metal bracelet that could have contacted Resident #1's skin. The Director of Nursing stated they held a Quality Assurance/an ad hoc committee meeting on 05/29/2025 and they reviewed the incident and root cause analysis which indicated Certified Nursing Assistant #1 was not familiar with Resident #1's preferences which might have triggered the resident's behavior. During an interview on 05/29/2026 at 12:05 PM, the Administrator stated they were notified of the incident on 05/27/2025 at approximately 10:35 PM by Registered Nurse Supervisor #1. The Administrator stated they went to the facility, and they also called 911. The Administrator stated they interviewed Resident #1 who reported that Certified Nursing Assistant #1 hit them. The Administrator stated they interviewed Certified Nursing Assistant #1, who reported that they were providing care to Resident #1 when the resident started flailing their hands towards them. Certified Nursing Assistant #1 reported to them that when they grabbed the resident's hands, the resident's hands slipped out of their (Certified Nursing Assistant #1) hands and accidentally hit the resident on their nose. The Administrator stated Certified Nursing Assistant #1 demonstrated how Resident #1's arms were moving in all direction and how they held Resident #1's hands. During an interview on 05/29/2026 at 1:24 PM, the Medical Director stated they were notified about the incident by the Director of Nursing on 05/28/2025 (unsure of time). The Medical Director stated that they are aware Resident #1 has dementia and brittle bones, and that they believe Resident #1 could have possibly hit themself or the side rail, sustaining the fracture, when they were fighting and turning in their bed or when Certified Nursing Assistant #1 was holding them while they were fighting. During a follow up interview on 06/24/2026 at 10:15 AM, Certified Nursing Assistant #1 stated Resident #1 asked them to take their personal bag with their clothes off their bed and put the bag on the chair, then later asked them to put the bag on the bottom shelf in the closet. Certified Nursing Assistant #1 stated that Resident #1 did not ask them to hang or fold any clothes. Certified Nursing Assistant #1 stated they do not know why Resident #1 became combative with them. 10 New York Codes, Rules, and Regulations 415.4(a) (2-7)The facility took immediate corrective actions and was found to be in substantial compliance on 05/30/2025 prior to surveyors onsite 05/28/2026.Immediate Corrective Actions: On 05/27/2025 at 10:25 PM- Registered Nurse Supervisor #1 was notified and assessed Resident #1. Resident #1 was placed on one-to-one supervision.On 05/27/2025 at 10:30 PM- Resident Representative, Director of Nursing and Administrator were notified. On 05/27/2025 at 11:15 PM- Administrator visited the facility and called the local police. 05/27/2025 - Certified Nursing Assistant #1 was immediately suspended pending investigation outcome. 05/28/2025 at 12:00 AM- Resident #1 transferred to hospital for further evaluation. 05/28/2026 - staff statements via telephone re-interviewed by Director of Nursing, Assistant Director of Nursing, and Administrator.05/28/2025- 05/30/2025- Facility wide in-service on abuse prevention, customer service and caring for the resident with behavior. Lesson Plan and attendance sheets reviewed. 05/29/2025 - Quality Assurance meeting was held to review the incident, identify immediate corrective actions, root cause analysis and implement facility wide interventions.05/29/2025- policy and procedure titled Abuse Policy dated 06/01/2024 reviewed with no revisions.05/29/2025- policy and procedure titled Accident-Incidents dated 06/01/2024 reviewed with no revisions.05/29/2025- policy and procedure titled Resident Rights dated 05/2024 reviewed with no revisions.05/29/2025- Additional signs posted throughout the facility with the Administrator and Director of Nursing contact information for visitors and staff to easily report abuse and neglect 24 hours seven days a week. 05/29/2025-06/08/2025- Director of Nursing generated the lists of residents who were cared for by Certified Nursing Assistant #1 for the past two (2) weeks. The lists were used by the registered nurses to audit and identify any new skin breaks. The care plan for risk for skin impairment updated to reflect that if resident is combative STOP and report to the nurse promptly. This information was conveyed to all staff including certified nursing assistants through the facility wide in-service. Braden Scale (an assessment tool used to predict risk of developing pressure ulcer) will be completed for the residents on the list. 05/29/2025 to 12/29/2025- An audit interview tool created to identify residents' potential for abuse. Audit interviewed 10 random residents weekly x 4 weeks, then 20 random residents monthly x 3 months, then 60 random residents quarterly. On 06/04/2025- Ad hoc Resident Council meeting to discuss residents' rights and protection from resident abuse. Attendance of residents reviewed. On 06/30/2025- a follow-up Quality Assurance meeting was held. Attendance sheets reviewed. On 08/30/2025 - a Quality Assurance meeting was held to discuss freedom from abuse. Findings of plan of correction on the incident 05/27/2025 were discussed. Audits ongoing. On 11/24/2025- a Quality Assurance meeting was held, discussed continuation on abuse prevention education, continues abuse audit tool on other units, and staff education on activities of daily living care. Total number of staff: 303Facility Wide In-ServiceDepartmentCompleted % CompleteAdministrative1100% Registered Nurse17100%Licensed Practical Nurse31100%Certified Nursing Assistant 147100%Rehabilitation21100%Recreation6100%Security5100%Director of Nursing 1100%Assistant Director of Nursing1100%Social Worker4100%Pastoral Care2100%Human Resource1100%Staffing Coordinator1100%Medical Records1100%Clinical Coordinator1100%Receptionist2100%Maintenance 5100%Finance 2100%Dietary 32100%Housekeeping 22100% TOTAL303

Based on observation, record review, and interviews conducted during an abbreviated survey (NY 00338277), the facility failed to protect residents from sexual abuse by nursing home staff. This was evident in two out of ten residents (Resident #1 and Resident #2) sampled for sexual abuse. Specifically, 1. On 04/06/24 at approximately 1:00 pm Resident #1 reported to Certified Nursing Assistant #1 that an Asian man (alleged perpetrator) entered their room and asked Resident #1 to see their hernia; the alleged perpetrator grabbed and fondled Resident #1's penis. Resident #1 reported the sexual abuse occurred on 04/06/24 at 10:00 am. Subsequently during an interview with Resident #1 on 04/16/24 at 12:19 pm, they stated at the time of the incident they were scared. 2. On 04/06/24 at 8:00 pm Resident #2 reported to Licensed Practical Nurse #1 that an Asian man (alleged perpetrator) entered their room and sexually assaulted them on 04/06/24 between 10:30am and 11:00am. Resident #2 was transferred to the emergency roiagnom on [DATE] and did not return to the facility. Subsequently during an interview with Resident #2 on 05/01/24 at 12:27 pm, Resident #2 stated they felt helpless and sick to their stomach because they could not move when they were being sexually assaulted. This resulted in actual harm to Resident #1 and Resident #2 that was not Immediate Jeopardy. The findings are: The Facility's Policy and Procedure on Abuse, revised date of 12/2023, documented the facility prohibits the mistreatment, neglect and abuse of residents/patients and misappropriation of resident/patient property by anyone including but not limited to staff, family, friends, and residents of the facility. The facility strives to ensure the prevention and reporting of suspected or alleged resident/patient abuse. Any time an allegation is made involving abuse, which names a specific employee, the employee is suspended until the completion of the investigation. Resident #1 was admitted to the facility with diagnoses including Schizophrenia, (a disorder that affected the ability to think, feel and behave clearly), Post Traumatic Stress Disorder, and right groin pain and mass. The Minimum Data Set (an assessment tool), dated 03/04/24, documented that Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 15 associated with intact cognition. The Comprehensive Care Plan dated 10/20/23, documented Resident #1 was at risk for neglect and abuse. The interventions documented to contact police authorities as needed and to monitor Resident #1 for signs of abuse and neglect. An Initial Event Documentation written by the Director of Nursing on 04/10/24, which indicated Date/Time of Event as 04/06/24 at 10:00 am, documented Resident #1 reported to staff that earlier during the morning a Chinese person (alleged perpetrator) came into their room and asked them to see their hernia, located on Resident #1's lower abdomen. The alleged perpetrator held onto and played with their penis and then left the room. Resident #1 did not tell anyone but reported the incident later in the day. Resident #1 refused to be assessed. On 04/06/24, the police from the 50 th precinct was contacted and responded. The facility's Investigation Summary dated 04/06/24 documented Resident #1 reported to staff the alleged perpetrator came into their room (early morning) and asked to see their hernia and then the alleged perpetrator held and played with their penis and then left the room. Resident #1 refused to be assessed. Resident #1 described the alleged perpetrator as being Chinese, tall, and bald. Resident #1 stated the alleged perpetrator had worn gray scrubs and black eyeglasses. The investigation documented that a female staff was assigned to Resident #1. The investigation also documented Resident #1 was inconsistent with their statement and reiterated different stories and different descriptions of the alleged perpetrator and gave different timeframes of when the alleged incident occurred. The investigation concluded there is no evidence to support that any alleged resident abuse, neglect, exploitation, or mistreatment occurred. Resident #1's Primary Physician's Progress Note dated 04/10/24 at 1:33 pm, documented Resident #1 reported an Asian man (alleged perpetrator) wearing ordinary clothes came into their room wearing a badge (did not see the name clearly as the badge was inverted) and identified themselves as an employee at the facility. The man asked Resident #1 about their right inguinal hernia and began touching the hernia, touched Resident #1's penis for 5 minutes, kissed and hugged Resident #1, and then left the room. Resident #1 said do not have same gender identity for sexual relationship. They were in shock and wanted to go to the Emergency Department to be examined. Resident #1 also voiced not wanting to return to the facility. Resident #1 was not transferred to the hospital for an evaluation. There was no documentation to support that Resident #1 refused to be transferred to the hospital. Resident #2 was admitted to the facility with diagnoses including chronic kidney disease, difficulty swallowing, and penile implant. The Minimum Data Set, dated dated dated [DATE] documented Resident #2 had a Brief Interview of Mental Status score of 14 indicating intact cognition. Resident #2 also had frequent incontinence of bladder/bowel and required maximum assistance of one person. A Comprehensive Care Plan for abuse dated 03/15/24 documented Resident #2 was at risk for neglect and abuse. The interventions documented to monitor for signs and symptoms of abuse, neglect, and report to facility staff. An Initial Event Documentation written by the Director of Nursing on 04/08/24, which indicated Date/Time When Nursing Became Aware of Event as 04/06/24 at 8:00 pm, documented Resident #2 reported that earlier today (04/06/24) between 9:30 am and 10:00 am, an Asian man (identified as Physical Therapist Assistant #1) came into their room and performed an oral sexual act while they were asleep. Resident #2 reported that they were startled, and the man pulled up their pants and left the room after telling Resident #2 not to tell anyone. Resident #2 was immediately placed on 1:1 monitoring. Resident #2 was assessed with no evidence of injury. The police and family member were notified. Resident #2 was transferred to the hospital for further evaluation. The facility's Investigation Summary dated 04/06/24, documented Resident #2 reported to staff, earlier in the day between 9:30 am and 10:00 am, the alleged perpetrator came into their room and performed an oral sexual act while they were asleep. Resident #2 stated the alleged perpetrator then took Resident #2's penis and put it into the alleged perpetrator's anus. It is documented staff reported that Resident #2 had a penile implant and had a large penis that was always erect. The investigation concluded there is no evidence to support that any alleged resident abuse, neglect, exploitation, or mistreatment occurred. Record review revealed that Resident #1 and Resident #2 resided on different units. Interviews conducted on 04/16/24, indicated that Resident #1 and Resident #2 have never visited each other and are not familiar with each other. An Emergency Department Provider Note dated 04/07/24 at 5:02 am documented Resident #2 reported around 12:00 pm on 04/06/24, Resident #2 thought they were waiting for someone to come and change them, but a young Asian male (alleged perpetrator) came into their room and placed their (the alleged perpetrator's) mouth on Resident #2's penis. Resident #2 reported that the alleged perpetrator then placed Resident #2's penis into the alleged perpetrator's rectum. Resident #2 stated they did not report the incident to the nursing manager for several hours because they did not feel comfortable telling a young female nurse. Assessment and Plan: New York Police City Department, Resident #2's adult child, and Domestic and Other Violence Emergence program representatives present at bedside. Resident #2 consented to a sexual assault forensic exam (SAFE) and evidence collected and released to New York City Police Department. Emergency Department Course: sexual assault forensic exam done; prophylactic treatment given. Resident #2 does not want to return to the facility. Physical Exam documented dried substance present on Resident #2's penis. During an interview on 04/16/24 at 12:19 pm, Resident #1 stated they told the alleged perpetrator that their hernia hurts. Resident #1 pulled their pants down and pulled up their shirt showing the alleged perpetrator their hernia. Resident #1 stated the alleged perpetrator touch and rub their sexual body part and said that it will make Resident #1 feel better. Resident #1 stated they did not call for help because they were afraid, and the alleged perpetrator was about 6 feet tall. Resident #1 stated they called for help between 1:00 pm and 4:00 pm. Resident #1 stated they are willing to testify against the alleged perpetrator. During a follow up interview via telephone on 05/02/24 at 12:10 pm, Resident #1 stated they told staff they wanted to go to the emergency room to be examined but did not want to return to the facility. Resident #1 stated they had never refused going to the hospital. During a telephone interview on 05/01/24 at 12:27 pm, Resident #2 stated on the day of the incident someone came to change their brief and they did not open their eyes as it was standard procedure. Resident #2 stated they felt something warm on their penis area and thought it was water but then they opened their eyes, and they saw the alleged perpetrator on their knees performing a sexual act. Resident #2 stated they pushed the alleged perpetrator off them. Resident #2 stated the alleged perpetrator turned them onto their left side, pulled their (alleged perpetrator's) pants down and inserted Resident #2's penis into the alleged perpetrator's rectum. Resident #2 stated they pushed the alleged perpetrator off them. Resident #2 stated the alleged perpetrator did not say anything to them, pulled their pants up and walked out of the room. They felt helpless and sick to their stomach because they could not move when they were being sexually assaulted. Resident #2 stated the alleged perpetrator was young, mixed Caucasian, Chinese Oriental look with no beard. Almost six feet tall, and well built. Resident #2 also stated the alleged perpetrator was not wearing any eyeglasses or mask, had on short sleeve T-shirt (regular clothes) and no lab coat. During an interview on 04/16/24 at 1:50 pm, the Physical Therapist Assistant #1 (alleged perpetrator) stated they were assigned on 04/06/24 to performed physical therapy activity for Resident #1 and Resident #2 who resided on different units. The Physical Therapist Assistant #1 stated they were wearing a facial mask (like other staff), had on eyeglasses, and lab coat. Physical Therapist Assistant #1 stated they went to Resident #1's room between 9:30 am and 10:00 am (not sure of the time) and asked Resident #1 if they would like to go to the gym and Resident #1 said no. The Physical Therapist Assistant #1 stated Resident #1 stated their hernia hurt and pulled up their shirt and pulled down their pants exposing their hernia located on the right side of Resident #1's penis. Physical Therapist Assistant #1 affirmed they could see the hernia bulging to the right of Resident #1's penis, but they did not touch Resident #1's penis. They instructed Resident #1 to pull up their pants because they were not the right person to show the hernia to and they would notify the nurse. The nurse was not informed. Physical Therapist Assistant #1 stated Resident #1 instructed them to close the room door which they did and started physical therapy that lasted about 30 to 40 minutes. Physical Therapist Assistant #1 stated they only touched Resident #1 on the shoulder during turning and ambulation activities. Physical Therapist Assistant #1 stated after the session was completed Resident #1 went back to bed and they both said bye. The interview of the Physical Therapist Assistant #1 continued: The Physical Therapist Assistant #1 (alleged perpetrator) stated they did not touch Resident #2's penis or performed any sex acts on Resident #2. Physical Therapist Assistant #1 stated went to Resident #2 'room (on another unit, don't remember time) and Resident #2 was lying in bed. Physical Therapist Asssitant #1 stated they instructed Resident #2 to stand up and when Resident #2 stood up their incontinent brief fell . Physical Therapist Asssitant #1 stated they assisted Resident #2 in pulling up their brief and proceeded with the exercises. Physical Therapist Asssitant #1 stated after therapy was completed Resident #2 requested to go to the bathroom. Physical Therapist Asssitant #1 stated they escorted Resident #2 to the toilet and supported Resident #2 from behind as Resident #2 pulled their incontinent brief down. Physical Therapist Asssitant #1 stated they assisted in pulling up Resident #2's brief and felt resistance (Resident #2 had an erection). Physical Therapist Asssitant #1 stated that Resident #2 pulled their brief up and they escorted Resident #2 out of the bathroom and Resident #2 transferred themselves back in bed and they left the room. Physical Therapist Asssitant #1 stated they never saw Resident #2's penis. During an interview on 04/17/24 at 9:58 am, Resident #2's significant other stated Resident #2 told them the alleged perpetrator performed fell atio on them but Resident #2 did not mention that they were penetrated. During an interview on 04/17/24 with Certified Nursing Assistant #1 and the Ombudsman, they both stated Resident #1 reported the alleged perpetrator asked to see their hernia and masturbated Resident #1's penis on 04/06/24. During an interview on 04/17/24 at 2:39 pm, the Director of Nursing stated Resident #1 provided conflicting statements about the time of the incident and the description of the alleged perpetrator to the supervisor at approximately 2:00pm-2:30 pm. Resident #1 refused assessment and transfer to the hospital. The Director of Nursing stated they spoke to Resident #2 via the telephone and Resident #2 informed them that at around 10:00 am, the alleged perpetrator performed an oral sexual act on them, and the alleged perpetrator turned them on their side and inserted Resident #2's penis in the alleged perpetrator's anus for a short time and then the alleged perpetrator ran off. The Director of Nursing stated Resident #2 also reported they fell back asleep after the alleged perpetrator left the room. The Director of Nursing stated abuse was ruled out because Resident #2 provided different versions of the incident. Resident #2 was transferred to the hospital and did not return to the facility. The Director of Nursing stated Resident #1 was placed on two-person approach for all services. The Physical Therapist Assistant #1 (alleged perpetrator) was terminated. During an interview on 04/18/24 at 11:43 am, Registered Nurse Supervisor #1 stated Licensed Practical Nurse #3 notified them Resident #2 reported an Asian American man came into their room and sexually assaulted them. Registered Nurse Supervisor #1 stated they assessed Resident #2's penis and there was no wetness, unusual stains, or drainage and Resident #2 did not complain of pain or discomfort to their penis. During a telephone interview on 04/19/24 at 3:57 pm Police Officer #1 stated they spoke to Resident #1 and Resident #2 on 04/07/24. Police Officer #1 stated Resident #1 reported to them an Asian person (alleged perpetrator) whom Resident #1 had never seen before entered Resident #1's room. Police Office #1 stated Resident #1 reported the alleged perpetrator asked Resident #1 a few questions about pain and Resident #1 told the alleged perpetrator they had a hernia. Police Officer #1 stated Resident #1 also reported they pulled their pants down and showed the alleged perpetrator their hernia and the alleged perpetrator grabbed their penis (Resident #1's penis) and attempted to masturbate it. Police Officer #1 stated on 04/10/24 they provided Resident #1 with 6 pictures, including a picture of the alleged perpetrator, and Resident #1 could not identify any as the perpetrator. Police Officer #1 stated Resident #1 told them they could not identify the alleged perpetrator because the alleged perpetrator had worn a mask. Police Officer #1 stated they interviewed Resident #2 who reported that an Asian person entered their room to change their (Resident #2) brief and they went back to sleep. Police Officer #1 stated Resident #2 stated they woke up to a great sensation and found the alleged perpetrator performing fell atio. Police Officer #1 stated Resident #2 stated the alleged perpetrator propped them on their side and inserted Resident #2's penis deep into the alleged perpetrator's anus, removed it, and exited the room. Police Officer #1 stated Resident #2 stated they did not report the incident earlier because Resident #2 did not trust the female staff. Police Officer #1 stated they provided Resident #2 with 6 pictures, including a picture of the alleged perpetrator, and Resident #2 could not identify any as the perpetrator. Police Officer #1 stated the investigation will continue because there are two residents involved. During a telephone interview on 05/02/24 at 11:14 am, the Medical Doctor stated on 04/08/24 (don't recall the time), they assessed Resident #1 after the allegation of sexual abuse and there were no injuries. The Medical Doctor stated Resident #1 requested to go the hospital to be examined and Resident #1 voiced they did not want to return to the nursing home. The Medical Doctor stated they gave a verbal order to the nurse (did not recall name of nurse) on the unit to transfer Resident #1 to the hospital. The Medical Doctor stated they do not know why Resident #1 was not transferred to the hospital and they did not follow up as to the reason why Resident #1 was not transferred. The Medical Doctor stated they did not examine Resident #2 as Resident #2 was transferred to the hospital. 10 NYCRR 415.4(b)(1)(i)

F609 S/S=E Based on observation, record review, and interviews conducted during an abbreviated survey (NY00338277), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, and mistreatment, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. This was evident in two out of four residents sampled (Residents #1 and #2). Specifically, 1. On 04/06/24 at approximately 1:00 pm Resident #1 reported to Certified Nursing Assistant #1 that an Asian man (alleged perpetrator) entered their room and asked Resident #1 to see their hernia and then the alleged perpetrator grabbed and fondled Resident #1's penis. Resident #1 reported that the sexual abuse occurred on 04/06/24 at 10:00 am. During an interview with Resident #1 on 04/16/24 at 12:19 pm, Resident #1 stated that at the time of the incident they were scared. The facility did not report the allegations of abuse within 2 hours to New York State Department of Health. The facility reported Resident #1's allegation of abuse on 04/07/24 at 1:08 am. 2. On 04/06/24 at 8:00 pm Resident #2 reported to Licensed Practical Nurse #1 that an Asian man (alleged perpetrator) entered their room and sexually assaulted them on 04/06/24 between 10:30 am and 11:00 am. Resident #2 was transferred to the emergency roiagnom on [DATE] and did not return to the facility. During an interview with Resident #2 on 05/01/24 at 12:27 pm, Resident #2 stated that they felt helpless and sick to their stomach because they could not move when they were being sexually assaulted. The facility did not report the allegations of abuse within 2 hours to New York State Department of Health. The facility reported Resident #2's allegation of abuse on 04/07/24 at 12:39 am. The findings include: The Facility's Policy and Procedure on Abuse and Neglect, revised 12/23, states on page 7 should the investigation reveal that abuse occurred the Administrator shall report such finds to local police department, the ombudsman and the state licensing certification agency within 2 hours of the results of the completion of the investigation. Resident #1 was admitted to the facility with diagnoses including Anxiety disorder, Schizophrenia, Post Traumatic Stress Disorder, and right groin pain/mass inguinal hernia. The facility's Investigation Summary dated 04/06/24 documented Resident #1 reported to staff that the alleged perpetrator came into their room (early morning) and asked them to see their hernia and then the alleged perpetrator held and played with their penis and then left the room. Resident #1 refused to be assessed. Resident #1 described the alleged perpetrator as being Chinese, tall, and bald. Resident #1 stated that the alleged perpetrator had worn gray scrubs and black eyeglasses. The investigation documented that a female staff was assigned to Resident #1. The investigation also documented Resident #1 was inconsistent with their statement and reiterated different stories and different descriptions of the alleged perpetrator and gave different timeframes of when the alleged incident occurred. The investigation concluded there is no evidence to support that any alleged resident abuse, neglect, exploitation, or mistreatment occurred. Resident #2 was admitted to the facility with diagnoses including Chronic Kidney Disease, Dysphagia, and penile implant. The facility's Investigation Summary dated 04/06/24 documented Resident #2 reported to staff earlier today that between 9:30 am and 10:00 am the alleged perpetrator came into their room and performed fell atio while they were asleep. Resident #2 stated that the alleged perpetrator then took Resident #2's penis and put it into the alleged perpetrator's anus. It is documented that staff reported that Resident #2 had a penile implant and had a large penis that was always erect. The investigation documented Resident #2's significant other reported that Resident #2 told them that they (Resident #2) heard staff on the unit talking about an Asian man on the loose on another floor giving fell atio and that they (Resident #2) had received fell atio, but there was no penetration. The investigation concluded there is no evidence to support that any alleged resident abuse, neglect, exploitation, or mistreatment occurred. During an interview on 04/22/24 at 12:24 pm, the Director of Nursing stated if there was reasonable cause for abuse, incident should be reported within 2 hours. The Director of Nursing stated that this allegation was not reported immediately because the Administrator and the Assistant Director of Nursing was not available, and they (Director of Nursing) did not have access to a computer. During an interview on 04/22/24 at 1:20 pm, the Administrator stated that all abuse allegations should be reported within 2 hours to New York State Department of Health. The Administrator stated that the incident was not reported within the timeframe because the Director of Nursing did not have access to a computer. 10 NYCRR 415.4(b)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00338277) the facility did not report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This was evident in two out of four residents sampled (Residents #1 and #2). Specifically, 1. On 04/06/24 at approximately 1:00 pm Resident #1 reported to Certified Nursing Assistant #1 that an Asian man (alleged perpetrator) entered their room and asked Resident #1 to see their hernia and then the alleged perpetrator grabbed and fondled Resident #1's penis. Resident #1 reported that the sexual abuse occurred on 04/06/24 at 10:00 am. During an interview with Resident #1 on 04/16/24 at 12:19 pm, Resident #1 stated that at the time of the incident they were scared. The facility became aware of the abuse allegations on 04/06/24 and completed their investigation on 04/15/24. The facility submitted their 5 days report on 04/15/24 at 12:39 pm to New York State Department of Health. 2. On 04/06/24 at 8:00 pm Resident #2 reported to Licensed Practical Nurse #1 that an Asian man (alleged perpetrator) entered their room and sexually assaulted them on 04/06/24 between 10:30 am and 11:00 am. Resident #2 was transferred to the emergency roiagnom on [DATE] and did not return to the facility. During an interview with Resident #2 on 05/01/24 at 12:27 pm, Resident #2 stated that they felt helpless and sick to their stomach because they could not move when they were being sexually assaulted. The facility became aware of the abuse allegations on 04/06/24 and completed their investigation on 04/15/24. The facility submitted their 5 days report on 04/15/24 at 3:21 pm to New York State Department of Health. The findings include: The Facility's Policy and Procedure on Abuse and Neglect, revised 12/23, states on page 7 should the investigation reveal that abuse occurred the Administrator shall report such finds to local police department, the ombudsman and the state licensing certification agency within 2 hours of the results of the completion of the investigation, as indicated, and to the state survey and certification agency within five (5) days of the completion of the investigation. Resident #1 was admitted to the facility with diagnoses including Anxiety disorder, Schizophrenia, Post Traumatic Stress Disorder, and right groin pain/mass inguinal hernia. The facility's Investigation Summary dated 04/06/24 (completed 04/15/24 at 12:39 pm) documented Resident #1 reported to staff that the alleged perpetrator came into their room (early morning) and asked them to see their hernia and then the alleged perpetrator held and played with their penis and then left the room. Resident #1 refused to be assessed. Resident #1 described the alleged perpetrator as being Chinese, tall, and bald. Resident #1 stated that the alleged perpetrator had worn gray scrubs and black eyeglasses. The investigation documented that a female staff was assigned to Resident #1. The investigation also documented Resident #1 was inconsistent with their statement and reiterated different stories and different descriptions of the alleged perpetrator and gave different timeframes of when the alleged incident occurred. The investigation concluded there is no evidence to support that any alleged resident abuse, neglect, exploitation, or mistreatment occurred. Resident #2 was admitted to the facility with diagnoses including Chronic Kidney Disease, Dysphagia, and penile implant. The facility's Investigation Summary dated 04/06/24 (completed 04/15/24 at 3:21 pm) documented Resident #2 reported to staff earlier today that between 9:30am and 10:00am the alleged perpetrator came into their room and performed fell atio while they were asleep. Resident #2 stated that the alleged perpetrator then took Resident #2's penis and put it into the alleged perpetrator's anus. It is documented that staff reported that Resident #2 had a penile implant and had a large penis that was always erect. The investigation documented Resident #2's significant other reported that Resident #2 told them that they (Resident #2) heard staff on the unit talking about an Asian man on the loose on another floor giving fell atio and that they (Resident #2) had received fell atio, but there was no penetration. The investigation concluded there is no evidence to support that any alleged resident abuse, neglect, exploitation, or mistreatment occurred. During an interview on 04/22/24 at 12:24 pm, the Director of Nursing stated that they submitted the summary within 5 working days. During an interview on 04/22/24 at 1:20 pm, the Administrator stated that the summary of investigation should have been reported within 5 working business days. 10 NYCRR 415.4 (b)(1)(ii)

Based on record review and interviews conducted during the recertification and complaint (NY00310433 and NY00316167) survey from 2/8/2024 to 2/15/2024, the facility did not ensure residents received adequate supervision to prevent accidents. This was evident for 2 (Resident #11 and #149) of 6 residents reviewed for accidents out of 39 total sampled residents. Specifically, 1) Resident #11, who is cognitively impaired with agitated behaviors, sustained a laceration on the left lower and upper leg when being transferred from chair to bed; 2) Resident #149, a cognitively impaired resident, did not receive adequate supervision and interventions to prevent seven falls in eight months. The findings are: The facility policy titled Accident-Incident dated 7/2023 documented all accidents, incidents, and adverse events occurring on the facility premises which is not consistent with the routine operation of the facility or care of a particular resident are monitored and evaluated. The occurrence may be a fall, skin tear, bruise, or a new pressure ulcer and may involve abuse, neglect, misappropriation, or an injury of unknown origin. The facility policy titled Fall Prevention and Management dated 12/2023 documented the interdisciplinary team identifies and implements appropriate interventions to reduce the risk of falls or injuries while maximizing dignity and independence. 1) Resident #11 had diagnoses of Dementia and Cerebrovascular Accident. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #11 was severely cognitively impaired, required extensive assistance of 1 person to transfer, and exhibited behavior of rejecting care. The Nursing Note dated 8/29/2022 documented the Licensed Practical Nurse assisted the Certified Nursing Assistant in changing Resident #11 and putting the resident to bed. Resident #11 became agitated and combative when staff attempted to remove the resident from the wheelchair. Resident #11 began banging their legs against the wheelchair as they were transferred to bed. Staff observed Resident #11 sustained a skin tear to their left leg after the resident was transferred to bed. The Nursing Note dated 9/1/2022 documented Resident #11 was sent to the hospital on 8/29/2022 after the Medical Doctor was informed the resident required sutures. The facility Investigation Report dated 8/29/2022 documented Resident #11 exhibited behaviors and was agitated at the time of their transfer from wheelchair to bed. Two staff attempted to transfer the resident and Resident #11 began kicking and biting staff. Resident #11 was at high risk of injury. On 2/15/2024 at 8:30 AM, the Certified Nursing Assistant #14 was interviewed and stated that Resident #11 did not want to go to bed. The assigned certified nursing assistant and the licensed practical nurse tried to put the resident back to bed, and the resident sustained a laceration. Certified Nursing Assistant #14 stated Resident #11 sat on the bed and would hold the bed rail and lay down when the resident was calm. On 2/15/2024 at 8:38 AM, Licensed Practical Nurse #11 was interviewed and stated that Resident #11 refused to be transferred back to bed but 2 staff members transferred the resident, and the resident began to kick their feet. Resident #11's left leg sustained a cut. On 2/15/2024 at 12:22 PM, the Director of Nursing was interviewed and stated that they were not working at the facility at the time the incident occurred with Resident #11. The staff should have left the resident to calm down before putting the resident to bed to prevent the injury. 45351 2) Resident #149 had diagnoses of Dementia and Chronic Obstructive Pulmonary Disease. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #149 was severely cognitively impaired and did not have any recent falls. The Comprehensive Care Plan related to fall risk created 4/15/2022 documented Resident #149 was at risk for falls due to cognitive impairment, sudden unsafe moves, and no safety awareness. Interventions included to anticipate early waking, anticipate sudden unsafe moves, assist out of bed when awake, observe for restlessness, refer to rehab, refer to psychiatry, provide floor mats, reposition when restless, call light placed within reach, maintain a safe environments, be mindful of cognitive limitations, do not leave unattended in the shower room, offer toileting, account for resident's location at the end of each shift, and apply a wander guard alarm. The Comprehensive Care Plan related to Resident #149's cognitive impairment related to dementia was initiated on 4/15/2022 and documented interventions included anticipate needs of Resident #149. The Comprehensive Care Plan related to wandering initiated 4/15/2022 documented Resident #149 was at risk for elopement and interventions included confirming resident's location at specified times and keeping the resident's location within line of sight when out of bed. Nursing Note dated 2/5/2023 documented Resident #49 was found on the floor in their room next to their bed. No injury was noted. Nursing Note dated 2/17/2023 documented Resident #149 was found kneeling on their room floor and required assistance of 2 people to place them back in their wheelchair. Nursing Note dated 3/28/2023 documented Resident #149 began ambulating in the hallway and attempted to grab the Certified Nursing Assistant and fell to the floor. The Comprehensive Care Plan related to Resident #149's risk for falls was revised on 3/31/2023 to include interventions of close monitoring of resident whereabouts, anticipate resident's needs, and refer resident to rehab. Nursing Note dated 4/1/2023 documented Resident #149 was found on the floor by the nursing station. Nursing Note dated 4/14/2023 documented Resident #149 was found on the floor in the dayroom bleeding from the back of the head. Nursing Notes dated 8/6/2023, 8/25/2023, 9/23/2023, and 9/29/2023 documented Resident #149 had fall incidents. There was no documented evidence Resident #149's Comprehensive Care Plan related to falls risk was reviewed and revised up on resident's fall on 2/5/2023, 2/17/2023, 4/1/2023, 4/14/2023, 8/6/2023, 8/25/2023, 9/23/2023, and 9/29/2023. There was no documented evidence Resident #149's fall risk assessment was completed following falls on. 2/5/2023, 2/17/2023, 3/28/2023, 4/1/2023, 4/14/2023, 8/6/2023, 8/25/2023, 9/23/2023, and 9/29/2023. There was no documented evidence a facility investigation was completed to determine root cause analysis and individualized interventions to address Resident #149's frequent falls on 2/5/2023, 2/17/2023, 3/28/2023, and 4/1/2023. There was no documented Resident #149 received the supervision necessary to prevent frequent reoccurring falls. On 2/14/2024 at 11:18 AM, Certified Nursing Assistant #10 was interviewed and stated Resident #149 had no safety awareness and would randomly get out of the wheelchair. Resident #149 was cognitively impaired, unable to verbalize their needs, required toileting every 2-3 hours, and had floor mats near their low bed to reduce injury risk. On 2/14/2024 at 10:17 AM, Licensed Practical Nurse #6 was interviewed and stated Resident #149 had multiple falls, was restless, not sleeping at night, and had no safety awareness. Resident #149 tried to get out of bed without assistance. Resident #149 got out of their wheelchair and fell to the floor on 4/14/2023. Staff always monitored the dining room especially if there was a resident present who was at high risk for falls. There was no staff present when Resident #149 fell in the dining room on 4/14/2023. Staff were supposed to communicate coverage of the dining room but did not. On 2/15/2024 at 11:54 AM, Registered Nurse #1 was interviewed and stated Resident #149 had multiple falls last year, but they were not aware of every incident occurred for this resident. They reviewed the fall assessments and care plan related to Resident #149's fall risk in the electronic medical record and confirmed the assessments and care plan were not reviewed or revised after every fall incident. Registered Nurse #1 was not able to explain why there were no new interventions implemented for Resident #149 after recurrent falls. 10 NYCRR 415.12(h)(1)

Based on observation, record review, and staff interviews conducted during the recertification/complaint survey, the facility did not ensure infection control practices and procedures were maintained to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections. This was evident for 2 (8th and 5th Floors) of 6 resident units. Specifically, 1) Licensed Practical Nurse #2 did not sanitize a blood pressure cuff in between resident use, and 2) Licensed Practical Nurse #6 did not sanitize a glucometer in between resident use. The findings are: The facility policy titled Equipment - Cleaning and Disinfecting dated 01/2023 documented resident care equipment, including reusable items, will be cleaned and disinfected. The glucometer should be disinfected after use on each patient. On 02/09/2024 at 8:34 AM, Licensed Practical Nurse #2 was observed on the 8th Floor using a blood pressure cuff on Resident #29's arm, then placing the cuff on a chair next to the resident while gathering medication. After administering medication to Resident #29, Licensed Practical Nurse #2 placed the blood pressure cuff on the blood pressure machine and wheeled it to Resident #133's room. Licensed Practical Nurse #2 did not sanitize the blood pressure cuff and applied the cuff to Resident #33's arm to take a blood pressure reading. On 02/09/2024 at 09:00 AM, Licensed Practical Nurse #2 was interviewed and stated the blood pressure cuff should have been sanitized in between use with Resident #29 and Resident #133. The blood pressure cuff was supposed to be sanitized before and after each resident use. 2) On 02/12/2024 at 11:37 AM, Licensed Practical Nurse #6 was observed on the 5th Floor with a glucometer checking the fingerstick blood sugar reading for Resident #161. Licensed Practical Nurse #6 did not sanitize the glucometer and used the same glucometer to check Resident #82's fingerstick blood sugar reading. Licensed Practical Nurse #6 did not sanitize the glucometer after use with Resident #82 and used the same glucometer on Resident #9. On 02/12/2024 at 11:59 AM, Licensed Practical Nurse #6 was interviewed and stated they were supposed to sanitize the glucometer in between each resident use but they became nervous and forgot to sanitize in between Resident #161, #82, and #9. 02/14/2024 at 11:55 AM, an interview was conducted with the Infection Preventionist who stated resident care equipment is supposed to be sanitized in between each resident use. They provided ongoing surveillance and education to staff to ensure compliance with infection control standards. 02/14/2024 at 11:59 AM, the Director of Nursing was interviewed and stated the Infection Preventionist made rounds every shift to ensure staff were practicing proper infection prevention protocol. Resident shared care equipment should be sanitized in between each resident use. 10 NYCRR 415.19(b)(4)

Based on record review and interviews conducted during the recertification and abbreviated (NY00316167) survey from 2/8/2024 to 2/15/2024, the facility did not ensure all alleged violations involving an injury of unknown origin were reported immediately, but not later than 2 hours after the allegation was made, to the New York State Department of Health. This was evident for 2 (Resident #34 and #149) of 39 total sampled residents. Specifically, 1) Resident #34 was found to have a left upper arm fracture of unknown origin that was not reported to the New York State Department of Health, and 2) the facility did not report an unwitnessed incident resulting in a hematoma to Resident #149's head to the New York State Department of Health. The findings are: The facility policy titled Prevention, Identification, and Reporting of Abuse, Neglect, Mistreatment or Exploitation of a Resident dated 8/2023 documented the facility will report alleged violations immediately but not later than 2 hours if the alleged violation involved abuse or resulted in serious bodily injury. 1) Resident #34 had diagnoses of coronary artery disease and Dementia. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #34 had severely impaired cognition. The Nursing Note dated 10/16/2023 documented Resident #34 was observed in their recliner in the hallway grimacing in pain with discoloration and swelling to their left upper arm. The Physician's Order dated 10/16/2023 documented stat x-ray of the Resident #34's left shoulder. The Nursing Note dated 10/17/2023 documented stat x-ray of Resident #34's left shoulder was done. Radiology Report dated 10/17/2023 documented x-ray of Resident #34's left shoulder revealed an acute comminuted humeral neck fracture. The facility Full Quality Assurance Report initiated 10/16/2023 documented Resident #34 had an injury of unknown origin to their left upper arm that was found to be a fracture. The conclusion of the report was dated 10/23/2023 and determined no abuse had occurred. There was no documented evidence the facility reported Resident #34's fracture of unknown origin to the New York State Department of Health within 2 hours of occurrence. On 2/15/2024 at 12:40 PM, the Director of Nursing was interviewed and stated they, along with the Administrator and Assistant Director of Nursing, were responsible for reporting alleged violations involving injury of unknown origin to the New York State Department of Health. Resident #34's left upper arm fracture should have been reported and the Director of Nursing stated they did not know why the case was not reported as it should have been. On 2/15/2024 at 1:15 PM, the Administrator was interviewed and stated Resident #34's fracture of unknown origin should have been reported to the New York State Department of Health. 45351 2) Resident #149 had diagnoses of Dementia and Chronic Obstructive Pulmonary Disease. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #149 was severely cognitively impaired. The Nursing Note dated 4/14/2023 documented Resident #149 was found on the floor in the dayroom by the Certified Nursing Assistant and was bleeding from the back of their head. The facility's Full Quality Assurance Report initiated 4/14/2023 documented Resident #149 had an unwitnessed fall and was sent to the hospital for evaluation due to a hematoma to the back of their head. The report documented that no abuse occurred in the conclusion dated 4/19/2023. There was no documented evidence the facility reported Resident #149's unwitnessed incident, resulting in a hematoma to the back of their head and hospital transfer, to the New York State Department of Health within 2 hours of occurrence. On 2/15/2024 at 1:05 PM, the Director of Nursing was interviewed and stated Resident #149's incident on 4/14/2023 was not reported to the New York Stated Department of Health. 10 NYCRR 415.4(b)(2)

Based on record review and interview conducted during the Recertification survey from 2/8/2024 to 2/15/2024, the facility did not ensure that resident comprehensive care plans were reviewed and revised after each assessment. This was evident for 2 (Resident #106 and #160) of 39 total sampled residents. Specifically, 1) the care plan related to Resident #106's pain management was not reviewed and revised upon assessment, and 2) the care plan related to Resident #160's anticoagulant use was not reviewed and revised upon assessment. The findings are: The facility policy titled Care Plans - Comprehensive dated 10/2019 documented assessments of residents are ongoing and care plans are revised as information about the residents and their condition changes. 1) Resident #106 had diagnoses of heart failure and renal failure. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #106 was cognitively intact, received pain medication, and should have a pain assessment conducted. The Comprehensive Care Plan related to pain initiated 01/19/2023 and last revised on 6/14/2023 documented Resident #106 experienced pain and had a history of fracture. There was no documented evidence Resident #106's care plan related to pain was reviewed and revised upon assessment dated [DATE]. 2) Resident #160 had diagnoses of Hypertension and Cerebrovascular accident. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #160 was moderately cognitively impaired and received an anticoagulant. The Comprehensive Care Plan related to anticoagulant therapy initiated 06/06/2022 documented Resident #160 received aspirin 81mg as a deep vein thrombosis prophylaxis. There was no documented evidence Resident #160's care plan related to anticoagulant use was reviewed and revised upon assessment dated [DATE]. On 02/14/2024 at 11:06 AM, an interview was conducted with Registered Nurse #2 who stated they were responsible for reviewing and revising residents' care plans. The Minimum Data Set 3.0 assessment triggered the care plans that required review during the resident's assessment period. Registered Nurse #2 was unable to provide a reason Resident #106's and #160's care plans were not reviewed and revised upon Minimum Data Set 3.0 assessment. On 02/14/2024 at 11:49 AM, an interview was conducted with the Director of Nursing who stated they were aware there were some Comprehensive Care Plans that had not been reviewed or revised because the facility changed their electronic medical record provider, and the care plans were not carried over to the new system. 415.11(c)(2)(i-iii)

Based on observations, record review and interviews conducted during an abbreviated survey (NY 317) on 10/28/2021, the facility did not ensure that a resident was free from physical abuse. This was evident in 1 of 3 residents sampled (Resident #1). Specifically, on 07/02/2021 at approximately 7:30 PM, Security Officer (SO) #1 witnessed Certified Nursing Assistant (CNA) #1 slapped Resident #1 on the forehead and verbally threatened the resident. CNA #1 continued to work on the unit until his/her shift ended at 11:00PM. The findings are: The Facility's Policy and Procedure entitled Abuse last revised date 09/15/2019 states that employees, consults, contractors, volunteers, and other caregivers will provide an environment for the residents that is safe and free from abuse, neglect, exploitation, mistreatment, and misappropriation. Treating each resident with respect, dignity, and provision of privacy. This document also revealed that upon notification of an alleged abuse incident, the Nursing Supervisor/Designee will conduct a nursing assessment of the Resident and document the findings in the Resident's medical record and on the Incident/Accident Report Form. Primary Care Physician will assess the resident and document the findings in the Resident's medical record and on the occurrence report form if appropriate. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 12/22/2020 documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) and scored 02/15 (00-07 severe impairment, 08-12 moderate impairment and 12-15 cognitively intact). The facility investigation dated 02/08/2021 revealed that the Security Officer reported on 02/08/2021 that he/she witnessed on 02/07/2021, CNA #1 slap Resident #1 on the forehead. CNA #1 also told the resident that next time he/she would punch Resident #1 in the face. Resident #1 was not able to provide an accounting of the occurrence due to impaired cognition. CNA #1 denied slapping Resident #1 on the forehead but stated that he/she (CNA #1) slapped Resident #1 on the arm to block the resident from hitting him/her (CNA #1). CNA #1 admitted to threatening Resident #1. CNA #1 reported that he/she said to Resident #1, you are lucky I did not punch you in the face. The facility concluded that CNA #1 abused Resident #1. Resident #1 did not sustain any pain, injury, or trauma because of the occurrence. Resident #1's family and the Police were notified. SO #1's written statement dated 02/08/2021, reviewed and revealed that the SO was conducting rounds patrol throughout the facility on the 6th floor on 02/07/2021. The SO documented that he/she witnessed a Nurse's Aide (CNA #1) physically harmed a resident (Resident #1). The Nurse's Aide yelled and slapped the resident on the forehead. The nurse's aide also threatened the resident by saying, next time, I'm going to punch you in the face. A Behavior Comprehensive Care Plan (CCP) dated 12/22/2020 documented that Resident #1 had behavioral problems as evidenced by physical aggression (kicking, scratching, grabbing the staff) and rejection of care. The interventions documented to approach calmly, to introduce self, give the resident a choice and make a request rather than a command. If the resident was too agitated or engaged in the activity of interest, modify the approach rather than insist on an activity. Set up a schedule agreeable to the resident. Interrupt behavior promptly without rebuking resident's actions. Encourage resident to calm down, refocus behavior. If behavior infringes on the health and/or safety towards self or others, notify MD. The care plan was not updated to reflect on the incident of 02/07/2021. A review of Resident #1's medical record revealed there was no documentation of assessment from the Registered Nurse (RN) or the Medical Doctor regarding the alleged physical abuse incident of 02/07/2021. Review of the CNA Accountability Record dated 02/2020 revealed no instructions on what staff to do if Resident #1 became combative during care. During an interview on 10/28/2021 at 12:40 PM, SO #1 stated that he/she conducted rounds on Resident #1's unit on 02/07/2021 on the evening shift (does not recall exact time). The SO stated that he/she observed CNA #1 yelled at Resident #1 and slapped Resident #1 with an open hand on the forehead. The SO stated that the slapped was hard enough. The SO stated that it he/she heard a slapping sound. The SO stated that Resident #1 was cursing at CNA #1 and was using foul language. The SO stated that CNA #1 said to Resident #1, next time I'm going to punch you in the face. The SO stated that Resident #1 was sitting in a wheelchair at the nursing station when he/she witnessed the incident. The SO stated that CNA #1 was the only staff member visible at the time of the incident. The SO verbalized that he/she reported the incident the next morning (02/08/2021) to his/her supervisor and the supervisor reported the incident to the Administrator. The SO contends that he/she was not aware that he/she was supposed to report the abuse immediately. The SO stated that he/she is no longer employed in the facility. During an interview on 12/20/2021 at 10:00 AM, CNA #1 stated that he/she worked on the 02/07/2021 on the 3-11 shift and was monitoring Resident #1 near the nursing station. CNA #1 stated that Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1 started punching him/her. CNA #1 stated that he/she tried to avoid to be hit by Resident #1. CNA #1 stated that he/she held his/her hand up to block Resident #1's hand. CNA #1 stated that he/she tried to walk away and at the same time was trying to protect Resident from falling. CNA #1 stated that Resident #1 started to fall and that he/she lowered Resident #1 to the floor and called for help. CNA #1 stated that the charge nurse came. CNA #1 voiced that he/she saw a security guard come out of the stairwell door and walked through the unit hallway but did not help with the combative resident. CNA #1 stated that he/she did not hit Resident #1 on the forehead or on the hand. CNA #1 stated that he/she does not remember, but he/she possibly said to Resident #1 you are lucky that I did not punch you back.'' CNA #1 stated that after the incident, the facility called him/her into the office, and the DNS told him/her that he/she slapped Resident #1. CNA #1 stated that the facility assumed that he/she hit Resident #1 because one person reported it. Attempts were made to contact the Licensed Practical Nurse (LPN), who worked on 02/07/2021 on the 3-11 shift, were unsuccessful. LPN #1 is no longer working in the facility and his/her whereabouts are unknown. During an interview on 10/28/2021 at 2:45 PM, random RNS #2 stated that the charge nurse on the unit is responsible for overseeing staff and ensuring that staff does not abuse the residents. All staff received in-service on abuse preventions. The RNS stated that if a resident is combative during care, the staff must notify the nurse immediately. During an interview on 12/21/2021 at 9:33 AM, the Medical Doctor stated that he/she does not recall being notified of the abuse of Resident #1. The MD stated that he/she would have evaluated Resident #1 and wrote a note in the resident's medical record. During a follow-up interview on 12/21/2021 at 9:50 AM, the DNS stated if the resident became combative during care, staff should try to calm the resident down and if unsuccessful, call for assistance and notify the nurse. The DNS stated that the CNA should have checked the CNA Accountability prior to attending to the resident. The DNS voiced that the nurse gives report to staff at the beginning of the shift. 415.4(b)(1)(i)

Based on observations, interviews, and record reviews conducted during an abbreviated survey (NY 317) on 10/28/2021, the facility did not ensure that an allegation of abuse was reported to facility staff immediately. This was evident in 1 out of 3 residents sampled (Resident #1). Specifically, on 02/07/2021, at approximately 7:30 PM, Security Officer (SO) #1 witnessed Certified Nursing Assistant (CNA) #1 slapped and threatened Resident #1. The abuse was not immediately reported to the Administrator or nursing staff. The incident was reported on 02/08/2021. CNA #1 continued working until his/her shift ended at 11:00 PM on 02/07/2021. The findings are: The Facility's Policy and Procedure entitled Abuse last revised date 09/15/2019 states that after ensuring the resident is protected, Nursing Home Staff must immediately report to his or her Supervisor of the Administrator any allegation or suspicion of abuse, neglect, mistreatment, or exploitation . The Supervisor shall immediately notify the Administrator of all reports. In addition, nothing shall prevent any Nursing Home Staff from reporting directly to state or federal agencies any allegations or suspicion of abuse, neglect, mistreatment, or exploitation. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #1 had a BIMS and scored 02/15 associated with severely impaired cognition. The facility investigation dated 02/08/2021 revealed that the Security Officer reported on 02/08/2021 that he/she witnessed on 02/07/2021, CNA #1 slap Resident #1 on the forehead. CNA #1 also told the resident that next time he/she would punch Resident #1 in the face. Resident #1 was not able to provide an accounting of the occurrence due to impaired cognition. CNA #1 denied slapping Resident #1 on the forehead but stated that he/she (CNA #1) slapped Resident #1 on the arm to block the resident from hitting him/her (CNA #1). CNA #1 admitted to threatening Resident #1. CNA #1 reported that he/she said to Resident #1, you are lucky I did not punch you in the face. The facility concluded that CNA #1 abused Resident #1. Resident #1 did not sustain any pain, injury, or trauma because of the occurrence. Resident #1's family and the Police were notified. SO #1's written statement dated 02/08/2021, reviewed and revealed that SO #1 was conducting rounds patrol throughout the facility on the 6th floor. The SO documented that he/she witnessed a Nurse's Aide (CNA #1) physically harm a resident (Resident #1). The Nurse's Aide yelled and slapped the resident on the forehead. The nurse's aide also threatened the resident by saying, next time, I'm going to punch you in the face. During an interview on 10/28/2021 at 12:40 PM, SO #1 stated that he/she conducted rounds on Resident #1's unit on 02/07/2021 on the evening shift (does not recall exact time). The SO stated that he/she observed CNA #1 yelled at Resident #1 and slapped Resident #1 with an open hand on the forehead. The SO stated that the slapped was hard enough. The SO stated that it he/she heard a slapping sound. The SO stated that Resident #1 was cursing at CNA #1 and was using foul language. The SO stated that CNA #1 said to Resident #1, next time I'm going to punch you in the face. The SO stated that Resident #1 was sitting in a wheelchair at the nursing station when he/she witnessed the incident. The SO stated that CNA #1 was the only staff member visible at the time of the incident. The SO verbalized that he/she reported the incident the next morning (02/08/2021) to his/her supervisor and the supervisor reported the incident to the Administrator. The SO contends that he/she was not aware that he/she was supposed to report the abuse immediately. The SO stated that he/she is no longer employed in the facility. During an interview on 10/28/2021 at 12:40 PM, the Administrator stated that he/she was not aware of the incident. The Administrator stated that the SO should have reported the incident immediately but did not. The SO reported the allegation on 02/08/2021. During the follow-up interview on 11/29/2021 at 3:00 PM, DNS stated that all incidents should be reported immediately to the nurse or supervisor. During an interview on 11/30/2021 at 9:59 PM, Registered Nurse Supervisor (RNS) #1, who worked on 02/07/2021 at 7:00 PM-7:00 AM shift, stated that no one reported the incident during his/her shift. RNS #1 stated that he/she became aware of the incident from reading the 24-hour report on 02/08/2021. RNS #1 stated that if a resident was abused it should have been reported immediately and the Medical Doctor (MD) should have been notified. 415.4(b)(1)(i)

Based on observations, interviews, and record reviews conducted during an abbreviated survey (NY 317) on 10/28/2021, the facility did not have evidence that an alleged violation was thoroughly investigated. This was evident in 1 of 3 residents sampled (Resident #1). Specifically, on 02/07/2021, a staff member witnessed another staff member physically abused Resident #1. Review of the facility's completed investigation revealed that the facility did not address the following issues: 1) Resident #1 was not assessed by a Registered Nurse. 2) The Medical Doctor was not notified and did not examined Resident #1. 3) There was no documentation in Resident #1's medical record. 4) The alleged abused was not reported immediately to facility Administrator or nursing staff and the accused staff continued to work on the unit until his/her shift ended at 11:00PM. The findings are: The Facility's Policy and Procedure titled Abuse last revised date 9/15/2019 documented that the Administrator will ensure investigations are initiated and review all investigatory documentation and ensure that report was made to the appropriate entity if necessary; Review that investigation is completed, including all statements from staff, residents and any other person deemed to complete the investigation. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #1 had a BIMS score of 02/15 associated with severely impaired cognition. The facility investigation dated 02/08/2021 revealed that the Security Officer reported on 02/08/2021 that he/she witnessed on 02/07/2021, CNA #1 slap Resident #1 on the forehead. CNA #1 also told the resident that next time he/she would punch Resident #1 in the face. Resident #1 was not able to provide an accounting of the occurrence due to impaired cognition. CNA #1 denied slapping Resident #1 on the forehead but stated that he/she (CNA #1) slapped Resident #1 on the arm to block the resident from hitting him/her (CNA #1). CNA #1 admitted to threatening Resident #1. CNA #1 reported that he/she said to Resident #1, you are lucky I did not punch you in the face. The facility concluded that CNA #1 abused Resident #1. Resident #1 did not sustain any pain, injury, or trauma because of the occurrence. Resident #1's family and the Police were notified. SO #1's written statement dated 02/08/2021, reviewed and revealed that the SO was conducting rounds patrol throughout the facility on the 6th floor when he/she witnessed a Nurse's Aide (CNA #1) physically harm a resident (Resident #1). The Nurse's Aide yelled and slapped the resident on the forehead. The nurse's aide also threatened the resident by saying, next time, I'm going to punch you in the face. A review of the facility's completed investigation report dated 02/08/2021, revealed that the Medical Doctor did not sign the incident report. There was no assessment done by the Medical Doctor or the Registered Nurse. There was not mentioned of the Security Offer not reporting the alleged abuse immediately which allowed the Certified Nursing Assistant to continue working with Resident #1. During an interview on 10/28/2021 at 12:40 PM, SO #1 stated that he/she conducted rounds on Resident #1's unit on 02/07/2021 on the evening shift (does not recall exact time). The SO stated that he/she observed CNA #1 yelled at Resident #1 and slapped Resident #1 with an open hand on the forehead. The SO stated that the slapped was hard enough that he/she heard a slapping sound. The SO stated that Resident #1 was cursing at CNA #1 and was using foul language. The SO stated that CNA #1 said to Resident #1, next time I'm going to punch you in the face. The SO stated that Resident #1 was sitting in a wheelchair at the nursing station when he/she witnessed the incident. The SO stated that CNA #1 was the only staff member visible at the time of the incident. The SO verbalized that he/she reported the incident the next morning (02/08/2021) to his/her supervisor and the supervisor reported the incident to the Administrator. The SO contends that he/she was not aware that he/she was supposed to report the abuse immediately. During an interview on 10/28/2021 at 3:45 PM, the Director of Nursing (DNS) stated that she/he worked in the facility for 2.5 months and was not in the facility at the time of the incident. The DNS stated that he/she is now responsible for investigating incidents in the facility. 415.4 (b)(3)

Based on interviews and record review conducted during an abbreviated survey, the facility did not provide proper supervision to ensure resident health and safety. Specifically, the facility did not respond appropriately to a door alarm. This was evident for 1 of 3 residents sampled for Quality of Care/Treatment (Resident #1). Resident #1 sustained multiple fractures, laceration and a hematoma, after opening and passing through an alarmed staircase door and subsequently falling down a flight of stairs (10 steps) in her wheelchair. Resident #1 was in the stairwell approximately 1 hour before being found by staff. Complaint # NY 706 The findings include: Resident #1 is an [AGE] year-old female, who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] identified Resident #1 with intact cognition. In addition, Resident #1 requires extensive assistance in all aspects of care. Section G of the MDS documented that Resident #1 requires extensive assistance of one person for walking in corridor and locomotion on unit. On 08/23/2016 at 11:00AM, Surveyor #1 and the Director of Communication/Security (DOCS) viewed the facility's video surveillance camera of the 8th floor dated 08/19/2016. The surveillance camera showed Resident #1 self-propelling the wheelchair in the direction of stairwell C. No staff members or other residents were noted in the corridor. Resident #1 opened the door to stairwell C on the 8th floor at 6:42PM and passed through to stairwell landing. The door took approximately 10-11 seconds to close. (The DOCS stated that the camera time stamped was off by 1 hour and 15 minutes. The actual recording time was approximately 7:53PM-8:00PM). Within a few seconds after the door was closed, Certified Nursing Assistant #1 (CNA#1), could be seen looking in the direction of stairwell C from the doorway of a resident room. As CNA #1 was looking in the direction of stairwell C, 14 seconds later, a resident in a wheelchair was seen coming out of the room that was next to stairwell C. CNA #1 walked in the direction of the resident, but did not go to the door of stairwell C. The surveillance camera showed CNA #2 coming out of a room and walked in the direction opposite of stairwell C. At no time did CNA #2 check the exit door at stairwell C. The security guard was seen on camera walking towards stairwell C exit door. As he approached the door of stairwell C, he looked through the glass window panel of the door. At no time did the security guard open the exit door at stairwell C. A nurse's note written by RN #1 on 08/19/2016 at 11:10PM, documented that while she was in the process of medication pass, CNA #2 approached her and informed her that Resident #1 was missing. The writer documented that she searched the high side of the floor and that she called the security guard at approximately 8:30PM to get further instructions on missing resident. The note documented that the security guard instructed the writer to thoroughly search. The writer documented that she checked the low side of the unit. No stairwell alarm heard at that time. The writer told the security guard to call 'Dr. Yellow' (missing resident) and connect her with the supervisor.The supervisor instructed the writer to search the floors then 'Dr. Yellow' was called. The writer further documented that as she went back to the floor, she heard an aide call out that Resident #1 was found in the stairwell. The writer went to the stairwell and stayed with Resident #1. The supervisor (RNS #2) immediately arrived. Resident #1 was observed lying on the landing of the stairwell between the 8th and 7th floor on her left side with the wheelchair rolled to the side. A small amount of blood was observed on the floor. RNS #2 called for cool compress and Normal Saline. Hematoma and laceration with depth that was unable to assess due to hair on left parietal side of the head. Tylenol 650mg was given for pain as evidenced by facial grimacing. More help was called to assist resident out of stairwell with the use of a full length backboard and the assist of eight staff. Resident #1 was placed in bed and the supervisor called the Emergency Medical Service (EMS). A nurse's note written by RNS #2 on 08/19/2016 at 9:24PM, documented that she received a call at 9:00PM from the nurse on the unit (RN #1), who stated that Resident #1 has been missing for a while and a thorough search already been done by staff without success. Writer came to unit and assisted in search for Resident #1 without success. Writer instructed security to initiate 'Dr. Yellow' for missing resident. While staff were already responding to 'Dr. Yellow,' received a call from staff, come quickly Resident #1 on stairway. Found Resident #1 lying on her left side on the floor at the bottom of stairwell C on the 8th floor with her wheelchair rolled next to her. Resident #1 was alert and responsive with confusion. No change in mental status. Noted moderate amount of bleeding to left parietal. Pressure dressing applied with cold compress with effect. Noted facial grimacing upon palpation to left parietal and left shoulder. Tylenol 650 mg by mouth given with effect. Resident assisted off the floor with the assistance of eight staff using first aid body board to transfer to bed. Body assessment done. Hematoma with laceration with depth to left parietal. Unable to assess laceration due to hair. 911 called arrived at 10:00AM (10:00PM not 10:00AM) and Resident #1 was transferred to the hospital. Review of the Facility's Internal Investigation, revealed that on 08/19/2016 at approximately 9:15 - 9:20PM, Resident #1 was found on the stairwell landing between the 8th and 7th floor. Resident #1 is wheelchair bound, went through the exit door (stairwell C) and fell down the stairs. Stairwell C is alarmed. The alarm did sound but was ignored by staff who heard it go off. The investigation also documented that after CNA #2 was unable to find Resident #1, she informed RN #1 and a coworker. Staff began searching. The supervisor (RNS #2) was notified and 'Dr. Yellow' was announced. They searched for some time, she then went back to the unit and a resident told her (CNA #2) that she thought somebody in a wheelchair went through the door. CNA #2 said she then went through the door (stairwell C) where she found Resident #1 lying on the landing next to her wheelchair. CNA #2 said she then screamed out to alert staff that she found Resident #1. Investigation concluded that CNA #1 and CNA #2 failure to respond to alarm did result in resident's injury. This was negligence on their part. Review of the nurse's progress note dated 08/23/2016, revealed that Resident #1 was readmitted from the hospital at 8:00PM. [DIAGNOSES REDACTED]. Noted with dry cut on the top of left of head with 4 staples. Complained of pain when move in bed. On Tylenol 650mg every 6 hours. Vital signs temperature 97.0, Pulse 74, Respiration 18, Blood Pressure 120/64. Also noted, Resident #1 on oxygen 2L/ML via nasal cannula. Oxygen saturation 99%. No distress noted. The hospital document dated 08/23/2016 documented the following: Scalp Laceration, left Pneumothorax (PTX) - trace bubble, Left Hemothorax (HTX)- trace, Left Clavicle Fracture, Left 6 Rib Fractures - #1,2,4,5,7 & 8. Resident admitted to Intensive Care Unit (ICU) also on pain management. Review of the hospital discharge medications revealed that Resident #1 received and was discharged on the following medications: [REDACTED]. The Doctor's Order Summary Report dated 08/23/2016 documented Acetaminophen Tablet 325mg give 2 tablet by mouth every 5 hours for chronic pai[DIAGNOSES REDACTED] and Lidocaine Patch 5% apply to left rib cage topically every 12 hours related to chronic pai[DIAGNOSES REDACTED]. The Medication Administration Record (MAR) of 08/24/2016, documented that Resident #1 started on Lidocaine Patch 5% to left rib cage topically in AM and removed at bedtime and Acetaminophen Tablet 325 mg give 2 tablet by mouth every 5 hours . The Acetaminophen Tablet 325mg was discontinued on 08/26/2016. The Physician Examination assessment dated [DATE] at 12:03 PM, documented that Resident #1 was status [REDACTED]. No new complaints. Pain controlled. The documentation further revealed that Resident #1 was assessed for pain and was on Lidoderm Patch. On 08/23/2016 at 6:26PM a telephone interview was conducted with CNA #2, who worked on the 3-11 shift on 08/19/2016. She stated that after she had completed caring for all her residents, she started looking for Resident #1 and was unable to find her. She also stated that she informed RN #1 who instructed her to search again. She also stated that when they did not find Resident #1, RN #1 called the supervisor. CNA #2 was asked if she had checked the stairwell as the door alarm was activated and she replied, No, I didn't check the stairways because I don't think she could open the door. When CNA #2 was asked if she had heard the door alarm, she stated that she heard the alarm when she was in a resident room. She also stated that she could not leave the resident in the bathroom. She also stated that after she had completed caring for the resident, she saw the security guard on the unit and the alarm was not sounding. She further explained that she found Resident #1 at the end of the stairs, lying on the floor with her wheelchair next to her. In addition, she stated that she alerted others by screaming. On 08/23/2016 at 6:37PM, a telephone interview was conducted with RN #1 who was assigned to the 8th floor on the 3-11 shift on 08/19/2016. She stated that she was away from the unit for approximately 10 minutes and that she returned to the unit at approximately 8:10PM. In addition, she stated that as she was in the process of medication pass, CNA #2 approached her at approximately at 8:30PM reporting that she was unable to find Resident #1 and that she had searched for Resident #1 for approximately 5-10 minutes. RN #1 stated that she reported to the security guard and RNS #1 that Resident #1 was missing and Code Yellow was subsequently announced. She affirmed that after Resident #1 was discovered on the stairs, she became aware that the alarm on the 8th floor at stairwell C had been activated. On 08/26/2016 at 10:02AM, a telephone interview was conducted with RNS #2, who worked on the 7:00AM to 7:00PM shift on 08/19/2016. She stated that RN#1 called her to the 8th floor on 08/19/2016 at approximately 9:00PM stating that they were unable to find Resident #1. She stated that she went to the 8th floor and extended the search to other floors. She also stated that she was informed that Resident #1 was located (RNS #1 unable to recall the time) and that she should go to the 8th floor stairwell C. She stated that Resident #1 was observed lying on her left side with blood on the left side of her head and the wheelchair was next to her. Further body assessment revealed that Resident #1 sustained laceration to the left parietal with hematoma. RNS #1 also stated that Resident #1 grimaced when her left shoulder was touched and she was given pain medication. Treatment was also done and 911 was also called. On 08/23/2016 at 3:41PM, the security guard, who worked on the 3-11 shift on 08/19/2016 was interviewed. He stated that he returned from break at approximately 7:48PM and the alarm was activated on the panel between 7:51PM and 7:53PM indicating stairwell C. He stated that a call was already made to the 8th floor, but there was no answer. He stated that when he went to the 8th floor, he heard an audible alarm and went towards stairwell C. He spoke with CNA #1 asking her, who tripped the alarm and she stated, it's ok, it's the lady in the wheelchair and she is fine. He also stated that he asked the CNA if the resident was good, and she responded ok. He also stated that, based on CNA's answer, he looked through the glass panel on the door and saw no one, therefore he reset the alarm by punching in the code. He stated that he proceeded to do his rounds by starting from the roof to the basement. He asserted that he utilized the elevator stopping on each floor, only checking the functioning of the door alarms. The security guard responded to a question regarding checking the stairwells. He stated that he did not check the stairwells and that he did not check the 8th floor stairwell C as he had already done it. In a subsequent telephone interview with the security guard on 09/23/2016 at 2:10PM, he stated that when he returned to the front desk, the panel was still sounding at approximately 8:01PM. The security guard responded to a question regarding the time he received the first phone alerting that Resident #1 was missing. He stated that RN #1 called him between 8:30PM and 8:40PM informing him that Resident #1 might be missing. He asserted that he instructed RN #1 to double check the unit first before calling Code Yellow. In addition, he stated that RN #1 called him back at approximately 9:00PM informing him that they were unable to find Resident #1 and to connect her to the nursing supervisor. He stated that the supervisor came down stairs to him asking if Resident #1 was found and when he said no, she instructed him to call 'Dr. Yellow' between 9:02PM and 9:05PM. He stated that between 9:10PM and 9:15PM he received a call stating that Resident #1 was found. On 10/18/2016 at 4:25PM, a telephone interview was conducted with the receptionist. She stated that on 08/19/2016 when the door alarm was activated on the 8th floor, it showed stairway C. She stated that she made three phone calls to the unit, but that no one answered. The receptionist responded to a question regarding how long it took between the time she called the unit and the time the security went up to the 8th floor. She stated that it took approximately 5-7 minutes. On 08/23/2016 at 10:49AM, a telephone interview was conducted with CNA #1 who worked on the 3-11 shift on 08/19/2016. She stated that she was in a resident room when she heard the door alarmed. The CNA did not recall the time she heard the alarm. CNA #1 was asked if she had responded to the alarming door and she stated that she I looked through out the door from the room that she was in, but that she did not see anybody by the door. She further stated, I did not go towards the door because I could not leave the resident I was caring for in the bathroom. She also stated that she saw the security guard going towards the door and that she assumed he would take care of it. CNA #1 stated that the security never spoke to her when he came to the unit. On 08/23/2016 at 10:00AM, an interview was conducted with the Director of Nursing (DON). She stated that she was informed that Code Yellow was activated on 08/19/2016 at approximately 9:00PM. She also stated that the facility's investigation revealed that the alarm on the 8th floor at stairwell C was activated at approximately 7:45PM for 2-3 minutes. In addition, she stated that the investigation revealed that prior to Resident #1 being found lying in the stairwell on the 8th floor, the security guard, CNA #1 and CNA #2 did not report that the alarm was activated. She also stated that during her interview with the staff, CNA #2 stated that she observed Resident #1 going to the elevator on 08/19/2016 but didn't tell the nurse. When the DON was asked how staff should respond to an alarming door, she stated that staff is supposed to go and check the stairway. In a subsequent telephone interview with the DON on 09/23/2016 at 9:37AM, she stated that when the alarm is activated staff should check up and down the stairs and if staff cannot be sure no one went through the door at that time, they do headcount. The Facility's Policy and Procedure on Wandering/Elopement Risk Assessment Procedure did not mention how staff should respond to an alarming door. On 10/27/2016 at 1:15PM, a telephone interview was conducted with Resident #1's readmitting physician. He stated that he examined Resident #1 upon her return from the hospital and she was in stable condition. He further stated that she had staples to the occipital area that was dry and no treatments were ordered. He also stated that she had pain that was controlled. 415.12 (h)(1)(2)