Every finding on record at The Paramount At Somers Rehab And Nursing Center

Based on observations, interviews and record reviews during survey, the facility failed to ensure a resident's right to be free from physical abuse. This was evident for one (1) (Resident #1) of six (6) residents reviewed for abuse. Specifically, on 04/25/2026, between 8:24PM and 8:28PM (actual time) Certified Nurse Aide #1 is observed on facility video surveillance using an overbed table to restrict Resident #1 from getting out of their wheelchair to ambulate. Further review of the footage showed Certified Nurse Aide #1 hitting and pinching the resident on their left arm, then spitting at the resident as the resident attempted to move the table. This resulted in physical abuse to Resident #1 and Immediate Jeopardy to all 48 residents on the behavioral unit. The findings include:The Facility Abuse Prevention Program policy dated 11/14/2024 documented it is the policy of the facility that residents have the right to be free from abuse neglect, misappropriation of the resident's property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.Resident # 1 was admitted to the facility with diagnoses that included vascular dementia (a type of dementia caused by reduced or blocked blood flow to the brain leading to cognitive decline and memory problems) with agitation, subarachnoid hemorrhage (bleeding in the space between the brain and the tissues that cover it) and depression (persistent feelings of sadness and loss of interest in activities once enjoyed.) The admission Minimum Data Set (a resident assessment tool) dated 04/19/2026 documented Resident #1 had severe impaired cognition with no documented behaviors. The resident had impairment on one side of the upper extremity and required moderate assistance with toileting/bed mobility and set up assistance with eating. Review of the Hospital Discharge summary dated [DATE] documented Resident #1 attacked their spouse and needed to have delirium precautions.The Comprehensive Care Plan related to falls dated 04/15/2026 documented Resident #1 was at risk for falls and has a history of falls. Interventions included getting the resident up at 7:30AM to be brought to the common area for increased supervision, reality orientation and encouraging resident to stay in a supervised areaReview of a behavioral note dated 04/17/2026 documented Resident #1 was restless, physically combative and agitated in the evening. Resident #1 was placed on one-to-one supervision.Review of Resident #1's Kardex (a quick reference that provides concise information on the resident's care plan, medical history and daily needs) documented no instructions for how to address behavioral symptoms prior to the incident on 04/25/2026. Review of the Comprehensive Care Plans revealed no documented behavior care plan to address Resident #1's behavior until after the incident on 04/25/2026. The Facility video surveillance dated 04/25/2026 with time stamp between 7:24PM and 7:28PM (due to daylight savings time, the clock on the surveillance was not updated and is one hour behind the actual time of occurrence) revealed Certified Nurse Aide #1, with their cell phone in hand, seated next to Resident #1 in the unit hallway. Certified Nurse Aide #1 and Resident #1 are observed in a verbal exchange, with the resident attempting to push the overbed table away. Certified Nurse Aide #1 is observed forcibly placing/repositioning the overbed table in front of the resident several times as the resident is trying to push the overbed table away. Certified Nurse Aide #1 is observed hitting the resident on their left arm followed by pinching the resident and then spitting at and hitting the resident again three (3) minutes later at 7:27PM. Licensed Practical Nurse #2 is seen at the nurse's station located directly across from where the incident was occurring and responds to the situation after Certified Nurse Aide #1 spits at the resident and then hits the resident for the second time at 7:27PM.In an interview with Certified Nurse Aide #1 they reported that they were instructed to place the overbed table in front of the resident to prohibit them from getting out of the chair or moving, as the resident had a history of falls. There was no documented evidence that Certified Nurse Aide #1 received behavior management training prior to caring for Resident #1.A review of the facility's 5-day report submitted to the Department of Health on 05/01/2026 documented a conclusion that the abuse was verified. Corrective actions taken because of the verified abuse included Certified Nurse Aide #1 was removed from the unit immediately and had no further contact with residents. Additionally, 911 was notified and State Troopers arrived; Certified Nurse Aide #1 was removed from the premises by State Troopers pending an appearance in court. Resident #1 was immediately assessed, and no physical injuries (no new redness and no new bruising) were observed. The resident's physician was notified. The resident's family was notified. Resident #1 was placed on every 30-minute observation rounds for 72 hours. All residents on Certified Nurse Aide #1's assignment were assessed for any new bruising or emotional distress injuries; no negative findings were identified. Staff were interviewed and statements obtained. The Staffing Agency (Clipboard Agency Staffing) that scheduled Certified Nurse Aide #1 was notified and the facility requested that Certified Nurse Aide #1 be placed on the do not return list for the facility. The 5-day report documented the resident was assessed by a Provider and was also assessed by a psychiatrist and there were no negative findings. The residents plan of care was updated. Staff were educated on abuse prevention and deescalating behaviors. During a telephone interview with Certified Nurse Aide #1 on 04/30/2026 at 2:01PM they stated that they had worked in the facility for three (3) weeks as agency staff. They stated they were not provided with any training by the facility. Certified Nurse Aide #1 stated they had to go to other certified nurse aides for information about the residents on their assignment or use common sense to care for the residents. Certified Nurse Aide #1 stated on the day of the incident Resident #1 began to stab them with the pen and spit on them while they were providing 1:1 supervision and they reported to Licensed Practical Nurse #1, who told them they needed to sit with Resident #1 because that is what they signed up to do. Certified Nurse Aide #1 stated they should not have tapped the resident; they looked for a supervisor but could not find one because it is difficult to find a supervisor in the facility.During an interview conducted on 04/30/2026 at 10:00AM the Director of Nursing stated Resident #1 had challenging behaviors. They were a high fall risk and were difficult to redirect. Resident #1 tried to stab their spouse and became unmanageable at home and was hospitalized . The Director of Nursing stated that as Resident #1's dementia progressed their behavior became increasingly aggressive. Since Resident #1 was admitted to the facility, they have had multiple falls. On the day of the incident, someone at the nurses' station was trying to redirect the resident. Resident #1 was restless, stabbed Certified Nurse Aide #1 with a pen, and hit Certified Nurse Aide #1. The Director of Nursing stated Certified Nurse Aide #1 informed them that as a reflex response, they spit on Resident #1 and then swatted the resident on the left arm. Other facility staff were in the area and heard a commotion and witnessed some portions of the incident. Licensed Practical Nurse #2 separated Certified Nurse Aide #1 away from the resident and Registered Nurse Supervisor #1 removed Certified Nurse Aide #1 from the unit, notified Administration and called 911. State Troopers arrived, interviewed Certified Nurse Aide #1 and Resident #1. State Troopers took Certified Nurse Aide #1 into custody. Clipboard Agency Staffing was notified via email that Certified Nurse Aide #1 should no longer be scheduled to work for the facility. The Director of Nursing stated the facility reached out to the Licensing board to report the incident. The facility began in-service training of staff on abuse. On 05/01/2026 at 11:26 AM and 05/07/2026 at 2:53 PM, the Medical Director was interviewed and stated they were the primary care physician for the Westminster Unit but gave this responsibility over to Physician #1 approximately one month ago. The Medical Director stated any indication on Resident #1's chart that the Medical Director was the resident's primary care physician was a mistake and would be corrected immediately by the facility. The Medical Director stated the Director of Nursing called to inform them of the incident involving Resident #1 and Certified Nurse Aide #1 on 04/25/2026. The Medical Director stated they assessed Resident #1 the following day, 04/26/2026, and found the resident to be in a good mood with no injuries from or memory of the incident. The Medical Director stated they did not watch the facility video footage of the incident and was told by the Director of Nursing that the aide only tapped the resident on their shoulder and did not cause the resident harm. The Medical Director stated staff should not touch a resident unless they were providing care. Resident #1 should have been assessed by a psychiatrist following the incident and stated they would have to check Resident 1's record to see if a Psychiatry Consult was done. The Medical Director stated the facility had a robust behavior management program that included strong communication with the Psychiatrist and the availability of psychiatric telehealth services for emergencies. The Medical Director stated they reviewed and signed every facility Incident Investigation at its conclusion to ensure accuracy and a determination clearly indicated whether resident abuse had been ruled out. The Medical Director stated they reviewed the facility investigation for Resident #1 and determined that abuse did occur when Certified Nurse Aide #1 struck Resident #1. During a follow up interview on 05/01/2026 at 1:05PM the Director of Nursing stated that the facility did not ensure agency staff received education on behavior management prior to working in the facility. During an interview conducted on 05/01/2026 at 2:40PM, the Administrator stated they were notified by the Director of Nursing on 04/25/2026 at 9:17PM about the incident with Resident #1. They received a snippet of the surveillance video from the Assistant Director of Nursing 30 minutes after notification, and they did review it. They observed the Certified Nurse Aide's hand on Resident #1. They arrived at the unit at 10:40PM and did not allow Certified Nurse Aide #1 to leave. The Resident was assessed by Registered Nuse Supervisor #1 and local law enforcement was notified. After local law enforcement reviewed the surveillance video footage, they informed them that based on what they saw they would be removing Certified Nurse Aide #1 to bring them to the precinct. The Administrator stated they reviewed the video surveillance several times and determined that abuse could not be ruled out because they saw Certified Nurse Aide #1 spit their gum at the resident and strike the resident. Abuse did occur. As part of the facility's investigation, they conducted staff interviews and collected statements. Every resident on Certified Nurse Aide #1's assignment was assessed. Resident #1 was evaluated by their provider after the incident.During an interview with Licensed Practical Nurse #2 on 05/04/2026 at 10:36AM, they stated they had worked with Certified Nurse Aide #1 prior to the incident without any issues. On the day of the incident (04/25/2026) Resident #1 was agitated and had a fall earlier that day. Resident #1 has behaviors where they try to get up and stand, and they scratch and spit on staff. On 04/25/2026 at around 8:00PM they finished their medication pass and were documenting. They turned their head and saw Resident #1 spitting, so they got up to de-escalate the situation. They approached the resident and spoke to them in a calm tone and the resident calmed down. Licensed Practical Nurse #2 stated after the resident calmed down, they went back to documenting and then heard a slap and observed Certified Nurse Aide #1's hand in a motion retracted back, but they did not observe the slap. Registered Nurse #1 on the unit called Registered Nurse Supervisor #1 and Certified Nurse Aide #1 was removed, and Resident #1 was assessed by Registered Nurse Supervisor #1. Licensed Practical Nurse #2 reported that Certified Nurse Aide #1 told them that in [NAME] they do not tolerate anyone spitting on them. Licensed Practical Nurse #2 acknowledged that the spitting could have been a trigger for Certified Nurse Aide #1, but they did not unassign the task of sitting with Resident #1 when they expressed that spitting was an issue. As the Nurse on the floor, they oversee everything. Licensed Practical Nurse #2 stated their last in-service was about two (2) weeks ago on abuse prevention. The educator gave them a 2-page handout with a multiple-choice quiz. The abuse training did not consist of a webinar presentation, or video training. Licensed Practical Nurse #2 stated the facility did not give them an in-service on how to identify and deal with staff that are at an increased risk of becoming abusive.During an interview with Certified Nurse Aide #7 on 05/05/2026 at 5:15PM, they stated they work in the facility as an agency staff. They have worked in the facility four (4) times. The facility did not train them on abuse, dementia care, or how to manage residents with behaviors. Certified Nurse Aide #7 stated they do not receive any of these training courses through their staffing agency. They have worked for other facilities through the agency, and some facilities provided training, but it depends on the facility. On 05/11/2026 at 11:19 AM, Nurse Practitioner #1 was interviewed and stated they were responsible for overseeing physician services on Resident #1's unit. Nurse Practitioner #1 stated they evaluated Resident #1 on 04/25/2026 earlier in the day after the resident had a fall and required x-rays. Nurse Practitioner #1 was unable to provide documented evidence of their visit with Resident #1 after the resident fell in the morning on 04/25/2026. Nurse Practitioner #1 stated they were not involved in any abuse investigations conducted by the facility and did not assess Resident #1 after they were struck by Certified Nurse Aide #1 on the evening of 04/25/2026. Nurse Practitioner #1 stated they answered directly to the Medical Director and conferred with the Medical Director via telephone about any concerns. Nurse Practitioner #1 stated Physician #1 was not assigned as the attending physician on Resident #1's unit and only completed admission assessments, discharge assessments, and sometimes completed a monthly assessment of the residents in compliance with physician services but Physician #1 did not manage the acute and daily medical needs of the residents on the Westminster Unit. The facility used a third-party vendor to provide on-call telehealth physician services when the facility nurse practitioners and medical doctors were not present in the building in the evening, at night, or on the weekend.There was no documented evidence Nurse Practitioner #1 evaluated Resident #1 on 04/25/2026 following their fall incident in the morning and following their incident with Certified Nurse Aide #1. The Facility implemented the following to remove the immediacy:The facility implemented the following training: Abuse prevention/restraints, staff wellness and burnout prevention and behavior management of residents with dementia for all facility and agency staff prior to providing direct care to residents. Audits were initiated to ensure all potentially affected residents with a diagnosis of dementia and behaviors had resident centered physician ordered care plansFacility Leadership (Director of Nursing/Nursing Supervisors and Unit Managers began scheduled rounding/monitoring of licensed practical nursing staff and certified nurse aides on the unit to oversee that residents receive quality care and are free from abuseThe facility policy titled Staff Orientation was revised to include ongoing in-service and education for scheduled agency staff and mandatory education provided be maintained in individual employee filesFacility provided in-service attendance/lesson plan provided to facility staff at 97% and 14 of 14 agency staff at100%.The facility will implement a tracking system with Human Resources, Nursing and facility educators to ensure employee files are complete with records of employment, competencies and ensure they are readily available for review.Interviews were conducted with Registered Nurses/Licensed Practical Nurses/Certified Nurse Aides/Physical Therapists/Housekeepers/Director of Nursing and Medical Director who confirmed receiving in-service on abuse prevention/restraints, staff wellness and burnout prevention and behavior management of residents with dementiaIJ was removed on 05/09/2026 at 4:20PM. 10 NYCRR 415.4(b)(1)(i)

Based on observations, record review, and interviews conducted during survey, the facility failed to ensure that two (2) of six (6) residents (Residents #7 and #1) received adequate supervision and interventions to prevent accidents. Specifically, 1) On 02/22/2026 Resident #7 had an unwitnessed fall sustaining a facial laceration requiring hospitalization and four staples to the resident's left temporal lobe and on 05/07/2026 had a fall and sustained bruising to the left side of their face and laceration to their left eye. Interventions to prevent falls were not developed and implemented following falls on 05/02/2026, 05/04/2026 and 05/05/2026. 2) Resident #1 had unwitnessed falls on 04/15/2026 and 04/21/2026, a witnessed fall on 04/24/2026, and another unwitnessed fall on 04/25/2026 where they sustained a right eyelid abrasion (cut) with bruising and swelling to their nose and right side of their face. This resulted in actual harm to Resident #7 and Resident #1 that was not Immediate Jeopardy.The findings are:The policy titled Fall Risk Managing dated 10/07/2025 documented the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Resident #7Resident #7 had diagnoses of congestive heart failure (a chronic condition where the heart is unable to pump blood effectively leading to a fluid buildup in the lungs and other parts of the body) and insomnia (a sleep disorder that can make it hard to fall asleep).The Minimum Data Set (a resident assessment tool) dated 02/23/2026 documented Resident #7 was severely cognitively impaired, had two (2) or more falls since the last assessment (one with injury), and required supervision when toileting and transferring in and out of bed.The Comprehensive Care Plan related to fall risk created 08/16/2025 documented Resident #7 had falls on 11/01/2025, 11/26/2025, 02/22/2026, and 02/23/2026. Interventions included reminding Resident #7 to use their call bell for assistance and encouraging the resident to stay in the common area when awake.The Nursing Note dated 02/22/2026 documented Resident #7 was found on their bedroom floor bleeding from their head and was sent to the hospital for evaluation.The Hospital Discharge summary dated [DATE] documented Resident #7 had a facial laceration.The Nursing Note dated 02/23/2026 documented Resident #7 was readmitted from the hospital with four staples to their left temporal lobe. The Fall Risk Evaluation dated 02/23/2026 documented Resident #7 was at high risk for falls.The care plan was revised 02/23/2026 to include an intervention to toilet Resident #7 every three (3) hours.The Incident Investigation dated 02/23/2026 documented Resident #7 just returned from the hospital and had an unwitnessed fall while trying to transfer themselves into bed.There was no documented evidence the facility evaluated the effectiveness of interventions.Nursing Notes and Incident Investigations by Registered Nurse #2 dated 05/02/2026, by Registered Nurse Supervisor #1 dated 05/04/2026, and by Registered Nurse Supervisor #1 dated 05/05/2026 respectively documented Resident #7 had unwitnessed falls on 05/02/2026, 05/04/2026, and 05/05/2026. There was no documented evidence that the care plan related to falls was reviewed or revised following Resident #7's falls on 05/02/2026, 05/04/2026, and 05/05/2026.The Nursing Note dated 05/07/2026 at 8:01 AM by Licensed Practical Nurse #2, documented Resident #7 was found on the floor with a laceration and bruising to their face.The Facility Incident Investigation dated 05/07/2026 documented Resident #7 was found on the floor in their room at 4:00 AM and stated they were trying to get up and tripped and fell. The resident had a wound to the left side of face on their eyebrow and bruises to the left side of face and right side of knee, left middle finger and a bump on the left shoulder. Stat (immediate) Xray ordered.During an observation 05/07/2026 at 10:56 AM, Resident #7 was observed with facial bruising on the left side of their face and eye. Resident #7 was grimacing in pain and grabbing their left shoulder. Registered Nurse #2 was present during observation and stated Resident #7 had an unwitnessed fall in their room early this morning on the night shift and x-rays were ordered.On 05/07/2026 at 1:30 PM, Certified Nurse Aide #8 was interviewed via telephone and stated they were regularly scheduled to work the night shift on the Westminster Unit. There were two aides scheduled to work and they split 51 beds on the unit on the night shift. Certified Nurse Aide #8 stated they rounded on their assigned residents and placed beds in the lowest position for their fall risk residents. Certified Nurse Aide #8 stated many of the fall risk behavioral residents wanted to be toileted between 4:00 AM and 5:00 AM and this was when the shift had a lot of their fall incidents. Certified Nurse Aide #8 stated the assignment was impossible to complete with two) aides on the unit.On 05/07/2026 at 2:29 PM, Certified Nurse Aide #9 was interviewed via telephone and stated they worked the night shift last night and were assigned to Resident #7. Certified Nurse Aide #9 stated they knew Resident #7 was a fall risk and tucked the resident in with pillows so the resident could not get out of bed. Certified Nurse Aide #9 stated they found Resident #7 on the floor while performing rounds around 4:00 AM. Certified Nurse Aide #9 stated they had just toileted Resident #7 and that toileting the resident regularly did not prevent the resident from attempting to get up without assistance. Certified Nurse Aide #9 stated they received report from the charge nurse at the beginning of their shift and were not informed that Resident #7 had a fall on 05/05/2026 and were not aware of any special interventions to prevent falls for Resident #7.Resident #1Resident #1 was admitted to the facility on [DATE] with diagnoses of vascular dementia (disease caused by decreased blood flow to the brain leading to cognitive impairments that affects daily functioning) with agitation and metabolic encephalopathy (a change in how the brain works due to an underlying condition leading to confusion/memory loss).The Minimum Data Set (a resident assessment tool) dated 04/19/2026 documented Resident #1 was severely cognitively impaired and had no history of falls. The Nursing Note dated 04/15/2026 by the Director of Nursing documented the dentist found Resident #1 on the floor at 8:22 AM in their room with their brief half off and the bed sheets tangled around their legs.The Comprehensive Care Plan related to fall risk, created 04/15/2026, documented Resident #1 had a fall on 04/15/2026 and included interventions to get the resident up by 7:30 AM and bring them to common area for increased supervision, keep the resident's bed in the lowest position, and maintain a clutter-free environment.The Nursing Note dated 04/17/2026 by Licensed Practical Nurse #4 documented Resident #1 was combative and agitated and was placed at the nursing station for one-to-one monitoring.The Incident Investigation dated 04/21/2026 documented Resident #1 was found on the floor in their room at 10:00 PM and their sheets were tangled around their legs.The Comprehensive Care Plan related to falls was revised on 04/21/2026 to include the intervention to keep Resident #1 out of bed until 11:00 PM.The Nursing Note dated 04/24/2026 authored by Registered Nurse #2 documented Resident #1 fell in front of the nursing station at 8:53 AM after getting up from their wheelchair.The Comprehensive Care Plan related to falls was revised on 04/24/2026 to include the intervention for staff to use footrest during propulsion and remove the footrest when Resident #1 was parked and locked because the resident tended to trip over their footrest.There was no documented evidence that Nurse Practitioner #1 evaluated Resident #1 following each fall incident.There was no documented evidence that the facility evaluated the effectiveness of new interventions to prevent falls.There was no documented evidence of other effective interventions to adequately address Resident #1's restless agitated behaviors. The Nursing Note dated 04/24/2026 by Registered Nurse #2 documented an aide witnessed Resident #1 fall on the floor on their buttock at the nursing station.The Nursing Note dated 04/25/2026 authored by Registered Nurse #2 documented Resident #1 fell in front of the nursing station onto the right side of their face and sustained facial swelling, bruising and a right eyelid abrasion.On 05/04/2026 at 10:36 AM, Licensed Practical Nurse #2 was interviewed and stated they were the charge nurse on Resident #1's unit and created a one-to-one supervision log on 04/25/2026 assigning each aide on the unit to sit with Resident #1 for 30 minutes at a time (for 72 hours) to make sure the resident did not get up out of their wheelchair. Licensed Practical Nurse #2 stated they were not instructed to create the log by their supervisor, and it was not ordered by the physician. Licensed Practical Nurse #2 stated they decided to place Resident #1 on one-to-one supervision because the resident fell earlier in the day and sustained injury to their face. On 05/05/2026 at 12:14 PM, Registered Nurse Supervisor #1 was interviewed via telephone and stated they were working on 04/25/2026 and was not aware Resident #1 received one-to-one supervision on their unit following a fall in the morning. Registered Nurse Supervisor #1 stated they were not responsible for placing residents on one-to-one supervision and did not know who was responsible for determining when increased supervision was necessary for residents at high risk for falls.On 05/01/2026 at 11:26 AM and 05/07/2026 at 2:53 PM, telephone interviews were conducted with the Medical Director who stated they were part of the quality assurance committee and falls were reviewed as part of the meeting topics. The Medical Director stated, contrary to the medical record for Resident #1 and Resident #7, they were not the attending physician responsible for overseeing the total plan of care for residents on the Westminster Unit.On 05/11/2026 at 11:19 AM, Nurse Practitioner #1 stated they were the attending physician for the residents on the Westminster Unit and was responsible for overseeing all their care. Nurse Practitioner #1 stated they were involved in discussions about falls with the interdisciplinary team at morning meeting. The team discussed interventions to prevent falls. Nurse Practitioner #1 stated the facility did not use restraints to prevent falls and this was the reason the residents had so many falls. Nurse Practitioner #1 stated Resident #7 was tricky because the resident was noncompliant and had a lot of falls because they got up without staff assistance. Nurse Practitioner #1 stated they decreased Resident #7's water pill to decrease their urinary frequency to address their falls but the resident started to retain too much fluid. Nurse Practitioner #1 stated they were not part of any fall prevention committee or care plan meetings to discuss residents at high risk for falls.During an interview on 04/30/2026 at 10:00 AM and 05/11/2026 at 3:56 PM, the Director of Nursing stated Resident #1 was a noncompliant resident with behaviors at risk for falls. Resident #1 had been placed at the nursing station for increased supervision on 04/25/2026 following a fall incident that morning. The Assistant Director of Nursing was responsible for conducting all the facility incident investigations and the Director of Nursing stated they were responsible for signing off on all investigations after reviewing them for completeness. The Director of Nursing stated they did not compile statistics and data on falls to compare across different shifts or different units. The Director of Nursing stated they did not know whether facility surveillance cameras were reviewed to determine how Resident #1 fell at the nursing station on 04/25/2026. The Director of Nursing stated they did not know about Resident #7's falls. On 05/11/2026 at 5:40 PM, the Administrator stated falls were not previously being tracked as part of the facility's quality improvement projects. The Administrator stated the facility now planned to have a falls committee to separately address residents that had frequent falls. 10 NYCRR 415.12(h)(2)

Based on observations, interviews, and record review conducted during survey, the facility failed to ensure procedures were developed and maintained to include screening and abuse prevention training of prospective staff. This was evident for five of five facility/agency staff (Certified Nurse Aides #1, #2, and #5, Licensed Practical Nurses #1 and #2) employee files reviewed. Specifically, there was no documented evidence that Certified Nurse Aides #1, #2, #5, and Licensed Practical Nurse #1 and #2 were screened or received training to competently address residents with behaviors and to prevent abuse.The findings are:The Facility assessment dated [DATE] documented a list of their outside contracts that did not include agency nursing staff.The facility policy and procedure titled Abuse, Neglect, Exploitation, and Misappropriation Prevention Program dated 11/14/2024 documented background checks were a part of abuse prevention. The policy did not document the procedure for screening and training prospective and current agency and facility staff.1) The employee file for Certified Nurse Aide #1, agency staff, was reviewed and did not contain documented evidence that the employee was fingerprinted, had their references checked, or had a review of their previous and current employment prior to their hire date on 04/16/2026. There was no documented evidence that Certified Nurse Aide #1 received in-service training related to abuse prevention for residents with behaviors.2) The employee file for Certified Nurse Aide #2, agency staff, was reviewed and did not contain documented evidence a background check was conducted, fingerprinting was done, references were checked, or previous and current employment was reviewed prior to their hire date of 01/20/2026. There was no documented evidence that Certified Nurse Aide #2 received in-service training related to abuse prevention for residents with behaviors. 3) The employee file for Licensed Practical Nurse #2, facility staff, was reviewed and did not contain evidence that a background check was conducted, fingerprinting was done, references were checked, or previous and current employment was reviewed prior to their hire date on 11/20/2025. There was no documented evidence that the facility obtained the status and disciplinary actions from other licensing and registry boards for Licensed Practical Nurse #2. There was no evidence Licensed Practical Nurse #2 received abuse prevention in-service training to competently identify, prevent, and address staff abuse of residents with behaviors.On 04/30/2026 at 3:54 PM, Human Resource Coordinator #1 was interviewed and stated their department received notification from nursing administration when prospective new hires were being considered. Human Resources Coordinator #1 stated they ran some agency personnel through a criminal history record check, and some agency nursing staff already come with background checks completed by their agency. Human Resources Coordinator #1 stated they were only responsible for employee screening assigned to her by the former Human Resources Director. The former Human Resources Director, who shared this responsibility with Human Resources Coordinator #1, was no longer employed by the facility. The former director was responsible for handling and maintaining record of staff disciplinary actions and writeups in each employee's file. Human Resources Coordinator #1 stated they were not familiar with Certified Nurse Aide #1 or Certified Nurse Aide #5 and did not screen them before they were hired by the facility. On 04/30/2026 at 4:12 PM, the new Human Resources Director #1 was interviewed and stated they were still in training and just started working for the facility on 04/13/2026. The facility's third-party vendor kept electronic records of pre-employment screening and tracked pre-employment and ongoing in-service education for facility staff. Human Resources Director #1 stated they were not involved in screening prospective nursing or agency staff. Human Resources Coordinator #1 was responsible for screening agency staff and maintaining these records in the employee files. The Human Resources Director #1 looked through the employee file records in their office and on their computer and stated they could not locate an employee file for Certified Nurse Aide #5. Human Resources Director #1 then stated that the staffing agency, not the facility, was responsible for screening and maintaining employee files for agency staff. Human Resources Director #1 stated license verification was done for Licensed Practical Nurse #2 prior to their hire date and there were no disciplinary actions associated with their nursing license in New York State.There was no documented evidence that the facility screened Licensed Practical Nurse #2 for the status and disciplinary actions from other licensing and registry boards in other states. On 05/01/2026 at 4:43 PM, a follow up interview was conducted with Human Resources Director #1 who stated Human Resources Coordinator #1 was responsible for all employee fingerprinting. Human Resources Director #1 stated they were unfamiliar with the facility's fingerprinting procedure for prospective new hires. Human Resources Director #1 stated the staffing agency was responsible for screening agency staff, including conducting background checks, and the facility did not have a system in place to screen agency staff before they began working at the facility.During an interview on 05/01/2026 at 1:05 PM, the Director of Nursing stated that the staffing coordinator was responsible for interviewing and hiring the certified nurse aides and the Assistant Director of Nursing interviews and hires the licensed nurses. The Director of Nursing stated that the Human Resources Department is responsible for the screening of prospective facility staff during the onboarding process prior to the employee's start date. Prospective agency staff were required to sign and complete forms that included information related to behaviors and abuse prevention prior to being able to schedule any shifts with the facility. The Director of Nursing stated that the training, education, and screening process for prospective facility staff was not the same for the agency staff. The Director of Nursing stated that agency staff did not receive orientation to the facility's systems and processes and were expected to start their first shift in the facility by going straight to the unit and getting report on their assignment by the charge nurse. The Director of Nursing stated they were not involved with screening or training prospective new hires and did not think there was an issue with the current screening and training process for agency staff.On 05/11/2026 at 5:40 PM, an interview was conducted with the Administrator who stated they began working for the facility seven months ago and identified staffing and new employee onboarding concerns via quality assurance performance improvement program meetings in January 2026 and April 2026. The Administrator stated the facility has begun the process of making changes to address areas of concern. The Administrator stated the facility recently hired Human Resources Director #1 to reshape the department and address the concerns identified during quality assurance performance improvement meetings.10 NYCRR 415.3(d)(1)(vii)

Based on interviews, and record review conducted during a survey, the facility assessment failed to adequately identify and indicate resource necessary to care for its residents. This was evident for seven (7) of 7 units during review of Administration. Specifically, the facility assessment did not include the resident population's behavioral health needs, necessary staff competencies and skill sets needed, the facility's structural needs, the use of third-party staffing agency, staffing needs for each individual unit, did not reflect changes to the nursing home leadership staff and resident assessments did not accurately reflect behaviors.The findings are:The Facility assessment dated [DATE] indicates the facility capacity of 300 residents split throughout seven (7) units. Out of an average daily census of 280 residents, the facility had 20 residents with behavioral health needs that included wandering, fall risk, and psychiatric needs. Services and care offered by the facility included fall prevention, mental and behavioral needs including psychiatry and psychological services, and assessment and early identification of infections.The Facility Assessment included a Staffing Plan for 10 licensed nurses providing direct care, 30 nurse aides, and four (4) registered nurse supervisors. The Staff Shortage Plan listed 8 licensed nurses providing direct care, 16 nurse aides, and 3 registered nurse supervisors. The Facility Assessment did not include staffing information detailing how staff would be dispersed on the units and the shift or shifts covered by the nursing staff listed.The Facility Assessment documented the facility was currently utilizing their Staffing Shortage Plan for loss of staff due to the COVID-19 virus. A rapid-onboarding system was implemented for agency staff.The Facility Assessment did not document the facility's use of a third-party staffing agency or significant changes to leadership in the position of Medical Director and Human Resources Director. The Facility Assessment did not document the facility's use of a locked dementia unit ([NAME]) and did not define the specific characteristics of the facility six (6) other units. The Facility Assessment did not document a staffing plan based on the facility population and unit characteristics. The facility did not document the different bed capacities of each unit- [NAME] - 39 beds, [NAME] - 39 beds, Berkshire - 39 beds, [NAME] - 41 beds , [NAME] - 41 beds, Westminster - 50, [NAME] - 51 beds.The Minimum Data Set 3.0 (an assessment tool) dated 03/20/2026 inaccurately documented Resident #4 did not display any wandering or physical behavior symptoms directed towards others. The Minimum Data Set 3.0 (an assessment tool) dated 04/09/2026 inaccurately documented Resident #2 displayed no inappropriate behavior.The Minimum Data Set 3.0 (an assessment tool) dated 04/19/2026 inaccurately documented Resident #1 displayed no behaviors.During an interview on 05/11/2026 at 5:40 PM, the Administrator stated they were responsible for revising and completing the Facility Assessment in 11/2025. The Administrator stated resident acuity was used to determine staffing levels presented in the Facility Assessment and the facility was still recovering from a significant number of staff lost during the COVID-19 pandemic. Each unit was able to operate with, at minimum, 2 (two) nurse aides on the night shift. The Administrator stated they understood the Facility Assessment did not include the characteristics and census of each unit in determining the staffing levels throughout the facility and acknowledged there was a larger population of residents in the facility that had behavioral health needs. The Administrator stated the facility has gone through several personnel changes, including the Human Resources Director and Medical Director, and would review the Facility Assessment to include new information and updates. 10 NYCRR 415.26

Based on observations, interviews, and record review conducted during a survey, the facility did not ensure an effective training program was developed, implemented, and maintained for all new and existing staff consistent with their expected roles and based on a facility assessment. This was evident for five (5) (Certified Nurse Aide #1, #5, and #7, Licensed Practical Nurse #2, Registered Nurse #2) of five (5) staff sampled for education and training review. Specifically, 1) The Facility Assessment did not include a plan to ensure mandatory and ongoing in-service and competencies were provided to agency staff, including Certified Nurse Aides #1, #5, and #7, and 2) there was no documented evidence of effective training developed for facility staff Registered Nurse #1 and Licensed Practical Nurse #2 to ensure competence in abuse prevention, behavior management, and dementia management.The findings are:The Facility assessment dated [DATE] documented the facility admitted residents with psychiatric and mood disorders that need intervention and all forms of dementia. Corporate clinical support would provide the policy and procedure, and the facility Nursing Staff Educator would in-service staff as indicated. Mandatory training/education and competencies were provided upon hire and annually to all staff on topics including resident abuse prevention, accident prevention, dementia care, and behavioral health. The Facility Assessment did not include the nurse staffing agency used by the facility in the list of facility vendors. A facility in-service education dated 1/26/2023 titled Preventing Abuse, Neglect, Exploitation, and Misappropriation of Resident Property included instructions for staff to report to their supervisor, charge nurse, any department head, hospital police officer or risk manager if there was reasonable cause to believe abuse occurred. The in-service education defined reasonable cause as having seen or heard enough evidence to make a reasonable person conclude abuse occurred and that it should be investigated. 1) The employee file for agency staff, Certified Nurse Aide #2, was reviewed and contained no documented evidence Certified Nurse Aide #2 completed abuse preventions training prior to their hire date on 01/20/2026.The employee file for agency staff, Certified Nurse Aide #5, was reviewed and contained no documented evidence Certified Nurse Aide #2 completed abuse prevention training, dementia training, or behavior management training prior to their hire date on 04/01/2026.The employee file for agency staff, Certified Nurse Aide #1, was reviewed and contained no documented evidence Certified Nurse Aide #1 completed abuse prevention training prior to their hire date on 04/16/2026.During an interview on 4/30/2026 at 12:15 PM, Certified Nurse Aide # 5 stated they began working for the facility three weeks ago through a staffing agency. Certified Nurse Aide #5 stated they were not assigned to work on the Westminster Unit when they began their shift and were reassigned to provide one-to-one supervision of Resident #1. Certified Nurse Aide #5 stated they were unaware staff-to-resident abuse involving Resident #1 and Certified Nurse Aide #1 occurred on 04/25/2026. Certified Nurse Aide #5 stated they received abuse prevention in-service within the last week and submitted a post-test. Certified Nurse Aide #5 stated they were not oriented to Resident #1's behaviors and did not receive behavior management training prior to their employment with the facility. Certified Nurse Aide #5 stated they were told by unit nursing staff that Resident #1 frequently tried to get up.2) The facility Incident Investigation dated 04/25/2026 documented Certified Nurse Aide #1 tapped Resident #1 on the shoulder while trying to redirect the resident. A statement written by Licensed Practical Nurse #2 documented they observed Resdiietn #1 make inappropriate contact with Certified Nurse Aide #1, they intervened to de-escalate, and they spoke to the aide prior to the incident. A statement written by Registered Nurse #1 documented Certified Nurse Aide #1 complained that Resident #1 was spitting on them and Registered Nurse #1 advised the aide to distance themselves from the resident while still maintaining eye contact.The employee file for facility staff, Licensed Practical Nurse #2, was reviewed and contained an acknowledgement by Licensed Practical Nurse #2 that they received the facility employee handbook, including the facility policy on reporting patient abuse, on 11/20/2025, their hire date. Page 36 of the employee handbook contained a paragraph on reporting patient abuse that documented never let a resident's insults cause you to lose control. Report such incidents at once to your supervisor.There was no documented evidence Licensed Practical Nurse #2 was provided with comprehensive abuse prevention, dementia management, and behavior management training prior to their hire date on 11/20/2025.There was no documented evidence that the facility had a system in place to track and record the training provided to each new and existing facility and agency staff consistent with their expected roles.During an interview on 04/30/2026 at 4:12 PM, Human Resources Director #1 stated that the employee files for facility staff contained the screening, onboarding, orientation packet, in-service education materials, disciplinary actions, and mandatory in-service tracking to ensure staff's timely completion. The facility used a third-party company to manage and track all the facility staff employee files and provided alerts and notifications when an employee misses a mandatory in-service. Human Resources Director #1 stated Licensed Practical Nurse #2 was facility staff and their file was readily available for review. Human Resources Director #1 stated the staffing agency, not the facility, was responsible for tracking and maintaining the employee records, including in-service and education training, for agency staff.During an interview on 05/04/2026 at 10:36 AM, Licensed Practical Nurse #2 stated that they were hired in November 2025, and they did not receive education that helped them to identify staff frustration and burnout to prevent instances of resident abuse. They stated that after reading written statement of Certified Nurse Aide #1 it did occur to them that they did observe Certified Nurse Aide #1 getting frustrated with Resident #1's behaviors while providing one-to-one supervision. Certified Nurse Aide #1 complained that Resident #1 called them racial slurs and was spitting on them prior to Certified Nurse Aide #1 hitting Resident #1 on their shoulder. Licensed Practical Nurse #2 stated they told Certified Nurse Aide #1 that their job as an aide was not meant for everyone and maybe it wasn't the job Certified Nurse Aide #1. Licensed Practical Nurse #2 stated that in hindsight, they should have addressed Certified Nurse Aide #1's behaviors prior to the incident with Resident #1 and they came to this determination from their own review of the events, not from facility in-service education after the incident occurred.During an interview on 05/4/2026 at 4:45 PM, Nursing Staff Educator #1 stated they did not know about the onboarding process the Human Resources Department had set up for agency staff. Nurse Staff Educator #1 stated they were only responsible for training the facility nursing staff. Department heads were responsible for training their respective employees and Nursing Staff Educator #1 stated they did not know who provided trainings for the agency staff. Nursing Staff Educator #1 stated in interview that they did not know how to track agency staff education, and they were unable to provide details of in-service education provided to facility staff throughout the last six months. During an interview on 05/06/2026 at 3:45 PM, Registered Nurse #1 stated they were facility staff and were present 04/25/2026 when Certified Nurse Aide #1 abused Resident #1. Registered Nurse #1 stated they observed Certified Nurse [NAME] #1 violate the employee policy and complain the Resident #1 was spitting on them and did not separate the resident and aide prior to the abuse incident. Registered Nurse #1 stated they did not receive in-service education to identify staff burnout and would not change how they interacted with Certified Nurse Aide #1 on 04/25/2026. During an interview on 05/01/2026 at 1:05 PM and 05/11/2026 at 3:56 PM, the Director of Nursing stated the Human Resources Department and the Nursing Staff Educator #1 were responsible for onboarding and providing in-service education on facility policies to new hires. The Director of Nursing stated behavior management in-service education was missing from the list of mandatory items for agency staff to complete. The Director of Nursing stated they were responsible for overseeing Nursing Staff Educator #1 and they believed education was being adequately provided.During an interview on 05/11/2026 at 5:40 PM, the Administrator stated they were in the process of changing the facility in-service and education program so there can be facility-wide tracking of trainings completed by staff. The Administrator stated they planned to also use sign-in sheets or digital signature sheets to ensure training records were organized and readily available for review.10 NYCRR 415.26(c)(1)(iv)

Based on observations, interviews, and record review conducted during a survey, the facility did not ensure all alleged violations involving abuse, including injuries of unknown origin, were reported immediately to the State Survey Agency and that reports submitted were accurate with all significant details. This was evident for four (4) Residents #3, # 4,#6, and #7) of six (6) residents reviewed for abuse reporting. Specifically, 1) the facility received an alleged incident of abuse that occurred on 04/10/2026 involving Resident #3, from a visitor. The facility submitted a report which documented a police report having been filed. During the onsite investigation, the facility Incident Investigation dated 04/10/2026 was reviewed and contained a Police Report filed on the morning on 04/10/2026, at 7:26 AM, while facility incident report documented Resident #3's incident occurred on 04/10/2026 between 4:00 PM and 4:30 PM, 2) Resident #7 had an unwitnessed fall on 2/22/2026 and was found on the floor with a head injury requiring hospitalization and four (4) staples. The facility did not report the incident to New York State Department of Health. 3) Resident 4 who had a history of behaviors including wandering and going through other residents' items was found in bed with Resident #6 on 02/11/2026. There was no incident report provided by the facility when requested and the incident was not reported to the New York State Department of HealthThe findings are:Resident #3 Resident #3 had diagnoses of dementia, depression, and unspecified mood disorder.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #3 was moderately cognitively impaired and displayed no behaviors.The Director of Nursing reported to the New York State Department of Health on 04/10/2026 at 7:20 PM that a family member reported hearing screaming from Resident #3's room between 4:00 PM and 4:30 PM, after staff entered and closed the door. Resident #3 was heard screaming stop, don't hit me. Resident #3 was interviewed and stated they were hit. A police report was filed.The facility Incident Investigation dated 04/10/2026 contained a Police Report filed in the morning on 04/10/2026, at 7:26 AM, when Resident #3's incident occurred on 04/10/2026 in the afternoon between 4:00 PM and 4:30 PM.There was no documented evidence that a police report was filed after the incident for the allegation of abuse involving Resident #3. Resident #4Resident #4 had diagnoses of dementia and syncope, anxiety dementia.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #4 had moderate cognitive impairment.The Nursing Note dated 02/11/2026 documented Resident #4 and Resident #6 were observed lying in bed together.There was no documented evidence Resident #4 and Resident #6's allegations of sexual abuse were reported to the New York State Department of Health.Resident # 6Resident # 6 was initially admitted to the facility with diagnosis that include Dementia with behavioral disturbances, psychosis, and anxiety.A quarterly minimum data set (an assessment tool) dated 11/24/2025 documented Resident # 6 had a brief interview for mental status score of 04, indicating severe cognitive impairment. Resident # 6 had disorganized thinking and no behaviors noted.The Nursing Note dated 02/11/2026 documented Resident #4 and Resident #6 were observed lying in bed together.There was no documented evidence Resident #4 and Resident #6's allegations of sexual abuse were reported to the New York State Department of Health.Resident # 7Resident # 7 was admitted with diagnosis that include congestive heart failure (chronic condition where the heart is unable to pump blood effectively leading to a fluid buildup in lungs and other parts of the body), insomnia (a sleep disorder that can make it hard to sleep), and muscle weakness.A quarterly minimum data set (an assessment tool) dated 02/23/2026 documented Resident # 7 had a brief interview of mental status score a 3; indicating the resident was severely cognitively impaired, had two (2) or more falls since last assessment (one with injury) and required supervision when toileting and transferring in and out of bed.Review of a Nursing Progress Note dated 2/22/2026 at 2:56 PM wrote by the Director of Nursing documented Director of Nursing was called to unit to assess Resident # 7 who had a fall. Blood observed from left temporal area, laceration present. Gauze and ice applied; pressure dressing placed which controlled bleeding. 911 called and resident's family was notified of transfer to hospital.There was no documented evidence Resident # 7's unwitnessed fall with head injury was reported to the New York State Department of Health.During an interview on 05/11/2026 at 3:56 PM, the Director of Nursing stated they did not know the reporting guidelines for injuries of unknown origin. They did not know that facial and head injuries were suspicious in nature. The Director of Nursing stated they would have to refer to the reporting manual guidelines. Regarding the incident with Resident #4's wrist fracture, they stated they could not recall the specific details of the injury, and they could not recall Resident #4's sexual encounter with Resident #6.10 NYCRR 415.4(b)(2)

Based on observations, interviews, and record review conducted during a survey, the facility did not ensure allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were thoroughly investigated for three (3) (Residents #1, # 4, and #6) of seven (7) sampled residents. Specifically, 1) the facility's investigation into staff-to-resident abuse involving Resident #1 and Certified Nurse Aide #1 did not identify failures leading up to the abuse 2) Resident #4 sustained a left distal impact fracture on 02/2026. There was no documented evidence that the facility investigated Resident #4's fracture of unknown origin. 3) Resident #4 and Resident #6, both cognitively impaired and unable to consent, were found in bed together on 02/11/2026 and the facility did not conduct an investigation or report the incident to the New York State Department of Health. The findings are:1) Resident #1 was admitted to the facility on [DATE] with diagnoses of vascular dementia with agitation and metabolic encephalopathy.The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #1 was severely cognitively impaired. The Facility video surveillance dated 04/25/2026 with time stamp between 7:24PM and 7:28PM (due to daylight savings time, the clock on the surveillance was not updated and is one hour behind the actual time of occurrence) revealed Certified Nurse Aide #1, with their cell phone in hand, seated next to Resident #1 in the unit hallway. Certified Nurse Aide #1 and Resident #1 are observed in a verbal exchange, with the resident attempting to push the overbed table away. Certified Nurse Aide #1 is observed forcibly placing/repositioning the overbed table in front of the resident several times as the resident is trying to push the overbed table away. Certified Nurse Aide #1 is observed hitting the resident on their left arm followed by pinching the resident and then spitting at and hitting the resident again three (3) minutes later at 7:27PM. Licensed Practical Nurse #2 is seen at the nurse's station located directly across from where the incident was occurring and responds to the situation after Certified Nurse Aide #1 spits at the resident and then hits the resident for the second time at 7:27PM.The Director of Nursing reported to the New York State Department of Health on 04/25/2026 at 11:39 PM that Resident #1 attempted to hit and spit on Certified Nurse Aide #1 who attempted to redirect the resident. Certified Nurse Aide #1 tapped Resident #1 on the shoulder. The Director of Nursing submitted a 5-day report to the New York State Department of Health on 05/01/2026 at 4:33 PM documenting that camera footage was reviewed and demonstrated Certified Nurse Aide #1spit in the direction of Resident #1 and made some type of contact with the resident's left arm. Certified Nurse Aide #1 tried numerous times to redirect Resident #1. The report documented Resident#1 was assessed by a physician and psychiatrist. There was no documented evidence this assessment was done following Resident #1's incident. Refer to F600, F604, F607, and F940. There was no documented evidence the facility conducted a thorough investigation into an incident of staff-to-resident abuse involving Resident #1 and Certified Nurse Aide #1 on 04/25/2026, failing to identify systemic failures leading up to the abuse incident.2) Resident #4 had diagnoses of dementia and syncope. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #4 had moderate cognitive impairment, had two or more falls since the last assessment, required supervision with transfers, and required moderate assistance from staff for toileting.Review of Resident #4 Physician Orders dated 02/25/2026 documented left-hand x-rays were ordered for Resident #4 for unspecified fracture of left radius (one of two long bones in the forearm). Review of a Nursing Progress Note dated 02/25/2026 at 9:35 PM documented x-ray results reviewed by the provider revealed Resident #4 had a left distal radius impact fracture. The Physician Note dated 03/02/2026 documented Resident #4 had a fall with a left wrist fracture and fall precautions should continue. There was no documented evidence that Resident #4's wrist fracture of unknown origin was investigated by the facility to rule out abuse. 3) Resident #4 had diagnoses of dementia and syncope. The Minimum Data Set 3.0 assessment dated [DATE] documented Resident #4 had moderate cognitive impairment, had two or more falls since the last assessment, required supervision with transfers, and required moderate assistance from staff for toileting. for locomotion. The Nursing Note dated 02/11/2026 documented Resident #4 and Resident #6 were observed lying in bed together, caring for each other, and the activity appeared consensual. The residents were separated, and the Administrator and Director of Nursing were made aware. The Comprehensive Care Plan developed on 02/13/2026 identified that Resident #4 exhibited hypersexual behavior and had no personal boundaries.The Facility did not provide an investigation for the incident on 02/11/2026 between Resident #4 and Resident #6. The incident was not reported to the New York State Department of Health.On 05/11/2026 at 3:56 PM, the Director of Nursing stated they could not recall the specific details of Resident #4's wrist fracture and physical activity and contact with Resident #6. The Director of Nursing stated they did not know why an investigation was not completed for Resident #4 and Resident #6.On 05/11/2026 at 5:40pm, the administrator stated they will be hiring an outside consultant to review their polices and procedures on abuse including reporting and investigating10 NYCRR 415.4(b)(3)

Based on observations, interviews, and record review conducted during the survey, the facility did not ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and maintain the well-being of each resident. This was evident for one (1) (Westminster Unit) of seven (7) units. Specifically, 1) the Facility Assessment did not adequately reflect characteristics of the Westminster Unit adequately to determine the level of staff needed to care for the acuity and needs of its residents 2) lack of competent and skilled nursing staff and 3) a pattern of falls for Resident #1 and Resident #7 resulting in harm. The unit was staffed with two (2) certified nurse aides to care for up to 50 residents on the night shift.The findings are:The facility policy titled Staffing Sufficient Competent Nursing dated 10/07/2025 documented staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident assessment, residents plan of care, and the facility assessment.1) Refer to F838.The facility's daily nursing Staffing Sheets from 04/01/2026 through 04/30/2026 were reviewed and documented two (2) certified nurse aides worked the night shift on the Westminster Unit for 18 of 30 nights.2) Refer to F600, F607, and F940.3) Refer to F689. During an interview on 04/30/2026 at 11:55 AM, Resident #9 stated it took staff a long time to answer the call bell on the night shift on the Westminster Unit.During an interview on 05/1/2026 at 4:45 PM, the Staffing Coordinator stated the Administrator and Director of Nursing determined adequate nursing staffing levels for the facility based on the census and acuity in the building. The Staffing Coordinator stated these staffing levels changed daily, and they were unable to provide the current par levels for each shift on each unit that they used to make their schedule.During an interview on 05/04/2026 at 10:36 AM, Licensed Practical Nurse #2 stated they had a standard assignment of four (4) aides on the evening shift on 04/25/2026 when Resident #1 experienced a staff-to-resident abuse by Certified Nurse Aide #1. Licensed Practical Nurse #2 stated they devised the one-to-one assignment for Resident #1 and ensured that every aide on the unit sat with the resident at 30-minute interval rotations regardless of what they were doing for other residents. Resident #1 was confused, agitated, and at high risk for falls. Licensed Practical Nurse #2 stated the number of assigned aides on their shift did not increase to reflect the need for rotating one-to-one supervision for the high fall risk residents on the Westminster Unit.During a telephone interview on 05/05/2026 at 5:15 PM, Certified Nurse Aide #7 stated they were agency staff and their usual assignment was 15 residents on the day, and evening shifts was heavy, and they were unable to complete their task and needed to work over their allotted hours to complete all their tasks. Certified Nurse Aide #7 stated there is not enough aides scheduled to work across all shifts.During an interview on 05/07/2026 at 10:40 AM, Certified Nurse Aide #10 stated they work up to five (5) double shifts a week on the day and evening shifts. Certified Nurse Aide #10 stated they would not work the night shift because 2 aides for up to 50 residents on the Westminster Unit and for the dementia behavioral population on the [NAME] Unit was not manageable. Certified Nurse Aide #10 stated they arrived to work on the day shift to find night shift assignments not done and residents in bed that should have gotten up. Certified Nurse Aide #10 stated work not done on the night shift carried over to the day shift and they found themselves overwhelmed with their assignment because there were only 2 aides working the night shift. Certified Nurse Aide #10 stated this would have been manageable if the facility still staffed an average of 5 aides on the day shift but now the day shift had an average of four (4) aides scheduled.During a telephone interview on 05/7/2026 at 1:30 PM, Certified Nurse Aide #8 stated they worked up to seven (7) days a week covering on all shifts but especially the night shift because there was no regularly assigned certified nurse aide on the night shift. New staff were hired and then leave after seeing the amount of work assigned on the night shift. Certified Nurse Aide #8 stated there were usually two (2) aides scheduled to work the night shift, and, with the showers and get-up assignment, they found this assignment unmanageable. Certified Nurse Aide #8 stated they expressed their workload concerns to the unit charge nurse and to their coworkers.During an interview on 05/07/2026 at 2:29 PM, Certified Nurse Aide #9 stated they worked the night shift, picked up a lot of shifts, worked at least three (3) double-shifts a week, and worked full-time hours even though they were a part-time employee. Certified Nurse Aide #9 stated the Westminster Unit had residents at high risk for or who have had actual falls, and they had their own system in place to make the workload manageable.During an interview on 05/01/2026 at 1:05 PM and 05/11/2026 at 3:56 PM, the Director of Nursing stated they were responsible for overseeing the nursing staffing par levels and based this on the acuity levels of residents on each unit. The Director of Nursing stated they did not know the current acuity levels for the facility's 7 units. The Director of Nursing stated the facility had difficulties with staffing 3 aides overnight on the Westminster or [NAME] Units and the Staffing Coordinator tried to schedule at least 2 aides on each unit, the facility's absolute lowest to be able to provide residents with quality care. The facility used a software program to pre-populate their staffing schedule weekly but there were glitches with this program and, if not caught by the Staffing Coordinator, the staffing schedule prints with omissions resulting in a shortage of staff. The Director of Nursing stated they have not heard of any concerns with staffing levels on the night shift and thought the assignments for 2 aides on the Westminster Unit was manageable.During an interview with the Administrator on 5/11/2026 at 5:40 PM they stated the Director of Nursing was responsible for communicating the acuity of each unit to the Administrator so that nursing staff par levels can be accurately set. The Administrator stated the facility should not be staffed for 2 aides overnight. Staffing would be part of their future quality assurance performance improvement projects. The Administrator stated the Facility Assessment developed by them in 11/2025 did not contain unique characteristics of each unit and did not account for the [NAME] Unit being a locked dementia unit or for the Westminster Unit's bed census of 50 as opposed to most other units with a bed census of 39 or 40.10NYCRR 415.13(A)(1) (i-iii)

Based on observations, record review, and interviews conducted during survey, the facility failed to ensure each resident received the necessary behavioral health care services to attain or maintain the highest practicable physical, mental and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for four) (Resident's #1, #2, #4, and #6) of six residents reviewed for behavioral health. Specifically, 1) there was no documented evidence agency staff were oriented to behavior management or that a care plan was developed and implemented to address Resident #1's behaviors prior to an incident of agency staff to resident abuse on 04/25/2026; 2) Resident #2's care plan was not developed or individualized and agency staff were not trained to address the resident's agitation and verbal abuse; 3) Resident #4's care plan was not revised to address adequate supervision and interventions following an incident of inappropriate sexual contact with Resident #6 on 02/11/2026, and 4) Resident #6's care plan was not developed or implemented to address an inappropriate sexual encounter with Resident #4 on 02/11/2026.The Findings are:The Facility policy titled Behavioral Health Services: dated 10/07/2025 documented that staff must promote dignity, monitor care plan interventions, and report changes in condition.1) Resident #1 was admitted to the facility on [DATE] with diagnoses of vascular dementia (disease caused by reduced blood flow to the brain leading to cognitive impairment that affects daily functioning) with agitation and depression.The Minimum Data Set (a resident assessment tool) dated 04/19/2026 documented Resident #1 was severely cognitively impaired and displayed no behaviors.Nursing progress note dated 04/13/2026 on admission documented Resident #1 tried to get out of bed/wheelchair several times unassisted. Physician Orders dated 04/14/2026 documented Resident #1 was ordered Depakote sprinkles (an anti-seizure medication) for agitation. The Physician Note dated 04/14/2026 documented an order for Resident #1 to receive a psychiatry consultation.There was no documented evidence that Resident #1 was evaluated by a psychiatrist.The Nursing Note dated 04/17/2026 by Licensed Practical Nurse #4 documented Resident #1 was placed on one-to-one supervision because they were restless, physically combative, and agitated.A review of the resident's medical record revealed no documented evidence a care plan was developed identifying the resident's behaviors or interventions implemented to address the resident becoming combative towards staff.The facility Incident Investigation dated 04/25/2026 documented Resident #1 had prior incidents of agitation, aggressive behavior including spitting at staff. There was no documented evidence of the facility providing Certified Nurse Aide #1 (agency staff) with education or training related to behavior management prior to being assigned to sit with Resident #1 or any other residents who exhibit combative behavior.During a telephone interview on 04/30/2026 at 2:01PM, Certified Nurse Aide #1 confirmed that three weeks prior to the incident, they were employed through an agency to work at the facility. They also confirmed that they did not receive orientation or education regarding Resident #1's combative behaviors or behavior management training prior to being assigned to work on the unit.2) Resident #2 was admitted to the facility with diagnoses of dementia (disease characterized by decline in cognitive function affecting memory, thinking/behavior and the ability to perform daily activities) with behavioral disturbance and altered mental status.The Admissions Minimum Data Set, dated [DATE] documented Resident #2 displayed no inappropriate behavior and did not identify the resident's severe cognitive impairments. There was no documented evidence in the Minimum Data Set, dated [DATE] of Resident #2's behaviors.The Comprehensive Care Plan developed on 04/03/2026 documented Resident #2 exhibited socially inappropriate behavior by yelling inappropriate words and racial slurs, and by sliding themselves to the edge of the bed despite frequent repositioning. Resident #2 was provided with a stuffed animal or baby doll to always hold to soothe the resident during behavior escalation. The care plan was not updated to reflect identified behaviors until 04/30/2026.The Nursing Note dated 04/06/2026 documented Resident #2 ripped their intravenous hydration line out of their arm.The Nursing Note dated 04/13/2026 documented Resident #2 was shaking vigorously on their bedrails causing their intravenous pole to fall over and hit them in the head.The Incident Investigation dated 04/26/2026 documented Resident #2 was found sitting on the floor of their room and concluded the resident had a behavior of sitting at the edge of their bed.The Incident Investigation dated 04/28/2026 documented Resident #2 was found by the Nurse Practitioner on the unit hallway floor in front of their wheelchair with redness to their back. The investigation concluded Resident #2 had restless behaviors and placed themselves on the floor.On 04/30/2026 at 10:56 AM, Resident #2 was observed sitting upright in their bed screaming at Certified Nurse Aide #5 while the aide was providing one-to-one supervision for Resident #2's roommate, Resident #1. Certified Nurse Aide #5 closed the resident's door and then quickly opened it back up as Resident #2 could be heard continuing to scream through the closed door. Certified Nurse Aide #5 then went to retrieve two other aides on the unit to assist with Resident #2's screaming and agitation.During an interview on 04/30/2026 at 12:15 PM, Certified Nurse Aide #5 was interviewed and stated they were agency staff and had worked for the facility for three weeks. Certified Nurse Aide #5 stated they were pulled from their assignment on another unit to provide one-to-one supervision to Resident #1. Certified Nurse Aide #5 stated they were not provided with orientation to Resident #1 or Resident #2's behaviors or behavior management training prior to being assigned to work on the unit.During an interview with the representative for Resident #2 on 05/09/2026 at 2:46 PM, they stated they were upset that since admission to the facility, the resident has exhibited increased agitation and behaviors. Resident #2's representative stated they spoke to Nurse Practitioner #1, but nothing has been done to address their concerns.3) Resident #4 had diagnoses of unspecified psychosis (a state of impaired reality, which may include hallucinations and delusions), unspecified dementia (significant decline in thinking, memory, and other cognitive abilities that interfere with daily life), and anxiety. The Minimum Data Set, dated [DATE] documented Resident #4 was moderately cognitively impaired and did not display any wandering or physical behavior symptoms directed towards others.The Nursing Note dated 02/11/2026 documented Resident #4 and Resident #6 were observed lying in bed together and the activity appeared consensual. The residents were separated, and the Administrator and Director of Nursing were made aware. There was no documented evidence detailing the account of the activity taking place while both Resident #4 and Resident #6 were in bed together.The Comprehensive Care Plan created/initiated on 02/13/2026 identified that Resident #4 exhibited hypersexual behavior and had no personal boundaries. Interventions included removing the resident from situations that trigger them and orienting the resident to their daily routines. The was no documented evidence of what situations triggered the resident.There was no documented evidence Resident #4's care plan was updated to address supervision and protection of Resident #4 following their inappropriate physical contact with Resident #6.On 05/07/2026 at 10:30 AM, Resident #4 and Resident #6 were observed seated in an alcove on their unit across from the nursing station and Resident #4 and Resident #6 were observed affectionately holding each other's hands. There were no staff observed in the area providing ongoing monitoring of Resident #6 for any potential inappropriate behavior.During a telephone interview on 05/01/2026 at 11:26 AM, the Medical Director stated they oversaw the facility's behavior management program and believed it did a great job at ensuring residents on psychotropic medication saw the psychiatrist and had gradual dose reductions. Although there was no documented evidence, the Medical Director stated they believed that Resident #1 saw the psychiatrist following the incident of abuse Certified Nurse Aide #1. The Medical Director stated all residents with mental health diagnoses and/or on psychotropic medication were evaluated within the first week of their stay at the facility. The Medical Director stated Resident #1 should have been evaluated by a psychiatrist during their stay.During an interview on 04/30/2026 at 10:00 AM and 05/01/2026 at 1:05 PM, the Director of Nursing stated Resident #1 had challenging, aggressive behaviors and was difficult to redirect. Behavior management training should be added to agency staff orientation packets. The Director of Nursing stated that the facility did not ensure agency staff received education on behavior management prior to working for the facility. The Director of Nursing stated they did not know Resident #4 and Resident #6 were found in bed together and had an inappropriate sexual encounter. The Director of Nursing stated the registered nurses were responsible for creating care plans. The licensed practical nurses and/or the registered nurses were responsible for updating resident care plans when there was a change in their condition or a need for new intervention. The residents' care plans were reviewed regularly during their scheduled Minimum Data Set assessments. The Director of Nursing was unable to explain Resident #1's lack of a behavior care plan, that Resident #2's behavior care plan that was not revised, or Resident #4's behavior care plan that did not adequately address their sexual behavior. The Director of Nursing stated the nursing staff did behavior monitoring for residents in accordance with the physician's orders and residents were referred to the psychiatrist for evaluation as needed. The Director of Nursing stated they were under the impression Nursing Staff Educator #1 was doing an adequate job educating the facility staff on behavior management.On 05/11/2026 at 5:40 PM, the Administrator was interviewed and stated they were aware the facility required some personnel changes at key positions to ensure adequate behavior management training of new and existing staff. The Administrator stated the facility would be enlisting the services of an outside consultant to identify failures in their screening and education process to ensure staff knew how to address the facility's resident population. The Administrator stated they understood where it was necessary to adequately depict facility and resident population characteristics in their facility assessment to ensure adequate use of resources.10 NYCRR 415.12

Based on observations, interviews, and record review conducted during a survey, the facility did not ensure the medical director was responsible for coordinating the medical care of one (1) (Westminster Unit) of seven (7) units. Specifically, the Medical Director was not involved in the facility assessment, quality assurance committee meetings, and did not oversee the development of facility policies and procedures to prevent abuse. The findings are:The facility policy titled Physician Services dated 10/09/2025 documented the medical care of each resident was supervised by a licensed physician. The Medical Directo identifies attending physician qualifications and responsibilities, based on clinical and regulatory requirements and the recommendations of relevant professional associations. Please refer to F600, F604, F838, F689, and F740. There was no documented evidence the Medical Director reviewed the Facility assessment dated [DATE]. Nurse Practitioner #1 was interviewed on 05/11/2026 at 11:19 AM and stated they were employed by the Medical Director's third-party physician staffing agency. As part of that employment, Nurse Practitioner #1 stated were assigned in 02/2026 to work full-time as the Attending Physician for three (3) units at the facility - Westminster (50-bed capacity), [NAME] (51-bed capacity), and [NAME] (39-bed capacity). Nurse Practitioner #1 stated they worked full-time until about 5PM and the facility used a third-party telehealth service to cover any concerns that arose in the evening or at night when Nurse Practitioner #1 was not present in the facility. Nurse Practitioner #1 stated they answered directly to the Medical Director. Nurse Practitioner #1 stated the Medical Director was responsible for all the residents in the facility and thereby was also responsible for all the residents on the Westminster Unit. Telephone interviews were conducted with the Medical Director on 05/01/2026 at 11:26 AM and 05/07/2026 at 2:53 PM, who stated they were appointed as the facility's Medical Director and was the attending physician for the Westminster Unit until approximately one month ago. The Medical Director stated they were responsible for reviewing all the facility's Incident Investigations upon conclusion and ensuring they were complete with all the elements of determining the root cause analysis for why an incident occurred and they had no issues regarding the facility's current process of incident investigation or reporting to the New York State Department of Health. The Medical Director stated they were involved in the facility's development of resident care policies and reviewed all of them when they took on their role as medical director. The Medical Director stated they were involved in all the quality assurance committee meetings except for the facility's most recent one held on 04/23/2026. The Medical Director stated they did not know what topics were discussed at the most recent quality assurance meeting. Medical Director stated they assessed Resident #1 following an incidence of abuse but was unable to provide documented eivedence of an assessment. The Medical Director stated they signed off on the completeness of all incident investigaigons but was unaware that Resident #1 was not assessed by a Psychiatrist in accordance with their faciilitty Incdient Investigaiton dated 04/25/2026. The Medical Director provided no evidence they were involved in developing the Facility Assessment. During an interview on 05/11/2026 at 5:40 PM, the Administrator stated they would be employing the services of an outside consulting agency to help address the facility's resident care and abuse prevention and reporting policies to ensure regulatroy compliance. The Medical Director was fairly new and the facility was in the process of changing some personnel at key positions to ensure the facility improved it's systems and quality of care. 10 NYCRR 415.15(a)

Based on observations, interviews, and record review, the facility did not ensure the resident's right to be free from physical restraints imposed for purposes of discipline or convenience. This was evident for one (Resident #1) of seven residents reviewed for abuse. Specifically, video surveillance dated 04/25/2026 showed Certified Nurse Aide #1 use an overbed table to prevent Resident #1 from getting up out of their wheelchair without documented evidence of restraint assessment or physician orders for such use.The findings are:The facility policy titled Physical Restraint Use dated 11/14/2024 documented restraints shall only be used to treat the resident's medical symptom(s) and never for the prevention of falls. Resident # 1 was admitted to the facility on [DATE] with diagnoses of vascular dementia with agitation and depression. The Minimum Data Set 3.0 (an assessment tool) dated 4/19/2026 documented Resident #1 was severely cognitively impaired, and required moderate assistance from staff for toileting, bed mobility, and transfers. The Comprehensive Care Plan related to falls dated 04/15/2026 documented Resident #1 had falls on 04/15/2026, 04/21/2026, 04/24/2026, and 04/25/2026. Interventions implemented on 04/15/2026 included getting the resident up at 7:30 AM to be brought to the common area for increased supervision and encouraging the resident to stay in a supervised setting. On 04/21/2026, interventions to place Resident #1 back into bed at 11PM were implemented. On 04/24/2026, staff to use footrest during propulsion and remove the footrest when Resident #1 was parked and locked because the resident tended to trip over their footrest. On 04/25/2026, Resident #1 was placed on 30-minute monitoring for 72 hours.There was no documented evidence Resident #1 was assessed for restraint use related to a medical condition or that a physician's order was in place for restraint use for Resident #1. The facility's video surveillance dated 4/25/2026 from 8:24 PM to 8:28 PM showed Certified Nurse Aide #1 seated next to Resident #1 in the unit hallway across from the nursing station. An overbed table was in front of Resident #1 while the resident was seated in their wheelchair. wheelchair. Resident #1 attempted to push the overbed table away from them six times and Certified Nurse Aide #1 pushed the overbed table back in front of Resident #1 each time. Resident #1 became increasingly agitated and, at 8:26 PM, began using their feet to push the overbed table away from them. Certified Nurse Aide #1 rose from their seat and grabbed Resident #1's feet, and raised them up, allowing Certified Nurse Aide #1 to push the overbed table closer to Resident #1's upper body. At 8:27 PM, Resident #1 attempted to raise the height of the overbed table and Certified Nurse Aide #1 lowered the table back down so that it was the height of Resident #1's wheelchair armrests, boxing the resident in their wheelchair seat and preventing them from moving around freely. On 04/30/2026 at 2:01 PM, Certified Nursing Aide #1 was interviewed and stated that they were assigned by Licensed Practical Nurse # 2 to sit with Resident #1 and provide one-to-one supervision. Certified Nurse Aide #1 stated they were instructed to make sure Resident #1 did not get up out of their wheelchair because the resident had a fall earlier in the day on 04/25/2026.On 05/04/2026 at 10:36 AM, Licensed Practical Nurse # 2 was interviewed and stated they assigned Certified Nurse Aide #1 to sit with Resident #1 because Resident #1 was at high risk for falls and had a fall earlier in the day on 04/25/2026. Licensed Practical Nurse #2 stated the facility did not use restraints on residents and they did not notice the overbed table being used as a restraint Resident #1 when Licensed Practical Nurse #2 was seated across from Certified Nurse Aide #1 at the nursing station on 04/25/2026. On 05/11/2026 at 3:56 PM, the Director of Nursing was interviewed and stated that they watched the surveillance video and did not see the overbed table as a restraint. Resident # 1 had a paper and pen and was using the table to write on. Resident # 1 was also able to move the table from in front of them; therefore, they did not view the overbed table as a restraint.There was no documented evidence Resident #1 used the overbed table for diversional activities on video surveillance or as a care plan intervention in the resident's record. On 05/11/2026 at 5:40 PM, the Administrator was interviewed and stated that they watched the video surveillance from the incident on 04/25/2026 multiple times. They did not identify concerns related to the overbed table being used as a restraint until the surveyors brought it to the facility's attention. The Administrator stated they can see how the overbed table was used as a restraint. 10 NYCRR 415.3(d)(1)(vii)

Based on record reviews and interviews during an abbreviated survey, the facility did not ensure residents diagnosed with dementia received the appropriate treatment and services for 1 (Residents #1) of 6 residents reviewed for dementia. Specifically, Resident #1's dementia care plan was not developed and implemented until 04/25/2026, after a staff-to-resident abuse involving Resident #1 and Certified Nurse Aide #1.The findings are:The facility's dementia policy dated 10/07/2025 documented the facility will strive to optimize familiarity through consistent staff-resident assignments and individualized care plans developed by the interdisciplinary team. Resident #1 was admitted to the facility on [DATE] with diagnoses of vascular dementia (disease caused by decreased blood flow to the brain leading to cognitive impairments that affects daily functioning) with agitation and metabolic encephalopathy (a change in how the brain works due to an underlying condition leading to confusion/memory loss).The Hospital Discharge summary dated [DATE] documented Resident #1required delirium precautions.The Minimum Data Set 3.0 (an assessment tool) dated 04/19/2026 documented Resident #1 was severely cognitively impaired and had history of falls.The Nursing Note dated 04/17/2026 documented Resident #1 had behaviors, was restless, and was physically combative and agitated in the evening. Resident #1 was placed on one-to-one supervision.The facility Incident Investigation dated 04/25/2026 documented Certified Nurse [NAME] #1 was monitoring Resident #1 on one-to-one supervision when an incident of staff-to-resident abuse occurred.The Comprehensive Care Plan related to dementia initiated 04/25/2026 documented Resident #1would maintain their current level of cognitive functioning with interventions that included breaking tasks into simple steps, encouraging self-performance in activities of daily living, providing leisure activities such as exercise groups, singing, etc., and using simple words or instructions.There was no documented evidence a care plan related to Resident #1's dementia diagnosis was developed and implemented upon Resident #1's admission to the facility on [DATE].During a telephone interview on 04/30/2026 at 2:01PM, Certified Nurse Aide #1 stated they were agency staff hired by the facility three weeks prior and they did not receive training and education related to dementia management.On 05/01/2026 at 1:05 PM, the Director of Nursing was interviewed and stated all facility employees were required to have orientation and annual mandatory inservices that included dementia management.On 05/11/2026 at 5:40 PM, the Administrator was interviewed and stated they were aware the facility required some personnel changes at key positions to ensure adequate behavior management training of new and existing staff. The Administrator stated the facility would be enlisting the services of an outside consultant to identify failures in their screening and education process to ensure staff knew how to address the facility's resident population.10 NYCRR 415.12

Based on record review and interviews during an abbreviated survey (2619941), the facility did not ensure that the resident received treatment and care in accordance with professional standards of practice for one (1) of four (4) residents reviewed. Specifically, Resident #1 who had moderate cognitive impairment and a history of constipation was triggered on the facility bowel list report in June, July, and August 2025 for no bowel movement. The facility bowel protocol was not initiated for the resident. Prior to discharge on [DATE] the resident received a dose of Milk of Magnesia on 08/08/2025 with no documented evidence of the effectiveness of the Milk of Magnesia. Subsequently Resident # 1 was admitted to the hospital on [DATE] after discharge and was found to have large amounts of stool seen in the rectum with rectal mural thickening on Computed Tomography of the abdomen.The Findings are: The facility's undated Treat in Place Guidelines for Constipation and Bowel Protocol documented the following Symptoms and Interventions: -if no bowel movement for six shifts, give 30 ml, sorbitol by mouth for one dose or via gastrostomy tube for feeding resident times one dose- if no movement in eight hours after sorbitol listen for bowel sounds; notify provider if no bowel sounds; give Dulcolax suppository rectally times one dose for constipation-if no bowel movement eight hours after Dulcolax suppository, give fleet enema rectally for one dose for constipation. Notify provider if fleet enema is not effective.-notify provider for increased pain and/or abdominal distention or if no bowel sounds Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to Fracture of Neck of Right Femur, Depression, Muscle Weakness. Resident #1 was discharged home from the facility on 08/09/2025. An admission Minimum Data Set assessment dated [DATE] documented Resident #1 had a Brief Interview Mental Status score of 12/15 denoting moderate cognitive impairment. Resident was frequently incontinent of bladder and bowel functions. Review of the Constipation care plan dated 06/15/2025 documented a goal that the resident will have normal bowel pattern every 2 days for 90 days with interventions that included assist resident to toilet per resident's bowel routine, initiate bowel protocol if no bowel movement in two days, and monitor and track bowel movements. Review of the Hospital Medication List dated 06/01/2025 documented Senna 8.6 mg tablet take 1 tablet by mouth nightly as needed for constipation. This was last administered on 05/28/2025 at 2:02 PM prior to admission to the facility. Review of Resident #1 admission progress note dated 06/01/2025 at 2:44 PM documented the hospital discharge diagnosis included constipation and sepsis, and the resident's current diagnosis in the facility included constipation and sepsis. Review of the Physician Orders for June 2025 documented Senna-Time Oral Tablet 8.6 MG (Sennosides) give two tablets by mouth two times a day for constipation start date 06/01/2025 and it was discontinued on 06/03/2025. Review of the Physician Orders for July 2025 documented Colace Oral Capsule 100 milligram (Docusate Sodium) give 2 capsules by mouth at bedtime for constipation with an order start date of 07/30/2025 and discontinued on 08/09/2025. Review of the Physician Orders for August 2025 documented Colace Oral Capsule 100 milligram (Docusate Sodium) give 2 capsule by mouth at bedtime for constipation with an order start date of 07/30/2025 and discontinued on 08/09/2025 and a one-time order for Milk of Magnesia Suspension 400 milligrams/ 5 milliliters (Magnesium Hydroxide) give 30 milliliters by mouth one time only for Constipation for 1 Day with a start date of 08/08/2025. A review of the facility clinical alerts for June 2025 documented Resident # 1 was listed on clinical alerts for bowel movements on 06/07/2025-06/11/2025, 06/22/2025-06/30/2025 that meant the resident had no bowel movements on those dates. A review of the facility clinical alerts for July 2025 documented Resident # 1 was listed on the clinical alerts for bowel movements on 07/18/2025, 07/22/2025-07/24/2025, 07/30/2025-07/31/2025 with a response of no bowel movement. A review of the facility clinical alerts for August 2025 documented Resident # 1 was listed on the clinical alerts for bowel movements on 08/02/2025, 08/03/2025, 08/06/2025, 08/07/2025 and 08/08/2025 with a response of no bowel movement. Review of a progress note dated 06/01/2025 at 5:14 PM documented Resident #1 was alert and oriented times two. Resident #1's representative was present during the evaluation. Resident #1 on exam was noted to have a soft non-tender abdomen with positive bowel sounds. Resident #1's last bowel movement was reported on 06/01/2025. Review of Nurse Practitioner #2's progress note dated 06/03/2025 at 3:16 PM documented Resident #1's Senna two tablets two times a day was discontinued due to the resident was declining the use. Resident #1 was seen by the Nurse Practitioner #2 on 06/10/2025 at 3:37PM and there was no documented evidence that the resident's no bowel movement alert on 06/07/2025, 06/08/2025 and 06/09/2025 was addressed. Resident #1 was seen by the Nurse Practitioner #2 on 06/27/2025 at 2:36 PM and there was no documented evidence that the resident's no bowel movement alert on 06/22/2025, 06/23/2025, 06/24/2025, 06/25/2025 and 06/26/2025 was addressed. Resident #1 was seen by the Nurse Practitioner #2 on 07/07/2025 at 1:42 PM and there was no documented evidence that the resident's constipation was being addressed after the Senna was discontinued. Resident #1 was seen by the Nurse Practitioner #2 on 07/09/2025 at 12:59 PM and there was no documented evidence that the resident's constipation was being addressed after the Senna was discontinued. Review of Resident # 1's medication administration record from 06/01/2025 to 06/30/2025 revealed no documentation that the bowel protocol was initiated. Review of Resident # 1's medication administration record from 07/01/2025 to 07/31/2025 revealed no documentation that the bowel protocol was initiated. Review of Resident # 1's medication administration record from 08/01/2025 to 08/09/2025 revealed that a bowel protocol was initiated on 08/08/2025. Resident # 1 was administered 30 ml of Milk of Magnesia for constipation. Review of Nursing Progress notes from 08/01/2025 to 08/09/2025 revealed no documented evidence of the effectiveness of the Milk of Magnesia that was administered on 08/08/2025. Resident #1 was discharged home from the facility on 08/09/2025 but was admitted to the hospital on [DATE] with a diagnosis of severe sepsis. A Computed Tomography of the abdomen and pelvis without contrast revealed large amounts of stool seen in the rectum with rectal mural thickening concerning for the developing stercoral colitis. Review of Resident #1's hospital documentation dated 08/10/2025 provided by the facility revealed the resident was admitted to the hospital on [DATE] with a chief complaint of constipation reporting their last proper bowel movement was on Friday, two days prior to the hospital admission. The emergency room review of systems documented Gastrointestinal: Positive for abdominal pain, constipation, nausea, and vomiting. During an interview on 09/22/2025 at 2:43 PM, Licensed Practical Nurse #1 stated if a resident does not have a bowel movement, the unit manager gets an alert on their dashboard informing them, they notify the Physician and obtain orders for a bowel regimen. Licensed Practical Nurse #1 stated that there is a way for the medication nurse to find out if a resident did not have a bowel movement, but the unit managers have the daily dashboard and inform them. Licensed Practical Nurse #1 stated, Treat in place guidelines can be used by the staff to treat the resident's constipation, but the Physician must be informed. Licensed Practical Nurse #1 stated they discuss the bowel alerts during morning meeting, and this would be very significant finding if a resident continuously flagged on the bowel list. Licensed Practical Nurse #1 stated if a resident refused the bowel protocol, there would be a documentation. They also document on the effectiveness of the medication after it has been administered. Licensed Practical Nurse #1 stated the unit managers review the certified nurse aide accountability documentation daily to be sure there are no repeated omissions otherwise the staff is written up. If task is not documented, then it is not done. Licensed Practical Nurse #1 stated they discuss the bowel alerts during morning meeting, and this would be very significant finding if a resident continuously flagged on the bowel list. During an interview on 09/23/2025 at 11:56 AM, the Director of Nursing stated the certified nurse aide documents the resident's bowel movements and if there is no bowel movement then they notify the medication nurse. The Director of Nursing stated the medication nurse checks to see how long they have not had a bowel movement and will determine if it meets the criteria to treat in place and notify the Physician. The Director of Nursing stated the night shift nurse runs the bowel list, and they either start the protocol or endorse it to the day shift if they are running late. The Director of Nursing stated the bowel protocol is initiated if indicated and they will also ask the residents if they had a bowel movement, as some resident's toilet themself. The Director of Nursing stated the medication nurse can run the bowel report to see if a resident was flagged and if a resident flagged, they then could investigate further and start the bowel protocol if indicated. The Director of Nursing reviewed Resident #1's medication administration record and stated the documentation is not great, after their review. The Director of Nursing stated they believe the blank spots on the certified nurse aide accountability are when Resident #1's representative toileted the resident or informed the staff they have toileted the resident. The Director of Nursing stated they did not see any orders for the initiation of the bowel protocol for Resident #1 by the medication nurses. The Director of Nursing stated Nurse Practitioner #2 addressed Resident #1's bowel management in their progress notes while the resident was in the facility. if a dose of Milk of Magnesia was administered, the medication nurse should document a progress note of the efficacy of the medication was effective or not. During an interview on 09/23/2025 at 1:12 PM, the Medical Director stated they are not informed if a resident is having simple issues, like constipation during their stay in the facility. The Medical Director stated the primary care Physician on each unit would address these issues. The Medical Director stated they reviewed Resident #1's chart and they did not see any issues with the resident. The Medical Director stated they doubt the documentation is accurate, but usually in these cases it is more of a lack of documentation. During an interview on 09/24/2025 at 9:57 AM, Licensed Practical Nurse #4 stated they cared for Resident #1 while they were in the facility. Licensed Practical Nurse #4 stated the bowel alerts come up on the clinical dashboard and if they see an alert they can give as needed medications if ordered. Licensed Practical Nurse #4 stated they check their clinical dashboard regularly throughout their shift and if a resident is administered milk of magnesia and it is not effective, then a suppository is given. Licensed Practical Nurse #4 stated they do not recall seeing any bowel alerts for Resident #1. During a telephone interview on 09/30/2025 at 1:40 PM, Nurse Practitioner #2 stated when they assessed Resident #1 on 08/07/2025 the resident did not complain of constipation. Nurse Practitioner #2 stated the last time they saw and examined Resident #1 was on 08/07/2025, before the administration of the milk of magnesia. Nurse Practitioner #2 stated they were aware Resident #1 received a dose of milk of magnesia on 08/08/2025, however if they are not in the facility, they would be unable to follow up. Nurse Practitioner #2 stated if Resident #1 was found to be impacted after discharge this would have been a concern for them regarding the resident. Nurse Practitioner #2 stated Resident #1 did not have a medical history of constipation, and they reviewed the discharge paperwork from the hospital, but they do not recall Resident #1 being diagnosed with constipation. Nurse Practitioner #2 stated Resident #1 was refusing their Senna laxative, and their representative told them the resident did not want the Senna laxative and that is why they discontinued the medication. Nurse Practitioner #2 stated they have access to see the facility clinical alerts and the bowel list. Nurse Practitioner #2 stated Resident #1 repeatedly flagging on the bowel list was not a concern to them because the resident never complained to them that they were having an issue. Nurse Practitioner #2 stated Resident #1 told them everything was fine, and that they were using the bathroom. Nurse Practitioner #2 stated they sometimes write a progress note that the resident informed them they were fine, but not always. During a telephone interview on 09/30/2025 at 2:34 PM, Registered Nurse #2 stated they do not recall Resident #1 off the top of their head but all the residents in the facility are monitored for their bowel movements. Registered Nurse #2 stated the nurse on the unit would monitor the clinical alerts, but they are not aware of an alert on their dashboard informing them if a resident did not have a bowel movement. Registered Nurse #2 stated there is a bowel protocol in the book, and the nurses would initiate it if a resident did not have a bowel movement. Registered Nurse #2 stated the Physician would be notified if a bowel protocol was initiated to inform them of the issue. Registered Nurse #2 stated there should be a progress note in the resident's chart indicating if the medication was effective or not. Registered Nurse #2 stated they are not tech savvy, so they are not aware of how to run the reports in Point Click Care (the electronic medical record), but there are usually two Registered Nurse supervisors on shift in the building who can perform that function. 10 NYCRR 415.12

Based on record review and interviews during an abbreviated survey (2619941), the facility did not ensure a resident right to voice a grievance, and to make prompt efforts to resolve grievances the resident may have for 1 out of 3 residents (Resident #1) reviewed for grievances. Specifically, Resident #1's representative informed the Patient Relations Concierge #1 that Resident #1 had several items that went missing from their room. Resident # 1's representative stated that they did not receive any follow-up from the facility regarding the missing items and no grievance was completed by the facility. The findings are: The facility Grievance/Concerns policy dated 02/14/2023 documented the residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances. The administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident and/or representative. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding their stay at the facility. Resident # 1 admitted to the facility on [DATE] with diagnoses including but not limited to Fracture of Neck of Right Femur, Depression, Muscle Weakness. An admission Minimum Data Set assessment dated [DATE] documented Resident #1 had a moderate cognitive impairment. The resident had impairment to the lower extremity on one side and used a walker for local motion. The resident required supervision for eating, maximal assistance for bed mobility, and was dependent for toileting and transfers. Resident was frequently incontinent of bladder and bowel. During a telephone interview on 09/18/2025 at 11:39 AM, Resident #1's representative stated that several items including a fleece blanket and nail manicure kit had gone missing from Resident # 1's room. Resident #1's Representative stated that they reported this to the Patient Relation Concierge #1 who stated they would relay that information to Resident # 1's social worker. Resident #1's representative stated that they did not receive any follow-up from the facility regarding the missing items. Resident #1's representative stated that no grievance was completed by the facility. Resident #1's representative stated the facility did eventually offer to reimburse Resident # 1 for the missing items, but it was not about the money or the items, it was the principle that someone was taking the residents things. There was no documented evidence of a grievance on file regarding Resident #1's missing items. During an interview on 09/18/2025 at 1:03 PM, the Patient Relations Concierge #1 stated they remember Resident #1's representative expressing concern over missing items from the resident's room. The Patient Relations Concierge #1 stated that they received two text messages from Resident #1's representative regarding Resident #1's missing items. The Patient Relations Concierge #1 stated when they were made aware of the of the grievance, they reached out to the Assistant Administrator #1 and the Director of Social Services via WhatsApp to inform them but never received any word back. They stated they would do a better job of following up in the future, but prior to the 09/18/2025, the day of the interview they were not given clear directives. They were unaware of any official grievance process; they did not have any documentation of past grievances. The Patient Relations Concierge # 1 stated that they are now learning about the grievance process and going forward they will have written documentation for all grievances. Patient Relations Concierge #1 specifically stated that they were told by the administration today (09/18/2025) that the Department of Health was in the building and that Patient Relations Concierge #1 needed to learn the grievance process. During an interview on 09/18/2025 at 5:13 PM, the Administrator retuned and stated they attempted to reach the Assistant Administrator #1 regarding the grievance with no success. The Administrator stated the Director of Social Services is their grievance officer and should have documented the report of the missing items on an official grievance form. The Administrator stated the facility staff were using the WhatsApp platform to communicate, but they are in the process of changing this because it is not an effective method. During an interview on 09/19/2025, the Director of Social Services stated there is no documented grievance for Resident #1's missing items and they were made aware about the missing items on 09/18/2025 by the Director of Nursing. The Director of Social Services stated the Patient Relations Concierge #1 must have worked on the grievance with someone else, because they knew nothing about this. The Director of Social Services stated they are the grievance officer in the facility and all grievances should be directed to them. The Director of Social Services stated they receive communication face to face, by email or in-person. The Director of Social Services stated if a grievance was initiated there would have been a progress note. It would also be documented on an official grievance form. The Director of Social Services reviewed Resident #1's chart and stated there was no grievance note documented in the resident's chart. Call placed to the Assistant Administrator #1 on 09/30/2025 and 10/01/2025, no response received. 10 NYCRR 415.3(d)(1)(i)

Based on record review and interviews conducted during an abbreviated survey (2619941), the facility did not ensure all relevant resident information necessary to meet the resident's needs was conveyed to avoid risk of complications at time of discharge to the home for 1 (Resident #1) of 3 residents reviewed for discharge planning. Specifically, Resident #1 was scheduled to be discharged from the facility on 08/09/2025 with home care services. Resident #1's home care services were delayed due to the late submission of necessary information to the home care agency. Resident #1's home care services was not initiated until 08/14/2025. The findings are:The facility Discharge/Summary and Plan dated 01/27/2025 documented when a resident's discharge is anticipated, a discharge summary and post discharge plan is developed to assist the resident with discharge. The post-discharge plan is developed by the care planning/interdisciplinary team with the assistance of the resident and their representative. Residents who are discharged to a home health agency, the data is used to help the resident select an appropriate facility include the receiving facility's: standardized patient assessment data, quality measures data and data on resource use. Resident # 1 was admitted to the facility on [DATE] with diagnoses including but not limited to Fracture of Neck of Right Femur, Depression, Muscle Weakness. An admission Minimum Data Set assessment dated [DATE] documented Resident #1 had a moderate cognitive impairment. The resident had impairment to the lower extremity on one side and used a walker for local motion. The resident required supervision for eating, maximal assistance for bed mobility, and was dependent for toileting and transfers. Resident was frequently incontinent of bladder and bowel. Review of a discharge planning care plan dated 06/03/2025 documented Resident #1 resided in a home with their representatives and previously required assistance with activities of daily living and had an aide five days a week for six hours a day. Interventions listed included make arrangements with required community resources to support independence post discharge. Review of a home health rapid referral form dated 08/13/2025 documented the reason for the referral medication management/education, disease management/education, therapeutic exercises, physical therapy and occupational therapy. The patient was an inpatient in the facility within the last 14 days. The form documented to fax the following documents back with the form: most recent exam notes, current medication list and a demographic sheet. During an interview on 09/18/2025 at 1:45 PM, the Director of Social Services stated they start sending discharge referrals for aftercare services two or three weeks before resident's discharge date . The Director of Social Services stated the documentation sent to referral agencies is not kept in the Point Click Care (the electronic medical record) and that it is emailed or faxed to the referral agencies and kept in paper records. During an interview on 09/18/2025 at 2:53 PM, the Registered Nurse Care Manager #1 stated home care services are usually initiated within 48 hours after discharge. During a telephone interview on 09/25/2025 at 11: 32 AM, Home Care agency representative #1 stated they did not receive everything that was needed from the facility to initiate services for Resident #1, as they needed the resident's demographics and had only received the clinicals from the facility. The Home Care agency representative #1 stated on 08/11/2025 they requested Resident #1's orders from the facility which detail what disciplines the resident needs at home as well as the patient's demographics. The Home Care agency representative #1 stated they cannot process/initiate services if they do not receive all needed information such as : disciplines needed, demographics and insurance information. The Home Care agency representative #1 stated they only received Resident #1's clinical information, so they could not tell if they provided services in the area Resident #1 lives or if they can provide the services the resident needs. The Home Care agency representative #1 stated Resident #1 started home care services on 08/14/2025, which was delayed due to the fact they did not have the required documentation from the facility. 10 NYCRR 415.11(d)(3)

Based on record review and interviews conducted during an abbreviated survey (2619941) the facility did not ensure a comprehensive care plan was developed and implemented to maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (1) of four (4) residents (Resident # 1) reviewed for constipation. Specifically, Resident # 1 was admitted to the facility on [DATE] and had a diagnosis of constipation with no care plan in place to address the constipation until 6/15/2025. On 8/9/2025, Resident # 1, was discharged from the facility and admitted to the hospital on [DATE] with a diagnosis of severe sepsis. Review of the Facility Care Plan Policy last revised March 2022 documented that Resident Care Plans are developed according to the timeframes and criteria established by S483.21.The facility's undated Treat in Place Guidelines for Constipation and Bowel Protocol documented Symptoms and Interventions: -if no bowel movement for six shifts, give 30 ml, sorbitol by mouth for one dose or via gastrostomy tube for feeding resident times one dose- if no movement in eight hours after sorbitol listen for bowel sounds; notify provider if no bowel sounds; give Dulcolax suppository rectally times one dose for constipation-if no bowel movement eight hours after Dulcolax suppository, give fleet enema rectally for one dose for constipation. Notify provider if fleet enema is not effective.-notify provider for increased pain and/or abdominal distention or if no bowel soundsResident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to Fracture of Neck of Right Femur, Depression, Muscle Weakness. An admission Minimum Data Set assessment dated [DATE] documented Resident #1 had a Brief Interview Mental Status score of 12; indicating the resident had moderate cognitive impairment. Resident requires set up or clean up assistance with eating and toileting. Resident was frequently incontinent of urine and always continent of bowel.A review of Comprehensive Care plan dated 6/15/2025 revealed that resident was at risk for constipation. The goal was that Resident #1 would have normal bowel pattern every two days for 90 days. The interventions listed included assist to the toilet per resident's bowel routine, direct care staff to monitor and track bowel movements, and nursing staff to initiate the bowel protocol, if there were no bowel movement in two days. Review of Resident # 1's Facility's Diagnosis did not list Constipation as a diagnosis.Review of medication administration records for June 2025, July 2025, and August 2025 documented that bowel protocol was not initiated for Resident # 1 until 08/08/2025. On 8/8/2025 the medication administration record documented Resident # 1 received 30 milliliters of Milk of Magnesia.Resident # 1 was triggered on the facility bowel alert lists on 6/7/2025-6/11/2025, 6/22/2025-6/30/2025, 7/18/2025, 7/22/2025-7/24/2025, 7/30/2025-7/31/2025, 8/2/2025, 8/3/2025, 8/6/2025, 8/7/2025 and 8/8/2025 with a response of no bowel movement.Review of Resident # 1's medication administration record for June and July 2025 there was no documented evidence that the bowel protocol was initiated.Review of a Medical Progress Note dated 6/1/2025 at 2:44pm documented that Resident #1 had a current diagnosis of constipation.Review of Nursing Progress Notes from 06/01/2025-08/09/2025 did not document the initiation of the bowel protocol until 08/08/2025. Resident # 1 was administered 30 milliliters of Milk of Magnesia with no documented evidence to show the administration of the Milk of Magnesia was effective.Review of a Medical Progress Note dated 6/3/20205 at 3:16 pm documented a plan for constipation to discontinue the Senna two (2) tablets two (2) times a day because of declining use.Review of the Medication Administration Record for June 2025 did not document that Resident # 1 refused Senna.Review of a Medical Progress Note dated 7/30/2025 at 12:28 pm documented the Resident # 1 complained of constipation. Resident # 1 had a small bowel movement in the morning and wanted a stool softener.Review of a Medical Progress Note dated 07/30/2025 at 12:34 pm documented for Constipation to add Colace 200 milligrams at bedtime.Review of Resident # 1's medication administration record for August 2025 there was documentation that bowel protocol was initiated on 8/8/2025. Resident # 1 was administered 30 ml of Milk of Magnesia for constipation.Resident #1 was discharged home from the facility on 08/09/2025 and was admitted to the hospital on [DATE] with a diagnosis of severe sepsis. Review of the Hospital Record dated 8/10/2025 documented a computed tomography of the abdomen and pelvis without contrast revealed large amounts of stool seen in the rectum with rectal mural thickening concerning for the developing stercoral colitis.During an interview on 9/30/2025 at 11:40 AM Licensed Practical Nurse #3 stated the baseline care plans are initiated by the nursing supervisor during the admission process. Licensed Practical Nurse #3 stated the baseline care plan is initiated at admission and one of the Registered Nurses in the facility then reviews the care plans to ensure the appropriate care plans are initiated. Licensed Practical Nurse #3 stated if a resident is admitted to the facility on Senna laxative, then they should have a risk/constipation care plan initiated. Licensed Practical Nurse #3 stated the Director of Nursing, and the Assistant Director of Nursing would review the care plans after initiation to ensure they are appropriate, and the care plans are reviewed every three months for appropriateness. Licensed Practical Nurse #3 stated Point Click Care (the electronic medical record) system generates the list of the residents that are due for care plan reviews.During a telephone interview on 10/1/2025 at 3:07 PM the Director of Nursing stated at admission the nurse managers review the chart and one of interdisciplinary team members or a Registered Nurse review the care plans after being initiated to ensure they are accurate and correct. The Director of Nursing stated they, the Assistant Director of Nursing or the Registered Nurse supervisor can review and sign off on the admissions. The Director of Nursing stated the residents care plans are reviewed frequently throughout the admission process and quarterly. The Director of Nursing stated Resident #1's care plans were revised by the interdisciplinary team and the final Registered Nurse review was completed by Registered Nurse #4. The Director of Nursing stated the initial clinical care plans were opened and initiated by the rehabilitation department. The Director of Nursing stated the final signature determines that the care plans have been reviewed and are accurate and appropriate. The Director of Nursing stated the baseline care plans can be initiated by the unit managers, because it is an evaluation that is done within 48 hours of the resident's admission. The Director of Nursing stated for nursing areas a Registered Nurse must review the baseline care plan evaluation and make sure it is accurate. The Director of Nursing stated the risk for constipation is their constipation care plan and they have 14 days to initiate care plans after admission, so they will look in the system to see when Resident #1's care plan was initiated. The Director of Nursing stated they are not sure why the diagnosis of constipation did not carry over to Resident #1's diagnostic list, but the minimum data set coordinator or the provider updated the resident's diagnoses on admission. The Director of Nursing stated a diagnosis can be resolved from the list, if not an active acute illness and it goes into the archived section. The Director of Nursing stated part of the challenge with Resident #1 was their representative was toileting them and they would toilet their self.10 NYCRR 415.11(c)(1)

Based on record review and interviews conducted during an abbreviated survey (2615374), the facility did not ensure that services being provided meet professional standards of quality in clinical practice for 1 out of 3 residents (Resident #8) reviewed for quality of care/treatment. Specifically, Resident #8 who had a history of stroke was noted to have a sudden onset of slurred speech by Licensed Practical Nurse #6 on 12/07/2024. Nurse Practitioner #3 was informed by Registered Nurse #1 of Resident #8's slurred speech and instructed the staff to place the resident back to bed for rest. Resident #8's slurred speech continued and was reported to Nurse Practitioner #3 and they ordered to treat the resident with intravenous fluids and obtain a speech evaluation done. Resident #8 continued with slurred speech and weakness on 12/07/2025 and was not transferred to the hospital for evaluation until 12/08/2025, after their representative demanded their transfer to rule out a stroke. Resident #8 was admitted to the hospital on [DATE] with a diagnosis of bilateral scattered infarcts.The findings are:The facility Medical Services policy dated 05/20/2023 documented the medical director oversees all medical care within the facility and coordinates with the attending physicians. The Medical Director intervenes on standards of care if a physician's or practitioner's medical care is inconsistent with current standards, the medical director is responsible for discussing and, if necessary, intervening in the care plan.Resident #8 had diagnoses including but not limited to Unspecified Sequelae of Cerebral Infarction, Peripheral Vascular Disease and Parkinson's disease.A Quarterly Minimum Data Set, dated [DATE] documented Resident # 8 had moderate cognitive impairment. The resident used glasses, a hearing device and had clear speech. The resident required a wheelchair for locomotion, supervision with eating, maximal assistance with toileting and bed mobility and dependent for transfers. Review of an impaired cognition: social skills care plan initiated 12/07/2024 documented Resident #8 spoke in fragmented sentences related to Parkinson's disease. Interventions listed included allow increased time for resident to respond and encourage to speak clearly and slowly.Review of a Licensed Practical Nurse #5's progress note dated 12/07/2024 at 04:42 PM documented Resident #8 was having a conversation with the writer, when they noticed the resident had a sudden onset of slurred speech. The nursing supervisor was notified and came immediately to assess Resident #8. Nurse Practitioner #3 was notified and instructed the staff to place the resident in bed to get some rest. Review of Licensed Practical Nurse #6's progress note dated 12/07/2024 at 11:09 PM documented Resident #8 was alert and still noted with slurred speech. Nurse Practitioner #3 was notified and ordered intravenous fluids and lab work.Review of Registered Nurse #1's progress note dated 12/08/2024 at 12:52 PM documented Resident #8 was noted with slurred speech. Nurse Practitioner #3 informed and ordered for Speech evaluation. Review of Registered Nurse #1's progress note dated 12/08/2024 at 01:37 PM documented Nurse Practitioner #3 advised for Resident #8 to be sent to the hospital to rule out Stroke due to Slurred Speech. Review of Nurse Practitioner #3's progress note dated 12/08/2024 at 02:44 PM documented they called Resident #8's representative, as per Registered Nurse #1's request and discussed the resident's slurred speech and general weakness, which was improving with intravenous fluids. Resident #8 had no facial drop or other neurologic deficits noted by the nurse supervisor's assessment. Resident #8's representative stated they were concerned about the resident having a stroke and requested the resident be sent to the hospital for a computed tomography of the head to rule out a stroke. The nurse supervisor was instructed to transfer the resident to the hospital as per their representative's request. Review of the Assistant Director of Nursing progress note dated 12/08/2024 at 07:21 PM documented they spoke with the hospital staff regarding Resident #8's status and per staff, Resident #8 was being admitted with a diagnosis of stroke. Nurse Practitioner #3 was informed.Review of the Medical Director's progress note dated 12/13/2024 at 10:01 PM documented Resident #8 had a new cerebrovascular accident with slight slurred speech/ bilateral scattered acute infarcts: status post hospitalization 12/08/2024 to 12/12/2024 for slurred speech.During a telephone interview on 09/24/2025 at 11:00 AM, Resident #8's representative stated the facility called them and informed them Resident #8 had slurred speech and they responded for them to transfer the resident to the hospital now. Resident #8's representative stated Nurse Practitioner #3, either the day of or the day before, saw and assessed the resident. Resident #8's representative stated the facility reported the wrong information to the emergency medical services stating Resident #8's symptoms started two hours before they arrived. Resident #8's representative stated the resident informed them they had been slurring their speech since breakfast. Resident #8's representative stated the resident was treated for their stroke in the hospital, but their speech never fully came back, and they had damage after this event.During a telephone interview on 10/01/2025 at 12:37 PM, Nurse Practitioner #3 stated not every resident presenting with stroke symptoms are sent out to the hospital and this depends on the residents age and condition. Nurse Practitioner #3 stated they had not known of Resident #8 having slurred speech in the past and they did not see Resident #8 on 12/07/2024 because they were not in the facility at the time, so they do not know if the resident was having any other symptoms. Nurse Practitioner #3 stated Resident #8 would be at a higher risk to have a stroke because they had one previously. Nurse Practitioner #3 stated Registered Nurse #1 called them back on 12/07/2024 and informed them Resident #8's condition was getting worse and, but they started the resident on intravenous fluids for hydration, they thought the resident was dehydrated. Nurse Practitioner #3 stated the next day, 12/08/2024, Resident #8 was still having symptoms. Nurse Practitioner #3 stated if they had suspected the resident was having a stroke they would have transferred the resident out to the hospital. Nurse Practitioner #3 stated Resident #8 had a complicated case, and they would inform and seek direction from the Medical Director at times if they have a complicated case, but they do not remember if they called the Medical Director on this case or not.During a telephone interview on 10/01/2025 at 01:34 PM, the Medical Director stated they knew Resident #8 very well and their normal speech was not clear. The Medical Director stated depending on how bad Resident #8's speech was, would determine if they needed to be sent out to the hospital or not. The Medical Director stated a lot of the time it is not a stroke when the elderly slur, it can be because of a dry mouth. The Medical Director stated if the Nurse Practitioner is not suspicious of the resident having a stroke, then they start to treat in place, and if the symptoms do not improve then they send the resident out. The Medical Director stated if Resident #8 was mumbling or not talking at all then, they would think the resident did not sleep, their mouth was dry etc. The Medical Director stated if Resident #8 had a change in their slurred speech a little more than normal, then they would not send the resident out to the hospital for a small symptom like that, but if the symptom does not improve then the resident is definitely being sent out. The Medical Director stated they would have recommended Nurse Practitioner #3 approach Resident #8's representative and inform them the resident had a stroke and ask what they want them to do, either send them to the hospital or treat in place in the facility. The Medical Director stated 30 minutes is the golden period with a stroke and once the emergency medical services arrive to the facility that time is out the window already. The Medical Director stated the Nurse Practitioner's manage the residents in the facility on their units without their collaboration at times and they did not question Nurse Practitioner #3's decisions regarding Resident #8 treatment. The Medical Director stated all of their Nurse Practitioners can manage their self appropriately and they call them for direction when they need it.10 NYCRR 415.11(c)(3)(i)

Based on record review and interviews during an abbreviated survey (2619941), the facility did not ensure the physician reviewed the resident's total program of care, including treatments at each visit for 2 out of 3 residents (Resident #1 and #10) reviewed for follow up consultation visits. Specifically, (1) Resident #1 who was admitted to the facility status post a right hip fracture had a follow up Orthopedic consultation visit on 06/12/2025. The consultation report documented Resident #1 was to be scheduled for a follow up visit in six weeks. Resident #1 was discharged home on [DATE] without getting the Orthopedic consultation. There was no documented evidence of a Physicians order for the six week follow up visit that needed to be scheduled by the facility for Resident #. The resident was discharged home from the facility on 08/09/2025 and instructed to follow up post discharge with the Orthopedic.(2) Resident #10 was admitted to the facility status post a left hip fracture and had an Orthopedic consultation on 06/02/2025. The consultation report documented Resident #10 was scheduled for a follow up consultation visit on 08/04/2025 at 1 PM. There was no documented evidence of a Physician's order for Resident #10's scheduled follow up consultation visit. Resident #10 was discharged from the facility on 08/23/2025 without their follow up orthopedic visitThe findings are: The facility Physician Services policy dated 11/08/2024 documented the medical care of each resident is supervised by a licensed physician. Consultative services are made available from community-based consultants or from a local hospital or medical center. 1) Resident # 1 admitted to the facility on [DATE] with diagnoses including but not limited to Fracture of Neck of Right Femur, Depression, Muscle Weakness. An admission Minimum Data Set assessment dated [DATE] documented Resident #1 had a moderate cognitive impairment. The resident had impairment to the lower extremity on one side and used a walker for local motion. The resident required supervision for eating, maximal assistance for bed mobility, and was dependent for toileting and transfers. Review of Resident #1's report of consultation dated 06/12/2025 documented the reason for the consult was an Orthopedic follow up. Resident #1 was status post right intertrochanter fracture and would be monitored. Resident #1 would have an x-ray in six weeks, continue with physical therapy and weight bearing as tolerated. Resident #1's knee x-ray shows tricompartmental osteoarthritis and the resident was due for and received a cortisone shot injection today, activity as tolerated. Resident #1 to be scheduled for follow up visit in six weeks. Review of Nurse Practitioner #2's progress note dated 06/13/2025 at 2:09 PM documented Resident #1 was seen for an Orthopedic follow up and consult. Resident #1 to continue weight bearing as tolerated. Knee x-ray noted tricompartmental osteoarthritis. Resident #1 received a steroid injection to the right knee. Activity as tolerated and follow up in six weeks. Resident #1's representative was present at the bedside and all questions were answered. There was no documented evidence of a six week follow up being scheduled for Resident #1, which should have been scheduled on or after 07/24/2025. Resident #1 was discharged from the facility on 08/09/2025 without the Orthopedic consult. During an interview on 09/24/2025 at 9:30 AM, Unit Clerk #1 stated they would be the one responsible to schedule the residents follow up six-week appointments. The Unit Clerk #1 stated the six-week follow up appointment for Resident #1 was not made because the resident was discharged shortly after, either the beginning of August or the end of July. During an interview on 09/24/2025 at 9:45 AM, Licensed Practical Nurse #3 stated Unit Clerk #1 would call the Orthopedics office to schedule the follow up appointment. Licensed Practical Nurse #3 stated there should be a Physician's order for follow up consult. Licensed Practical Nurse #3 stated when the resident returns from a consult visit, Nurse Practitioner #2 is provided the consult documentation, and they order the follow up appointment. During a telephone interview on 09/24/2025 at 2:20 PM, Nurse Practitioner #2 stated they do not have anything to do with scheduling residents follow up appointments. Nurse Practitioner #2 stated they approve the recommendations made from the consultation visits, but they do not enter any orders in Point Click Care (the electronic medical record) for consultation visits. Nurse Practitioner #2 stated if a resident returned with recommendations from a consultation visit, they would have a discussion with the nursing staff on the unit and inform them the resident needs to have a follow up appointment scheduled. Nurse Practitioner #2 stated the process is a verbal communication with the nursing staff and if the Surveyor is looking for this information in the system, it is not there. During an interview on 09/25/2025 at 3:40 PM, Licensed Practical Nurse #3 stated when a consultation is ordered for a resident an order should be entered into Point Click Care (the electronic medical record) by the Nurse Practitioner or the Physician. During an interview on 09/25/2025 at 3:44 PM, the Director of Nursing stated there should be a Physician's order documented for a consultation visit with an outside Physician. 2) Resident #10 admitted to the facility 05/15/2025 with diagnoses including but not limited to Fracture of Unspecified Part of Neck of Left Femur, Muscle Weakness and Pain in Left Knee. A Comprehensive Minimum Data Set, dated [DATE] documented Resident #10 was cognitively intact. The resident had impairment to the upper and lower extremity on one side and required supervision for eating, maximal assistance with bed mobility and dependent for toileting and transfers. Review of a consultation note revealed Resident #10 was seen by the Orthopedist on 06/02/2025 and was scheduled for a follow up visit on 08/04/2025 at 1 PM. Review of Resident #10's census history revealed they were admitted on [DATE] to the Westminster unit Rm #120-W and their room was changed to 1-[NAME] on 06/10/2025. Review of the email correspondence regarding Resident #10's follows up consultation visit revealed Nurse Practitioner #2 sent an email to the unit clerk on 08/06/2025 at 2:11 PM asking if the resident had a follow up appointment scheduled with the Orthopedist because they told the resident to return to the office for follow up in two months. During a telephone interview on 09/30/2025 at 1:40 PM, Nurse Practitioner #2 stated Resident #10 would cancel appointments scheduled for them by their self. Nurse Practitioner #2 stated if they know about a follow up consultation appointment, then they will write a progress note about it. Nurse Practitioner #2 reviewed Resident #10's medical record and stated they did not see any documentation regarding the follow up consultation visit. Nurse Practitioner #2 stated if they are at the nurse's station and a resident needs a follow up consultation visit scheduled, they will turn around and state aloud the resident needs a follow up to the unit clerk, the unit clerk will then schedule the transportation for the appointment. Nurse Practitioner #2 stated they have not been putting in an actual order in Point Click Care (the electronic medical record) for a consult or follow up appointment. Nurse Practitioner #2 stated generally there is no issue, and residents make it to where they need to be, but Resident #10 would cancel their appointments regularly. Nurse Practitioner #2 stated they or nursing would document a progress note regarding Resident #10 cancelling their appointment and if they spoke with the resident, they would generally write a progress note unless they get distracted and forget to write that in their note. Nurse Practitioner #2 stated the residents are educated about the risk of canceling important appointments. During a telephone interview on 10/01/2025 at 1:34 PM, the Medical Director stated their expectation is that an order would be entered in Point Click Care (the electronic medical record) system for a consultation visit as well as a small progress note documenting the recommendations and the follow up from the visit. The Medical Director stated they expect the follow up from the consultations are documented, that the resident came back and needs to follow up in three weeks. The Medical Director stated the documentation is passed amongst many hands and this can cause things to slip through the cracks and they are not 100% efficient on the consultations and follow ups unfortunately. The Medical Director state they are going to work harder with the Nurse Practitioners and the Unit Clerk to ensure there are few or no missed appointments. The Medical Director stated they must improve the system, and they will work on this with the staff. 10NYCRR 415.15(b)(2)(iii)

Based on record review and interviews during an abbreviated survey (NY00372705/568716), the facility failed to ensure residents were free from medication errors for one (1) out of four (4) residents (Resident #4) reviewed for medication administration. Specifically, on 02/20/2025, Resident #4 was administered crushed extended-release Morphine by Licensed Practical Nurse #4 at 9:00 AM. At 10:15 AM, Resident #4 was found in their room in bed lethargic by Speech Language Pathologist #1. Resident #4 was assessed and noted to be lethargic with decreased respirations, wheezing, and pinpoint pupils. Resident #4 was administered Naloxone to reverse the effects of the crushed extended-release Morphine and returned to baseline shortly after. This resulted in actual harm to Resident #4 that was not Immediate Jeopardy. The findings are:The facility Narcotic Handling and Administration policy, initiated 01/2020, documented it is the policy of the facility to ensure that all nursing staff charged with administering medications are proficient and compliant with handling and administration of narcotic medications within the facility. Nurses are to check the pharmacy label for all pertinent information including the resident's name, medication, dose, route of administration, and timing, as well as any specific instructions (ex: do not crush, take on an empty stomach, etc). Before administering the medication, the nurse is to check the order in the computer against the written instructions on the blister pack or container to ensure they match and instructions are being followed appropriately.Resident #4 had diagnoses including, but not limited to, muscle weakness, chronic obstructive pulmonary disease (lung and airway diseases that restrict your breathing), and pulmonary hypertension (high blood pressure that affects arteries in the lungs and heart).A Prospective Payment System Minimum Data Set (an assessment tool) dated 01/02/2025, documented Resident #4 was cognitively intact. The resident required supervision for eating, maximal assistance with toileting, bed mobility and transfers. Review of a Pain Care Plan initiated 02/12/2025, documented Resident #4 was at risk for pain due to thoracic spine fractures. Interventions listed included: administer medications, discuss with resident pain management, monitor behavior and assess pain/discomfort if change in behavior noted, and monitor for side effects and adverse reactions resulting from interventions rendered.The facilities undated, unsigned investigative summary documented the following: on 02/20/2025, Resident #4 received naloxone in response to receiving their Morphine Sulfate 30 mg extended-release medication crushed. Licensed Practical Nurse #4 was assigned to administer Resident #4 their medications on the day shift on 02/20/2025. Licensed Practical Nurse #4 stated Resident #4 was spitting out their medications and was known to become verbally disruptive and abusive if their pain medication was not given on time as per their preference. Licensed Practical Nurse #4 stated they wanted to ensure Resident #4 received their pain medication and inadvertently crushed their Morphine Sulfate. Resident #4 took the medication without issue and Licensed Practical Nurse #4 continued with their medication pass. Resident #4 was next seen by Speech and Language Pathologist #1; they entered the room at 10:15 AM to work with the resident and noted the resident was lethargic. Speech Language Pathologist #1 called Licensed Practical Nurse #4, who notified Licensed Practical Nurse #2 and Registered Nurse #2. Registered Nurse #2's assessment of Resident #4 revealed the resident had coarse crackles, wheezing and hypoxia. As a result, the Physician ordered 40 mg of Solumedrol (a steroid that acts on the immune system to suppress the body's inflammatory and allergic responses) and 40 mg of Lasix(a diuretic used to treat conditions involving fluid retention) intramuscularly. Both medications were administered, and Resident #4 was also noted with cool extremities and pinpoint pupils. At approximately 10:50 AM, Licensed Practical Nurse #4 reported they realized they had crushed the extended-release Morphine Sulfate and notified Registered Nurse #2 and Nurse Practitioner #2. Naloxone (medication that rapidly reverses the overdose effect of morphine) 0.4 mg intramuscular was ordered and administered to Resident #4's left deltoid at approximately 11:15 AM. Shortly after, Resident #4 returned to their mental baseline and was verbally responsive to staff. Resident #4 was further assessed by the Physician and their representative was made aware of the resident's clinical presentation and all medication administered to the resident and stated they wanted the resident to be treated in the facility over being sent to the hospital. During an interview on 08/22/2025 at 1:32 PM, Registered Nurse #2 stated they remember being called over to see Resident #4 after morning report, around 10:00 AM. Registered Nurse #2 stated they were often called to see Resident #4 due to their frequent exacerbations of chronic obstructive pulmonary disease. They stated the resident's usual signs and symptoms with their exacerbation were lethargy, low oxygen saturation, and bilateral rales and rhonchi. Registered Nurse #2 stated they called the Physician and obtained orders for Resident #4's respiratory concerns. Registered Nurse #2 stated Resident #4 was slightly more lethargic than normal, so they went and spoke with Licensed Practical Nurse #4 assigned to the resident and asked if there was anything else that had occurred. Licensed Practical Nurse #4 informed them about the issue with the Morphine. Registered Nurse #2 stated they recall the Licensed Practical Nurse #4 stated they crushed an extended-release tablet and administered it to Resident #4. During an interview on 08/22/2025 at 12:20 PM, the Director of Nursing stated they believe Licensed Practical Nurse #4 was rushing to make sure the resident got their pain medication, and in a haste, crushed the extended-release Morphine tablet and administered it to Resident #4. The Director of Nursing stated when Licensed Practical Nurse #4 realized this, it was too late, and they believe the nurse realized right after the administration and everyone [NAME] into action. The Director of Nursing stated Resident #4 was assessed, given Naloxone, and had no ill effects from receiving their extended-release medication crushed.During an interview on 08/22/2025 at 4:08 PM, the Administrator stated they were in the facility on 02/20/2025 when Resident #4 was administered the crushed extended-release Morphine, and they thought the call was a rapid response (a system to quickly identify and address critical situations to prevent adverse outcomes). The Administrator stated Licensed Practical Nurse #4 was familiar with Resident #4 and had given them medications prior. The Administrator stated they think Licensed Practical Nurse #4 just made a mistake. During an interview on 08/22/2025 at 2:53 PM, Speech Language Pathologist #1 stated that on 02/20/2025 they went into Resident #4's room to treat/work the resident. They stated normally Resident #4 presented with a lot of anxiety and would call out, help me, help me, I need help. On this day, Speech Language Pathologist #1 stated the resident was very out of it (lethargic and unresponsive), so they called Licensed Practical Nurse #4 and informed them and left the unit to treat another resident. Speech Language Pathologist #1 stated whenever a resident does not present as they usually do, they alert the nursing staff. During a telephone interview on 09/02/2025 at 3:29 PM, Licensed Practical Nurse #4 stated they remember Resident #4, and stated the resident was chronically in pain. Licensed Practical Nurse #4 stated Resident #4 wanted their pain medication before breakfast because they felt this was the only way to get ahead of the pain. Licensed Practical Nurse #4 stated Resident #4 did take some of their daily medications crushed. Licensed Practical Nurse #4 stated they got Resident #4's medications together, crushed everything and administered the medications to Resident #4. Licensed Practical Nurse #4 stated Resident #4 was in bed, was lethargic and not very responsive, and this was not their baseline. Licensed Practical Nurse #4 stated this was not the first time that they had given Resident #4 their medication, but it was the first time they had crushed the extended-release Morphine. Licensed Practical Nurse #4 stated the blister was labelled no crush, but they were in a rush to give the medication because the resident was in chronic pain. Licensed Practical Nurse #4 stated Resident #4 did return back to base line soon after receiving Naloxone treatment. During a telephone interview on 09/09/2025 at 11:11 AM, the Medical Director stated they were called on 02/20/2025 and informed Resident #4 was having respiratory symptoms. The Medical Director stated they ordered for Resident #4 to be administered Lasix and Solumedrol due to the resident's extensive chronic obstructive pulmonary disorder. The Medical Director stated they were not informed initially that Resident #4 received crushed extended-release medication, they were only informed the resident had respiratory symptoms. The Medical Director stated they arrived at the facility about five (5) minutes after they ordered administration of Narcan. The Medical Director stated they had not known about the crushed medication and asked the staff on the phone if Resident #4 had received any narcotic medication and that is when they ordered the Naloxone. The Medical Director stated Resident #4 had no ill effects from the medication and came around quickly with the Naloxone. 10 NYCRR 415.12(m)(2)

Based on record review and interviews conducted during an abbreviated survey (NY00385588/568719, NY00373004/568714) the facility did not ensure that the comprehensive care plan was updated and revised for 2 out of 4 residents (Resident #1, Resident #3)) reviewed for falls. Specifically, (1) Resident #1 had a fall from the Hoyer lift while being transferred by Certified Nurse Aide #1 and Certified Nurse Aide #2 on 07/02/2025. Review of Resident #1's fall risk care plan revealed it was not updated to reflect the actual fall. (2) On 03/10/2024, Resident #3 had an unwitnessed fall in their room and sustained laceration to their left eyebrow. Review of Resident #3's care plans revealed their risk for fall care plan was not updated with the actual fall that occurred on 03/10/2024.The findings are:The facility Fall Prevention protocol policy created 08/20/2018 documented a goal of the facility is to provide a safe and healthful environment for residents, visitors and employees. A comprehensive approach to safety, which considers the hazards identified in the environment and individual resident risk factors and then adjusts interventions accordingly. If a fall occurs the plan of care will be reviewed and revised to include the fall and new interventions placed to prevent further falls with each incidence of falls, quarterly, upon significant change and at admission/readmission. 1) Resident #1 had diagnoses including but not limited to Dementia, Cognitive Communication Deficit and Bipolar Disorder.A Quarterly Minimum Data Set, dated [DATE] documented Resident #1 had severe cognitive impairment. The resident is bedridden and requires moderate assistance with eating, dependent for toileting, bed mobility and transfers.Review of a risk for falls care plan initiated 09/23/2024 documented Resident #1 was at risk related to decreased mobility and a history of falls prior to admission. Interventions listed included keep bed in lowest position, maintain a clutter-free environment, call bell/personal items within reach and encourage resident to stay in a supervised area while out of bed. The care plan was updated 07/03/2025 with staff education and Physical Therapy evaluation.There was no documented evidence of Resident #1's risk for fall care plan being updated with their actual fall from the Hoyer lift on 07/02/2025.During an interview on 08/18/2025 at 1:11 PM, Licensed Practical Nurse #1 stated they were unaware that Resident #1 needed their care plan updated to reflect they had an actual fall after the incident occurred. 2) Resident #3 had diagnoses including but not limited to Dementia, Muscle Weakness and Difficulty in Walking.A Quarterly Minimum Data Set, dated [DATE] documented Resident #3 was cognitively intact and exhibited verbal behavioral symptoms directed towards others. Resident #3 had impairment to their upper extremity on one side and used a walker for locomotion. The resident required supervision for eating, moderate assistance with bed mobility and maximal assistance with toileting and transfers. Review of an accident/incident report dated 03/10/2024 at 10:23 AM documented the writer was informed by the assigned nurse on the unit that Resident #3 was on the floor and bleeding. Upon arriving to Resident #3's room, the writer found the resident sitting on the floor, resting with their back against the frame of the bed, facing the door, and touching the left side of their face. Wheelchair located next to Resident #3. Resident #3 was noted to have a laceration to their left eyebrow and complained of excruciating pain to the site. Resident #3 was also noted to have two small skin tears to the left forearm. Review of a risk for falls care plan initiated 02/07/2024 documented Resident #3 was at risk for falls due to ambulatory dysfunction, muscle weakness and joint pain. Interventions listed included call bell/personal items within reach, investigate cause of falls and evaluate patterns if more than one, keep bed in lowest position and maintain a clutter free environment.Review of Resident #3's care plans revealed their risk for fall care plan was not updated with the fall that occurred on 03/10/2024.During an interview on 08/18/2025 at 1:53 PM, the Director of Nursing stated they do not list the falls on the care plan, they write a progress note corresponding with the incident and implement interventions dated from the day of the incident. The Director of Nursing stated the care plan for Resident #1 was updated with staff education and a Physical Therapy evaluation the day after the fall and this was the care plan update. During a telephone interview on 09/02/2025 at 9:00 AM, Registered Nurse #1 stated most of the time the unit manager is responsible to update the care plans, but they work as a team, and they could update the care plans as well. Registered Nurse #1 stated the care plans should be updated immediately following a fall. Registered Nurse #1 stated if a resident has an actual fall, the care plan has to be updated depending on what led to the fall. Registered Nurse #1 stated the fall risk care plan would be updated and also any care plan that is related to the cause of the fall, example behaviors. 10 NYCRR 415.11 (c)(2)(ii)

Based on observations, interviews, and record reviews conducted during the abbreviated (NY00347929) survey, the facility did not ensure a resident was free from physical abuse by a staff member. This was evident for 1 (Resident #1) of 3 residents sampled for abuse. Specifically, on 7/11/2024 between 1:48 AM to 1:49 AM, Certified Nursing Assistant #1 was seen on the facility surveillance video approaching Resident #1 from behind at the entrance of another resident's room. Certified Nursing Assistant #1 was seen hitting Resident #1 on the upper part of their left shoulder, which startled Resident #1. Resident #1 was seen turning and trying to push Certified Nursing Assistant #1 away. Certified Nursing Assistant #1 was seen shoving Resident #1 and they both start hitting each other. Resident #1 was seen bending over and Certified Nursing Assistant #1 continued to hit Resident #1 with a closed fist several times on the arm and mid-section. Certified Nurse Assistant #1 then pushed Resident #1 and Resident #1 fell to the floor. Resident #1 was seen getting up and walking off camera. Resident #1 sustained an abrasion to the bridge of the nose. This resulted in actual harm to Resident #1 that was not immediate jeopardy. The findings are: The undated facility policy titled Abuse, Neglect, and Exploitation of Residents documented incidents are reviewed to identify areas for improvement, including environmental, operational, and staffing issues, as a form of abuse prevention. Resident #1 was admitted to the facility on [DATE] with diagnoses of Lyme disease and Unspecified Dementia without behavioral disturbance. The Minimum Data Set 3.0 assessment, dated 6/7/2024, documented Resident #1 was severely cognitively impaired, displayed physical aggression towards others on 1 to 3 days in the 7 days prior to the assessment, and did not exhibit wandering behavior. Review of a Victim for Abuse Comprehensive Care Plan initiated on 5/24/2024 documented Resident #1 had cognitive impairment, Dementia, wanders and had physical aggression which placed the resident at risk of being abused. Interventions included an assessment for abuse, investigation of allegations of abuse, provide support, referral to social services and the Medical Doctor, and offering the resident a snack or activities of interest while they wandered. The Comprehensive Care Plan related to behavior initiated 5/24/2024 documented Resident #1 exhibited physical aggression and wandering behavior. Interventions included allowing Resident #1 time to de-escalate when agitated and providing a safe and secure environment. On 7/11/2024 between 1:48 AM and 1:49 AM, Certified Nursing Assistant #1 was seen on surveillance video approaching Resident #1 from behind while Resident #1 attempted to wander into another resident's room. Certified Nursing Assistant #1 used their right hand to shove Resident #1 on the left shoulder, which startled Resident #1. Resident #1 turned and used their left arm to swat at Certified Nursing Assistant #1 to push them away. Certified Nursing Assistant #1 shoved Resident #1 and they began hitting and pushing each other. Certified Nursing Assistant #1 used a closed fist to hit Resident #1 on their right arm and upper midsection of their body, causing the resident to bend over. Certified Nursing Assistant #1 then pushed Resident #1 causing the resident to fall on the floor. Resident #1 got up from the floor and walked off camera while Certified Nursing Assistant #1 stood at the door of room [ROOM NUMBER]. No other staff or residents were observed on surveillance footage in the area at the time of the incident. Certified Nursing Assistant #1's written Statement dated 7/11/2024 documented Resident #1 became aggressive when redirected from wandering into other resident's rooms and punched Certified Nursing Assistant #1 in the face. The facility Investigative Summary dated 7/11/2024 documented Licensed Practical Nurse #1 called a Code [NAME] alerting facility staff to the need for behavioral assistance on Resident #1's unit. Registered Nurse #1 arrived on the unit and was informed Resident #1 was aggressive and punched Certified Nursing Assistant #1 in the face. Certified Nursing Assistant #1 provided their statement and was sent to the hospital emergency room for evaluation. Registered Nurse #1 found Resident #1 had a small abrasion on the bridge of their nose. Resident #1 was unable to state what occurred due to cognitive impairments. Upon reviewing the surveillance video, the Administrator and Director of Nursing suspended Certified Nursing Assistant #1 pending completion of investigation. The facility's 5-day Investigation Report dated 7/16/2024 documented there was reasonable cause to believe that abuse of Resident #1 occurred on 7/11/2024. X-rays of Resident #1's nasal bone, hips and left ankle were negative for fracture. Resident #1 had no memory of the event and continued at baseline. There was no apparent psychosocial distress or harm. Certified Nursing Assistant #1 was terminated from the facility and reported to the police. Certified Nursing Assistant #1's Employee File contained a Progressive Discipline/Corrective Action Form dated 10/21/2022. The Form documented that on 10/3/2022, Certified Nursing Assistant #1 witnessed a resident-to-resident altercation on a Unit and while attempting to separate the residents involved caused one of the residents to fall to the floor. The Form noted that Certified Nursing Assistant #1 did not report the incident appropriately and should have separated the residents in a different manner. Certified Nursing Assistant #1 was directed to immediately report all abuse incidents to the abuse neglect officer and to call Code [NAME] if the situation escalated. On 7/11/2024 at 1:25 AM, Licensed Practical Nurse #1 documented Resident #1 was restless, agitated, wandering into other residents' rooms, and required constant redirection. Resident #1's agitation increased, and they became aggressive towards staff, cursing at Certified Nursing Assistant #1. Licensed Practical Nurse #1 documented they made the Nursing Supervisor (Registered Nurse #1) aware and indicated staff would continue to monitor Resident #1's behavior. Several attempts were made to contact Certified Nursing Assistant #1 for an interview without response. During an interview with Resident #1's Designated Representative on 7/26/2024 at 12:45 PM, they stated Resident #1 was severely cognitively impaired and would forget occurrences immediately after they happened. During an interview with Licensed Practical Nurse #1 on 7/23/2024 at 2:13 PM, they stated they regularly work the 11PM to 7AM shift on the Resident #1's Unit, a locked dementia Unit. Licensed Practical Nurse #1 stated regular staffing for the night shift included 2 Certified Nursing Assistants and 1 Licensed Practical Nurse for 40 residents, including 6 residents that required 2-person assistance with Activities of Daily Living and 4 residents who wander throughout the night. Licensed Practical Nurse #1 stated they were the charge nurse on 7/11/2024 when Resident #1 was agitated, wandering into other residents' rooms, and aggressive towards staff. Licensed Practical Nurse #1 stated at 1:33AM they texted Registered Nurse #1 about Resident #1's escalating behaviors. Licensed Practical Nurse #1 did not receive a response from Registered Nurse #1, and they were at the Nursing Station in the center of the unit when Resident #1 wandered out of their view towards room [ROOM NUMBER]. Licensed Practical Nurse #1 stated at that time, Certified Nursing Assistant #1 was the only aide on the floor, and they were at a computer kiosk in the hall near room [ROOM NUMBER] completing their medical record documentation. Certified Nursing Assistant #2 was on their break and was off the unit at that time. Licensed Practical Nurse #1 stated they waited for about 15 minutes and paged Code [NAME] overhead to alert facility staff that assistance was needed to address a resident's escalating behavior. Licensed Practical Nurse #1 stated they then went towards room [ROOM NUMBER] and saw Resident #1 wandering away from room [ROOM NUMBER] and towards the nursing station. Licensed Practical Nurse #1 stated they observed Certified Nursing Assistant #1 near the entryway of room [ROOM NUMBER] bleeding from the nose and stated they were punched by Resident #1. Licensed Practical Nurse #1 followed Resident #1 in the hallway to a sitting area near the nursing station and stayed with Resident #1 until Registered Nurse #1 and another staff member came to the unit in response to Code Green. Licensed Practical Nurse #1 stated Certified Nursing Assistant #1 did not approach or interact with Resident #1 after the incident and after speaking with Registered Nurse #1 left the unit to go to the emergency room . Licensed Practical Nurse #1 stated they did not know Certified Nursing Assistant #1 had hit Resident #1 until the facility investigation was initiated and Certified Nursing Assistant #1 was suspended. Licensed Practical Nurse #1 stated Resident #1 had previous episodes of aggression towards staff, but they did not realize that Resident #1 was at risk for being victimized by staff. During an interview with Registered Nurse #1 on 7/29/2024 at 9:15 AM, they stated they were the Nursing Supervisor for the night shift on 7/11/2024 when Certified Nursing Assistant #1 accused Resident #1 of punching them in the face. Registered Nurse #1 stated Licensed Practical Nurse #1 texted Registered Nurse #1 at 1:30 AM to inform them Resident #1 was agitated and was becoming more aggressive towards staff when redirected. Registered Nurse #1 stated they did not see the text message until later because they were busy assessing a resident on another unit. Registered Nurse #1 stated they heard the Code [NAME] page overhead and came to Resident #1's unit to find Licensed Practical Nurse #1 sitting with Resident #1 near the nursing station. Registered Nurse #1 stated Licensed Practical Nurse #1 informed them Resident #1 punched Certified Nursing Assistant #1 in the face. Registered Nurse #1 stated they assessed Resident #1 and observed redness and a small scratch on the resident's nose. Registered Nurse #1 stated Resident #1 was not aggressive towards staff, was confused, and stated they were attempting to sweep up when they got into a physical altercation with a drunken man, were punched in the nose and on the side of the head during the altercation and was waiting to give a statement to police upon their arrival. Registered Nurse #1 stated they found Certified Nursing Assistant #1 in room [ROOM NUMBER] bleeding from their nose. Registered Nurse #1 stated Certified Nursing Assistant #1 reported Resident #1 attacked them and denied hitting Resident #1. Registered Nurse #1 stated Certified Nursing Assistant #1 gave them a written statement and went to the emergency room for evaluation. Registered Nurse #1 stated they initiated an incident investigation and text messaged the Director of Nursing and Administrator to inform them Certified Nursing Assistant #1 required hospitalization . Registered Nurse #1 stated they began to question Certified Nursing Assistant #1's account of the incident because Resident #1 was consistent that they were involved in a physical fight with someone and had a scratch on their nose. Registered Nurse #1 stated upon the Director of Nursing's arrival at the facility in the morning, Registered Nurse #1 expressed their concern regarding the validity of Certified Nursing Assistant #1's version of events. During an interview with the Director of Social Work on 7/29/2024 at 3:03 PM, they stated they assessed Resident #1's cognitive and mental status following the incident on 7/11/2024 and Resident #1 had no recollection of the incident. During an interview with the Director of Nursing on 07/23/2024 at 4:30 PM, they stated they have staffing issues, they do need more staff, however, with the help of the nurses and the whole administrative team they are able to provide the care necessary. The Director of Nursing stated that they provide assistance when needed and the students from the New York Certified Nursing Assistant Schools also volunteer as needed. The Director of Nursing stated staff is trained to call a code if assistance is needed and that was why Licensed Practical Nurse #1 activated a Code [NAME] on 07/11/2024. The Director of Nursing stated they conducted a facility wide refresher on the emergency code (Code Green), and they completed a facility wide re-education on Managing Residents with Dementia and Behaviors with 100% compliance. The Director of Nursing stated that camera's surveillance video can only be accessed by the Administrator, the Director of Nursing, the Assistant Director of Nursing, the Administrator Assistant, and the Food Services Director. The Director of Nursing stated the facility does not have security around the clock. During an interview with the Administrator on 07/23/2024 at 4:16 PM, they stated nothing of this nature (staff to resident altercation) had happened at the facility. The Administrator stated after the incident, all staff were in serviced on abuse prevention. The Administrator stated they are doing everything they can do with what they can control. The Administrator also stated that they hired a consultant to help them write a lesson plan for employees to handle and prevent burn out and avoid stressful life experiences. 10 NYCRR 415.4(b)(1)(i)