Every finding on record at Hempstead Park Nursing Home

Based on observation, interview and record review during a survey, the facility failed to ensure that the residents' right to personal privacy, including the right to send and promptly receive unopened mail and other letters, packages, and other materials delivered to the facility for the residents, including those delivered through a means other than a postal service, was maintained. This was identified for one (Resident #8) of seven residents reviewed Resident/Patient/Client Rights. Specifically, a mailed package for Resident #8 was delivered from outside to the facility; however, the package was not received by the resident.Complaint #273787 The findings include: A facility policy and procedure titled Resident Main Services documented the facility shall ensure that each resident is afforded the right to send and receive mail promptly, privately, and without interference. The facility shall not delay, withhold, censor, open, or otherwise interfere with resident mail except when assistance is specifically requested by the resident or when legally authorized by the resident's designated representative or legal decision-maker. The Recreation department will distribute incoming resident mail promptly. Resident #8 was admitted with diagnoses including multiple sclerosis, seizure disorder, and Schizophrenia. A quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. During an interview on 06/10/2026 at 10:10 AM, Resident #8 stated that their mail is not delivered timely and items they have ordered, such as books, do not get delivered to them. During an interview on 06/10/2026 at 2:08 PM, the Receptionist stated that when a package arrives for a resident, they log it in the binder labeled Resident Package Delivery Inspection Log, that is maintained at the front desk. The Recreation staff is then responsible for delivering the package to the resident and completing the information on the log form. The Receptionist reviewed the Resident Package Delivery Inspection logbook starting from 01/01/2026 to present and identified an entry for 03/17/2026 where a package for Resident #8 was logged in; however, there was no documentation that the package was delivered to the resident. During an interview on 06/10/2026 at 2:18 PM, the Director of Recreation stated that they were certain the package had been delivered, but it was just the fault of the recreation staff for not signing off for it on the Resident Package Delivery Inspection Log. During an interview on 06/10/2026 at 3:30 PM, the Administrator stated that packages are logged in at the reception desk, placed on a rack near the front desk, and recreation staff should deliver them to the residents. They further stated that the incomplete logbook form was probably just an oversight by the recreation staff. During an interview on 06/30/2026 at 12:35 PM Recreation Aide #2 stated that they were assigned to unit where Resident #8 resides. They stated that there is a logbook at the front desk, and the date of the delivery is entered by the receptionist when the package is first delivered. Recreation Aide #2 stated they identify a package for a resident on their unit, they will collect it and deliver it to the resident. Recreation Aide #2 stated that they did not specifically remember delivering a package for Resident #8 back in March 2026. Recreation Aide #2 stated they should have documented in the log when they delivered the package to the resident. New York Code of Rules and Regulations 415.3 (e)(1)

Based on observation, interviews, and record review during the abbreviated survey, the facility failed to ensure resident rights to be free from abuse for two (Resident #11 and Resident #12) of three residents reviewed for Abuse. Specifically, Staff observed Resident #12 having a physical altercation with Resident #11. Resident #12 was on top of Resident #11 with both hands placed around Resident #11's neck. Resident #12 stated they were attempting to retrieve a belt they alleged Resident #11 had taken. Assessment of Resident #11 revealed bleeding from their nose, mouth, and the right second toe.Incident # 2693929The findings include:The facility's Abuse Prevention Policy, dated 09/19/2022 and revised on 05/10/2025, documented that it is the facility's policy to provide a safe resident environment that protects residents from abuse, including verbal, mental, sexual, or physical abuse. This includes staff-to-resident abuse of any type, resident-to-resident abuse of any type, and visitor-to-resident abuse of any type. Physical abuse is inappropriate physical contact resulting in injury or likely to harm a resident. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. Abuse will be monitored for negative psychosocial outcomes related to crime, allegation, or incident. Residents will be provided with needed interventions to mitigate the potential for developing negative psychosocial outcomes. Resident #12 was admitted with diagnoses of a traumatic brain injury, epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and metabolic encephalopathy (a brain disorder caused by a chemical imbalance). The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated Resident #12 had intact cognition. The Minimum Data Set assessment documented that Resident #12 did not exhibit any behaviors, and it was very important for Resident #12 to take care of their personal belongings.A Comprehensive Care Plan titled Risk for Abuse initiated on 10/23/2025, documented Resident #12 will be free from abuse, with interventions that included to address concerns as they arise.A Comprehensive Care Plan titled Mood State Psychosocial Well-Being, dated 10/23/22025, documented interventions including monitoring for negative psychosocial outcomes related to untoward events, monitoring for non-verbal signs of distress such as restlessness, decreased appetite, agitation and or isolation after an untoward event.A Comprehensive Care Plan titled Behaviors, Altercation dated 07/09/2025 last revised on 8/27/2025 included interventions to set and enforce clear limits, assess and address for contributing sensory deficits, analyze the time of day, place, circumstance, triggers and what de-escalated the behavior and document.A review of the electronic medical record from April 2025-December 2025 indicated the resident had a history of physical altercation with a resident on 04/25/2025 and a verbal altercation with another resident on 07/09/2025.A Physician's progress note dated 12/16/2025, documented Resident #12 was seen after peer-to-peer altercation where Resident #12 was the aggressor. Resident #12 presented as angry, defensive, and argumentative. Resident #12 reported only having an argument with Resident #11 and was defensive when asked to provide details. Resident #12 denied choking behavior and blamed incident on staff, the roommate, and the Psychologist.Resident #11 was admitted with diagnoses that included chronic obstructive pulmonary disease (progressive lung disease that causes breathing difficulty), benign prostatic hyperplasia (enlarged prostate that can slow or block the flow of urine), and type 2 diabetes mellitus (where the body cannot use insulin properly). The quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score was not completed and that Resident #11 was rarely or never understood. The Minimum Data Set assessment documented Resident #11 was not short tempered, or easily annoyed, Resident #11 did not have a behavior of wandering.A Comprehensive Care Plan titled Risk for Abuse related to vulnerability due to deficits in medical/physical conditions, dated 06/07/2025, documented the resident demonstrates behaviors that can disturb others. Interventions included encouraging resident to voice concerns to staff regarding their peers.A Comprehensive Care Plan titled Behaviors related to Dementia, dated 06/07/2025 documented Resident #11 had a tendency to take food off the food truck. Interventions included approaching the resident in a calm manner and addressing the resident's concerns as they arise.An Abuse Risk assessment dated [DATE] documented Resident #11 had a history of mental illness and history of dementia. It documented Resident #11 did not have a history of taking other residents' belongings, displaying threating or intimidating behaviors, or being physically aggressive toward peers.A review of the Accident/Incident Report dated 12/15/2025 documented Resident #12 and Resident #11 were in their shared bedroom and #12 was observed sitting on the floor with their hands around the neck of Resident #11, Resident #12 stated Resident #11 took his belt. Resident #11 had bleeding from their nose, mouth right second toe and pinky finger. Resident #12 sustained no injuries. Both residents transferred to two area hospitals. The root cause analysis documented Resident #12 had a psyche diagnosis and complained about any roommate they had and presented with impulsive behaviors toward Resident #11, stating Resident #11 took their belt. This incident constituted resident-resident abuse because the aggressor was alert and oriented. The conclusion documented resident to resident incident was the result of an impulsive aggression by an alert and oriented resident toward his roommate over his belt they assumed on Resident #11 possession. During an interview on 06/08/2026 at 11:08 AM, Resident #12 stated they had a roommate who left, that roommate took their belt, they took it back. They denied going to the hospital after taking the belt back. They stated the roommate they have now is fine, we get along. This Resident did not recall any problems with other residents in the facility and denied any aggressive behavior toward others.Resident #11 was not interviewable.During an interview on 6/10/2026 at 9:07 AM, Certified Nursing Assistant #3 stated they heard a resident yelling for help and called the nurse. Certified Nursing Assistant #3 stated they saw Resident #12 sitting on top of Resident #11 with their hands around Resident #11's neck. Resident #12 was angry and said Resident #11 took their belt, and they wanted the belt back.During an interview on 06/10/2026 at 11:25 AM, Certified Nursing Assistant #2 stated they were regularly assigned to both Resident #11 and Resident #12. They did not witness the altercation between Resident #11 and Resident #12 on 12/15/2025 as they were in the dining room at the time of the incident. Resident #11 and Resident #12 did not have a history of altercation prior to 12/15/2025. During an interview on 6/10/2026 at 11:32 AM, Licensed Practical Nurse #3 stated on 12/15/2025 they were near Resident #11 and Resident #12's room when they heard a commotion. They went into the room and saw Resident #12 sitting on top of Resident #11 with their hands on Resident #11's neck. Resident #12 said Resident #11 took their belt and they wanted it back. Both residents were sent out to hospital, they could not recall if either resident had any injuries. Licensed Practical Nurse #3 stated that Resident #12 and Resident #11 did not have any altercation with each other prior to 12/15/2025.During an interview on 06/10/2026 at 12:28 PM, Registered Nurse Supervisor #1 stated when they responded to the residents' room Licensed Practical Nurse #3 had already separated the two residents. Resident #11 was observed bleeding from the right foot 2nd toe, right fifth finger, nose, and tongue. Resident #11 was sent to the hospital. Resident #12 did not have visible injuries; however, they were sent to the hospital for a psychiatric evaluation. Resident #12 alleged that Resident #11 took their belt, and they wanted the belt back. After the incident Resident #11 was moved to another unit to keep them safe. During an interview on 06/11/2026 at 10:48 AM, the Minimum Data Set Coordinator, who was the Director of Nursing Services on 12/15/2025, stated they completed the investigation related to an altercation that took place on 12/15/2025 between Resident #11 and Resident #12 and concluded that resident to resident abuse occurred as Resident #12 was alert and oriented and willfully hit Resident #11 with an intent to take their belt back from Resident #11.10 New York Code Rules and Regulations 415.4(b)(1)(i)

Based on observation, record review, and interviews during the survey, the facility failed to ensure that each resident had a clean, comfortable, and homelike environment. This was identified for four (2 North, 2 South, 3 North, and 3 South units) of six units observed for environment. Specifically, during observations the day rooms and hallways in units 2 North, 2 South and 3 North had ripped sheetrock and peeling wallpaper; the shower rooms in units 2 South, 3 North and 3 South had torn privacy curtains; Unit 3 South resident bathroom was in an unsanitary condition with debris on the floor and had a foul odor; and unit 3 North resident bathroom was observed with missing wall tiles.Complaint #2717918The findings include:The facility policy titled Preventative Maintenance /Safety, dated 07/23/2025 documented the objective of the preventative maintenance /safety program is to assess, inspect, evaluate, and inventory equipment used for patient care. It is the policy of this facility to provide a safe, sanitary and comfortable environment for residents, staff, and visitors. The facility will make certain the building is always maintained in good repair. Residents' rooms, including floors, walls, ceiling, shall be clean and in good repair.The facility policy titled Homelike Environment dated 04/25/2025 documented the facility will ensure that all residents' rooms are cleaned and sanitized according to set standards to maintain a safe, sanitary and comfortable homelike environment. This includes ensuring that residents can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. Walls, blinds and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. Hallways, dining rooms, and shower rooms must be cleaned and mopped according to a set schedule.During an observation of the unit 2 North dining room, in the presence of Registered Nurse #4, on 06/09/2026 at 1:30 PM, there were 12 residents sitting in the dining room. The walls were observed with peeled wallpaper and exposed sheetrock. The wall behind the ice machine had raised (bubbled) area.During an observation on 06/09/2026 at 1:31 PM, unit 2 South dining/day room walls had peeled wallpaper with exposed sheetrock. There were 9 residents sitting in the dining room during the observation.During an observation, in the presence of the Director of Maintenance, on 06/09/2026 at 1:45 PM, the floor grout in unit 2 South shower rooms was soiled, and the privacy curtains were ripped.During an observation, in the presence of the Director of Maintenance, on 06/09/2026 at 1:50 PM, unit 3 South resident bathroom toilet seat and the bathroom floor were observed with dried, brown substance. The bathroom had a foul odor. The Director of Maintenance identified the dried brown substance as feces. Ripped toilet paper, three empty water cups, and three surgical gloves were observed on the bathroom floor. The two resident shower rooms on the third floor were observed with ripped shower curtains, and soiled tile floor grout. The third-floor day/dining room walls were ripped with exposed sheetrock and peeled wallpaper.During an interview on 06/09/2026 at 02:00 PM, Registered Nurse #4 stated the Environmental Services staff and the Administrator were aware of the physical condition of units 2 North and 2 South. Registered Nurse #4 stated there is a maintenance logbook to request repairs, but they did not document the conditions because the maintenance staff were aware.During an interview on 06/11/2026 at 10:05 AM, Houskeeper#1 stated they observe feces in the resident bathroom at least once a week and they clean it right away. Houskeeper #1 stated they must replace the ripped shower curtains. Houskeeper #1 stated the grout in the shower rooms cannot be washed and it needed to be replaced.During an observation, in the presence of the Corporate Director of Maintenance, on 06/11/2026 at 10:30 AM, the 3 North resident bathroom was missing wall tiles, and some were partially ripped. There was a foul odor in the resident bathroom. The 3 South hallway was observed with peeling wallpaper. The Corporate Director of Maintenance stated that the condition of the bathroom was not acceptable, and they will get it fixed.During an interview on 06/11/2026 at 10:40 AM, Housekeeper #2 stated that unit 3 South resident bathrooms always have feces on the toilet seat or on the floor despite daily cleaning. Housekeeper #2 stated the grout needs to be replaced because they could not remove the black discoloration when they attempted to clean it yesterday (06/10/2026). Housekeeper #2 stated they did not know how long the shower curtains were in disrepair and that they would now replace them.During an interview on 06/11/2026 at 12:21 PM, the Director of Maintenance stated there are ongoing constructions throughout the facility and they were aware of the environmental issues on the second and third floor including the ripped sheetrock and peeled wallpaper. The Director of Maintenance stated that unit 3 South has confused residents and that may be the contributing factor that the bathrooms in that unit sometimes have feces. They stated they will fix grouts in the bathrooms and the shower rooms. The Director of Maintenance stated it was not safe for the residents to use the bathroom with missing wall tiles in unit 3 North. The construction crew should have closed residents' access to the bathroom; however, they may have forgotten. The Director of Maintenance stated the facility was in the process of renovating the building because it is an old building and the construction was started approximately six months ago.During interview on 06/11/2026 at 02:46 PM, the Administrator stated the third-floor resident bathroom with missing tiles should not be accessible for residents' use. The Administrator stated that the facility was in the process of renovating the building and once the work is completed the residents will have a clean and homelike environment. 10 New York Code Rules and Regulations 415.5(h)(2)

Based on record review and staff interviews during the Recertification Survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure that residents' drug regimens were free from unnecessary psychotropic medications. This was identified for one (Resident #14) of five residents reviewed for Unnecessary Medications. Specifically, Resident #14 had a Physician's Order to receive Olanzapine (an antipsychotic medication) 5 milligrams once a day from 04/16/2025 to 05/15/2025. On 05/16/2025, the Physician lowered the resident's Olanzapine dose to 2.5 milligrams once a day. On 06/04/2025, the facility changed its Electronic Medical Record (EMR) to another vendor company. Resident #14's Olanzapine order was inadvertently reverted to 5 milligrams of Olanzapine daily without the consent or knowledge of the resident or the resident's Physician.The finding is:The facility's policy titled Psychoactive Medications, last reviewed on 03/06/2025, documented the Psychiatrist will attempt to reduce psychotropic medications in accordance with regulatory requirements for Gradual Dose Reduction as stipulated by the Centers for Medicare & Medicaid Services. The Primary Physician will review the recommendations made by the Psychiatrist and incorporate them into the medical record.Resident #14 had diagnoses that include Schizophrenia and Anxiety Disorder. The significant change Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three (3), which indicated the resident had severely impaired cognitive skills for daily decision making. The resident received an antipsychotic medication in the last seven (7) days.The readmission Physician's Order in the old Electronic Medical Record system dated 04/16/2025 documented for the resident to receive Olanzapine 5 milligram tablet, give one tablet by oral route once daily for Schizophrenia, and Sertraline (an antidepressant medication) 25 milligram tablet, give 1 tablet by oral route once daily for Anxiety Disorder. The old Electronic Medical Record (EMR) system Medication Administration Record (MAR) for April 2025 documented the resident received Olanzapine 5 milligram tablet by oral route once daily for Schizophrenia from 04/17/2025 to 04/30/2025. The old Electronic Medical Record (EMR) system Medication Administration Record (MAR) for May 2025 documented the resident received Olanzapine 5 milligram tablet by oral route once daily for Schizophrenia from 05/01/2025 to 05/15/2025. The Psychiatric Consultation dated 05/15/2025 documented the plan/recommendation was to lower the resident's Olanzapine to 2.5 milligrams once daily in the evening. The Physician's Monthly Progress Note dated 05/16/2025 documented the resident was seen by the Psychiatrist on 05/15/2025 for Mood Disorder and Neurocognitive Disorder with Agitation. The plan/recommendation was to lower the resident's Olanzapine to 2.5 milligrams once daily in the evening. The Physician's Order in the old Electronic Medical Record system dated 05/16/2025 documented to discontinue Olanzapine 5 milligrams. The Physician's Order in the old Electronic Medical Record system dated 05/16/2025 documented for the resident to receive Olanzapine 2.5 milligram tablet, give one tablet by oral route once daily every day at 5:00 PM for Schizophrenia. The old Electronic Medical Record (EMR) system Medication Administration Record (MAR) for May 2025 documented the resident received Olanzapine 2.5 milligram tablet by oral route once daily for Schizophrenia from 05/16/2025 to 05/31/2025. The old Electronic Medical Record (EMR) system Medication Administration Record (MAR) for June 2025 documented the resident received Olanzapine 2.5 milligram tablet by oral route once daily for Schizophrenia from 06/01/2025 to 06/03/2025.The Physician's Order in the new Electronic Medical Record system dated 06/04/2025, documented for the resident to receive Olanzapine 5 milligram tablet, give one tablet by oral route in the evening.The Physician's Monthly Progress Note dated 06/16/2025 documented the resident was seen by the Psychiatrist on 05/15/2025 for Mood Disorder and Neurocognitive Disorder with Agitation. The plan/recommendation was to lower the resident's Olanzapine to 2.5 milligrams once daily in the evening. The new Electronic Medical Record system Medication Administration Record (MAR) for June 2025, documented the resident received Olanzapine 5 milligram tablet by oral route in the evening from 06/04/2025 to 06/30/2025. The Physician's Monthly Progress Note dated 07/15/2025 documented the resident was seen by the Psychiatrist on 05/15/2025 for Mood and Neurocognitive Disorder with Agitation. The plan/recommendation was to lower the resident's Olanzapine to 2.5 milligrams once daily in the evening. The new Electronic Medical Record (EMR) system, Medication Administration Record for July 2025, documented the resident received Olanzapine 5 milligram tablet by oral route in the evening from 07/01/2025 to 07/29/2025. During an interview on 08/01/2025 at 10:30 AM, the Pharmacy Electronic Medical Record Specialist #1 stated all the facility's Pharmacy Orders were electronically moved from the previously used Electronic Medical Record system to a new Electronic Medical Record system on 05/14/2025; however, the new system went live on 06/04/2025. Resident #14's Olanzapine 5 milligram Physician's Order that was in place on 05/14/2025 was also moved to the new system. The Pharmacy Electronic Medical Record Specialist #1 stated that someone from the facility should have manually entered the order for the 2.5 milligrams of Olanzapine to the new Electronic Medical Record system on 05/16/2025 since the order was changed after the data was transferred to the new system on 05/14/2025. During an interview on 08/01/2025 at 11:10 AM, Primary Physician #1 stated they were not aware the resident was receiving the higher dose of Olanzapine 5 milligrams instead of Olanzapine 2.5 milligrams. Primary Physician #1 stated the resident should have received 2.5 milligrams of Olanzapine, and it was never their (Primary Physician #1's) intention for the resident to go back to the higher dosage. During an interview on 08/01/2025 at 11:20 AM, the Administrator stated they were not monitoring how the Pharmacy Orders were carried over when the facility changed from one Electronic Medical Record system to another. The Administrator stated they were only monitoring that staff attended educational meetings to learn how to use the new Electronic Medical Record system. During an interview on 08/04/2025 at 3:00 PM, Licensed Practical Nurse #5 stated they did not double-check if the Physician Orders for Resident #14's Olanzapine were transferred accurately from the old Electronic Medical Record system to the new Electronic Medical Record. Licensed Practical Nurse #5 stated they dispensed whatever Olanzapine dosage was indicated in the new Electronic Medical Record System Medication Administration Record.During an interview on 08/05/2025 at 11:50 AM, the Director of Nursing stated Licensed Practical Nurse #5 should have clarified the order for the Olanzapine before administering the medication.10NYCRR 415.4(a)(1) and 415.3(d)(1)(vii)

Based on observations, record review, and interviews during the Recertification Survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure that there was sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was identified on one (1) (Unit 4 South) of six (6) units reviewed for the Sufficient Nursing Staffing Task. Specifically, the Centers for Medicare and Medicaid Services Payroll-Based Journal Staffing Data Report for Fiscal Year Quarter Two 2025 (January 1st-March 31st) indicated that the facility had a one (1)-star staffing rating. Additionally, there were multiple occasions when the facility had insufficient Licensed Practical Nurses assigned to Unit 4 South, as specified on the Facility Assessment. The finding is:The Centers for Medicare and Medicaid Services Payroll-Based Journal Staffing Data Report for Fiscal Year Quarter Two 2025 (January 1st-March 31st) documented the facility triggered for the Metric of One Star Staffing Rating.The Facility assessment dated [DATE], last reviewed and/or updated on 06/2025, documented that the facility had a 251-bed capacity with an average daily census of 225.The Administrator provided an updated Facility Assessment on 08/01/2025, which indicated Unit 4 South had a 41-bed capacity and required two Licensed Practical Nurses during the 7:00 AM-3:00 PM shift.A review of the Facility Unit Census logs from 01/05/2025 to 01/11/2025; 02/09/2025 to 02/15/2025; 03/16/2025 to 03/22/2025, and 07/28/2025 to 08/04/2025 revealed resident census on Unit 4 South was between 37 and 41 residents.A review of the 7:00 AM-3:00 PM shift schedule for Unit 4 South from 01/05/2025 to 01/11/2025 indicated the following:- On 01/06/2025, 01/07/2025, 01/08/2025, 01/09/2025, and 01/10/2025, there was one (1) Licensed Practical Nurse assigned to Unit 4 South with a census of 38 residents.A review of the 7:00 AM-3:00 PM shift schedule for Unit 4 South from 02/09/2025 to 02/15/2025 indicated the following:- On 02/10/2025 and 02/11/2025, there was one (1) Licensed Practical Nurse assigned to Unit 4 South with a census of 40 residents.- On 02/12/2025, 02/13/2025, and 02/14/2025, there was one (1) Licensed Practical Nurse assigned to Unit 4 South with a census of 41 residents. A review of the 7:00 AM-3:00 PM shift schedule on Unit 4 South from 03/16/2025 to 03/22/2025 indicated the following:- On 03/17/2025 and 03/19/2025, there was one (1) Licensed Practical Nurse assigned to Unit 4 South with a census of 37 residents.- On 03/16/2025, 03/20/2025, there was one (1) Licensed Practical Nurse assigned to Unit 4 South with a census of 38 residents.- On 03/21/2025, there was one (1) Licensed Practical Nurse assigned to Unit 4 South with a census of 38 residents.A review of the 7:00 AM-3:00 PM shift schedule on Unit 4 South from 07/28/2025 to 08/4/2025 indicated the following:- On 07/28/2025 and 07/30/2025, there was one (1) Licensed Practical Nurse assigned to Unit 4 South with a census of 39 residents.- On 08/01/2025, there was one (1) Licensed Practical Nurse assigned to Unit 4 South with a census of 40 residents.Resident #133 was admitted with diagnoses of Type 2 Diabetes Mellitus, Hypertension, and Major Depressive Disorder. The Annual Minimum Data Set assessment dated [DATE] documented that Resident #133 had a Brief Interview for Mental Status score of 15, which indicated the resident had intact cognition. During an interview on 07/28/2025 at 10:35 AM, Resident #133 stated that they had not received their morning medications today.During the Medication Administration task observation with Licensed Practical Nurse #8 on 07/28/2025 from 11:07 AM to 11:30 AM, Licensed Practical Nurse # 8 administered Resident #133's 10:00 AM medications at 11:30 AM, which was 30 minutes beyond the facility's required time frame. During an interview immediately after the observation on 07/28/2025, Licensed Practical Nurse #8 stated they were the regularly assigned charge nurse on Unit 4 South. Licensed Practical Nurse #8 stated there were usually two Licensed Practical Nurses assigned to each of the 4th-floor units (4 South and 4 North). Licensed Practical Nurse #8 stated that both the assigned Licensed Practical Nurses were responsible for administering medications. Licensed Practical Nurse #8 stated today (07/28/2025) they were alone on the unit, and the second Licensed Practical Nurse (# 2), who usually worked on Unit 4 South, was assigned to work alone on Unit 4 North. Licensed Practical Nurse #8 stated they were passing medications and providing treatments by themselves and therefore were not able to administer Resident #133's morning medications on time. During an interview on 07/28/2025 at 11:40 AM, Licensed Practical Nurse #2 stated that they regularly worked with Licensed Practical Nurse #8 on Unit 4 South and were reassigned to Unit 4 North today (07/28/2025) due to a call-out. Licensed Practical Nurse #2 stated there should be two Licensed Practical Nurses assigned to each unit (4 South and 4 North).During an interview on 07/29/2025 at 12:22 PM, the Staffing Coordinator stated they have worked as a Staffing Coordinator for six months at the facility. The Staffing Coordinator stated that based on the par levels, there should be two Licensed Practical Nurses assigned to each resident unit during the day shift (7:00 AM-3:00 PM) on weekdays (Monday to Friday).During an interview on 07/30/2025 at 10:37 AM, Registered Nurse #1stated there should be two Licensed Practical Nurses on each unit on the 4th floor. Registered Nurse #1 stated there was one Licensed Practical Nurse on each unit (4 South and 4 North) today (07/30/2025). Registered Nurse #1 stated that they had to assist with dining room monitoring today, which would normally be the Licensed Practical Nurse's responsibility.During a re-interview on 07/30/2025 at 11:47 AM, Licensed Practical Nurse #8 stated that they were working alone on unit 4 South today. Licensed Practical Nurse #8 stated that Registered Nurse #1 had to assist them with Dining room monitoring so they could give medications to residents on time. Licensed Practical Nurse #8 stated it is overwhelming when they have to give medication and treatment all by themselves. During a re-interview on 08/05/2025 at 9:56 AM, the Staffing Coordinator stated they were not able to schedule Licensed Practical Nurses during the day shift (7:00 AM-3:00 PM) on weekdays, according to the par levels (provided to them by the Corporate staff), due to a shortage of available Licensed Practical Nurses. The Staffing Coordinator stated that the Director of Nursing Services, the Administrator, and the Human Resources personnel were aware of the issue, and they (the Staffing Coordinator) were told, We are working on it. The Staffing Coordinator stated that the 4th floor units (4 South and 4 North) only had one Licensed Practical Nurse assigned to each unit on 07/28/2025 and 07/30/2025 due to staff vacation and call-out. During an interview on 08/05/2025 at 11:22 AM, the Director of Nursing Services stated they were not familiar with the facility's overall nursing staffing needs; however, each nursing unit should have two Licensed Practical Nurses assigned on the day shift during the weekdays as per the Facility Assessment.During an interview on 08/05/2025 at 11:50 AM, the Administrator stated each resident unit should have two Licensed Practical Nurses assigned on the day shift during the weekdays as per the Facility Assessment. The Administrator stated they submitted the Payroll-Based Journal Staffing Data Report, but did not know that the facility triggered the Metric of One Star Staffing Rating. 10 NYCRR 415.13(a)(1)(i-iii)

Based on observations, record review, and interviews during the Recertification Survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure that drugs and biologicals were stored in a locked compartment. This was identified for one (1) (Resident #208) of eight (8) residents reviewed for Accidents. Specifically, a tube of unlabeled Hydrocortisone (a steroid cream to treat inflammation and allergies) cream 0.5 percent, and a labeled Triamcinolone (a prescription steroid cream to treat allergies and inflammation), 0.1 percent, cream were observed on Resident #208's overbed table. Additionally, there was a labeled Chlorhexidine Gluconate (anti-microbial mouthwash to treat inflammation of the gums) 0.12 percent bottle, a labeled Fluticasone (nasal spray for allergy) nasal spray, a labeled Patadine (eye drop for allergy) 0.1 percent eye drop bottle, and an unlabeled Refresh (eye lubricant) eye drop bottle on Resident #208's nightstand. There was no Nursing staff in the vicinity of Resident #208's room. Resident #208 was not assessed to self-administer their medications. The finding is:The facility's undated policy titled Storage of Drugs documented that all medications and other drugs, including treatment items, shall be stored in a locked cabinet inaccessible to residents and visitors. Only Registered Nurses, Licensed Practical Nurses, the Consultant Pharmacist, Attending Physicians, and the Medical Director are authorized to have access to the keys of locked medication storage cabinets and carts. Resident #208 was admitted with diagnoses including Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, and Hypertension. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated that Resident #208 had intact cognition. The Quarterly Minimum Data Set assessment documented that Resident #208's vision was adequate. A Physician's Order dated 01/08/2025 and renewed on 06/04/2025 documented Flonase Allergy Relief 50 micrograms nasal spray for each nostril as needed. A Physician's Order dated 2/14/2025 documented Peridex (Chlorhexidine Gluconate-antiseptic mouthwash) 0.12 percent mouthwash, place 15 milliliters in the mouth by mucous membrane route twice a day, swish for 30 seconds, then spit out. A Physician's Order dated 03/24/2025 Olopatadine (Patadine) Hydrochloride ophthalmic solution (anti-allergy) 0.1 percent, one drop in both eyes twice a day. A Physician's Order dated 05/09/2025 documented Triamcinolone acetonide (cortisone cream) 0.1 percent topical ointment. Apply one applicator by the topical route twice a day for four weeks to the back of both elbows. A review of Resident #208's electronic medical record revealed that Resident #208 did not have a Physician Order for the Hydrocortisone 0.5 percent cream or the Refresh eye drops. A review of Resident #208's Electronic Medical Record revealed that Resident #208 did not have an assessment to self-administer any of their medications. A Comprehensive Care Plan (CCP) titled Respiratory Disorder/Chronic Obstructive Pulmonary Disease, dated 01/2/2022, documented interventions including administering medications as per the Physician's Orders and monitoring respiratory status, lung sounds, and shortness of breath. During an observation on 07/28/2025 at 10:40 AM, Resident #208 was observed with a tube of unlabeled Hydrocortisone (a steroid cream to treat inflammation and allergies) cream 0.5 percent, a labeled Triamcinolone (a prescription steroid cream to treat allergies and inflammation) 0.1 percent cream on Resident #208's overbed table. Additionally, there was a labeled Chlorhexidine Gluconate (anti-microbial mouthwash to treat inflammation of the gums) 0.12 percent bottle, a labeled Fluticasone (nasal spray for allergy) nasal spray, a labeled Patadine (eye drop for allergy) 0.1 percent eye drop bottle, and an unlabeled Refresh (eye lubricant) eye drop bottle on Resident #208's nightstand. There was no Nursing staff in the vicinity of Resident #208's room.During an interview on 07/28/2025 at 10:45 AM, Licensed Practical Nurse #2, Medication Nurse, stated they had already administered the medications to Resident #208 outside Resident #208's room. Licensed Practical Nurse #2 stated they did not know that Resident #208 had some of their medications in the room; otherwise, they would have removed the medications from the resident's room. During an interview on 07/28/2025 at 11:30 AM, Registered Nurse #1, the Unit Manager, stated that Resident #208 should not have any medications stored in their room. Registered Nurse #1 stated that Resident #208's medications should be stored in the medication cart. Registered Nurse #1 stated that the facility did not initiate a self-administration assessment because Resident #208 had never requested to administer their medications. During an interview on 07/29/2025 at 8:44 AM, Resident #208 stated that they did not remember if the Nurses had left the medications on their overbed table and the nightstand. Resident #208 stated they had some medications from home, but they never used those medications. Resident #208 stated that the Nurses bring the medications and supervise Resident #208 in administering the medications, particularly the mouthwash. Resident #208 stated they are capable of administering their medications but wanted the nurses to supervise. During an interview on 08/04/2025 at 8:25 AM, the Director of Nursing Services stated that the Nursing staff should not have left any medications on Resident #208's table and the nightstand. The Director of Nursing Services stated they expect all their Nursing staff to check the rooms for unattended medications and report to the Nursing Supervisors. 10NYCRR 415.18(e) (1-4)

Based on record review and interviews during the Recertification Survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure that the resident representative and Ombudsman were notified for each resident discharged from the facility. This was identified for one (Resident #241) of two residents reviewed for Discharge. Specifically, Resident #241 had a planned discharge from the facility on 04/20/2025 to another facility. There was no documented evidence that the resident's representatives and the Ombudsman were notified of the discharge.The finding is:The facility's policy titled Transfer and Discharge Planning and Documentation, effective 4/28/2025, documented notifying the resident/family/ombudsman in writing before a transfer or discharge. The unit Social Worker will be responsible for ensuring that the resident (and representative when applicable) receives written notice of any discharge. The Director of Social Work will be responsible for ensuring that the Ombudsman receives notice of all discharges. When the discharge is planned, the facility's Social Worker will send a copy of the notice to the representative of the Office of the State Long-Term Care Ombudsman as soon as practicable.Resident #241 was admitted with diagnoses including Bipolar Disorder, Depression, and Chronic Obstructive Pulmonary Disease. The 03/12/2025 admission Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact.A Comprehensive Care Plan, effective 03/05/2025, titled Discharge Planning, documented the resident's discharge status was uncertain. The resident was transferred from another facility and indicated they would like to be discharged back to the community. Resident has a PASRR (a person-centered evaluation that is completed for anyone having a serious mental illness to ensure they are properly placed in the nursing home) screen in place, and discharge was unknown at this point.A progress note written by Social Worker #1, dated 04/21/2025, documented that the resident inquired about returning to the former facility. A discharge note written by Social Worker #1 dated 04/30/2025 documented the resident requested to return to the former facility and was accepted by them. The resident left (to go to the requested facility) around 11:45 AM today via ambulette. Review of the medical record revealed no documented evidence that the resident's representative or the Ombudsman was notified of the discharge.During an interview on 07/31/2025 at 11:45 AM, Social Worker #1 stated that an email was sent to the Ombudsman regarding the discharge, and they would have to find the email. During an interview on 07/31/2025 at 1:10 PM, Social Work Director #1 stated there was an oversight; Resident #241's name was inadvertently removed from the list of discharges that was prepared for notification to the Ombudsman, therefore, the notification to the Ombudsman regarding Resident #241's discharge did not take place. The notification was sent out today.During a re-interview on 08/1/2025 at 9:52 AM, Social Worker #1 stated they did not notify the resident's representative of the resident's discharge to the other facility. The resident was their own representative because they were alert and oriented. The resident did not request to notify their representative. The resident had their own cellphone and was in communication with their family. Social Worker #1 stated they did not believe the resident had anyone listed in the medical record as their contact on their contact list.A review of the resident's contact list in the electronic medical record revealed that there were three family members on the list.During a re-interview on 08/01/2025 at 10:30 AM, Social Work Director #1 stated that if a resident did not want the facility to call their family regarding a discharge, that should be documented. In general, the facility would call the resident representative unless the alert resident specifically requested not to notify their representative.10NYCRR 415.3

Based on observation, record review, and interviews during the Recertification Survey and Abbreviated Survey (Complaint #697429) initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure resident rights to be free from abuse. This was identified for two (Resident #83 and Resident #98) of three residents reviewed for Abuse. Specifically, on 04/25/2025, Resident #83, with intact cognition, was using a common bathroom. Resident #98, with severely impaired cognition, attempted to enter the same bathroom, and Resident #83 told Resident #98 to get out. Resident #98 made a fist and swung at Resident #83. Resident #83, in turn, punched Resident #98 in the right eye; Resident #98 was sent to the emergency room for evaluation for complained of pain and redness in the right eye.The finding is:The facility's Abuse Prevention Policy, dated 9/19/2022 and revised on 2/3/2025, documented to provide a safe resident environment that protects residents from abuse, including verbal, mental, sexual, or physical abuse. This includes staff-to-resident abuse of any type, resident-to-resident abuse of any type, and visitor-to-resident abuse of any type. Physical abuse is inappropriate physical contact resulting in injury or likely to harm a resident. Physical abuse includes, but is not limited to, hitting, slapping, punching, biting, and kicking. The policy defined willful as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.Resident #83 was admitted to the facility with diagnoses of Diabetes, Epilepsy (a disorder in which nerve cell activity in the brain is disturbed, causing seizures), and Metabolic Encephalopathy (a brain disorder caused by a chemical imbalance). The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 15, which indicated Resident #83 had intact cognition. The Minimum Data Set documented that Resident #83 did not exhibit any behaviors.A Comprehensive Care Plan titled Risk for Abuse, dated 04/24/2023 and updated on 04/24/2025, with interventions including observing changes in customary routines, keeping the resident away from other peers whenever possible, and staff to observe during rounds and care.Resident #98 was admitted to the facility with diagnoses of Diabetes, Alzheimer's, and Hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of seven (7), which indicated Resident #98 had severe cognitive impairment. The Quarterly Minimum Data Set assessment documented that Resident #98 did not exhibit any behaviors.A review of the Abuse Risk assessment dated [DATE] revealed that Resident #98 had behavior factors of being verbally disruptive, repetitive calling out, and had a history of being aggressive to peers.A Comprehensive Care Plan titled Behaviors, as evidenced by an altercation dated 04/25/2025, documented interventions including administering medications as ordered, observing for changes in behaviors, and redirecting the resident to an alternative environment. The Resident-to-Resident Altercation Report dated 04/25/2025 documented that Resident # 83 was in the common bathroom, by the Activity Room, when Resident #98 went in [the same bathroom] to wash their hands. Resident #83 told Resident #98 to get out, but Resident #98 insisted on coming in. Resident #98 then swung their fist, tapping Resident #83's right side of the chin. Resident #83 then punched Resident #98's right eye. The Recreation Aide (#1) immediately intervened and separated both residents. The investigation summary concluded there was no evidence of abuse, neglect, or mistreatment. The incident was unpredictable. Resident #98's insights and judgment were poor. The facility will continue to offer resident #98 diversional activities and redirection.The Accident and Incident report dated 04/25/2025 for Resident #83 documented a statement from Resident #83 indicating stated the resident was using the bathroom, and Resident #98 opened the bathroom door. Resident #83 stated they told Resident #98 to leave, but Resident #98 refused. Resident #83 stated they hit Resident #98.The Accident and Incident report dated 04/25/2025 for Resident #98 documented a statement from Resident #98 indicating the resident went to the bathroom, but Resident #83 was inside, and they (Resident #98) told Resident #83 to leave. Resident #98 stated that Resident #83 punched them (Resident #98) in the face.During an interview on 07/29/2025 at 10:30 AM, Resident #83 stated they remembered the altercation with Resident #98. Resident #83 stated they were using the bathroom first and needed privacy, and Resident #98 did not acknowledge their request to wait until they were finished using the bathroom. Resident #83 stated they punched Resident #98 to stop them (Resident #98) from coming into the bathroom.During an interview on 07/31/2025 at 8:47 AM, the Recreation Aide #1 stated that they went into the bathroom when a resident reported to them that something was going on in the bathroom. Resident #83 and Resident #98 were already separated. The Recreation Aide stated that they immediately reported the incident to Registered Nurse #2. Recreation Aide #1 stated Resident #83 participates in most activities. Resident #98 would join activities at times, and a staff member would accompany Resident #98 from the Unit to the Activity Room because Resident #98 needed redirection. The Recreation Aide #1stated that Resident #98 often sat next to them (Recreation Aide #1) during activity because the resident needed assistance with participation.During an interview on 08/01/2025 at 12:27 PM, Registered Nurse #2, Unit Manager, stated they were called to assess Resident #83 and Resident #98 after the Recreation Aide had reported the incident on 04/25/2025. Registered Nurse #2 stated that Resident #98 had redness around the right eye and complained of pain. Resident #98's Physician ordered to send Resident #98 to the emergency room for evaluation. Resident #83 told Registered Nurse #2 that Resident #98 would not leave the bathroom, so they punched Resident #98 to get them out.During an interview on 08/05/2025 at 11:17 AM, the Director of Nursing Services stated that they were not the Director of Nursing at the time of the incident. The Director of Nursing Services stated that they had two staff members in the Activity Room to supervise the Activity, but there was no staff in the lobby leading to the bathroom where the incident occurred between Resident #83 and Resident #98. The Director of Nursing Services stated that Residents with cognitive impairment should have been supervised more because they are at risk for abuse.10 NYCRR 415.4(b)(1)(i)

Based on observations, record review, and interviews during the Recertification Survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure it developed and implemented a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. This was identified for one (1) (Resident #65) of two (2) residents reviewed for Rehabilitation and one (1) (Resident #11) of two (2) residents reviewed for Positioning/Mobility. Specifically, 1) Resident #65 had a right above-the-knee amputation and was in the process of getting a prosthetic limb device. There was no comprehensive care plan regarding the amputation, including the status of the prosthetic device; and 2) Resident #11 had a Physician's order to apply a hand roll at all times or as tolerated. On 07/28/2025 and 08/01/2025, the resident was observed without any hand roll to the right hand. The findings are: The facility's policy titled Comprehensive Care Planning, last reviewed 08/01/2025, documented that each resident will have a comprehensive person-centered care plan developed that is in compliance with Federal and State regulations. The facility will establish an interdisciplinary team care planning process to ensure that resident care and treatment are planned appropriately for the resident's needs and condition, impairment, disability, or disease process in a timely, systematic, and comprehensive manner. The interdisciplinary team will address individualized resident needs to include medical, physical, psychosocial, cognitive, functional, activities, spiritual, cultural, and communication needs. 1) Resident #65 was admitted with diagnoses including Diabetes Mellitus, Bipolar Disorder, and Acquired Absence of Limb (amputation). The 03/12/2025 admission Minimum Data Set Assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact and had a limited range of motion on one side of the lower extremities. The Physician's admission Evaluation Note dated 03/07/2025 documented that the resident had a right above-knee amputation. Comprehensive Care Plans titled Resident has Limited Physical Mobility Related to Weakness, initiated on 06/05/2025, and Fall Prevention, initiated 06/19/2025, did not document that the resident had a right above-knee amputation. During an interview on 07/29/2025 at 10:12 AM, Resident #65 stated they had the right above-knee amputation approximately one year ago and were told that upon admission to this facility, they would be fitted for a prosthetic leg. The resident stated they were unsure about the status of the plan and would like to get the prosthetic so that they could walk again. During an interview on 07/312025 at 11:07 AM, the Rehabilitation Department Director #1 stated that the Rehabilitation Department would not create a care plan until the device is obtained from the orthotic provider. They stated that the communications with the orthotic provider are not documented in the medical record but are documented in a book in the Rehabilitation Department, and a care plan is not developed until the prosthetic device is delivered. A letter provided from the Prosthetic Lab to the facility dated 07/31/2025 documented: Unfortunately, very few prosthetic components exist that will accommodate the patient's weight of 380 pounds. Both the knee and the foot (of the prosthetic) are affected by these criteria. An additional hurdle was to ensure that this componentry would be covered by the insurance carrier. We were also apprised that the patient had an existing prosthesis, and we were trying to determine the date on which it was manufactured, as there are restrictions on frequency for a new device. One of the problems we have also encountered is that the insurance policy that the patient possesses does not cover the cost of the specialized components necessary to make the prosthesis according to the current weight. We have casted, fabricated, and fit check sockets since we have encountered the patient to attempt to expedite the process. Once we receive authorization from the insurance company, fabrication and delivery will happen in a timely manner. During a re-interview on 08/04/2025 at 2:59 PM, Rehabilitation Department Director #1 stated the efforts to obtain the prosthesis are in process, but it is difficult to make the prosthesis for Resident #65, due to the resident's weight. The resident was last seen by a prosthetist in May 2025. The Rehabilitation Department does not make a care plan until the prosthesis is in place. The Rehabilitation Department develops the care plan for the prosthesis, and the Nursing staff is responsible for developing the care plan for the amputation. During a re-interview on 08/05/2025 at 9:45 AM, Resident #65 was in bed, and their old orthotic device was on the floor. The resident stated the device did not fit well, and when they put on the device, it was uncomfortable. The resident stated they want a new prosthesis so they can start walking again. During an interview on 08/05/2025 at 9:47 AM, Registered Nurse Wound Care Nurse #1 (and acting supervisor on the unit) stated that care plans should be initiated on admission by the admission nurse. All licensed nurses can generate care plans based on the resident's needs. The care plan for the amputation should have been in place because the amputation has a significant effect on the resident's life. During an interview on 08/05/2025 at 10:21 AM, the Director of Nursing Services stated there should be a care plan in place for the amputation, especially when the resident is waiting for a prosthesis to be developed. The care plan should address the progress of the prosthesis development. 2) Resident #11 was admitted with the diagnoses including Central Pain Syndrome (a chronic pain condition caused by damage to the central nervous system), Diabetes Mellitus, and Pyridoxine (Vitamin B6) Deficiency. The Quarterly Minimum Data Set assessment dated [DATE] indicated a Brief Interview for Mental Status was not conducted because the resident's cognitive skills for daily decision making were severely impaired. The minimum data set assessment documented the resident had impairment to the range of motion of both upper extremities. A Physician's Order dated 07/03/2025 documented to apply a hand roll to the right hand at all times or as tolerated by the resident. Remove as scheduled and for Activities of Daily Living Care, restorative nursing program, or functional maintenance program, and check skin integrity. A comprehensive care plan titled Activities of Daily Living, last revised on 07/22/2025, documented interventions including applying a hand roll to the right hand at all times or as tolerated by the resident. Remove as scheduled and for Activities of Daily Living Care, restorative nursing program, or functional maintenance program, and check skin integrity. The Kardex (a summary of a resident's needs and care instructions) for Resident #11 documented to apply a hand roll to the right hand at all times or as tolerated by the resident. Remove as scheduled and for Activities of Daily Living Care, Restorative nursing program, or functional maintenance program, and check skin integrity. During an observation on 07/28/2025 at 11:12, Resident #11 was observed lying in bed with no hand roll to the right hand. During a subsequent observation on 08/01/2025 at 10:44 AM, the resident was observed lying in bed in their room with no hand roll applied to the right hand. During an interview on 08/01/2025 at 10:51 AM, Certified Nursing Assistant #8, the regularly assigned Certified Nursing Assistant for Resident #11, stated that the resident does not use a hand roll and is very resistant when staff tries to touch or provide care to the resident's hands. Certified Nursing Assistant #8 stated they could not recall ever seeing a hand roll in the resident's room. Certified Nursing Assistant #8 stated there were no instructions for the use of a hand roll documented in the Certified Nursing Assistant Accountability Record. During an interview on 8/1/2025 at 12:43 PM, Licensed Practical Nurse #7, the charge nurse, stated Resident #11 had an order to apply a hand roll to the right hand. Licensed Practical Nurse #7 stated at times they would apply a rolled gauze to the resident's right hand; however, they did not instruct the Certified Nursing Assistants to do the same, as they (Licensed Practical Nurse #7) were responsible for applying the hand roll. Licensed Practical Nurse #7 stated that if a hand roll was missing, they were supposed to notify the Rehabilitation department, but they usually get so busy on the unit that they lost track of it. Licensed Practical Nurse #7 further stated the hand roll should have been applied to Resident #11's right hand as ordered. During an interview on 8/1/2025 at 1:28 PM, the Occupational Therapist stated they had treated Resident #11 several months ago, and Resident #11 started with a rigid joint to the right hand and had low potential for any significant improvements. The Occupational therapist stated they trialed several devices for the resident, including hand splints and palm guards, but ultimately the resident was only able to tolerate a hand roll. The Occupational Therapist stated they were not aware of the missing hand roll for Resident #11. During an interview on 08/05/2025 at 9:45 AM, the Director of Nursing Services stated that the nursing staff should have ensured that a device was in place as per the Physician's orders. The Director of Nursing Services stated that nursing staff should have followed the order and instructions for Resident #11's hand roll. 10 NYCRR 415.11(c)(1)

Based on observations, record review, and staff interviews during the Recertification Survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure that a resident received treatment and care in accordance with professional standards of practice. This was identified for one (1) (Resident #232) of three (3) residents reviewed for Choices. Specifically, Resident #232 returned to the facility from the hospital on [DATE] after a Pacemaker (a small implanted medical device that helps regulate a slow heart rate by sending electrical impulses to the heart) Implantation. Resident #232 had a recommendation from the hospital for a follow-up consultation with an Electrophysiologist (a Cardiologist who specializes in diagnosing and treating heart rhythm disorders) after three weeks. There was no documented evidence that a follow-up consultation with the Electrophysiologist was scheduled; the direct care nurses were not aware that the resident needed to be connected to the Pacemaker transmitter; no interventions were put in place to monitor the pacemaker site; and there was no physician's order for Pacemaker monitoring until 07/29/2025. The finding is:The facility's policy titled Pacemaker and Internal Defibrillator Monitoring, last revised on 06/2025, documented that upon admission, the Nurse will review the resident's medical history and ascertain the presence of a Permanent Pacemaker (PPM) for inclusion in the resident's medical record. Nursing will care plan for the appropriate Pacemaker as indicated. The Primary Physician will order a Pacemaker battery check regularly. Pacemaker checks will be ordered by the Physician as recommended by the Electrophysiologist/Cardiologist, and these will be done outside the facility at an Arrhythmia Center (specializing in heart rhythm disorders). The facility's policy titled Consultants, last revised on 02/2025, documented that the Charge Nurse in the Unit is responsible for informing the Physician of the Consultant's recommendations. It is expected that all consults will be completed in 30 days, and the Physician will be notified in situations when the consult is not possible. Any difficulties in obtaining consults and /or following up with recommendations must be brought to the attention of the Director of Nursing and the Medical Director. The facility's policy titled Comprehensive Care Planning, last revised on 05/10/2025, documented that the care plan for each resident is revised when appropriate to reflect the resident's current needs based on evaluation and episodic changes to include but not limited to; significant changes in the resident's status, response to care and treatment and changes in activities of daily living function. Resident # 232 was admitted with diagnoses including Left Bundle Branch Block (a delay or blockage of electrical impulses to the left side of the heart), Congestive Heart Failure, and Hypertension. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of three (3), which indicated Resident #232 had severe cognitive impairment. The Minimum Data Set (MDS) assessment documented that Resident # 232 had an Active Diagnosis of Presence of a Cardiac Pacemaker. A review of Resident #232's Pacemaker transmitter device manual documented that the Pacemaker transmitter device must be placed on a sturdy, flat, hard surface, including a nightstand. The Pacemaker transmitter manual documented that scheduled sessions and device checks occur automatically if requested by an Arrhythmia Clinic. An unscheduled session sends data manually as per the Clinician's instructions.The Progress Note dated 04/13/2025 documented that Resident #232 was readmitted from the Hospital at 06:52 PM. Resident #232's skin assessment documented that Resident #232 had a dressing on the left chest wall after a Pacemaker Implantation.The hospital Discharge summary dated [DATE] documented that Resident #232 required a follow-up consultation with the Electrophysiologist in three (3) weeks. A review of Resident#232's electronic medical record revealed no evidence of the Pacemaker site monitoring or that the Pacemaker transmitter was set up, until 07/29/2025.A Comprehensive Care Plan titled Cardiovascular Alteration, dated 01/29/2025 and revised on 04/13/2025, documented that Resident #232 had Congestive Heart Failure, Hypertension, and Hyperlipidemia (high cholesterol) with interventions including monitoring vital signs and oxygen saturation as necessary, Cardiology consult, and monitoring laboratory values.A review of Resident #232's Comprehensive Care Plan did not indicate that Resident #232 had a Pacemaker until 07/30/2025.During an observation on 07/28/2025 at 9:54 AM, Resident #232 was lying in bed. A sealed box of a Pacemaker transmitter device was noted on the floor next to Resident #232's bed. Resident #232 was unable to identify the contents of the box.During a second observation on 07/29/2025 at 9:00 AM, Resident #232 was lying in bed. A sealed box of a Pacemaker transmitter device was on the floor next to Resident #232's bed. Registered Nurse #1, the Unit Supervisor, came into the room and identified that the box next to Resident #232's bed was a Pacemaker transmitter device.During an interview on 07/29/2025 at 10:59 AM, Registered Nurse #1 stated they were the covering Unit Manager as the regularly assigned Unit Manager was on vacation. Registered Nurse #1 stated they knew that Resident #232 had a Pacemaker but did not know that a Pacemaker transmitter was to be set up to monitor the resident's cardiac rhythm. Registered Nurse #1 stated that the Unit Manager was responsible for setting up the Pacemaker transmitter.During a subsequent interview on 07/31/2025 at 10:00 AM, Registered Nurse #1 stated Resident #232's Discharge Summary from the Hospital indicated that the resident should have had a follow-up consultation with the Electrophysiologist within three weeks of when the Pacemaker was first implanted. Registered Nurse #1 stated they did not know why the consultation visit was not scheduled. Registered Nurse #1 stated they called the Arrhythmia Clinic on 07/28/2025, and the Pacemaker transmitter was set up in Resident #232's room on 07/29/2025. Registered Nurse #1 stated they did not know why there was no order for monitoring the Pacemaker. Registered Nurse #1 stated that the Nurse should have revised the care plan to reflect the Pacemaker for Resident #232.During an interview on 07/31/2025 at 11:00 AM, Licensed Practical Nurse #2 stated they only administer medications; Resident #232 often refuses their medications, and they seldom go to Resident #232's room. Licensed Practical Nurse #2 stated they did not know Resident #232 had a Pacemaker transmitter box in their room and that the Pacemaker transmitter should have been set up for the Arrhythmia clinic to remotely monitor the resident's cardiac activities.During an interview on 07/31/2025 at 11:44 AM, Physician Assistant #1 at the Arrhythmia Clinic stated they started receiving transmission from Resident #232's Pacemaker on 07/29/2025. Physician Assistant #1 stated that ideally, the Pacemaker transmitter should have been set up in April 2025, when the resident returned from the Hospital, to ensure that the Pacemaker was functioning. Physician Assistant #1 stated that Resident #232 needed an Electrophysiologist consult at the Arrhythmia Clinic as soon as possible. Physician Assistant #1 stated that Resident #232 should have had a consult two to three weeks after their discharge from the Hospital.During a subsequent interview on 08/01/2025 at 11:03 AM, Physician #3 stated the facility should have followed up on Resident #232's consultation with the Electrophysiologist to evaluate the Pacemaker treatment and monitoring.During an interview on 08/04/2025 at 8:30 AM, the Director of Nursing Services stated that when Resident #232 returned from the Hospital with a Pacemaker, the care plan should have been revised, and the Pacemaker should have been added to the care plan. The Director of Nursing Services stated there should have been a Physician's Order to monitor the Pacemaker, and the follow-up consultation with the Electrophysiologist should have been arranged by the facility.10 NYCRR 415.12

Based on observation, record review, and staff interviews during the Recertification Survey initiated on 7/28/2025 and completed on 8/5/2025, the facility did not ensure that each resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences. This was identified for one (Resident #6) of two residents reviewed for Respiratory Care. Specifically, Resident #6 had a Tracheostomy (a surgical procedure where a hole is made in the windpipe (trachea) to create an opening in the neck, allowing a tube to be inserted for breathing assistance). The facility converted to a different electronic medical record company in June 2025. When this occurred, the orders for daily tracheostomy care did not carry over to the new electronic medical record, and therefore, the nurses did not document that daily tracheostomy care and suctioning were being done. In addition, the physician's order was for the resident to receive oxygen at 3 liters per minute; however, the resident was receiving 8 liters per minute during multiple observations, and there was no documented evidence that the resident's oxygen saturation status was being checked and monitored.The finding is:The facility's policy titled Care of the Resident with Tracheostomy, effective 7/30/2021, documented that Tracheostomy care and stoma (opening) care will be done each shift and as needed. Residents will be assessed for the need for suctioning. Residents with a disposable inner cannula (a removable tube within the tracheostomy that can be easily cleaned and replaced without having to remove the main tracheostomy tube) will have a new inner cannula inserted daily on the 7:00 AM-3:00 PM shift and as needed. Tracheostomy care, stoma care, and suctioning will be documented on the treatment administration record.The facility's policy titled Oxygen Therapy, effective 7/30/2021, documented that residents will be provided with oxygen therapy as ordered by the Physician. The Physician will specify the flow rate and whether the oxygen is continuous or as needed. The nurse will check the liter flow rate on the tank or concentrator and sign the treatment record each shift.Resident #6 was admitted with diagnoses including Chronic Respiratory Failure, Diabetes Mellitus, and Morbid Obesity. The 05/17/2025 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 8, indicating the resident had moderate cognitive impairment and received tracheostomy care and oxygen therapy.Review of the Physician's orders from the previous electronic medical record revealed the following:-Tracheostomy inner cannula Shiley size 6 IC75 renewed 05/30/2025,-Oxygen as needed at 3 liters per minute; the order was renewed on 05/30/2025.-Suction tracheal secretions every shift and as needed; the order was renewed on 05/30/2025.-Tracheostomy care every shift; the order was renewed on 05/30/2025.- Change the tracheostomy inner cannula daily; the order was renewed on 05/30/2025.Review of the Treatment Administration Record from the former electronic medical record revealed that the last day the nurses signed for these orders was 06/03/2025.Review of the Treatment and Medication Administration records from the new electronic medical record revealed that nurses began signing for the physician's orders on 06/04/2025 (when the new electronic medical record was rolled out); however, the orders identified above (Tracheostomy inner cannula Shiley size 6, Oxygen at 3 liters per minute, Suction tracheal secretions, Tracheostomy care, and Changing the tracheostomy inner cannula) were not signed for until 07/31/2025, indicating no documentation between 6/3/2025 and 07/31/2025.The Physician's order dated 06/06/2025 for Oxygen 3 liters per minute via tracheostomy mask as needed for Acute Respiratory Failure with Hypoxia (low oxygen level in blood) was not carried over from the previous electronic medical record to the current electronic medical record. Additionally, there was no order to monitor the resident's oxygen saturation (oxygen concentration in the blood).During an interview on 07/29/2025 at 10:26 AM, Resident #6 was observed in bed. The resident had a tracheostomy. The resident stated they have difficulty breathing at times and frequently feel the need to call the nurse for attention. The oxygen concentrator was set at 8 liters per minute.A Respiratory Therapy note dated 07/31/2025 at 12:34 AM documented the resident was resting comfortably, alert, and responsive with no respiratory distress. The resident received tracheostomy care and suctioning. All respiratory equipment was checked and was working properly. The resident remained stable. Continue to monitor the resident as needed.During an interview on 07/31/2025 at 10:53 AM, Resident #6 was observed in bed. The oxygen concentrator was set at 8 liters per minute. The resident stated that the nurse (Licensed Practical Nurse #1) changes the tracheostomy dressing every day. They stated, I have a little trouble breathing right now.During an interview on 07/31/2025 at 11:00 AM, Licensed Practical Nurse #1 stated they provide tracheostomy care for Resident #6 every day; however, they did not Licensed Practical Nurse #1 observed the oxygen setting of 8 liters on the concentrator, checked the resident's orders in the current electronic medical record, and stated there were no current orders for the tracheostomy care, the inner cannula size, or for suctioning, and that the oxygen order was for 3 liters of oxygen per Licensed Practical Nurse # stated the orders for tracheostomy care, the inner cannula, and suctioning were not transferred over to the new electronic medical record that went into effect in June 2025. Licensed Practical Nurse #1 could not state where they were documenting the tracheostomy care when there were no orders in the current electronic medical record.During a re-interview on 07/31/2025 at 1:22 PM, Licensed Practical Nurse #1 stated, there was no explanation related to how the care was documented between 06/04/2025 and 07/31/2025. Licensed Practical Nurse #1 stated they were not able to document the care because the orders were not there. They said they monitor oxygen saturation for Resident #6 when they provide tracheostomy care and suction the resident but have not been documenting the result.During an interview on 8/1/2025 at 8:27 AM, Registered Nurse Wound Care Nurse #1 (and acting supervisor for the unit) stated that if a treatment order was not carried over after the electronic medication record changed, the treatment or medication nurse should have notified the supervisor rather than continuing the care without orders. During an interview on 08/01/2025 at 10:20 AM, the Director of Nursing Services stated if the treatment nurse noticed that the orders for tracheostomy care and the inner cannula were not in the new electronic medical record and therefore could not document the care, the nurse should have reached out to the supervisor to get this rectified.During an interview on 08/01/2025 at 11:17 AM, the Administrator stated there was some catch-up still taking place to make sure all the orders from the previous electronic medical record had been transferred over to the new electronic medical record. The corporate staff was in charge of the electronic medical record transfer. The Administrator stated their (Administrator's) role was to make sure that the facility staff attended meetings to learn how to use the new electronic medical record. They were not following the process of how the transition was taking place.During an interview on 08/04/2025 at 8:19 AM, Physician #2 stated the oxygen saturation should be checked every shift for a resident with a tracheostomy, and the result should be documented in the electronic medical record.10NYCRR 415.12(k)(6)

Based on interviews and record review during the recertification survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure If the facility did not employ a qualified professional person to furnish a specific service to be provided by the facility, services were furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act for each resident. This was identified for one (1) (Resident #179) of one (1) resident reviewed for Vision/Hearing. Specifically, Resident #179 was seen by the Optometrist on 04/28/2025 and recommended a referral for an Ophthalmology consult for Cataract (a clouding of the lens of the eye) surgery. The facility did not arrange an appointment with the Ophthalmologist until 08/04/2025, approximately three (3) months after the recommendation was made. The finding is:The facility policy titled Consultants, last reviewed on 02/2025, documented the nurses on the unit will pick up an order for a consultant and complete a consult form. If the consultant is an outside consultant, the nurse will fill out a consultant form and forward the form to the Medical Records Coordinator. The Medical Records Coordinator will make arrangements for the transportation. The Charge nurse is responsible for informing the primary Physician of the consultant's recommendations. It is expected that consults will be completed in a thirty-day period. Resident #179 was admitted with the diagnoses including Glaucoma (an eye condition that damages the optic nerve), Parkinson's Disease, and Hypertensive Heart Disease. The Quarterly Minimum Assessment Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, indicating the resident had intact cognition. The Minimum Data Set assessment documented the resident had adequate vision and wore corrective lenses.A comprehensive Care Plan titled Visual Function initiated 06/23/2025 and last revised 08/04/2025 documented potential for visual impairment due to Cataracts of the right and left eye. Interventions included identifying/recording factors affecting visual function and providing reading glasses as requested. An Optometry Consult form dated 04/28/2025 documented Resident #179 had Cataracts to the left and right eye with no impact to activities of daily living or quality of life, and to monitor for progression. Prescription glasses were not ordered for Resident #179. The recommendations included a referral to an Ophthalmologist for Cataract surgery. A review of the electronic medical record indicated no physician order for an Ophthalmology consult until 08/04/2025. A Physician's order dated 08/04/2025 documented a scheduled appointment for an Ophthalmology consult for 08/08/2025 at 11:00 AM. During an interview on 07/28/2025 at 10:24 AM, Resident #179 stated they needed new glasses as the previous glasses broke, and they still had not received. During an interview on 08/01/2025 at 11:15 AM, Licensed Practical Nurse #7 stated Resident #179 complained about their eyeglasses, and an order for an Optometry consultation was placed. Licensed Practical Nurse #7 stated they put the consult form for the Optometrist in their mailbox and did not know what happened after that During an interview on 08/04/2025 at 11:52 AM, Optometrist #1 stated they had been following the resident for years. Optometrist #1 stated they did not order any glasses for Resident #179 during the last visit on 4/28/25 because glasses would not benefit the resident due to the Resident's Cataracts. Optometrist #1 stated they recommended a referral for an Ophthalmology consult for cataract surgery.During an interview on 08/04/2025 at 1:25 PM, Registered Nurse #4 stated the nursing supervisor was responsible for printing out consultation forms from the Optometrist and informing the Medical Records/Transportation Coordinator to arrange an appointment and transportation according to the recommended referral. During an interview on 08/04/2025 at 02:10 PM, the Medical Records/Transportation Coordinator stated they were only made aware on 08/04/2025 that Resident #179 needed an appointment for an Ophthalmologist, and they then scheduled an appointment for 08/08/2025.During an interview on 08/04/2025 at 03:04 PM, Registered Nurse #5, the nursing supervisor for the unit where Resident #179 resides, stated that the previous Director of Nursing Services provided the nursing supervisors a list of residents that were seen by an in-house consultant, including the Optometrist. The supervisor would then review the consult note and the recommendations. If the recommendations included a referral to another consultant or specialist, then the supervisor would place an order for the referral and provide a copy of the order to the Medical Records/Transport Coordinator to set up an appointment. Registered Nurse #5 could not recall if Resident #179 was seen by the Optometrist on 04/28/2025, and did not know why the recommendations for the Ophthalmology consult made by the Optometrist were not addressed in April 2025.During an interview on 08/05/2025 at 09:29 AM, the Director of Nursing Services stated that the Ophthalmologist consult for Resident #179 should have been ordered and scheduled as soon as possible after the recommendations were received from the Optometrist. 10 NYCRR 15.26(e)(1)(i-iv)

Based on observations, interviews, and record review during the Recertification Survey initiated on 07/28/2025 and completed on 08/05/2025, the facility did not ensure each resident's bedside was adequately equipped to allow residents to call for staff assistance through a communication system that relayed the call directly to a staff member or to a centralized staff work area. This was identified for one (Resident #40) of three (3) residents reviewed during the Environmental Task. Specifically, on 07/28/2025 and 07/29/2025, Resident #40's call bell was not functioning, and the annunciator system at the nursing station did not register the calls from Resident #40's room. The finding is:The facility's policy, titled Resident's Use of Call Bells, last reviewed on 07/29/2025, documented call bell functioning will be checked monthly and as needed by the Maintenance Department. A supply of tap bells/hand bells will be available in the event of a call bell system malfunction. Any staff member who hears or sees a call bell activated is responsible for answering immediately. A review of the call bell check log on Unit 4 South, dated 07/18/2025, documented that the call bells were checked in Resident #40's room and required repairing. Resident #40 was admitted with diagnoses of Spinal Stenosis (narrowing of the spinal canal), Pain, and Atrial Fibrillation. The Quarterly Minimum Data Set assessment dated [DATE] documented that Resident #40 had a Brief Interview for Mental Status score of 12, which indicated the resident had moderately impaired cognition. Resident #40 had clear speech, was able to understand, and was understood. Resident #40 was dependent for activities of daily living, including toileting, hygiene, and upper/lower body dressing. Resident #40 was dependent for bed mobility, including rolling left to right, sitting to lying. Resident #40 did not have the ability to walk ten feet. During the Resident Screening and Environmental observation on 07/28/2025 at 10:11 AM, Resident #40 was heard shouting from inside their room, calling for staff assistance. When the surveyor approached Resident #40's room at 10:17 AM, Resident #40 was still shouting for assistance. The call light above Resident #40's room was not turned on. There was no call bell sound emitting from the room. There was no staff in the vicinity. Upon entry to the resident's room, Resident #40 was observed in bed, holding and pressing the call bell. Resident #40 stated they had been pressing the call bell and calling for help for the last 30 minutes because they were feeling cold and could not turn the air conditioner off themselves. Resident #40 stated that no staff had responded to their call. During an observation on 07/28/2025 at 10:20 AM, in the presence of the Lead Engineer, Resident #40's bedside call bell did not trigger the sound or the call light above the resident's room door. The Lead Engineer stated they most likely needed to replace a new call bell cord, and they would follow up. During an interview on 07/28/2025 at 10:45 AM, the Lead Engineer stated there was no call bell issue identified during the last inspection; however, they did not know when the call bell system was last checked on Resident #40's unit. The Lead Engineer stated that they had replaced a new call bell cord for Resident #40 today (07/28/2025), and the call bell is now functioning properly. During an observation on 07/29/2025 at 9:28 AM, Resident #40 was again heard from the hallway calling out for help from their room. The call light above Resident #40's room was not turned on. There was no call bell sound emitting from the room. There was no staff in the vicinity. Registered Nurse # 1, who was the unit supervisor, was called to Resident #40's room by the surveyor and confirmed that Resident #40's call light did not turn on. Registered Nurse #1 was immediately interviewed and stated that the call bell should trigger a light and sound above the door to alert staff. Registered Nurse # 1 stated that the call bell system was also connected to the nursing station monitor, which would indicate which room had the call bell activated. Registered Nurse # 1 stated they did not know Resident #40's call bell was not working. During an observation of the nursing station call bell annunciator with Licensed Practical Nurse # 8 on 07/29/2025 at 9:33 AM, there was no sound or light activated when the call bell was pressed by Registered Nurse #1 from Resident #40's room. During an interview on 07/30/2025 at 10:07 AM, the Director of Maintenance stated that the call bell system in each resident's room was inspected monthly. The Director of Maintenance stated that residents must have working call bells at all times so they can ask for assistance as needed. The Director of Maintenance stated that nursing staff should provide a handbell to the resident if the resident's call bell issue could not be resolved immediately. During an interview on 07/31/2025 at 9:39 AM, the Administrator stated that residents should have working call bells at all times so they can ask for help when needed. 10 NYCRR 415.29

Based on record review and interview during the Recertification Survey initiated on 07/28/2025 and completed on 08/5/2025, the facility did not ensure the Facility Assessment considered specific staffing needs for each resident unit for each shift, such as day, evening, and night. This was identified during the Sufficient Nursing Staffing Task. Specifically, the Facility Assessment, last reviewed in June 2025, did not indicate staffing needs for Certified Nursing Aides, Monday to Friday, for each unit and each shift. Additionally, the Facility Assessment did not specify the staffing needs for Licensed Practical Nurses for each unit for the 3:00 PM-11:00 PM shift and the 11:00 PM-7:00 AM shift during the weekdays. The finding is:The facility's policy, titled Facility Assessment, last reviewed/revised on 8/1/2024, documented the facility will conduct and document a facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergency services. The Facility Assessment will identify the facility's resident population, including the number of residents, residents' capacity, and the care required by the residents. The Facility Assessment will provide a staffing template for both weekday and weekend/holiday staffing [need] for each shift.A review of the Facility assessment dated [DATE], revealed the Facility Assessment did not indicate weekdays (Monday to Friday) staffing needs for Certified Nursing Aides for each unit and each shift (7:00 AM-3:00 PM, 3:00 PM-11:00 PM, and 11:00 PM-7:00 AM). Additionally, the Facility Assessment did not specify the staffing needs for Licensed Practical Nurses for each unit for the 3:00 PM-11:00 PM shift and the 11:00 PM-7:00 AM shift during the weekdays. During an interview on 08/1/2025 at 08:45 AM, the Administrator stated they and the Director of Nursing Services were involved in developing and reviewing the Facility Assessment. The Administrator stated the Director of Nursing Services was responsible for completing the nursing staffing portion of the Facility Assessment. The Administrator stated they were responsible for reviewing and ensuring the Facility Assessment was completed accurately. The Administrator stated they were not aware that the Facility Assessment did not include the number of nursing staff required for each unit, each shift, for the weekdays (Monday to Friday). The Administrator stated that the Facility Assessment should have clearly indicated specific nursing staffing needs by resident units for each shift, and it was an oversight. The Administrator stated that the Director of Nursing Services, who was responsible for the nursing staffing portion of the Facility Assessment, was no longer employed at the facility.10 NYCRR 415.26

Based on interviews and record review in an abbreviated survey (Complaint # NY00340378), the facility did not ensure that Residents were appropriately supervise and implement interventions to prevent resident to resident sexual abuse for one Resident (Resident #2) of three residents reviewed for sexual abuse. Specifically, Resident #1 (Brief Interview Mental Status score 11) who is cognitivly impaired was observed behind closed doors engaging in sexual activities with Resident #2 (Brief Interview Mental Status score 0) The findings are. The Review of the facility policy dated 9/19/2022 entitled Abuse Prevention documented the resident has the right to be free from abuse. Sexual Abuse-nonconsensual sexual contact of any type with a resident. This includes non-consensual sexual intrusion, touching intimate body parts. The facility will evaluate an individual resident's capacity to consent to sexual activity when indicated. Resident #1 admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, heart failure, and high blood pressure. The review of the Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score- 11 indicating moderately impaired for decision making, delirium-disorganized thinking- continuously, mood-total score 6, physical behaviors directed towards others-1-3 day. The review of the Comprehensive Care Plan Dated 6/1/2022 behavior physically aggressive, verbally abusive, rejection of medications, history of engaging in sexually inappropriate behavior, delusional the interventions documented and observe for changes in behavior every 30-minute visual checks. The review of the Comprehensive Care Plan Dated 4/25/2024 inappropriate sexual activity, observed performing oral sex with peer in room, the interventions documented 30-minute visual checks, floor change, and Psychiatric follow-up. Resident #2, admitted to the facility dated 8/22/2023 with diagnosis hard of hearing, brain swelling and high blood pressure. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score- 0 indicating severe impairment for decision making for Resident#2. The review of the Comprehensive Care Plan (CCP) documented dated 8/22/2023 communication documented potential for impairment, hard of hearing the interventions documented speak slowly and clearly, genetic disorder, born without ears, deaf on the left ear and hard of hearing on the right; sign language but could not respond appropriately for communication, The Nursing Progress Notes dated 4/25/2024 at 12:00PM, documented that CNA#1 witnessed Resident #2 in Resident #1's room and Resident #1 was performing fell ation (oral sex) on Resident #2. Resident #2 quickly stepped away and zipped pants. The Certified Nurse's Aide separated Resident #1 and Resident#2 and led Resident #2 out of the room and went to the Registered Nurse Supervisor#1. The staff was interviewed and placed on a one to one for supervision. The Medical Doctor and the Next of Kin were made aware. During the interview dated 5/6/2024 at 11:04AM, with the unit 7:00 AM -3:00 PM shift Certified Nurse's Aide # 1 who was working on 4/25/2024 they stated at 12:00PM, making rounds to look for residents, the door to the room of Resident#1's room was closed, knocked, and entered the room and saw Resident #2 with Resident #1's mouth on penis, Resident #1 was lying on side on bed and Resident#2 was leaning forward, pants of Resident #2 were up and around waist, the resident's zipper was open. Resident#1 was fully dressed, and no body parts were showing. The Certified Nurse's Aide #1 separated the residents and reported to the Nursing Supervisor. During the interview dated 5/6/2024 at 1:30PM, with the unit 7:00 AM -3:00 PM Registered Nurse Supervisor #1 who was on duty 4/25/2024 they stated they were present on the unit, at about 12:00PM, Certified Nurse's Aide #1, reported that Resident #1 and Resident #2 were observed performing oral sex. The Certified Nurse's Aide #1 stated they saw Resident #1 performing oral sex for Resident#2. Resident was placed on one to one. Resident #1 denied this event, and Resident#2 denied this also. The Registered Nurse Supervisor #1 stated the resident had many behaviors and was on a 30-minute visual check, both Residents are confused. During the interview dated 5/6/2024 at 3:30PM with Director of Nursing, and the Administrator, the Administrator stated Police Report is not yet available, but they were notified. The Administrator stated both residents do not have the capacity based on the Brief Interview Mental Status score and diagnosis to consent to sexual activities. The Director of Nursing stated Resident #1 and Resident #2 has known behaviors and require 30 minuet checks. The Director of Nursing stated both residents have impaired cognition and are not able to consent to sexual activities. Resident #2 was taken to the Nursing Supervisor, and later a one to one was placed on both residents. 483.12[a][1]

Based on observation, record review and interviews during an abbreviated survey (Case #NY00321006) the facility failed to ensure that a resident identified as an elopement risk received adequate supervision to prevent elopement from the facility. This was evident in 1 out of 3 residents reviewed for elopement (Resident #1). Specifically, Resident #1 who was cognitively impaired, was initially assessed as an elopement risk on 07/07/2022. At that time, the resident was placed on 15-minute monitoring, and a wander alert device was placed on the left ankle. Subsequently, on 02/19/2024 at 4:54 PM, Resident #1 walked through the front door undetected, and was returned to the facility by relatives and local police on 02/20/2024 at 12:57 PM. This resulted in Immediate Jeopardy with the likelihood for a serious adverse outcome to Resident #1 and 31 other residents who were at risk for elopement. The findings include. Resident #1 was admitted to the facility on [DATE] with a diagnosis of non-Alzheimer's dementia (defined as dementia associated with cerebrovascular disease, dementia associated with extrapyramidal features, and the frontotemporal dementias). The Minimum Data Set (MDS) dated [DATE] quarterly assessment documented a Brief Interview for Mental Score (BIMS) of 5/15, representing impaired cognition. The MDS further documented resident walked in corridor on and off unit, and the use of wander/elopement alarm. The policy titled Elopement Prevention/Wandering Behavior Management dated 08/12/2022 documented it is the policy of the facility to utilize all possible measures to maintain the safety and wellbeing of all residents. To have a system and tools in place to do all that is reasonable to identify and prevent unsafe wandering and/or elopement and to act quickly and prudently should either occur. The Comprehensive care plan updated 12/27/2023 titled Elopement documented Resident is at risk for elopement secondary to dementia. Interventions included: monitor whereabouts and document in the visual observation logbook, check function of secure bracelet every night. The physician order was renewed on 02/12/2024 and documented visual check every 15 minutes for safety. The visual monitoring sheet documented Resident #1 was last seen on unit 3-hallway on 02/19/2024 at 4:45 PM by Certified Nursing Assistant #3. There were no further entries on the monitoring sheet for this resident. The review of the video surveillance revealed that on 02/19/2024 at 4:54 PM, Resident #1 was seen walking from the double doors which separate the lobby from the resident elevator, passing the main security desk and exiting the building. The security guard was seen disarming the system with a brief exchange with Resident #1, a male, and female visitor and then returned to the desk. The facility investigation dated 02/19/2024 included a statement from Security Guard #1 and documented Resident #1 walked past the security desk with 2 visitors. Security Guard #1 stated they had never seen Resident #1 before and did not know they were a resident. Security Guard #1's statement further documented the alarm went off and they turned off the alarm. The Timeline of events was as follows: 4:45 PM Resident #1 was last seen on seen on unit. 4:54 PM Resident #1 was seen leaving the facility via video surveillance. 6:15 PM Dinner tray was served, Resident #1 was noted to be missing, unit was searched. 6:30 PM Code Honeymoon (the facilities overhead code word for elopement) was called. 6:40 PM Facility administration notified. 6:45 PM local Police department notified. 6:50 PM Resident Representative notified. The temperature reading on 02/19/2024 for [NAME] New York, from the [NAME] F [NAME] international airport station, was 41 degrees at 4:51 PM. The facility is located on a main street with 2-way traffic. During an interview conducted on 03/13/2024 at 11:30 AM with Resident #1 they stated they walked to see mom. They further stated they had a sweater on because it was cold outside. During an Interview conducted on 03/13/2024 at 4:00 PM, Certified Nursing Assistant #3 stated that all Nursing Assistants are responsible for monitoring the residents and completing the visual monitoring logbook. They further stated that on 02/19/2024 at approximately 6:00 PM, they noticed Resident #1 was not in their room when they went in with the dinner tray. They notified the nurse. Certified Nursing Assistant #3 stated Resident #1 visual check was not completed after 4:45pm because the unit was busy that night. During an interview conducted on 03/12/2024 at 3:30 PM, Licensed Practical Nurse #2 stated they were notified by Certified Nursing Assistant #3 that Resident #1 was not in the room during dinner. Licensed Practical Nurse #2 stated they initiated a search on the unit, as well as on the floor above and below the resident's unit. Licensed Practical Nurse #2 stated when they were unable to locate Resident #1, they notified the supervisor, and a code was called. Licensed Practical Nurse #2 stated they went to the first floor and Security Guard #1 told them the alarm sounded earlier. They stated when they reviewed the camera, they identified Resident #1 left the facility. Licensed Practical Nurse #2 stated they also drove around looking for Resident #1 but could not find them. Security Guard #1 was unavailable for interview despite multiple attempts. During a phone interview on 03/12/2024 at 5:26 PM the Director of Nursing stated, Residents are free to leave the unit and wander around the building. The Director of Nursing stated all staff are responsible for the safety of all residents. They further stated that Residents who are on 15- minute monitoring can leave the unit and their assigned Certified Nursing Assistant will call either security or go to other floors to locate the patient and ensure their safety. The Director of Nursing stated the security guard should have checked with the nursing supervisor prior to disarming the alarm. The Director of Nursing further stated there is a binder in place at the security desk with pictures of residents at risk for elopement. The Director of Nursing further stated the Security Guard should have stopped everyone and notified the supervisor to identify the cause of the alarm. During an interview on 03/12/2024 at 6:00 pm the former Facility Administrator (Administrator #1) stated the doors automatically open when someone approaches. The alarm will sound if a wander guard is detected. Administrator #1 stated there is no mechanism in place to identify if a resident is off the unit other than staff observation. Administrator #1 stated the security guard should have notified the supervisor immediately when the alarm sounded to identify who triggered the alarm. During an interview conducted with the Maintenance Director on 03/12/2024 at 4:25 PM, they stated there are 5 exit doors leading to outside. They further stated the alarm sounds; however, it does not impede the door from opening or closing. The Maintenance Director further stated there is no mechanism on the elevator to detect a wander guard. During an interview on 03/12/2024 at 6:20 PM, the Medical Director stated they were made aware of the incident by the Director of Nursing. Resident #1 had dementia and was wandering. The Medical Director stated Residents on every 15-minute monitoring should be visualized by staff. The Medical Director stated they do not know how Resident #1 was able to get out. 10 NYCRR 415.12(h)(2)

Based on observation, record review and staff interviews conducted during the Recertification Survey and Abbreviated Survey (NY003183311) initiated on 11/28/2023 and completed on 12/5/2023 the facility did not ensure that each resident was free from abuse. This was identified for three (Resident #61, Resident #71 and Resident #84) of eight residents reviewed for resident to resident altercation. Specifically, on 6/13/2023 Resident #61 threw a can of soda at Resident #71. Resident #71 then threw a can of soda at Resident #61. Resident #61 was assisted to their room by Certified Nursing Assistant (CNA) #9. CNA #9 exited Resident #61's room to get a Hoyer (Mechanical) lift. Resident #61 exited their room with a broomstick and hit Resident #71 and Resident #84 with the broomstick. The finding is: The policy and procedure titled, Abuse Prevention effective 9/19/2022 and last reviewed on 9/19/2023 documented the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation by anyone in the facility. The facility defined physical abuse as a willful infliction of injury with resulting physical harm, pain, or mental anguish. Physical abuse includes but is not limited to hitting, slapping, punching, biting, or kicking. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Under the procedure section, abuse of any kind is prohibited by all residents of the facility and all visitors in the facility. - Resident #61 was admitted with diagnoses including Persistent Mood Disorder, Depression, and Hemiplegia (paralysis) affecting the right dominant side. The Annual Minimum Data Set (MDS) assessment dated [DATE] documented Resident #61 had a Brief Interview for Mental Status (BIMS) score of 10 which indicated moderately impaired cognition. Resident #61 used a wheelchair as a mobility device. The Comprehensive Care Plan (CCP) for Behavior Victim/Victimizer initiated on 12/28/2022 and last revised on 12/29/2022 documented Resident #61 is at risk for abuse due to congregate living, demonstrates behaviors that have a potential to disturb others and was abusive to a peer on 12/28/2022. Interventions of the CCP included to observe during rounds and one to one supervision to ensure safety of self and others. A physician's order dated 1/18/2023 and discontinued on 6/15/2023 documented to place the resident on one to one monitoring on the 3PM-11PM shift from 3PM-6PM for safety of others. Resident must be placed back in bed at 6 PM daily. The CCP for at risk for abuse initiated on 3/24/2021 and last updated on 6/14/2023 documented Resident #61 was at risk of abuse secondary to congregate living situation, vulnerability due to deficits in cognitive/mental status, vulnerability due to deficits in medical/physical condition and the resident was abusive to peer on 12/28/2022. Interventions included to encourage the resident to voice concerns to staff regarding their peers, address resident concerns as they arise, staff to observe resident during rounds, and monitor for changes in mood/manner. The CCP was updated on 6/14/2023 to include interventions to keep resident away from either peer whenever possible and thirty-minute visual monitoring for behavior. A nursing progress note dated 6/13/2023 documented that Resident #61 was involved in an altercation with Resident #71 and Resident #84 at approximately 4:00 PM. Resident #61 became upset and threw their soda can at Resident #71. Then Resident #71 threw their soda can at Resident #61. The staff present intervened and provided redirection. Resident #61 was wheeled to their room by CNA #9. CNA #9 left Resident #61 in their room to get a Hoyer lift from another room. When CNA #9 stepped away Resident #61 entered the hallway with a broomstick and hit Resident #71 and Resident #84. Staff was unable to redirect Resident #61 and as they attempted to hit Resident #71 and Resident #84 again, they (Resident #61) fell out of their wheelchair. The Registered Nurse Supervisor assessed all residents, and no visible injuries were noted. Resident #61 was sent to the emergency room for a psychiatric evaluation. A nursing progress note dated 6/13/2023 at 11:45 PM documented that Resident #61 returned from the hospital at 10:47 PM. Resident #61 was transferred to a new room (on another floor) upon return to the facility. A medical progress note dated 6/15/2023 documented Resident #61 was seen after a peer to peer altercation. Resident #61 admitted to hitting Resident #71 and Resident #84 with a mop handle. Resident #61 reported their family member brought in the mop to clean their room. -Resident #71 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Bipolar Disorder, and Epileptic Spasms. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated intact cognition. Resident #71 used a wheelchair as a mobility device. Resident #71's Comprehensive Care Plan (CCP) for at risk for abuse initiated on 2/14/2019 and last reviewed on11/27/2023 documented the resident is at risk for abuse secondary to a congregate living situation, vulnerability due to deficits in medical/physical condition, and demonstrates behaviors that have a potential to disturb others. Interventions included the resident would report any arguments or miscommunication with peers to a nurse and would avoid peers or persons who are argumentative. A nursing progress note dated 6/14/2023 documented that Resident #71 was status/post peer to peer altercation, no visible injuries or complaint of pain noted. -Resident #84 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Wernicke's Encephalopathy (a neurological condition), and Bipolar disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had a Brief Interview for Mental Status (BIMS) score of 12 which indicated moderate cognitive impairment. The resident did not use any mobility devices. The Comprehensive Care Plan (CCP) for Victim/Victimizer initiated on 6/13/2023 documented Resident #84 was at risk for abuse secondary to a congregate living situation, resident was involved in a resident-to-resident altercation and resident was abused by a peer. Interventions included to encourage the resident to voice concerns to staff regarding peers. The CCP for at risk for abuse initiated on 4/13/2021 and last reviewed on 10/24/2023 documented Resident #84 is at risk for abuse secondary to a congregate living situation and vulnerability due to deficits in cognitive/mental status. The resident was involved in a resident-to-resident altercation and was abused by a peer. Interventions included to encourage the resident to voice concerns to staff regarding other residents and to observe during rounds and care. A nursing progress note dated 6/14/2023 documented Resident #84 was status/post a peer to peer altercation, no injury or distress noted. The Accident and Incident (A/I) report dated 6/13/2023 documented that at approximately 4:00 PM Resident #61 and Resident #71 were engaged in a confrontation at the nurse's station on the fourth floor. Resident #61 became upset and threw a can of soda at Resident #71. Then Resident #71 threw a can of soda at Resident #61. Staff intervened and separated Resident #61 and Resident #71 and provided redirection. Resident #61 was taken back to their room via wheelchair by CNA #9. CNA #9 left Resident #61 in their room while they (CNA#9) went to another resident's room to get a Hoyer lift to assist Resident #61 to bed. While CNA #9 was gone Resident #61 took a broomstick from their room and went into the hallway where they met and hit Resident #71 on the left side of their face. Resident #84, who was present at the scene, intervened and was also hit with a broomstick by Resident #61. Staff was unable to redirect Resident #61 and Resident #61 fell out of their wheelchair while continuing to attempt to hit Resident #71 and Resident #84. The Registered Nurse Supervisor assessed Resident # 61, Resident #71, and Resident #84. No visible injuries were noted for all three residents. Resident #61 was sent to the emergency room for psychiatric evaluation. The Accident and Incident report concluded the root cause of the incident was identified and there was satisfactory information that abuse occurred. A review of admission and transfer data revealed Residents #71 and #84 shared a room. Resident #61 resided in the room next to Resident #71 and Resident 84's room. Resident #61 was moved to a different floor on 6/13/2023 after the incident. Resident #71 was interviewed on 11/28/2023 at 3:24 PM. Resident #71 was observed sitting in their wheelchair in their room. Resident #71 stated Resident #61 had a behavior of inappropriately touching women and they (Resident #71) confronted Resident #61 and that is when Resident #61 threw a can of soda at them. Resident #71 stated they were going back to their room when Resident #61 hit them (Resident #71) on the side of the face with a broomstick. CNA #9 was interviewed on 11/30/2023 at 4:06 PM. CNA #9 stated they entered the area of the nurse's station after the soda cans were thrown. CNA #9 stated they wheeled Resident #61 to their room and planned to assist Resident #61 to go back to bed. CNA #9 stated they left Resident #61's room to get a Hoyer lift. CNA #9 stated they did not see Resident #61 hit Resident #71 and Resident #84 with a broomstick. CNA #9 stated they were not aware there was a broomstick in Resident #61's room. Resident #71 was re-interviewed on 12/5/2023 at 9:34 AM. Resident #71 stated they told Resident #61 not to touch women. Resident #61 did not like what they (Resident #71) said, and threw a can of soda at them. Resident #71 stated they (Resident #71) then threw a can of soda back at Resident #61. Resident #71 stated Resident #61 was taken to their room. Resident #71 stated they were returning to their room when Resident #61 wheeled down the hallway toward them and hit them (Resident #71) in the face with a broomstick. Resident #71 stated Resident #84 tried to defend them and was also hit with the broomstick. Resident #71 reported they were upset by the incident. Resident #84 was interviewed on 12/5/2023 at 9:39 AM. Resident #84 stated he observed Resident #61 hit Resident #71. Resident #84 stated they were upset by the incident and attempted to defend Resident #71 when they (Resident #84) were also struck by the broomstick. Resident #84 stated they were upset about being struck. Licensed Practical Nurse (LPN) #9 was interviewed on 12/5/2023 at 11:16 AM. LPN #9 stated on 6/13/2023 at approximately 4:00 PM they were at the nurse's station with Resident #61 and Resident #71. LPN #9 stated they turned to get ice from the ice machine and did not hear what led up to the soda can being thrown. LPN #9 reported they intervened and asked CNA #9 to wheel Resident #61 to their room. LPN #9 stated they observed Resident #61 wheel themselves backward down the hallway, turn their wheelchair around, and strike Resident #71 with a broomstick. LPN #9 stated Resident #61 then struck Resident #84 with the broomstick. LPN #9 stated the incident happened quickly and they were not able to reach Resident #61 before Resident #71 and Resident #84 were struck. The Director of Nursing Services (DNS) was interviewed on 12/5/2023 at 4:36 PM. The DNS stated they completed the investigation of the peer-to-peer altercation between Resident #61, Resident #71, and Resident #84 that occurred on 6/13/2023. The DNS stated CNA #9 should not have left Resident #61 alone while they went to get a Hoyer lift. The DNS stated CNA #9 should have asked another staff member to stay with Resident #61 while they (CNA #9) left the room. 10 NYCRR 415.4(b)(1)(i)

Based on observations, record review, and interviews during the Recertification Survey initiated on 11/28/2023 and completed on 12/5/2023 the facility did not ensure the residents had a safe, clean, comfortable, and homelike environment. This was identified for one (Resident #29) of one resident reviewed for the Environment. Specifically, Resident #29's bed rail, wheelchair arm rest, and left side of the wheelchair were observed soiled with a cream colored and crusty substance on multiple occasions (11/28/2023, 11/29/2023 and 11/30/2023). The finding is: The facility's policy titled, Wheelchair/Gerichair/Cleaning Monitoring dated 10/12/2021 documented the 3 PM - 11 PM shift will prepare and have all wheelchairs and Geri chairs ready for cleaning. Any wheelchair designated by nursing which needs additional cleaning will be cleaned and returned to the unit by housekeeping staff. The facility policy titled, Cleaning and Disinfecting Resident Rooms dated 5/2020 documented to ensure that all resident's rooms are cleaned and sanitized according to set standards and guidelines to ensure resident's quality of life. Resident room cleaning includes cleaning of horizontal surfaces (e.g., bedside tables, over bed tables, and chairs) daily with disinfectant solution. Clean personal use items (e.g., lights, phones, call bells, bedrails, etc.) with disinfectant solution daily. Resident #29 has diagnoses which include Type 2 Diabetes, Alzheimer's Disease, and Bipolar Disorder. The annual Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had a Brief Interview for Mental Status (BIMS) score of 4 which indicated the resident had severely impaired cognitive skills for daily decision making. Resident #29 used a wheelchair for mobility. The MDS documented Resident #29 required partial/moderate assistance of a helper in order to sit on the side of the bed from a lying position, to stand from a sitting position, and for a chair/bed-to-chair transfer. The MDS documented Resident #29 required supervision or touching assistance for eating. A Comprehensive Care Plan (CCP) titled, Activities of Daily Living (ADL) All Tasks, effective 10/5/2023 documented interventions including bilateral (two sides) half bedrails as enablers for turning and positioning for bed mobility. The CCP documented the resident used a wheelchair for primary locomotion, required partial/moderate assistance for chair transfer, and required meal setup and supervision or touch assistance for eating. On 11/28/2023 at 11:04 AM Resident #29 was observed sitting in their wheelchair in their room. The wheelchair's left armrest and the panel beneath the armrest were soiled with a cream colored and crusty substance. The right half siderail of the bed was also coated with a cream colored and crusty substance. On 11/29/2023 at 3:02 PM Resident #29 was observed sitting on the right side of their bed. Resident #29's wheelchair was positioned next to the bed by the footboard. The right half side rail was soiled with a cream colored and crusty substance. A urinal was hanging on the right half siderail. The urinal handle was coated with a cream colored and crusty substance. The stand of the overbed table was observed to have long drips of a cream-colored substance running down the side. Resident #29's wheelchair was soiled with a cream-colored and crusty substance on the left side of the seat cushion, the left armrest, the panel beneath the armrest, and the mechanism that houses the left footrest. On 11/30/2023 at 8:20 AM the right half siderail was observed with a cream colored and crusty substance. A urinal was hanging on the right half siderail. The urinal handle was coated with a cream colored and crusty substance. The stand of the overbed table was observed to have long drips of a cream-colored substance running down the side. Resident #29's wheelchair was soiled with a cream-colored and crusty substance on the left side of the seat cushion, the left armrest, the panel beneath the armrest, and the mechanism that houses the left footrest. Resident #29 was not able to identify the substance. Certified Nursing Assistant (CNA) #5 was interviewed on 11/30/2023 at 8:25 AM. CNA #5 stated they assisted Resident #29 with care earlier in the morning on 11/30/2023 and did not notice the cream-colored crusty substance on the bed's half siderail or the CNA #5 stated if they observed a soiled area they would wipe the area or alert the housekeeper on the unit. Housekeeper #1 was interviewed on 11/30/2023 at 8:41 AM. Housekeeper #1 stated they clean the resident's bathroom and wipe down the furniture daily and sweep and mop the resident's room twice a day. Housekeeper #1 stated when they are in the room they look around the room for any soiled areas and clean as needed. Housekeeper #1 stated they had not reached Resident #29's room on 11/30/2023 because they started cleaning on the other side of the unit. Housekeeper #1 stated they did not observe the soiled right siderail and wheelchair the previous day. Registered Nurse (RN) #1 was interviewed on 11/30/2023 at 8:54 AM. RN #1 stated the wheelchairs are cleaned on an overnight shift but they were not sure on which day. RN #1 stated the resident rooms are cleaned daily and the side rails and wheelchairs should be checked and cleaned at that time. Licensed Practical Nurse (LPN) #5 was interviewed on 11/30/2023 at 8:45 AM. LPN #5 stated they never observed the resident's soiled siderail or soiled wheelchair; if they observed an area that required cleaning, they would have informed the housekeeper on the unit. The Housekeeping Director was interviewed on 11/30/2023 at 2:12 PM. The Housekeeping Director stated the responsibility of the housekeeper is to inspect the resident's room for cleanliness and any problem areas should be cleaned. The Housekeeping Director stated resident's wheelchairs are cleaned on the overnight shift on Thursday and Friday. The Housekeeping Director stated there was no documentation of wheelchair cleaning. RN #1 was re-interviewed on 12/4/2023 at 9:51 AM. RN #1 stated there are no cleaning logs kept on the unit regarding housekeeping concerns. RN #1 stated anyone can report housekeeping concerns to the unit housekeeper and it is up to that person to ensure the concern has been resolved. The Housekeeping Director was re-interviewed on 12/4/2023 at 10:09 AM. The Housekeeping Director stated there were no logs available for the the wheelchair cleaning schedule. The Housekeeper Director stated they were not able to say when Resident #29's wheelchair was last cleaned. 10 NYCRR 415.5(h)(2)

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY00327941), initiated on 11/28/2023 and completed on 12/5/2023 the facility did not ensure that all incidents were investigated thoroughly. This was identified for one (Resident #16) of 12 residents reviewed for Abuse. Specifically, Resident #16 was observed with a discoloration to the lower left eyelid, an injury of unknown origin, on 11/11/2023 at approximately 4 AM. The facility investigation did not include the assigned Certified Nursing Assistant (CNA) #1's statement to determine the root cause of the injury. The finding is: The facility Accident and Incident Investigation and Reporting policy and procedure dated 10/20/2023 documented that investigation statements are to be obtained from the assigned CNA, any witnesses to the occurrence, and the person who reported the occurrence. Resident #16 was admitted with diagnoses of Non-Alzheimer's Dementia, Insomnia, and Psychosis. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #16 had a Brief Interview for Mental Status (BIMS) score of 5, indicating severely impaired cognition. The At Risk for Abuse care plan dated 4/3/2019 and last reviewed on 11/28/2023 documented that Resident #16 was at risk for abuse secondary to congregate living situation, deficits in cognitive/mental status, medical/physical condition, deficits in communication status, and demonstrates behaviors that have potential to disturb others. The Accident Incident (A/I) report dated 11/11/2023 documented that on 11/11/2023 the Director of Nursing Services (DNS) was made aware that Resident #16 was noted with a swollen black and blue lower eye lid during the overnight shift (11/10/2023 to 11/11/2023). Upon assessment by the Registered Nurse (RN) Supervisor, Resident #16 voiced no complaint of pain and was unable to state what happened secondary to cognitive deficit. As per the night nurse on duty, Licensed Practical Nurse (LPN) #1, the discoloration was noted by CNA #1 when CNA #1 went into Resident #16's room to provide care. The RN Supervisor was immediately notified. The Physician was notified and gave an order to send Resident #16 to the emergency room for further evaluation. The A/I report did not include a statement from CNA #1 who was assigned to Resident #16 on the 11PM-7AM shift on 11/10/2023. LPN #1 was interviewed on 12/1/2023 at 11:00 AM and stated that on 11/11/2023 at 4:30 AM, CNA #1 told them that there was black ink on Resident #16's leg. They both (LPN #1 and CNA #1) observed Resident #16 in the bed with [writing] pens in the resident's brief, which was Resident #16's known behavior. LPN #1 and CNA #1 also observed redness and swelling on the resident's lower left eyelid. CNA #1 told LPN #1 that they had not observed that while providing care because the room was dark. LPN #1 stated that Resident #16's roommate did not say anything had occurred. Resident #16 told LPN #1 that a family member had hit them. LPN #1 stated that Resident #16 was confused and did not have any visitors on that shift. LPN #1 stated that they did not hear any commotion from the room at all during the shift and they reported the injury to the supervisor. CNA #1 was interviewed on 12/1/2023 at 1:45 PM. CNA #1 stated when they were providing care to Resident #16 on 11/11/2023 at around 4:00 AM they found burst pens in Resident #16's brief. CNA #1 stated they informed LPN #1 and when LPN #1 came into the room they both (LPN #1 and CNA #1) observed Resident #16's left lower eyelid was red and swollen. CNA #1 stated that they typically do write statements for a resident injury; however, no one asked them (CNA #1) to write a statement related to Resident #16 and therefore they did not provide a written statement to anyone. The Director of Nursing Services (DNS) was interviewed on 12/4/2023 at 9:06 AM and stated they (DNS) had interviewed CNA #1 over the phone and did not document CNA #1's statement while conducting the investigation. The DNS stated that CNA #1 provided care to Resident #16 when the injury was observed, and that CNA #1's statement should have been documented with the investigation. 10 NYCRR 415.4(b)(3)

Based on record review and staff interviews during the Recertification Survey initiated on 11/28/2023 and completed on 12/5/2023 the facility did not ensure that all services provided by the facility met professional standards of quality. This was identified for one (Resident #140) of five residents reviewed for Medication Regimen Review (MRR). Specifically, Resident #140's Insulin injections sites and Nitroglycerin (Heart medication) transdermal (through the skin) 24-hour patch application sites were not documented on the Medication Administration Record (MAR) on multiple occasions. The finding is: The facility's policy titled, Special Considerations for Medication Administrations, effective 10/10/2022 documented nurses administering medications will adhere to professional standards of practice as stipulated by the American Nurses Association, Centers for Medicare and Medicaid Services, and the Centers for Disease Control. There were no procedures specific to Insulin injections and medicated patch application other than the Fentanyl (controlled substance) patch. Resident #140 was admitted with diagnoses that include Type 2 Diabetes, Chronic Obstructive Pulmonary Disease, and Bipolar Disorder. The 10/1/2023 Annual Minimum Data Set (MDS) assessment documented the resident had a Brief Interview for Mental Status (BIMS) score of 15 indicating Resident #140 was cognitively intact. The Comprehensive Care Plan (CCP) for Endocrine/Metabolic Alteration effective 11/13/2022 and last updated on 10/30/2023 documented the resident had an alteration in Endocrine/Metabolic status related to Diabetes Mellitus. Interventions included to administer medication as ordered and to monitor for effectiveness and for side effects. A physician's order dated 7/18/2023 documented the following orders: -Lantus Solostar U-100 Insulin 100 unit/milliliters (mL) (3mL) subcutaneous pen, inject 20 units by subcutaneous route once daily at bedtime. -Apply one Nitroglycerin 0.1 milligrams (mg)/hour (hr) transdermal 24 hour patch by transdermal route once daily. A review the Medication Administration Record (MAR) for 8/10/2023 through 8/31/2023 documented Lantus was administered twenty-two times and the injection site was documented two times. The Nitroglycerin patch was applied twenty-two times and the application site was documented zero times. A review of the September 2023 MAR documented Lantus was administered thirty times and the injection site was documented two times. The Nitroglycerin patch was applied twenty-nine times and the application site was documented zero times. A review of the October 2023 MAR documented Lantus was administered thirty-one times and the injection site was documented nine times. The Nitroglycerin patch was applied thirty times and the application site was documented zero times. A review of the November 2023 MAR documented Lantus was administered twenty-nine times and the injection site was documented thirteen times. The Nitroglycerin patch was applied twenty-nine times and the application site was documented two times. A review of the MAR from 12/1/2023 through 12/4/2023 documented Lantus was administered four times and the injection site was documented three times. The Nitroglycerin patch was applied four times and the application site was documented one time. Registered Nurse (RN) #1, the supervisor on Resident #140's unit, was interviewed on 11/30/2023 at 12:11 PM. RN #1 stated the nurse who administered the Insulin and the Nitroglycerine patch should have documented the administration sites to prevent the same site from being used repeatedly. Licensed Practical Nurse (LPN) #6 was interviewed on 11/30/2023 at 4:10 PM. LPN #6 stated when Insulin injection and the Nitroglycerin patch are administered the site must be documented so the same site is not used. RN #6 was interviewed on 11/30/2023 at 4:32 PM. RN #6 stated they are regularly assigned to Resident #140 on the 3 PM - 11 PM shift and administer the Lantus injection. RN #6 stated they were aware the injection site for Insulin had to be documented and rotated. RN #6 stated the physician's order for Resident #140's Lantus did not include that the injection site had to be documented. RN #6 was re-interviewed on 12/5/2023 at 3:37 PM and stated Insulin injection sites should be rotated because an abscess could develop if the same site was used repeatedly. LPN #7 was interviewed on 12/5/2023 at 2:46 PM and stated they regularly apply Resident #140's Nitroglycerin patch in the morning. LPN #7 stated they did not document the application site because the physician's order did not indicate to do so. LPN #7 stated they were aware they must rotate the application site of the patch. LPN #7 stated they knew where to place the Nitroglycerin patch because the Nitroglycerin patch is applied every twenty-four hours and they would not apply the patch to the site they just removed it from. The Director of Nursing Services (DNS) was interviewed on 12/5/2023 at 4:25 PM. The DNS stated Insulin injection sites are expected to be rotated because repeated injections to one site could cause inflammation and decrease insulin absorption. The DNS stated Nitroglycerin patches should be rotated because they may cause irritation if applied to one site repeatedly. The DNS further stated they expected the medication nurses to document injection sites of Insulin and the application sites of Nitroglycerin patches on the resident's MAR. 10 NYCRR 415.11(c)(3)(i)

Based on observation, resident and staff interviews and record review during a recertification/abbreviated and extended survey, it was determined that the facility failed to implement policies and procedures to ensure that residents were free from abuse, neglect and mistreatment. Specifically, 1) one of 38 residents (Resident #29) reviewed for abuse prohibition had been identified as a possible victim of sexual abuse in June, 2010. Facility staff, including key personnel, were reportedly aware of these allegations but failed to investigate them or implement necessary interventions to protect the resident's health and safety. On August 28, 2010, it was reported that the resident was allegedly targeted by the same perpetrator again. The facility's failure to implement intervention strategies to prevent occurrences of abuse has the potential of jeopardizing the health and safety of twenty-six (26) residents currently identified by the facility with cognitive impairments on unit 2 North. This resulted in no known actual harm with the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. Complaint ID Number: NY 943 The findings are: 1) Resident #29 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 2.0 (a resident assessment tool) dated 08/19/10 documented that the resident's short and long-term memory are impaired. The resident is assessed as moderately impaired in daily decision-making. Activities of Daily Living (ADL) skills require no physical assistance. The ADL Comprehensive Care Plan (CCP) dated 05/20/10 and updated 08/24/10 documented that the resident transfers and ambulates independently and is independent in toilet use. The Elimination Needs Comprehensive Care Plan (CCP) dated 05/20/10 and updated 08/24/10 documented that the resident is continent in bowel and bladder. The facility's Policy and Procedure on Resident Abuse (PPRA) documents that all residents will be free and protected from abuse, neglect and mistreatment including verbal, sexual, written, gestural, physical and mental abuse. The PPRA states that a full investigation will be initiated as soon as an allegation of resident abuse of any kind has been voiced and the facility will ensure all residents are protected from further abuse during the investigatory process. An interview was conducted with an alert and oriented resident on 09/21/10 at 12:26 PM (Resident # 30). The MDS assessed this resident with modified independence in cognitive skills for decision-making. Resident #30 stated that she previously resided on the second floor, across the hall from Resident #29. She said she had complained about a Certified Nurse Aide (CNA #4) who was having sex with Resident #29. Resident #30 stated that she saw it happen once, reported it and nothing was done. She stated there were other times when CNA #4 touched Resident #29's breasts. Resident #30 stated that she had told CNA #1, CNA #2 and a Licensed Practical Nurse (LPN #1). Furthermore, Resident #30 stated she reported the abuse to the Director of Social Services (DSS) but does not believe that the facility's administration ever acts on these kinds of complaints. An interview was conducted with the 7:00 AM to 3:00 PM LPN #1 on 09/21/10 at 2:08 PM. LPN #1 stated that, sometime in June 2010, Resident #30 told LPN #1 that she had seen CNA #4 having sex with Resident #29. LPN #1 stated that she tried to question Resident #30 at the time but Resident #30 did not want to talk about it. LPN #1 stated that she did not report this to anyone at that time because she had not seen anything herself. An interview was conducted with the 7:00 AM to 3:00 PM CNA #1 on 09/22/10 at 10:47 AM. CNA #1 stated that she had been told by Resident #30 a few months ago that CNA #4 was "raping" Resident #29. CNA #1 stated that she had reported this to the Registered Nurse Supervisor (RNS #4) and the DSS but "no one ever did anything." A telephone interview was conducted with the former RNS #4 on 09/23/10 at 3:46 PM. RNS #4 stated that she was never told by any resident or staff member that sexually inappropriate conduct was taking place between Resident #29 and CNA #4. An interview was conducted with the 6:00 AM to 2:00 PM CNA #2 on 09/22/10 at 10:19 AM. CNA #2 stated that a few months ago, in May or June 2010, Resident #30 reported that CNA #4 was having sex with Resident #29. CNA #2 stated that she told RNS #4 about this at the time, but CNA #2 did not feel anything was being done. CNA #2 further stated that, at that time, she decided to call the DSS. She said she spoke with the DSS, advising her that Resident #30 had said she saw CNA #4 have sex with Resident #29. CNA #2 stated that the DSS told her that Resident #30 did not like the DSS and would probably not talk to her. CNA #2 then began to cry during this interview and stated "I didn't know what else to do. No one would do anything." The Social Work Progress Notes from 04/23/10 to 08/30/10 were reviewed. There was no documentation that an allegation of potential abuse involving Resident #29 was reported. A telephone interview was conducted with the Director of Social Services (DSS) on 09/23/10 at 11:07 AM. The DSS stated that she is not aware of any reports of sexual misconduct between CNA #4 and Resident #29 prior to the incident of 08/28/10. She denied being told by staff or residents of any alleged abuse. An interview was conducted with the 7:00 AM to 3:00 PM CNA #3 on 09/22/10 at 10:38 AM. CNA #3 stated that "there has been talk for a while" that CNA #4 was doing sexually inappropriate things with Resident #29. CNA #3 stated that she never actually witnessed anything but heard about this from other staff members and from Resident #30. CNA #3 stated that she never reported anything because she was aware that other staff members had notified the facility's administration, but nothing was done. The facility's Accident/Incident Report (A/I) dated 8/29/10 documented a "questionable resident abusive incident" and that the resident was unable to give a statement. The report goes on to state that the CNA #4 was seen on 08/28/10 standing close to the female resident, who was noted with her underwear partially down and blouse raised up, partially exposing her breasts. The section entitled "Recommendation for preventative measures not in place/additional corrective measures, "documented (CNA)" suspension during investigation, transfer from floor, in-service on abuse prohibition." The A/I also documented that the physician was notified on 08/29/10 at 2:30 PM. An interview was conducted with the 7:00 AM to 3:00 PM medication nurse, LPN #2, on 09/21/10 at 1:20 PM. LPN #2 stated that, on 8/28/10, she walked into Resident #29's room to administer medications. She found Resident #29 bent slightly over, with no pants on, panties down, shirt up with breasts exposed. CNA #4 was standing behind the resident with a towel in his hand. CNA #4 threw the towel down and left the room. LPN #2 said she asked the resident if she was okay and the resident said 'Yes.' LPN #2 acknowledged that she did not report her observations to anyone. LPN #2 further stated that she did not know, at the time, that CNA #4 was not assigned to care for Resident #29. An interview was conducted with a member of the Housekeeping staff (HK) on 09/21/10 at 1:54 PM. The HK stated that LPN #2, on 08/28/10, told her that she (LPN #2) had gone into Resident #29's room and observed the resident's panties all the way down and shirt up. The HK stated that LPN #2 said she believed CNA #4 "was playing with her." The HK also stated that she told LPN #2 that she had heard about this before, but the facility's administration had never done anything about it. The HK further stated that LPN #1 had known about CNA #4's inappropriate behavior and that Resident #30 had also said something about it "a while ago." The HK stated that she did not report her conversation with LPN #2 on 08/28/10 to anyone because the facility's administration "has heard this before. You report it and nothing gets done." The Clinical Assignment Record documented that CNA #4 worked the 7:00 AM-3:00 PM shift on 08/28/10 and 08/29/10. The accused CNA #4 is no longer working in the facility. A Doctor's Progress Notes dated 08/31/10 documented that somebody possibly molested Resident #29 and the resident was sent to the hospital for gynecological examination. A physician's orders [REDACTED]. The physician's orders [REDACTED]. The Resident Transfer Form (RTF) dated 08/31/10 documented that the resident was being transferred to the hospital due to suspected sexual molestation. The resident was transferred to the hospital three (3) days after the alleged incident on 08/28/10. The RTF documented the resident's self-care status as independent. A telephone interview was conducted with the Hospital Emergency Department Physician (HEDP) on 09/22/10 at 3:10 PM. The HEDP stated that Resident #29 was sent to the hospital by the facility on 08/31/10. The HEDP stated that she phoned the facility to determine why the resident was sent to the hospital. The HEDP stated that she spoke with the Director of Nursing (DON), who advised the HEDP that there was a possible sexual assault and that it may not have been the first time. The HEDP stated she examined the resident but did not have any conclusive findings. She said physical evidence of a sexual assault may not have been present if a condom had been used. The Hospital Emergency Department Patient Discharge Instructions documented a discharge [DIAGNOSES REDACTED]. An interview was conducted with the Administrator on 09/23/10 at 3:22 PM. The Administrator stated that the DON informed him on 08/30/10 of a possible sexual assault of Resident #29 that allegedly occurred on 08/28/10. The Administrator also stated that it was not until a few days after the 08/28/10 incident that the DON made him aware that there were also rumors of prior instances of abuse. 415.4(b)

Based on observation, resident and staff interviews and record review during a recertification/abbreviated and extended survey, the facility failed to report and immediately investigate allegations of resident sexual abuse. The facility also failed to protect residents from further, potential abuse after the allegations were first raised. Specifically, 1) one cognitively impaired resident (Resident #29) out of 38 residents reviewed for abuse prohibition, had been identified as a possible victim of sexual abuse in June, 2010. Facility staff, including key personnel, were reportedly aware of these allegations, but failed to report them to the Administrator and the New York State Department of Health, and failed to implement any interventions to protect the resident from further abuse. On August 28, 2010, a Licensed Practical Nurse (LPN) witnessed suspicious and inappropriate behavior by another staff member (CNA #4) with the resident (Resident #29). This incident was not reported until the next day. Over the next two days, the nursing staff did not assess the resident and did not immediately notify the physician or the resident's family. The facility's failure to report and immediately investigate allegations of sexual abuse, and to implement strategies to prevent further abuse, has the potential of jeopardizing the health and safety of twenty-six (26) residents currently identified by the facility with cognitive impairments on unit 2 North. 2) Additionally, a physical altercation between Resident #35 and Resident #40 as well as 3) an ecchymotic area of unknown etiology for Resident # 23, were not thoroughly investigated. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. Complaint ID Number: NY 943 The findings are: Resident #29 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 2.0 (a resident assessment tool) dated 08/19/10 documented that the resident's short and long-term memory are impaired. Cognitive Skills for Daily Decision-Making are coded as moderately impaired. Activities of Daily Living (ADL) skills require no physical assistance. The ADL Comprehensive Care Plan (CCP) dated 05/20/10 and updated 08/24/10 documented that the resident transfers and ambulates independently and is independent in toilet use. The Elimination Needs Comprehensive Care Plan (CCP) dated 05/20/10 and updated 08/24/10 documented that the resident is continent in bowel and bladder. The facility's Policy and Procedure on Resident Abuse (PPRA) documents that all residents will be free and protected from abuse, neglect and mistreatment including verbal, sexual, written, gestural, physical and mental abuse. The PPRA states that a full investigation will be initiated as soon as an allegation of resident abuse of any kind has been voiced and the facility will ensure all residents are protected from further abuse during the investigatory process. An interview was conducted with an alert and oriented resident on 09/21/10 at 12:26 PM (Resident #30). The MDS assessed this resident with modified independence in cognitive skills for decision-making. Resident #30 stated that she previously resided on the second floor, across the hall from Resident #29. She said she had complained about a Certified Nurse Aide (CNA #4) who was having sex with Resident #29. Resident #30 stated that she saw it happen once, reported it and nothing was done. She stated there were other times when CNA #4 touched Resident #29's breasts. Resident #30 stated that she had told CNA #1, CNA #2 and LPN #1. Furthermore, Resident #30 stated she reported the abuse to the Director of Social Services (DSS) but does not believe that the facility's administration ever acts on these kinds of complaint. An interview was conducted with the 7:00 AM to 3:00 PM LPN #1 on 09/21/10 at 2:08 PM. LPN #1 stated that, sometime in June 2010, Resident #30 told LPN #1 that she had seen CNA #4 having sex with Resident #29. LPN #1 stated that she tried to question Resident #30 at the time but Resident #30 did not want to talk about it. LPN #1 stated that she did not report this to anyone at that time because she had not seen anything herself. An interview was conducted with the 7:00 AM to 3:00 PM CNA #1 on 09/22/10 at 10:47 AM. CNA #1 stated that she had been told by Resident #30 a few months ago that CNA #4 was "raping" Resident #29. CNA #1 stated that she reported this to the Registered Nurse Supervisor (RNS #4) and the DSS but "no one ever did anything." CNA #1 also stated that on 08/28/10 she heard a member of the housekeeping staff allege that CNA #4 was doing inappropriate things with Resident #29. CNA #1 then said she decided to report this to the charge nurse (LPN #3) the next day. A telephone interview was conducted with the former RNS #4 on 09/23/10 at 3:46 PM. RNS #4 stated that she was never told by any resident or staff member that sexually inappropriate conduct was taking place between Resident #29 and CNA #4. An interview was conducted with the 6:00 AM to 2:00 PM CNA #2 on 09/22/10 at 10:19 AM. CNA #2 stated that a few months ago, in May or June 2010, Resident #30 reported that CNA #4 was having sex with Resident #29. CNA #2 stated that she told RNS #4 about this at the time, but CNA #2 did not feel anything was being done. CNA #2 further stated that, at that point, she decided to call the DSS. She said she spoke with the DSS, advising her that Resident #30 had said she saw CNA #4 have sex with Resident #29. CNA #2 stated that the DSS told her that Resident #30 did not like the DSS and would probably not talk to her. CNA #2 then began to cry during this interview and stated "I didn't know what else to do. No one would do anything." The Social Work Progress Notes from 04/23/10 to 08/30/10 were reviewed. There was no documentation that an allegation of potential abuse involving Resident #29 was reported. A telephone interview was conducted with the Director of Social Services (DSS) on 09/23/10 at 11:07 AM. The DSS stated that she is not aware of reports of sexual misconduct between CNA #4 and Resident #29 prior to the incident of 08/28/10. She denied being told by staff or residents of any alleged abuse. An interview was conducted with the 7:00 AM to 3:00 PM CNA #3 on 09/22/10 at 10:38 AM. CNA #3 stated that "there has been talk for a while" that CNA #4 was doing sexually inappropriate things with Resident #29. CNA #3 stated that she never actually witnessed anything but heard about this from other staff members and from Resident #30. CNA #3 stated that she never reported anything because she was aware that other staff members had notified the facility's administration, but nothing was done. There was no documented evidence that an investigation was initiated or that an Accident/Incident (A/I) report was completed in June, 2010 in connection with the allegations of resident sexual abuse that were being raised by staff. The facility's Accident/Incident Report (A/I) dated 8/29/10 documented a "questionable resident abusive incident" and that the resident was unable to give a statement. CNA #4 was seen on 08/28/10 standing close to the female resident, who was noted with her underwear partially down and blouse raised up, partially exposing her breasts. The section entitled "Recommendation for preventative measures not in place/additional corrective measures," documented (CNA) "suspension during investigation, transfer from floor, in-service on abuse prohibition." The A/I also documented that the physician was notified on 08/29/10 at 2:30 PM. An interview was conducted with the 7:00 AM to 3:00 PM medication nurse, LPN #2, on 09/21/10 at 1:20 PM. LPN #2 stated that, on 8/28/10, she walked into Resident #29's room to administer medications. She found Resident #29 bent slightly over, with no pants on, panties down, shirt up with breasts exposed. CNA #4 was standing behind the resident with a towel in his hand; CNA #4 threw the towel down and left the room. LPN #2 said she asked the resident if she was okay and the resident said 'Yes.' LPN #2 acknowledged that she did not report her observations to anyone. LPN #2 further stated that she did not know, at the time, that CNA #4 was not assigned to care for Resident #29. An interview was conducted with a member of the Housekeeping staff (HK) on 09/21/10 at 1:54 PM. The HK stated that, on 8/28/10, LPN #2 told her that she (LPN #2) had gone into Resident #29's room and observed the resident's panties all the way down and shirt up. The HK stated that LPN #2 said she believed CNA #4 "was playing with her." The HK also stated that she told LPN #2 that she had heard about this before, but the facility's administration had never done anything about it. The HK further stated that LPN #1 had known about CNA #4's inappropriate behavior and that Resident #30 had also said something about it "a while ago." The HK stated that she did not report her conversation with LPN #2 to anyone because the facility's administration "has heard this before. You report it and nothing gets done." An interview was conducted with the 7:00 AM to 3:00 PM charge nurse, LPN #3, on 09/21/10 at 1:34 PM. LPN #3 stated that on 8/29/10 (time unknown) CNA #1 reported to her that on the previous day, LPN #2 had seen CNA #4 standing behind Resident #29, who had her pants down and breasts exposed. LPN #3 stated that she had concerns because CNA #4 was not assigned to the resident. Furthermore, she said that the resident does not need to be taken to the bathroom. In addition, LPN #3 stated that she was aware of "talk of this kind of thing before." LPN #3 phoned the nursing supervisor to report her concerns. LPN #3 stated that she talked with the resident but did not look at the resident's body. LPN #3 also stated that she did not notify the nurse practitioner, the doctor or the resident's family. The Clinical Assignment Record documented that CNA #4 worked the 7:00 AM-3:00 PM shift on 08/28/10 and again on 08/29/10. The accused CNA #4 is no longer working at the facility. An interview was attempted with CNA #4 on 09/23/10 at 10:01 AM. CNA #4 stated, "I don't want to say anything about this right now. I don't know how this could be used." An interview was conducted with the 7:00 AM to 3:00 PM RNS #1 on 09/21/10 at 12:40 PM. RNS #1 stated that on 08/29/10 the LPN charge nurse (LPN #3) spoke to her, at approximately 3 PM that day, regarding an observation made by the medication nurse (LPN #2) the previous day. RNS #1 stated that she was told that LPN #2 had observed the resident with her panties down and breasts exposed while CNA #4 was standing behind the resident with a towel in his hand. RNS #1 stated that LPN #3 was concerned because an aide (CNA #1) had informed LPN #3 that staff were talking about possible sexual assault. Furthermore, the accused aide, CNA #4, was not assigned to care for the resident and the resident did not need any assistance with ADL skills. CNA #4 had already completed his 7:00 AM-3:00 PM shift that day. The Nursing Progress Notes dated 08/29/10 at 7:00 PM documented that, "on physical assessment" the resident "showed no signs or symptoms of distress." The notes were written by the 3:00 PM to 11:00 PM RNS #1. RNS #1 phoned the Director of Nursing (DON), started an incident report and began an investigation. RNS #1 stated that she did not phone the physician or the resident's family but believes the Nurse Practitioner (NP) may have seen the resident on 08/30/10. RNS #1 admitted that she documented, in the resident's medical record, that she performed a physical assessment of the resident when, in fact, she did not assess her. RNS #1 stated that she was directed to write "on physical assessment" in the medical record, but she would not disclose who instructed her to document the medical record in that manner. An interview was conducted with the 3:00 PM to 11:00 PM RN Supervisor (RNS #2) on 09/22/10 at 9:34 AM. RNS #2 stated that she received a verbal report from RNS #1 on 08/29/10 that there was a possible sexual assault of Resident #29 by CNA #4 the previous day. RNS #2 also stated that on 08/29/10 she documented, in the resident's medical record, that she physically assessed the resident. However, she admitted that she did not actually do a physical assessment because she thought it was inappropriate to examine the resident by pulling her pants down. RNS #2 stated that she interviewed the resident and assessed the resident as having no changes in mood. A review of the Progress Notes dated 08/29/10 at 11:30 PM revealed an entry by RNS #2 indicating that there was no change in the resident's behavior or mood. In a subsequent interview with RNS #2 on 09/23/10 at 9:39 AM, she stated that she used the wrong terminology when she made notations in Resident #29's medical record on 8/29/10. RNS #2 stated that a physical assessment would involve disrobing the resident and checking the resident's body. RNS #2 admitted that she did not do this and only spoke with the resident. RNS #2 added that the resident did not seem to have any emotional distress so she did not think it warranted a physical assessment. An interview was conducted with the NP on 09/22/10 at 10:34 AM. The NP stated that she believes (but could not be certain) she was asked to see the resident by RNS #1 on 8/30/10 due to a possible sexual assault. The NP stated that she asked the resident if she was in any pain and the resident responded, 'No.' The NP stated that she performed a physical examination of the resident's outer vaginal area and found no abnormal findings. There was no redness, swelling or discharge. She further stated that she made a recommendation for the resident to see a gynecologist. The NP did not know if a doctor saw the resident, and she did not call the doctor herself. The NP also said that she would normally document her findings in the Doctor's Progress Notes but admitted that she failed to write a note in the resident's medical records and did not issue an order with her recommendation. The medical record lacked documented evidence of the NP's physical examination of the resident or any evidence that she issued an order with her recommendation.. An interview was conducted with the DON on 09/23/10 at 12:25 PM. The DON stated that RNS #1 reported the alleged incident to her on 08/29/10 (time unknown). The DON then instructed RNS #1 to remove CNA #4 from the staffing schedule. The DON stated that she would not expect her staff to assess the resident until they had an opportunity to speak with CNA #4 in order to get his story. She said that when she first learned of the 08/28/10 incident, she was unaware that there had been prior allegations of sexual misconduct by CNA #4. However, she subsequently learned from staff that there were rumors in the facility months before the August, 2010 incident. The DON further stated that she is in charge of the Abuse Prohibition Review. Since the 08/28/10 incident no formal interventions, including re-inservicing of staff, have been put in place to prevent recurrence and protect other residents. The DON explained that the facility was awaiting a "DOH conclusion" on the matter before taking such action. She concluded the interview by stating she had "other things to do." The Nursing Progress Notes dated 08/30/10 at 9:00 AM documented that the resident was interviewed and "denies any current relationship with male." The notes were written by the DON. The Doctor's Progress Notes dated 8/31/10 documented that somebody possibly molested the resident and the facility is still investigating. The resident was sent to the hospital for gynecological examination An interview was conducted with the Attending Physician (AP) on 09/23/10 at 10:19 AM. The AP stated that he was never advised of the alleged incident with Resident #29 until he came into the facility for routine rounds on 08/31/10. At that time, the DON asked the AP to see the resident due to a possible sexual assault. The AP stated that he should have been called when the alleged incident happened or, at the very least, when staff was aware. The AP stated that he would have sent the resident out to the hospital earlier. The AP stated that he was not aware of any earlier incidents of sexual abuse of Resident #29. An interview was conducted with the Administrator on 09/23/10 at 3:22 PM. The Administrator stated that the DON informed him on 08/30/10 of a possible sexual assault of Resident #29 that occurred on 08/28/10. The Administrator also stated that it was not until a few days after the 08/28/10 incident that the DON also made him aware that there were rumors in the facility of prior acts of sexual abuse. 2A) Resident #35 has [DIAGNOSES REDACTED]. The annual Minimum Data Set (MDS) assessment dated [DATE] documented that the resident had moderately impaired cognitive skills for daily decision-making with no short or long-term memory problems. The resident was independent regarding transfers and ambulation and exhibited verbally abusive behavioral symptoms on 1-3 occasions in the past seven days. A Nurse's Progress Note dated 09/05/10 at 10:20 PM documented that the Smoking Aide (Monitor) telephoned at 9:15 PM to report that there were verbal agitations with residents in the backyard (smoking area). The Smoking Monitor also stated that when she returned to the backyard she witnessed Resident #35 sitting on the floor and swearing loudly. The resident stated that she was pushed by Resident #40 to the floor and sustained a scratch to her right outer ankle. Resident #35 was advised to stay on her nursing unit, but went to the unit of the accused resident after this occurrence. A Nurse's Progress Note dated 09/06/10 at 12:30 AM documented that the resident was transferred to the hospital. A Nurse's Progress Note dated 09/06/10 at 4:25 AM documented that the resident returned to her unit. The Accident/Incident (A/I) Report dated 09/05/10 documented that Resident #35 stated, "He pushed me." The A/I Summary documented that Resident #35 was observed on the ground. Resident #40 stated that Resident #35 hit him, he got angry, and hit Resident #35 causing Resident #35 to fall off her chair. The statement from the Smoking Monitor documented that she stepped away from the patio for a few minutes to get cigarettes and upon her return, saw Resident #35 on her knees getting up from the ground. The plan included Social Service intervention and to counsel resident to avoid contact with Resident #40. There was no documented plan to counsel the Smoking Monitor who had left the smoking area unattended. The Social Work (SW) Note dated 09/07/10 documented that Resident #35 had an altercation with Resident #40. Resident #35 stated that she was punched by Resident #40 because she witnessed them drinking beer outside on the patio. Resident #35 stated that Resident #40 also stated to her if she said anything to Resident #21 he would hit her. Resident #35 stated that she then cursed at Resident #21 resulting in Resident #40 punching her and they both landed on the floor. Resident #35 was later transferred to the hospital for evaluation. The Director of Recreation was interviewed on 09/28/10 at 2:30 PM and stated that she oversees the three employees who are the Smoking Monitors and that there are four times each day when residents are permitted to smoke: 9:00 AM-10:30 AM, 1:00 PM-2:00PM, 3:30 PM-4:30 PM, and 6:30 PM-9:30 PM. The Director also stated that at each smoking session, one Smoking Monitor was responsible to monitor the smoking area, but there was no limit to the amount of residents that may smoke at any given time. The Director stated that she verbally informed the Smoking Monitors if there were any particular residents that must be closely monitored due to behavioral issues. The Director also stated that the Smoking Monitors should not leave the smoking area unattended and should have a walkie-talkie to communicate with the Receptionist's desk if any problems arose. The Director stated that there were no cameras to monitor the smoking area that she was aware of. The Director also stated that the Smoking Monitor was verbally counseled regarding leaving the smoking area unattended. The Director further stated that she was not aware of Resident #35's statement to the SW that residents were drinking beer on the patio on 09/05/10. The Director of Nursing (DON) was interviewed on 09/28/10 at 3:15 PM and stated that she was unaware that Resident #35 told the SW that residents were drinking beer on the smoking patio on 09/05/10 despite signing the A/I report on 09/07/10 and indicating that the review of this investigation had been completed. Additionally, the DON signed that enough information had been identified that the cause of the A/I could be identified and there was enough information to rule out abuse, neglect or mistreatment. The SW who had written the note on 09/07/10 was interviewed on 09/28/10 at 3:30 PM and she stated that she reported Resident #35's statement regarding beer drinking on the patio on 09/05/10 to the DON. 2B) Resident #40 has [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented that Resident #40 had no long or short-term memory problems, had independent cognitive skills for daily decision-making, and could understand and be understood. The MDS further documented that Resident #40 did not have behavioral symptoms. The Interim/Telephone physician's orders [REDACTED]. Review of the A/I Report dated 09/05/10 documented that Resident #40 had a physical altercation with another resident (Resident #35). The A/I report documented that Resident #40 stated, "I was provoked. She hit me first and then I hit her." The A/I Summary of Investigation documented that the Smoking Monitor had stepped away to get cigarettes and did not witness the incident. It also documented that Resident #40 was transferred to the emergency room for psychiatric evaluation. During an interview with the Director of Recreation on 09/28/10 at 2:30 PM she stated that she had not investigated why the Smoking Monitor had to leave the smoking area to obtain cigarettes or why the Monitor did not call another staff person to cover the smoking area in her absence. An observation of the patio smoking area on 09/28/10 between 1:05 PM and 1:30 PM revealed that there were 21 residents initially on the patio. During the observation approximately 12-15 other residents entered the smoking area. The patio smoking area is accessed by exiting the lobby of the facility into a large unsupervised dayroom that exits to the right onto the patio. The entrance to the patio is protected by an awning that extends forward and to the left and right of the entrance and down the right side of the center of the open yard. An attached clear plastic drape that protects the residents from the elements extends down from the awning. Paths from the entrance and either side of the awning area exit onto the open yard area which is approximately 160 square feet with bushes and a fence surrounding the yard. An observation of the Smoking Monitor at the same time revealed that the Monitor was positioned at the exit of the dayroom under the awning. The Monitor had a table with boxes of labeled cigarettes and was observed to light residents' cigarettes as she dispensed them. The usual daytime Smoking Monitor was interviewed on 09/28/10 at 1:20 PM and stated that there can be over 57 residents that smoke present on the patio during smoking times. The Smoking Monitor further stated that she currently had a walkie-talkie to contact staff if she needed to leave the area or if a problem occurred. The Monitor further stated that she was not always provided with a walkie-talkie, but she now ensures she has one (a walkie-talkie) every day. 3) Resident #23 has [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] documented that the resident had moderately impaired cognitive skills for daily decision-making with short and long-term memory problems. A Nurse's Progress Note dated 05/11/10 documented that the resident was noted at 8:15 PM with a bluish discoloration to the left outer thigh measuring four centimeters (cm) by three cm. The A/I Report dated 05/11/10 at 8:15 PM documented that the Certified Nursing Assistant (CNA) identified a bluish discoloration to the resident's left outer thigh. The summary of the investigation documented that the resident returned from [MEDICAL TREATMENT] and must have hit the left side of their wheelchair/left armrest area while being transferred from their wheelchair to the [MEDICAL TREATMENT] area. The A/I report contained statements from the CNA who identified the bluish discoloration, the Licensed Practical Nurse (LPN) on duty for that nursing shift, and the Registered Nurse (RN) who the discoloration was reported to. The A/I also contained statements from the LPN who provided care to the resident on the previous day on the 11:00 PM-7:00 AM shift. There were no statements obtained from the CNAs who provided care to the resident on the 7:00 AM-3:00 PM nursing shift on 05/11/10 or the 11:00 PM-7:00 AM nursing shift on 05/10/10. The Director of Nursing (DON) was interviewed on 09/21/10 at 3:00 PM and stated that there must be some more statements somewhere. As of the exit on 09/28/10 at 5:30 PM, no additional statements were presented to the Surveyor Team. 415.4(b)(1)(ii)

Based on observation, resident and staff interviews and record review during a recertification/abbreviated and extended survey, it was determined that the facility failed to implement its abuse prohibition policies and procedures, which were designed to prevent resident abuse and neglect and protect residents from further abuse whenever abuse was identified. The facility also failed to review its policies and procedures for reporting and investigating abuse and failed to provide re-training to its staff. Specifically, one resident (Resident #29) of 38 residents reviewed for abuse prohibition was identified as a potential victim of sexual abuse on August 28, 2010. Over the next two days, the nursing staff did not assess the resident, notify the physician or put measures in place in order to protect the resident's health and safety. Furthermore, several months prior to the August 28, 2010 incident, facility staff were aware of similar allegations of sexual abuse of the resident, but the facility failed to investigate these allegations and protect the resident's well-being. The facility's failure to fully implement policies and procedures to prevent abuse and protect residents from instances of abuse has the potential of jeopardizing the health and safety of twenty-six (26) residents currently identified by the facility with cognitive impairments on unit 2 North. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. Complaint ID Number: NY 943 The findings are: Resident #29 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 2.0 (a resident assessment tool) dated 08/19/10 documented that the resident's short-term and long-term memory are impaired. Cognitive Skills for Daily Decision-Making are coded as moderately impaired. Activities of Daily Living (ADL) skills require no physical assistance. The facility's Policy and Procedure on Resident Abuse (PPRA) documented that all residents will be free and protected from abuse, neglect and mistreatment including verbal, sexual, written, gestural, physical and mental abuse. The PPRA documented that a full investigation will be initiated as soon as an allegation of resident abuse of any kind has been voiced and the facility will ensure the protection of all residents during the investigatory process. The Accident/Incident Report (A/I) dated 8/29/10 documented a "questionable resident abusive incident" and that the resident was unable to give a statement. The Certified Nursing Assistant (CNA #4) was seen on 8/28/10 standing close to the female resident, who was noted with her underwear partially down and blouse raised up and partially exposing her breasts. The section, entitled "Recommendation for preventative measures not in place/additional corrective measures," documented (CNA) "suspension during investigation, transfer from floor, in-service on abuse prohibition." The Doctor's Progress Notes dated 8/31/10 documented that somebody possibly molested the resident and the resident was sent to the hospital for gynecological examination. An interview was conducted with an alert and oriented resident (Resident #30) on 09/21/10 at 12:26 PM. The MDS assessed this resident with modified independence in cognitive skills for decision-making. Resident #30 stated that she had previously resided on the second floor, across the hall from Resident #29. She said she had made complaints to staff regarding CNA #4 having sex with Resident #29. Resident #30 stated that she saw it happen once, reported it and nothing was done. She stated that there were times that CNA #4 touched Resident #29's breasts as well. Resident #30 stated that she had told CNA #1, CNA #2 and a Licensed Practical Nurse (LPN #1). She stated that she also called the Director of Social Services (DSS) to report the abuse but Resident #30 added that she does not believe that the facility's administration ever does anything about these situations. An interview was conducted with the 7:00 AM to 3:00 PM Registered Nurse Supervisor (RNS #1) on 09/21/10 at 12:40 PM. RNS #1 stated that on 08/29/10 the LPN charge nurse (LPN #3) spoke to her, at approximately 3 PM that day, regarding an observation made by the medication nurse (LPN #2) the previous day. RNS #1 stated that she was told that LPN #2 had observed the resident with her panties down and breasts exposed while CNA #4 was standing behind the resident with a towel in his hand. RNS #1 stated that LPN #3 was concerned because an aide (CNA #1) had informed LPN #3 that staff were talking about possible sexual assault and the resident did not require assistance with adult daily living skills. Furthermore, the accused aide, CNA #4, was not assigned to care for the resident. RNS #1 phoned the Director of Nursing (DON), started an incident report and began an investigation. RNS #1 stated that she did not phone the physician or the resident's family but believes the Nurse Practitioner (NP) may have seen the resident on 08/30/10. RNS #1 stated that she documented, in the resident's medical record, that she performed a physical assessment of the resident, but, in fact, she did not assess her. An interview was conducted with the 7:00 AM to 3:00 PM LPN #1 on 09/21/10 at 2:08 PM. LPN #1 stated that, sometime in June 2010, Resident #30 (an alert and oriented resident) had told LPN #1 that she had seen CNA #4 having sex with Resident #29. LPN #1 stated that she tried to question Resident #30 at the time but Resident #30 did not want to talk about it. LPN #1 stated that she did not report this to anyone at that time. There was no documented evidence that an Accident/Incident report or investigation was completed in June 2010. An interview was conducted with the 7:00 AM to 3:00 PM medication nurse, LPN #2, on 09/21/10 at 1:20 PM. LPN #2 stated that, on 08/28/10, she walked into Resident #29's room to administer medication and observed the resident with no pants on, panties down, shirt up with breasts exposed and slightly bent over. CNA #4 was standing behind the resident with a towel in his hand. When LPN #2 walked in, CNA #4 threw the towel down and left the room. LPN #2 asked the resident if she was okay and the resident said 'Yes.' LPN #2 acknowledged that she did not report her observation to anyone. An interview was conducted with the 7:00 AM to 3:00 PM charge nurse, LPN #3, on 09/21/10 at 1:34 PM. LPN #3 stated that, on 8/29/10, CNA #1 came to her (unknown time) saying that, on 8/28/10, LPN #2 had seen CNA #4 standing behind Resident #29, who had her pants down and breasts exposed. LPN #3 stated that she had concerns because CNA #4 was not assigned to the resident. Furthermore, the resident does not need to be taken to the bathroom. LPN #3 also stated that she was aware of "talk of this kind of thing before." LPN #3 phoned the nursing supervisor to report her concerns. LPN #3 stated that she did not notify the nurse practitioner, the doctor or the resident's family. An interview was conducted with the Housekeeper (HK) on 09/21/10 at 1:54 PM. The HK stated that on 08/28/10 LPN #2, told the HK that LPN #2 had gone into Resident #29's room to find the resident's panties all the way down and shirt up. The HK stated that LPN #2 said she believed CNA #4 "was playing with her." The HK stated that she told LPN #2 that she had heard this before but the facility's administration had never done anything about it. The HK stated that LPN #1 had known about CNA #4's inappropriate behavior with the resident and that Resident #30 had also said something about it "a while ago." The HK stated that she did not report the alleged incident in August 2010 because the facility's administration "have heard this before. You report it and nothing gets done." The Clinical Assignment Record documented that CNA #4 worked the 7:00 AM-3:00 PM shift on 08/28/10 and 08/29/10. The accused CNA #4 is no longer working in the facility. An interview was conducted with the 7:00 AM to 3:00 PM CNA #1 on 09/22/10 at 10:47 AM. CNA #1 stated that she had heard the housekeeper talking on 08/28/10 about the accused CNA #4 doing inappropriate things with Resident #29 so she decided to tell the nurse in charge (LPN #3) the next day. CNA #1 stated that she had been told by Resident #30 a few months ago that the accused was "raping" Resident #29. CNA #1 stated that she had reported this to RNS #4 and the DSS but "no one ever did anything." A telephone interview was conducted with the former RNS #4 on 09/23/10 at 3:46 PM. RNS #4 stated that she was never told by any resident or staff member that sexually inappropriate conduct was taking place between Resident #29 and CNA #4. An interview was conducted with the 6:00 AM to 2:00 PM CNA #2 on 09/22/10 at 10:19 AM. CNA #2 stated that a few months ago, in May or June 2010, Resident #30 had reported that CNA #4 was having sex with Resident #29. CNA #2 stated that she told RNS #4 about this at the time but CNA #2 did not feel anything was being done. CNA #2 further stated that, at that time, she decided to call the DSS. She said she spoke with the DSS, advising her that Resident #30 had said she saw the accused having sex with Resident #29. CNA #2 stated that the DSS told her that Resident #30 did not like the DSS and would probably not talk to her. CNA #2 then began to cry during this interview and stated "I didn't know what else to do. No one would do anything." The Social Work Progress Notes from 04/23/10 to 08/30/10 were reviewed. There was no documentation that an allegation of potential abuse involving Resident #29 was reported. A telephone interview was conducted with the Director of Social Services (DSS) on 09/23/10 at 11:07 AM. The DSS stated that she is not aware of reports of sexual misconduct between CNA #4 and Resident #29 prior to the incident of 08/28/10. She denied being told by staff or residents of any alleged abuse. An interview was conducted with the 7:00 AM to 3:00 PM CNA #3 on 09/22/10 at 10:38 AM. CNA #3 stated that "there has been talk for a while" that the accused was doing sexually inappropriate things with Resident #29. CNA #3 stated that she never actually witnessed anything but has heard about this from other staff members and from Resident #30. CNA #3 stated that she has never reported anything but is aware that other staff members have notified the facility's administration, but nothing was done. An interview was conducted with the 7:00 AM to 3:00 PM LPN #4 on 09/22/10 at 2:51 PM. LPN #4 stated that she had heard talk about CNA #4 having sex with Resident #29 in the past but LPN #4 considered it a rumor. LPN #4 stated that she never reported these rumors to anyone. An interview was attempted with accused CNA #4 on 09/23/10 at 10:01 AM. CNA #4 stated, "I don't want to say anything about this right now. I don't know how this could be used." An interview was conducted with the Attending Physician (AP) on 09/23/10 at 10:19 AM. The AP stated that he was never advised of the alleged incident with Resident #29 until he came into the facility for routine rounds on 08/31/10. At that time, the DON asked the AP to see the resident due to a possible sexual assault. The AP stated that he should have been called when the alleged incident happened or, at least, when staff was aware. The AP stated that he would have sent the resident out to the hospital earlier. The AP stated that he was not aware of any earlier incidents of sexual abuse of Resident #29. An interview was conducted with the In-Service Director (ISD) on 09/23/10 at 10:35 AM. The ISD stated that facility staff utilize self-help, computerized in-service programs for abuse, neglect and mistreatment. Since the alleged incident on 08/28/10, there has been no specific training or in-service to staff regarding abuse, neglect or mistreatment, according to the ISD. The ISD further stated that the facility will plan to institute something once the New York State Department of Health concludes its current investigation. An interview was conducted with the DON on 09/23/10 at 12:25 PM. The DON stated that RNS #1 reported the alleged incident to her on 08/29/10 (time unknown). The DON then instructed RNS #1 to remove CNA #4 from the staffing schedule. The DON stated that when she saw the resident on 08/30/10, she did not look at the resident's private areas, but there was nothing on her underwear to suggest any indication of foul play. The DON acknowledged that her examination of the resident occurred two days after the incident. The DON further stated that she would not expect her staff to have assessed the resident before getting a chance to speak with CNA #4 in order to get his story. She was not aware of any prior allegations of misconduct on the part of CNA #4 when she first learned about the 08/28/10 incident. However, she subsequently learned from staff that there were rumors in the facility months before the August, 2010 incident, that CNA #4 was victimizing Resident #29. The DON further stated that, since the August, 2010 incident, no formal interventions have been put in place to prevent recurrence and protect other residents. She explained that the facility was awaiting a "DOH conclusion" on the matter before taking such action. The DON stated that she is in charge of the Abuse Prohibition Review. An interview was conducted with the Administrator on 09/23/10 at 3:22 PM. The Administrator stated that the DON informed him on 08/30/10 of a possible sexual assault of the resident on 08/28/10. The Administrator stated that he would not necessarily expect his staff to have performed a physical assessment of the resident before interviewing staff. The Administrator stated that it was not until a few days after the alleged incident in August 2010 that the DON made him aware that there were also rumors of prior instances of abuse. The Administrator further stated that there has been no specific training since the alleged incident. A telephone interview was conducted with the Medical Director (MD)on 09/24/10 at 12:07 PM. The MD stated that he is not aware of any action taken by the facility after the 08/28/10 incident to in-service facility staff. 415.4(b)

Based on resident and staff interviews and record review during a recertification/abbreviated and extended survey, it was determined that the facility failed to provide medically related social services to attain the highest practicable, physical, mental and psychosocial well-being of each resident. Specifically, a cognitively impaired resident (Resident #29) was identified as a potential victim of sexual abuse in June, 2010. Another resident and several staff members stated they reported this to the Director of Social Services. The Director of Social Services (DSS), however, failed to act on these allegations and did not take measures to protect the health and safety of Resident # 29. The DSS also did not report these allegations to the facility's Administrator. Resident #29 was subsequently identified as a potential victim of sexual abuse, involving the same alleged perpetrator, on August 28, 2010. The facility's failure to identify and pursue the need for medically related social services to prevent occurrences of resident abuse has the potential of jeopardizing the health and safety of twenty-six (26) residents currently identified by the facility with cognitive impairments on unit 2 North. This resulted in no actual harm with the potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. Refer to additional deficiencies cited under Immediate Jeopardy and Substandard Quality of Care: F 224, F 225, F 226 and F 490. Complaint ID Number: NY 943 The findings are: The facility's Statement of Residents' Rights (SRR) documented that each resident shall have the right to be free from verbal, sexual, mental or physical abuse. SRR documented that each resident shall have the right to obtain prompt efforts by the facility to resolve grievances, including those with respect to the behavior of other residents. The facility's Policy and Procedure on Resident Abuse (PPRA) documents that all residents will be free and protected from abuse, neglect and mistreatment including verbal, sexual, written, gestural, physical and mental abuse. PPRA also documents that a full investigation will be initiated as soon as an allegation of resident abuse has been voiced and the facility will ensure the protection of all residents during the investigatory process. Resident #29 is [AGE] years old and was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 2.0 (an assessment tool) dated 08/19/10 documented that the resident's short and long-term memory are impaired. Cognitive Skills for Daily Decision-Making are coded as moderately impaired. Activities of Daily Living (ADL) skills require no physical assistance. An interview was conducted with an alert and oriented resident on 09/21/10 at 12:26 PM (Resident #30). The MDS assessed this resident with modified independence in cognitive skills for decision-making. Resident #30 stated that she previously resided on the second floor, across the hall from Resident #29. She said she had complained about a Certified Nurse Aide (CNA #4) who was having sex with Resident #29. Resident #30 stated that she saw it happen once, reported it and nothing was done. She stated there were other times when CNA #4 touched Resident #29's breasts. Resident #30 stated that she had told CNA #1, CNA #2 and a Licensed Practical Nurse (LPN #1). Furthermore, Resident #30 stated she reported the abuse to the DSS but does not believe that the facility's administration ever acts on these kinds of complaint. An interview was conducted with the 7:00 AM to 3:00 PM CNA #1 on 09/22/10 at 10:47 AM. CNA #1 stated that she had been told by Resident #30 a few months ago that CNA #4 was "raping" Resident #29. CNA #1 stated that she had reported this to the DSS but "no one ever did anything." An interview was conducted with the 6:00 AM to 2:00 PM CNA #2 on 09/22/10 at 10:19 AM. CNA #2 stated that a few months ago, in May or June 2010, Resident #30 reported that CNA #4 was having sex with Resident #29. CNA #2 stated that she told RNS #4 about this at the time, but CNA #2 did not feel anything was being done. CNA #2 further stated that, at that time, she decided to call the DSS. She said she spoke with the DSS, advising her that Resident #30 had said she saw CNA #4 have sex with Resident #29. CNA #2 stated that the DSS told her that Resident #30 did not like the DSS and would probably not talk to her. CNA #2 then began to cry during this interview and stated "I didn't know what else to do. No one would do anything." The Social Work Progress Notes from 04/23/10 to 08/30/10 were reviewed. There was no documentation that an allegation of potential abuse involving Resident #29 was reported. The facility's Accident/Incident Report (A/I) dated 8/29/10 documented a "questionable resident abusive incident" and that the resident was unable to give a statement. The Certified Nurse Aide (CNA #4) was seen on 08/28/10 standing close to the female resident, who was noted with her underwear partially down and blouse raised up, partially exposing her breasts. The section entitled "Recommendation for preventative measures not in place/additional corrective measures," documented (CNA) "suspension during investigation, transfer from floor, in-service on abuse prohibition." The A/I also documented that the physician was notified on 08/29/10 at 2:30 PM. A telephone interview was conducted with the DSS on 09/23/10 at 11:07 AM. The DSS stated that she believes the DON started an investigation into the alleged incident of August, 2010 but the DSS is uncertain if a conclusion had been reached. The DSS stated that she was not aware of any prior reports of sexual misconduct between CNA #4 and Resident #29. She denied being told by staff or residents of any alleged abuse. The DSS stated that, based on the alleged event, the family of Resident #29 is now considering discharge options including home care. The DSS further stated that she did not know if the resident was being seen by a psychologist, but the DSS said she saw the resident on routine rounds after the alleged incident in August, 2010. There was no documented evidence in the medical record that the resident was seen by Social Services from 09/01/10 to 09/13/10. On 9/13/10 the Social Work Progress Notes documented that the resident's daughter is considering home care for the resident and Social Work can assist with home care planning when the family provides the facility with the resident's new living arrangements and address. An interview was conducted with a Social Worker (SW) on 09/23/10 at 2:23 PM. The SW stated that she was aware of the alleged incident of 08/28/10. The SW stated that, to her knowledge, there has been no follow-up or training since the alleged incident. The SW stated that she would think Social Services would be involved given the nature of the alleged incident. 415.5(g)(1)(i-xv)

Based on staff interviews and record reviews conducted during a recertification/abbreviated and extended survey, the facility's Administrator failed to ensure that all staff were trained and knowledgeable with respect to the protocols for abuse prohibition. Specifically, the Administrator failed to provide the necessary care and services to protect the health and safety of a cognitively impaired resident (Resident #29) who was allegedly sexually abused by a Certified Nurse Aide (CNA #4). Allegations of sexual abuse of the resident were first raised in June, 2010, but facility staff and key personnel failed to report this alleged abuse to the Administrator and the New York State Department of Health, and failed to implement interventions to prevent further abuse. The allegations were never investigated. On August 28, 2010 nursing staff witnessed suspicious and inappropriate behavior by CNA #4, with Resident #29, but did not immediately report this incident. Over the next two days, the facility did not assess the resident or notify the physician or the resident's family. The facility failed to fully investigate and assess the potential harm to residents, protect those residents during the investigatory process or implement corrective measures to prevent a recurrence of abuse. The facility's failure to ensure that staff were sufficiently knowledgeable and trained to report instances of abuse immediately to supervision and the New York State Department of Health, and the failure to implement policies and procedures to ensure that each resident was protected from further abuse, has the potential of jeopardizing the health and safety of twenty-six (26) residents currently identified by the facility with cognitive impairments on unit 2 North. This resulted in no actual harm with a potential for serious harm that is Immediate Jeopardy and Substandard Quality of Care. Refer to additional deficiencies cited under Immediate Jeopardy and Substandard Quality of Care: F 224, F 225 and F 226. Complaint ID Number: NY 943 The findings are: The facility's Policy and Procedure on Resident Abuse (PPRA) documents that all residents will be free and protected from abuse, neglect and mistreatment including verbal, sexual, written, gestural, physical and mental abuse. The PPRA states that a full investigation will be initiated as soon as an allegation of resident abuse of any kind has been voiced and the facility will ensure all residents are protected from further abuse during the investigatory process. An interview was conducted with the Director of Nursing (DON) on 09/23/10 at 12:25 PM. The DON stated that she would not expect her staff to assess the resident until they had an opportunity to speak with CNA #4 in order to get his story. She said that when she first learned of the 08/28/10 incident, she was unaware that there had been prior allegations of sexual misconduct by CNA #4. However, she subsequently learned from staff that there were rumors in the facility months before the August, 2010 incident. The DON further stated that she is in charge of the Abuse Prohibition Review. Since the 08/28/10 incident no formal interventions, including re-inservicing of staff, have been put in place to prevent recurrence and protect other residents. The DON explained that the facility was awaiting a "DOH conclusion" on the matter before taking such action. She concluded the interview by stating she had "other things to do." An interview was conducted with the Administrator on 09/23/10 at 3:22 PM. The Administrator stated that the Director of Nursing informed him on 08/30/10 of a possible sexual assault of the resident on 08/28/10. The Administrator stated that he would not necessarily expect his staff to have performed a physical assessment of the resident before interviewing staff. The Administrator stated that it was not until a few days after the alleged incident on 08/28/10 that the DON made him aware that there were also rumors of prior instances of abuse. The Administrator further stated that there has been no specific, additional training since the alleged incident. A telephone interview was conducted with the Medical Director on 09/24/10 at 12:07 PM. The Medical Director stated that he is not aware of any action taken by the facility after the 08/28/10 incident to in-service facility staff. The Medical Director stated that he reviews policies and procedures for the facility and that, to his knowledge, the facility's policy on abuse has not been reviewed or updated since the incident. 415.26