Every finding on record at St Mary's Hospital For Children

Based on observation, interview, and record review, the facility failed to ensure that a resident who required respiratory care, including tracheostomy (a surgically created opening called a stoma in the front of the neck leading into the windpipe (trachea) to help a person breathe) care, received services consistent with professional standards of practice and the comprehensive person-centered care plan. This deficient practice was evidenced by the facility's nursing and respiratory therapy staff's failure to respond to critical oxygen saturation alarms for one (1) of six (6) residents (Resident #1) sampled for respiratory care. Specifically, on [DATE] at 8:58 AM, the resident's oxygen saturation dropped to 84%. A mobile alert was transmitted sequentially to Registered Nurses #1, #2, #3, and Respiratory Therapist #1. From 8:58 AM - 9:23 AM, the assigned staff failed to respond to the alarm or perform a clinical assessment of the resident. The alarm cycle continued for 25 minutes without intervention. At 9:23 AM, a second alert was triggered when saturation levels reached 52%, Registered Nurse #4 (not assigned to the resident) responded after hearing the alarm while near the room. Registered Nurse #4 discovered Resident #1 unresponsive with gray skin. A Code Blue was activated, and although a pulse was briefly restored via cardiopulmonary resuscitation, the resident was transferred to the hospital and determined to have no brain activity. On [DATE], life support was terminated, and the resident expired. This failure resulted in actual harm and Immediate Jeopardy to Resident #1, who expired following a period of unresponsiveness and brain death, and placed 105 residents connected to the vital signs and respiratory alert systems at risk.The findings are:The facility's policy and procedure, titled Pulse Oximetry created on 01/2020, reviewed 12/2025 to include the escalation pathway. Clinical alerts will be delivered to nursing staff via Vocera devices (handheld communication devices) as per oxygen and pulse rate parameters ordered by medical providers. The primary nurse will receive the first notification/alert. The secondary notification is sent to the Nurse Buddy if not acknowledged by the Primary Nurse. The third escalation point is the clinician designated as the backup depending on the alarm type if not acknowledged by the Nurse Buddy. Charge nurse (third nurse) will receive both alerts (SpO2 and pulse). Respiratory therapists will only receive SpO2 (oxygen saturation).Resident #1 was admitted to the facility with diagnoses that include spastic quadriplegic cerebral palsy (a neurological condition that causes increased muscle tone (spasticity) and stiffness, affecting all four limbs and the face), severe hypoxic ischemic encephalopathy (a critical brain injury in newborns caused by significant oxygen deprivation or restricted blood flow) chronic respiratory failure.The Minimum Data Set (a resident assessment tool) dated [DATE] identified that the resident was severely cognitively impaired. The resident was totally dependent on staff for all activities of daily living.A review of the Care Plan titled, Respiration Alteration, initiated on [DATE], identified the resident with tracheostomy and pulse oximeter noted in place with oxygen saturation level parameters set for an alert below 92%.A physician's order dated [DATE] ordered mechanical ventilation, continuous positive airway pressure to tracheostomy collar 12:00 AM to 8:00 AM and humidified trach collar oxygen 8:00 AM to 12:00 AM. It is also documented to maintain oxygen saturation above 92%.A review of the facility's investigation form dated [DATE] revealed that the facility conducted an investigation into the incident and concluded that staff failed to respond to alarms. The report documented that there was a failure of staff to appropriately acknowledge and review alerts. It also concluded that there was a failure by nursing and respiratory therapy staff to maintain accessibility to required communication devices and failure to escalate when they were occupied or unable to respond to the alert. The report specified Registered Nurse #1, Registered Nurse #2, Registered Nurse #3 and Respiratory Therapist #1 as having failed to respond to the alert and assess the resident.A review of the facility's video surveillance footage revealed that on [DATE] at 9:22 AM, Registered Nurse #4 entered Resident #1's room.A review of the facility's staffing sheet dated [DATE] for Unit 4C reported a census of 25 residents and documented five (5) registered nurses from 7:00 AM to 7:30 PM. Registered Nurse #1 worked until 3:30 PM and was relieved by another nurse. Staffing sheet revealed there were five (5) registered nurses and seven (7) certified nursing assistants on the unit at the time of the incident and one (1) respiratory therapist scheduled for that shift.A review of the Call Point Detailed Activity Report dated [DATE] revealed the time each nurse and the respiratory therapist received an alert on their Patient Safe Solutions (mobile phone). The report revealed that at 8:58 AM, Resident #1's oxygen saturation levels dropped to 84% and an alert was sent to Registered Nurse #1, at 8:59 AM an alert was sent to Registered Nurse #2, and at 9:01 AM an alert was sent simultaneously to Registered Nurse #3 (unit charge nurse) and Respiratory Therapist #1. The report indicated that Registered Nurse #1 pressed Accepted on their device at 9:04 AM, again when it alerted at 9:17 AM, and again when it alerted at 9:18 AM, all for decreased oxygen saturation levels. A review of nursing notes on [DATE] did not include documentation from Registered Nurses #1, #2, or #3 indicating that they responded to the alerts or assessed the resident in response to the decreased oxygen saturation levels. During a telephone interview on [DATE] at 11:00 AM, Registered Nurse #1 stated they were the primary registered nurse assigned to the care of Resident #1 on that day. They acknowledged that on [DATE] at 8:58 AM, they received an alert on their Patient Safe Solutions phone from Resident #1's pulse oximeter. Registered Nurse #1 stated at that time they were unable to accept or escalate the alert because they were assisting another resident. Registered Nurse #1 stated they expected the other assigned staff (Registered Nurse #2, Registered Nurse #3, or Respiratory Therapist #1) to respond to the alert since they could not. Registered Nurse #1 stated they recalled accepting the alert once but did not go to the room to assess the resident. Registered Nurse #1 stated that they were unaware activating the accept would end the alerts. Registered Nurse #1 stated they did receive training when they were hired but could not recall a more recent in-service on the alert system.A review of in-service records revealed that nursing and respiratory staff were trained on [DATE] on Vocera Edge Alerts and Alarms systems. Registered Nurse #1 was hired on [DATE] and received training upon hire. Registered Nurse #2 was hired on [DATE] and received training on [DATE]. Registered Nurse #3 was hired on [DATE] and received training on [DATE]. Respiratory Therapist #1 was hired on [DATE] and received training upon hire.During an interview on [DATE] at 1:00 PM, Registered Nurse #2 (buddy nurse) stated they could not recall hearing the alert. They stated they can recall administering medications, and the schedule was hectic that day. They stated that they were unaware Resident #1 was in distress until they heard the rapid response, and they went to assist. Registered Nurse #2 stated they were in-serviced on using the alert phone on orientation and recently after the incident on [DATE].During an interview on [DATE] at 12:37 PM, Registered Nurse #3 (charge nurse) stated that they did receive the alert and did not respond timely. They stated that they expected a response from the primary nurse (Registered Nurse #1) or buddy nurse (Registered Nurse #2). Registered Nurse #3 stated they and the buddy nurse went to the resident's room when rapid response was announced. They stated that they received an in-service on the pulse oximetry policy and training to use the Patient Safe Solutions (phone). Registered Nurse #3 stated they met with the Human Resources Director, the Director of Nursing, and their union representative on [DATE] to discuss the incident and received a written warning. They stated that they were taken off duty until [DATE] and were required to complete in-service prior to assignment.During an interview on [DATE] at 12:03 PM, Registered Nurse #4 stated they were not assigned to Resident #1 but while passing their room, they heard an alarm and went into the room to check Resident #1. Resident #1 was sitting in a chair, skin appeared gray, and they were unresponsive. Registered Nurse #4 stated they activated rapid response and Registered Nurse #5 responded. Both nurses returned Resident #1 to bed and Registered Nurse #5 started chest compressions. Registered Nurse #5 stated Code Blue (part of rapid response activity) was activated at 9:23 AM and the team arrived. They stated emergency medical service was called and responded at 9:44 AM. They stated Resident #1 regained a pulse, was connected to the respirator, and transferred to the hospital.During a telephone interview on [DATE] at 12:36 PM, Respiratory Therapist #1 stated they worked per-diem at the facility since 02/2025. Respiratory Therapist #1 stated they were trained on the Patient Safe Solution system (mobile devices to send alerts) during orientation. Respiratory Therapist #1 stated they worked on [DATE] in the morning and at 8:15 AM they did rounds and Resident #1 was on continuous positive airway pressure overnight and tracheostomy collar during the daytime. Respiratory Therapist #1 stated they assessed, suctioned, and placed the tracheostomy collar on Resident #1. Respiratory Therapist #1 stated that when they were finished, certified nursing assistants came in the room to provide morning care to Resident #1. Respiratory Therapist #1 stated Resident #1's oxygen saturation was 96% and they were comfortable. Respiratory Therapist #1 stated they were in the room when Resident #1 was taken out of bed to the wheelchair. Respiratory Therapist #1 received the alert on the mobile device but was busy with other residents and expected the other staff to respond. Respiratory Therapist #1 stated when they heard the rapid response overhead, they went to the room and Resident #1 was in their wheelchair. Respiratory Therapist #1 stated they used the Ambu bag (artificial manual breathing unit) on Resident #1 and checked their tracheostomy. Respiratory Therapist #1 remained at the bedside during the Code Blue and placed Resident #1 on the ventilator with pressure control settings that were ordered. Respiratory Therapist #1 stated they met with their manager and Director of Human Resources on [DATE]. They were instructed to see their manager on [DATE] when they return to work.During an interview on [DATE] at 3:20 PM, the Nurse Educator stated, if the primary nurse does not answer the alarm, it escalates to the buddy nurse, and if no response, it escalates to the charge nurse and the respiratory therapist. They stated that the settings for the Vocera Edge Alerts and Alarms Training system are View, Accept, Escalate. The Nurse Educator stated if nothing is done (not accepted), the system will escalate and alarm again in 75 seconds. The Nurse Educator stated, on [DATE] at 8:58 AM, the alarm went off and Registered Nurse #1 got an alert alarm in 15 seconds, no response in 75 seconds so the alert went to Registered Nurse #2 (buddy nurse). No response, and the alert went to Registered Nurse #3 (charge nurse) and Respiratory Therapist #1. If escalate is pushed, the alert goes to the buddy nurse immediately. The Vocera system alarm is audible in the room and close by in the hallway. The Nurse Educator stated the Vocera (hands free wearable communication device) system was launched in 2020, and nursing and respiratory staff were trained. There was a re-education in 2024, and training launched [DATE] after the incident. The Nurse Educator stated that the facility did not offer annual in-service for the Vocera Alert and Alarm.During an interview on [DATE] at 11:35 AM, the Chief Medical Officer explained that residents with respiratory and cardiac issues are equipped with pulse oximeters linked to the Vocera monitoring system, which alerts staff when vital signs fall outside of set parameters. Specifically, Resident #1 had a physician's order for alarms to activate when oxygen saturation levels exceeded 92% or dropped below 84%. The Chief Medical Officer noted that when these levels were not within range, the Vocera system triggered alarms both at Resident #1's bedside and on the mobile devices of nursing and respiratory staff. However, a delay in responding to these alerts led to a postponement in assessing Resident #1, which could have resulted in the critical intervention for a Code Blue situation.During an interview on [DATE], at 4:17 PM, the Director of Nursing recounted the incident from [DATE], when they were on their way to the facility and received a call from the Nurse Educator about a Code Blue involving Resident #1. The Nurse Educator reported that Resident #1 had regained their heart rate and was subsequently transported to the hospital. Upon arriving at the facility, the Director of Nursing checked the Vocera (hands free wearable communication device) alerts and found that Registered Nurse #1 had accepted the alarms three (3) times, which halted the notifications to Registered Nurse #2, the charge nurse (Registered Nurse #3), and Respiratory Therapist #1. The alarms later cycled again, and a review of hallway video footage showed that Registered Nurse #1 did not assist Resident #1. When the Director of Nursing interviewed Registered Nurse #1 on [DATE], they claimed they were attending to another resident and had only acknowledged the alarms on their Patient Safe Solution device. Registered Nurse #2, who was administering medications at the time, assumed that Registered Nurse #1 had responded when the alarms ceased. Similarly, Registered Nurse #3 (charge nurse) also did not respond after the alarms stopped. Following these interviews, the Director of Nursing and the Director of Human Resources met with Registered Nurses #2 and #3 and provided them with written counseling for their lack of response to the alarms. Both nurses received three (3) days of administrative leave and were required to complete mandatory Vocera Edge training upon their return. Additionally, all nursing and respiratory staff were scheduled for Vocera in-service training from [DATE] to [DATE]. The Director of Nursing emphasized the need for increased diligence in reviewing and instructing staff on the pulse oximetry policy, along with additional education through mock codes throughout the year.During an interview on [DATE] at 5:16 PM, the Administrator reported that they were present at the facility on [DATE] but were not informed about the Code Blue incident until they were notified by the Chief Medical Officer on [DATE]. The Administrator learned about the delayed response of the registered nurses and respiratory therapist to the Vocera alarm during an administrative meeting on [DATE]. They advised the Director of Nursing that the incident needed to be reported to the New York State Department of Health, and the necessary submission was made. The Administrator also mentioned that they are now part of the Code Blue debriefing process and have directed the assistant directors of nursing, nursing supervisors, and the respiratory director to report all incidents directly to them.During an interview on [DATE] at 4:00 PM, Director of Quality stated they reviewed the Quality Assurance Performance Improvement Plan with the committee members and conduct quarterly meetings. They stated areas for improvement are evaluated by using the Plan Do Study Act performance improvement model and a fish bone Root Cause analysis is further used to analyze the deficient practice. The Director of Quality stated they currently conduct monthly audits for compliance with following physician orders to set respirator and pulse oximeter parameters. They stated based on the incident on [DATE], they are planning audits to monitor the two (2) steps in the process of response and action to alarms/alerts. First step, review the alert system report for time alarm initiated and time it took clinician to respond. Second step, check for escalation and accepted. In addition, observe when clinicians are at residents' bedside.Based on the corrective actions taken by the facility there was sufficient evidence that the facility corrected the identified non-compliance and was in substantial compliance for this specific regulatory requirement on [DATE], prior to surveyor's onsite visit on [DATE].10 New York Codes, Rules and Regulations 415.12(k)(4,6)Corrective actions taken by the facility as of [DATE]Review of the camera footage (8:43 AM to 10:02 AM), Patient Safe Solution phone verification notifications, pulse oximetry policy.Re-education to involved staff on the pulse oximetry alarm response, notification handling and escalation expectations.Voice alarm presentation sent via email to all assistant nurse managers/assistant directors of nursing to review during evening huddle [DATE] and morning huddle [DATE].Enforce that Vocera device functionality was reviewed, and staff were instructed to ensure devices always remain accessible and operational.IT/MIS checked and confirmed monitoring equipment to be functioning properly.Disciplinary action to the staff involved - three (3) registered nurses and one (1) respiratory therapist.A root cause analysis was discussed on [DATE] and formally initiated on [DATE].Review and revision of pulse oximetry policyLeadership oversightAn audit for alert response time audit to be implemented.

Based on record review and interviews, the facility failed to ensure that alleged violations involving neglect, was reported immediately, but not later that two (2) hours after the allegation is made, if the events that caused the allegation involved or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation do not involved abuse and do not result in serious bodily injury, to the administrator of the facility of the facility and to other officials (including to the State Agency and adult protective services where state law provides for judications in long term care facilities). This was evident for one (1) out of six (6) residents sampled (Resident #1) for respiratory care. Specifically, on [DATE] at 8:58 AM, facility staff neglected the resident by not responding to the resident alert alarm indicating that the resident oxygen levels were decreasing and failed to provide timely assessment of the resident resulting in the resident being unresponsive with gray skin. Cardiopulmonary resuscitation was initiated, and the resident was transferred to the hospital and was determined to have no brain activity. On [DATE], life support was terminated, and the resident expired. The incident occurred on [DATE] and the Administrator was notified on [DATE]. The New York State Department of Health was notified on [DATE], four (4) days after the event occurred.The findings are:The facility's policy and procedure, titled Reporting to State Agency and Other Entities/Individuals last reviewed 12/2025 states that all alleged/suspected violations of all substantiated incidents will be promptly reported to appropriate state agencies and other entities or individuals as may be required by law. The procedure documented should an alleged/suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, abuse, or qualified Department of Health reportable event be reported. The hospital Administrator, or his/her designee, will promptly notify the following persons or agencies of such incident: The State Survey Agency responsible for surveying/licensing the facility, the Office of Professions [if appropriate] and law enforcement officials [if appropriate]. Notices to the above agencies/individuals shall be made no later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury. All other events that cause suspicion that do not result in serious bodily injury shall be done within 24 hours. The report is to be made to the Department of Health using the electronic submission survey.The facility's policy and procedure, titled Pulse Oximetry created 01/2020, reviewed 12/2025 includes the escalation pathway for responding to alerts/alarms.Resident #1 was admitted to the facility with diagnoses that include spastic quadriplegic cerebral palsy (a neurological condition that causes increased muscle tone (spasticity) and stiffness, affecting all four limbs and the face), severe hypoxic ischemic encephalopathy (a critical brain injury in newborns caused by significant oxygen deprivation or restricted blood flow) chronic respiratory failure.The Minimum Data Set (a resident assessment tool) dated [DATE] identified that the resident was severely cognitively impaired. The resident was totally dependent on staff for all activities of daily living.A review of the facility's summary of investigation initiated on [DATE] revealed that the facility conducted a thorough investigation and concluded that no abuse, mistreatment, or neglect occurred rather there was a deviation from facility policy and procedure regarding responding to PSS Phone Alarms.During an interview on [DATE] at 4:17 PM, the Director of Nursing stated they were notified of the Code Blue and the resident being transferred to the hospital. They were not aware that nursing staff did not respond to the alerts or assess the resident timely until they reviewed the alert system report and interviewed the staff. They stated they were unaware the incident should have been reported to New York State Department of Health and that it is the Administrator's responsibility to report incidents to the Department of Health.During an interview on [DATE] at 5:16 PM, the Administrator stated they were in the facility on [DATE] and was not notified of the Code Blue. They stated the Chief Medical Officer notified them on [DATE] about the incident and the Code Blue. The Administrator stated during an administrative meeting on [DATE] they were made aware of the incident involving the Registered Nurses and Respiratory Therapist not responding promptly to the Vocera alarm. The Administrator stated in the meeting they informed the Director of Nursing that the incident was reportable to the New York State Department of Health, and they proceeded with the submission. The Administrator stated they are now included in the Code Blue debriefing. The Administrator stated they instructed the Assistant Directors of Nursing, the Nursing Supervisors and Respiratory Director to report all incidents to the Administrator directly.10 New York Codes, Rules, and Regulations 415.4(b)(2).

Based on observation, record review, and interviews during the Recertification Survey conducted from 02/05/2025 to 02/12/2025, the facility did not ensure a resident with limited mobility received appropriate services, equipment, and assistance to maintain, improve, or prevent avoidable decline in range of motion and mobility. This was evident in 1 (Resident #18) of 3 residents reviewed for Limited Range of Motion, out of 25 sampled residents. Specifically, Resident #18 who had a physician's order to apply bilateral wrist cock-up splints was observed on multiple occasions without the splint applied. The findings are: The facility's policy titled Osteopenia with a revised date of 06/2024 documented that the facility will screen and provide assessments upon admission and at least quarterly of all residents with potential/actual diagnosis of osteopenia. Safe handling guidelines, as outlined, should be always practiced. The policy documented that appropriate physical and occupational therapy evaluation will be ordered. The Rehabilitation Services Department will make recommendations regarding orthotic and/or positioning devices such as splints, braces, supine stander, wedges and followed by physician's orders. Nursing will ensure that appropriate care plans are identified, and interventions are implemented. Resident #18 had diagnoses which include Spastic Quadriplegic Cerebral Palsy, Epilepsy, and Encounter for Attention to Tracheostomy. The Minimum Data Set assessment dated [DATE] documented that Resident #18's cognitive status was severely impaired. The Minimum Data Set assessment also documented that Resident #18 had impairments on both sides of upper extremity and required total assistance with grooming. A Comprehensive Care Plan for Musculoskeletal Care dated 06/25/2023 with a last reviewed date of 12/22/2024 documented the following interventions: perform musculoskeletal assessment every shift, implement osteopenia protocol, assess for sign and symptom of functional weakness/paralysis, and perform restorative nursing care, such as the use of assistive devices. A physician's order dated 08/09/2024 documented orders for right and left wrist cock-up splints to apply all daytime, from 8:00 AM to 8:00 PM. During observations made on 02/05/2025, 02/06/2025, 02/07/2025 and 02/10/2025, between the hours of 09:45 AM to 12:00 PM. Resident #18 was observed in bed, alert and awake. The Resident was confused and nonverbal, was observed with weakness to bilateral wrists. There was no bilateral wrist cock-up splints applied. On 02/10/2025 at 11:15 AM, an interview was conducted with Certified Nursing Assistant #1 who was assigned to Resident #18. Certified Nursing Assistant #1 stated they were aware of the order for the wrist splint and that it was not applied because it was communicated by the Rehabilitation Services Department to only apply the wrist splint when Resident #18 is out of bed. On 02/10/2025 at 11:21 AM, an interview was conducted with Registered Nurse #1 who stated they are responsible for clinical aspects of resident care. Registered Nurse #1 stated that Resident #18's wrist cock-up splint is normally applied when the Resident is out of bed. They stated that Resident #18 cannot have the splint for 12 hours because their skin was too fragile. On 02/10/2025 at 11:45 AM, an interview was conducted with Occupational Therapist #1. They stated they recommend splint devices after conducting assessments. Occupational Therapist #1 stated that the cock-up splints are to be applied to the resident's wrist to maintain joint integrity and to prevent further contractures. On 02/11/2025 at 10:10 AM, an interview was conducted with the Director of Nursing who stated that the Rehabilitation Service Department and physicians are responsible for the assessment and recommendation of splint devices and nursing staff implements them. The Director of Nursing stated if a resident cannot tolerate the splint, it needs to be communicated with the physician so the order can be adjusted. The Director of Nursing stated that the wrist cock-up splints order for Resident #18 has to be applied all day from 8:00 AM - 8:00 PM as stated in the physician's order. 10 NYCRR 415.12 (e)(2)

Based on record review and staff interview during the recertification survey conducted from 11/8/2023 to 11/16/2023, the facility did not ensure each resident received preadmission screening for a mental disorder or intellectual disability. This was evident for 1 (Resident #99) of 27 total sampled residents. Specifically, Resident #99 did not have a Level 1 Preadmission Screening and Resident Review (PASARR) completed prior to their admission to the facility. The findings are: The facility policy titled PASRR Screen dated 12/2022 documented the PASARR Screen for all residents will be reviewed prior to their admission to protect their rights and ensure the identification and delivery of specialized developmental and mental health services. Resident #99 was admitted to the facility on [DATE] with diagnoses of chronic respiratory failure and ventilator dependence. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #99 was severely cognitively impaired and admitted from an acute hospital on 8/3/2023. There was no documented evidence a Level 1 PASARR was completed prior to Resident #99 being admitted to the facility. On 11/10/2023 at 12:57 PM, the Admission Director (AD) was interviewed and stated that Resident #99 was admitted to the facility without a Level 1 PASARR because they were admitted from a hospital in New Jersey. On 11/16/2023 at 2:03 PM, the Director of Patient/Family Services (DPS) was interviewed and stated Level 1 PASARRs were completed by referring facilities and received prior to a resident's admission to the facility. The DPS was unable to obtain a Level 1 PASARR for Resident #99 prior to their admission to the facility because the PASARR is not required in New Jersey. 10 NYCRR 415.11(e)

Based on observation, interviews, and record review conducted during an abbreviated survey (NY00303294), the facility did not ensure that a resident was free from physical abuse. This was evident for 1 of 3 residents (Resident #1) reviewed for abuse. Specifically, on 10/04/22, a Registered Nurse (RN#1) reported to the Assistant Director of Nursing (ADNS) that a Certified Nursing Assistant (CAN#1) who was assigned to resident #1 on 10/03/22 was witnessed slapping resident's arm twice while the resident was reaching out to the nebulizer treatment. In addition, the RN#1 failed to remove the accuse C.N.A#1 from patient care and allowed the C.N.A#1 to continue to work until end of shift. Resident #1 was assessed with no injury sustained from the incident. The findings are: The facility Policy and Procedure titled Resident Abuse, Neglect, and Exploitation subtitled states that all residents are treated with consideration, respect and full recognition of dignity and individuality, including privacy in treatment, and care for personal needs. To ensure that residents are free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restrain not required to treat the resident's symptoms. Resident #1 was admitted to the facility with diagnoses including Generalized Epilepsy and Epileptic syndrome, Developmental Delays, Cortical Blindness, Tracheostomy and Gastrostomy Status. The Minimum Date Set (MDS) dated [DATE] documented that Resident #1 had a severely impaired cognition. Resident #1 also required a total assist of one person when performing Activity of Daily Livings. (ADLS). On 10/19/23 at 2:00 PM, the resident was observed in the day room performing school activity. The resident appeared confused, unable to make needs known to staff. It also appeared that the resident does not have awareness of their surroundings and did not respond when called by name. Staff were present at the time of this observation. A review of the facility completed investigation summary, dated 10/4/23 documented that, on 10/3/22 at approximately 8:30PM, the RN#1 witnessed the C.N.A #1 slapped resident #1's arm twice in a hard way. The investigation also documented that a physical assessment was immediately completed on resident #1 and found no visible injury. Staff were interviewed and statements collected from eyewitness. The facility concluded that there is caused to believe that an alleged resident abuse, crime, mistreatment, or neglect had occur. The incident was reported to the appropriate state agencies and the C.N.A #1 was terminated. No longer employed with the facility. A review of (RN) progress note dated 10/03/23 documented that resident # 1 was assessed for possible trauma to the hands. Resident is stable and no findings or any changes to baseline. A review of Nurse Practitioner (NP) progress note dated 10/03/23 documented that resident #1 was assessed with no sign of trauma, bruising and or abnormal findings. Resident was noted to be within their baseline. On 10/24/23 at 11:30 AM, an interview conducted with the C.N.A #1 who stated that on that, the resident likes to grab anything they see, and that was the reason why the resident was placed on one to one (1:1). The C.N.A #1 further stated that the resident was on one to one because the resident likes to attempt to reach to the tracheostomy and the gastrostomy tube. On 10/03/22, they stated that the RN#1 was about to start administering medications and the resident was trying to grab the tracheostomy tube as the RN #1 was preparing nebulizer treatment. The C.N.A #1 stated that they quickly grabbed the resident hands and said, don't do it The C.N.A #1 stated that they never slapped resident's hands, and that it was a gentle grappling. On 10/24/23 at 1:30PM, further interview conducted with the C.N.A#1 who stated that they believe that the RN#1 was rebelling on her because of a dispute they had on 10/03/22. The C.N.A#1 stated that they accused the RN#1 for leaving resident #1 in the pool of water on her diaper as the RN#1 was trying to flush the tube feeding and the resident got wet during the process. The C.N.A# acknowledged that they had a verbal argument with RN#1. The C.N.A #1 sated that the RN#1 did not say anything related to the abuse concerns before the end of the shift, and that they were surprised to hear that the Rn#1 reported her for an alleged abuse. They concluded by saying that they know when and how to report an allegation of abuse and also received abuse training two weeks prior to the incident. On 10/26/23 at 1:20 PM, an interview conducted the RN #1 who stated that they witnessed the C.N.A #1 slammed the resident #1 s right hand in a hard way while they were preparing medications for the resident. The RN#1 also stated that the resident was observed frozen for a few seconds after the slap, and the resident is nonverbal. The RN#1 stated that they did not interject or speak to the C.N.A#1 when they witness the slapping. They stated that the C.N.A#1 was a very unpleasant and unapproachable person, so they tried to avoid the C.N.A#1. The RN stated the incident occurred on 10/03/22 and they waited until the following day before they reported the incident to the nursing supervisor. The RN#1 stated they were not aware that that the incident of abuse supposed to be reported immediately. The RN #1 continues to say that they have completed an abuse training five months before the incident and they were fairly a new nurse at that time. On 10/26/23 at 1:45PM, an interview conducted with the C.N.A #2 who stated that they were in the same room performing ADLS care for another resident. The C.NA #2 stated that they did not observe the C.NA #1 slapped resident however they heard the C.NA#1 saying in a loud voice stop touching a few times. The C.NA # 2 described the C.NA#1 as rude and nasty person to other staff member but they cannot really tell if they can abuse a resident. On 10/27/23 at 11.21AM, an interview conducted with the Director of Nursing (DON) who stated that all employees receive abuse trainings and when they were first hired and annually They stated that staff are knowledgeable on what to do if they witness resident abuse, and that they completed abuse training and they know what it takes to protect resident from abuse. The DON stated part of their trainings is to report abuse immediately, and to remove the accuse person from resident care before the investigation completed. Any form of abuse Neglect, and Exploitation are to be reported immediately and the DON will be the lead on investigating abuse and include all interdisciplinary team. The DON also stated that they found the RN#1 witness credible and they believe an abuse occurred and that was the reason why they terminated the C.N.A#1, however, the RN#1 also failed to report and remove the accuse C.N.A immediately. On 10/31/23 at 1:05 PM, an interview conducted with the Administrator who stated that stated that, it is the responsibility of the facility to make sure that each resident has the right to be free from abuse, neglect, and corporal punishment of any type by anyone. The administrator also stated that they did not aware of the incident until the following day at the end of shift. The incident should have been reported imminently. They further stated that the RN #1 also failed to remove the C.N.A # 1 immediately. 10 NYCRR 415.4(b)(1)(i)

Based on observation, interviews, and record review conducted during an abbreviated survey (NY00303294), the facility did not ensure that an alleged violation of physical abuse was reported immediately, but not later than 2 hours if the alleged violation involves abuse to the New York State Department of Health (NYSDOH). Additionally, the facility did not report the alleged violation of abuse to local law enforcement (LLE). This was evident for 1 out of 3 residents (Resident #1) reviewed for abuse. Specifically, Resident #1 was slapped twice on their right hand by Certified Nursing Assistant (CNA) #1 on 10/03/22 at approximately 08:30 PM. Registered Nurse (RN) #1 witnessed the abuse on 10/03/22 and reported it to the Assistant Director of Nursing (ADON) on 10/04/22 at 08:30 AM. The facility reported the violation of abuse to NYSDOH on 10/04/22 at 08:42 AM. The facility did not report the abuse to local law enforcement. The findings are: The facility Policy and Procedure titled Resident Abuse, Neglect, and Exploitation subtitled Reporting last updated 10/2022, states that all employees and contractors providing patient care must report any allegation of abuse to the administrator and the Director of Nursing immediately, but not later than two hours after being informed of the allegation. The policy also states that incidents resulting in serious bodily injury, where there is reasonable suspicion to believe that the events causing the injury to constitute a crime and/or abuse against the resident, must be reported within 2 hours after forming the suspicion, and as applicable, the local police department., Resident #1 was admitted to the facility with diagnoses including Generalized Epilepsy and Epileptic syndrome, Developmental Delays, and Cortical Blindness The Minimum Date Set (MDS, a resident assessment tool) dated 09/19/22 documented that Resident #1 had a severely impaired cognition. A progress note, Registered Nurse Supervisor (RNS) #1, dated 10/04/22, documented that Resident #1 was assessed for possible trauma to the hands. Resident #1 was stable and there were no findings or any changes to baseline. The completed investigation summary dated 10/04/22 documented that on 10/03/22 at approximately 8:30 PM, RN #1 witnessed the CNA #1 slapped Resident #1's right arm twice in a hard way. A physical assessment was done and there was no visible injury. The investigation concluded that an alleged resident abuse had occurred. The incident was reported to the appropriate state agencies. The Intake Information notes documented that the incident occurred on 10/03/22 at 08:30 PM and the submission date 10/04/22 at 08:42:42 AM. The alleged violation of physical abuse was not submitted within 2 hours to NYSDOH. There is no documented evidence that the alleged violation was reported to local law enforcement. On 10/26/23 at 1:20 PM, RN #1 was interviewed and stated that they witnessed CNA #1 slapped Resident #1 on their right hand twice. RN #1 stated Resident #1's hand was slapped hard by CNA #1. RN #1 stated that Resident #1 froze for a few seconds after being slapped. RN #1 stated that Resident #1 was unable to respond verbally as the Resident is nonverbal. RN#1 stated that they reported the incident to the supervisor the following day (10/04/22 at 08:30 AM). RN #1 said that they received abuse training and was aware that the abuse must be reported. However, RN #1 stated that they were not aware that the abuse should have been reported immediately. RN #1 stated that they received in-service on abuse when they were first hired (five months ago) and that the in-service was brief and not detailed. On 10/27/23 at 11:21 AM, the Director of Nursing (DON) was interviewed and stated that the abuse allegation was credible. The DON stated that everyone goes through an abuse training from time to time and that all the staff are aware that they should report an allegation of abuse right away. The DON said that RN #1 was supposed to report the abuse to the nursing supervisor same day, instead, RN #1 reported the abuse at the end of their shift the following day (10/04/22) and that was not good. On 10/31/23 at 12:28 PM, the Administrator was interviewed and stated that the staff received mandatory training on abuse reporting upon hire and annually. The Administrator stated that they did not report the abuse to local law enforcement because they were not sure that the abuse had occurred. The Administrator said that the incident should have been reported immediately. 10 NYC RR 415.4(b)

Based on observation, interviews, and record review conducted during an abbreviated survey (NY00303294), the facility did not ensure that an alleged violation of physical abuse was reported immediately, but not later than 2 hours of the alleged violation involves abuse to the New York State Department of Health (NYSDOH). This was evident for 1 of 3 residents reviewed for abuse (Resident #1). Specifically, the facility did not report the alleged allegation of abuse of resident #1 to the NYSDOH within 2 hours when the assigned Certified Nurse Assistant (C.N.A#1) was witnessed slapping resident's arm hard, twice while the resident was reaching out to the nebulizer treatment. The findings are: The facility Policy and Procedure titled Resident Abuse, Neglect, and Exploitation subtitled States Reporting last updated 10/2022 documented that the facility staff immediately reporting all alleged violations to the Administrator and to the DNS; and when necessary, to the police and the NYS DOH within specified timeframes. A review of the intake notes with complaint# (NY00303294) documented that the incident occurrence date as 10/03/2022 at 08:30 PM and the submission date 10/04/2022 at 08:42:42 AM. The alleged violation of physical abuse was not submitted within 2 hours to New York State Department of Health (NYSDOH Resident #1 was admitted to the facility with diagnoses including Generalized Epilepsy and Epileptic syndrome, Developmental Delays, Cortical Blindness, Tracheostomy and Gastrostomy Status. The Minimum Date Set (MDS) dated [DATE] documented that Resident #1 had a severely impaired cognition. Resident #1 also required a total assist of one person when performing Activity of Daily Livings. (ADLS). On 10/19/23 at 2:00 PM, the resident was observed in the day room performing school activity. The resident appeared confused, unable to make needs known to staff. It also appeared that the resident does not have awareness of their surroundings and did not respond when called by name. Staff were present at the time of this observation. A review of Registered Nurse (RN) progress note dated 10/3/22 documented that resident # 1 was assessed for possible trauma to the hands. Resident is stable and no findings or any changes to baseline. A review of medical progress note dated 10/3/22 documented that resident #1 was assessed, no sign of trauma, bruising and or abnormal findings. Resident was noted to be within their baseline. A review of the facility completed investigation summary, dated 10/4/22 documented that, on 10/3/22 at approximately 8:30PM, the RN#1 witnessed the C.N.A #1 slapped resident #1's right arm twice in a hard way. The investigation also documented that a physical assessment was immediately completed on resident #1 and found no visible injury. Staff were interviewed and statements collected from eyewitness. The facility concluded that there is caused to believe that an alleged resident abuse had occur. The incident was reported to the appropriate state agencies and the C.N.A #1 was terminated and no longer employed with the facility. On 10/26/23 at 1:20 PM, an interview conducted the RN #1 who stated that witnessed they C.NA#1 slapped resident #1 right hand while they were preparing medications for the resident. The RN #1 also stated that the slapping was hard to the extent that the resident became frozen for a few seconds after the slap. They stated that the resident is nonverbal. The RN# stated that they did not report the incident to the supervisor until the following day. The RN also stated that they had abuse training when they were first haired, like 5 months ago but it was brief and was not detailed. The RN stated that they were not aware that abuse need to be reported within the 2 hours. On 10/27/23 at 11.21AM, an interview conducted with the DON who stated that they found the abuse allegation credible because the RN#1 witnessed it. The DON stated that everyone goes through abuse training from time to time and they all know and should report allegation of abuse right away. The DON stated that they reviewed the C.N.A# 1's employee file and there was no prior history of abuse or discipline found. On 10/31/23 at 12:28 PM, an interview conducted with the Administrator who stated that all staff going through mandatory abuse training during hire and annually. They stated that staff who witness an abuse would report it to the charge nurse and/or supervisor. They stated it was the process of the facility to report allegations of abuse to the NYSDOH within required time frames. The investigation will start right away, and the interdisciplinary team will ensure the investigation completed on a timely manner. Administrator stated an investigation is comprised of a report of what had happened, staff statements, staff interviews, and resident interviews if possible. It should also include notification of the physician and family. An assessment is also completed to assess for injury. The resident will also be referred to social services and/or psychiatry or other disciplines as needed. The Administrator stated that the RN#1 failed to remove the C.N.A immediately but waited till the following morning at end of their shift. They concluded that that they believe an abuse occurred because the RN #1 witness it and her testimony was found credible. 10 NYCRR 415.4(b)(1)(i)

Based on observation, interviews, and record review conducted during an abbreviated survey (NY00303294, the facility did not ensure that ensure a person-centered Comprehensive Care Plan (CCP) was developed and implemented to meet resident needs. This was evident for 1 (Resident #1) of 3 total sampled residents. Specifically, a CCP related to abuse prevention was not developed for Resident #1 following a substantiated abuse allegation. The finding is: The facility policy titled CCP last revised 10/2023 documented the CCP should be kept current by all disciplines on an ongoing basis. Disciplines will be responsible for updating the plan of care when there is a new problem that requires that discipline to intervene. The care plan will be revised to reflect the resident's current status, need, and achievements. Resident #1 was admitted to the facility with diagnoses including Generalized Epilepsy and Epileptic syndrome, Developmental Delays, Cortical Blindness, Tracheostomy and Gastrostomy Status. The Minimum Date Set (MDS) dated [DATE] documented that Resident #1 had a severely impaired cognition. Resident #1 also required a total assist of one person when performing Activity of Daily Livings. (ADLS). On 10/19/23 at 2:00 PM, the resident was observed in the day room performing school activity. The resident appeared confused, unable to make needs known to staff. It also appeared that the resident does not have awareness of their surroundings and did not respond when called by name. Staff were present at the time of this observation. A review of the facility completed investigation summary, dated 10/4/23 documented that, on 10/3/22 at approximately 8:30PM, the RN#1 witnessed the C.N.A #1 slapped resident #1's arm twice in a hard way. The investigation also documented that a physical assessment was immediately completed on resident #1 and found no visible injury. Staff were interviewed and statements collected from eyewitness. The facility concluded that there is caused to believe that an alleged resident abuse, crime, mistreatment, or neglect had occur. The incident was reported to the appropriate state agencies and the C.N.A #1 was terminated. No longer employed with the facility. A review of (RN) progress note dated 10/03/23 documented that resident # 1 was assessed for possible trauma to the hands. Resident is stable and no findings or any changes to baseline. A review of Nurse Practitioner (NP) progress note dated 10/03/23 documented that resident #1 was assessed with no sign of trauma, bruising and or abnormal findings. Resident was noted to be within their baseline. There was no documented evidence a CCP related to abuse treatment and prevention was developed and implemented following a Resident #1 s substantiated allegation of abuse on 10/04/22. During an interview on 05/03/2023 at 1:30PM, the Director of Nursing (DON) stated the nursing department initiate abuse prevention CCPs upon admission, quarterly, significant changes and during annual assessments. They stated that the resident was known to be at risk for self-inflicted injury and that that is why they created a care plan for injury, and to provide supportive and safe environment for the resident. The DON stated that a CCP related to abuse prevention was not initiated for Resident #1.

Based on record review and interviews conducted during an abbreviated survey (NY00302182, NY00303936), the facility failed to ensure that comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments. This was evident in 2 (Residents #2 and #3) of 3 residents reviewed for care planning. Specifically, Resident #2's and Resident #3's comprehensive care plan (CCP) for alteration in urinary elimination were not reviewed and revised at each quarterly assessment and after a change in resident condition. The findings are: The facility policy titled Comprehensive Care Plan that was last revised on 10/2023 documented the CCP should be kept current by all disciplines on an ongoing basis. Disciplines will be responsible for updating the plan of care when there is a new problem that requires that discipline to intervene. The care plan will be revised to reflect the resident's status, need, and achievements. The policy further documented that the care plan will be periodically reviewed and revised by the CCP team after each assessment, and the care plan will be updated on an on-going basis. Resident #2 was admitted to the facility with diagnoses of Congenital Malformation of Corpus Callosum, Congenital Deformity of Spine, and Epilepsy. The Minimum Data Set (MDS, a resident assessment tool) dated 10/17/22 documented that Resident #2 had severely impaired cognition. The MDS documented that Resident #2 was always incontinent of urinary bladder. A Nursing Note dated 09/11/22 at 6:14 PM documented that warm compress was applied by Licensed Practical Nurse #1 (LPN #1) to Resident #2's lower abdomen to encourage urination. A CCP for alteration in urinary elimination was initiated for Resident #2 on 09/20/14. Further review of the CCP revealed no documented evidence that it was reviewed and revised at each quarterly assessment or change in condition. Resident #3 was admitted to the facility with diagnoses of Congenital Laryngomalacia, Epilepsy, and Dysphagia. The MDS dated [DATE] documented that Resident #3 had severely impaired cognition. A CCP for alteration in urinary elimination for Resident #3 was initiated on 10/18/22. There was no documented evidence that the CCP was reviewed and revised at each quarterly assessment after 10/18/22. During an interview on 10/31/23 at 2:30 PM, Registered Nurse Supervisor #1 (RNS #1) stated that the RN is responsible to initiate, review, and revise care plans. RNS #1 stated that CCPs are reviewed and revised quarterly, during annual assessments, and when there are significant changes. RNS #1 could not explain why the care plans were not reviewed and revised. During an interview on 10/31/23 at 2:55 PM, the Administrator stated that the CCP identified that Resident #2 and Resident #3 were at risk for urinary incontinence. The Administrator stated that with the new Electronic Medical Record (EMR), some of the CCP's were not revised. The Administrator stated that these care plans will be revised to reflect the resident's status, need, and achievements. 415.11(c)(2)(i-iii)

Based on observation, record review, and interviews conducted during an abbreviated survey (NY00302182 and NY00303936), the facility did not ensure that residents were free from accidents. This was evident for 2 out of 3 residents (Resident #2 and #3) reviewed for accident. Specifically, 1.) Resident #2 was observed with redness to the right lower abdomen, by Certified Nursing Assistant (CNA) #3, on 09/11/22. The facility Investigation Summary dated 09/13/22 documented that Licensed Practical Nurse (LPN) #1 applied a hot compress to Resident #2's right lower abdomen to elicit elimination. LPN #1 left Resident #2's room and did not monitor the hot compress. As a result, Resident #2 sustained redness to the abdomen. Vitamin A & D Ointment was applied. Additionally, there was no Physician's Order for the use of the hot pack. 2.) Resident #3 was observed with a blister to the upper right thigh on 10/17/22 at 2:57 PM. The facility's Investigation Summary documented that Registered Nurse (RN) #5 placed a hot pack on Resident #3's right thigh on 10/17/22 at approximately 7:00 AM. There was documented evidence that the hot pack was monitored as per the facility's policy and Resident #3's plan of care. Additionally, a Physician's Order dated 09/15/22 documented instructions to apply a warm pack to Resident #3's suprapubic area if no void greater than 12 hours. The order did not indicate the duration and frequency. The findings are: The facility's Policy and Procedure titled, Heat and Cold Application dated 10/2022 documented the following: It is the policy of the facility that the application of heat or cold to treat a designated area be prescribed by the provider. The Heat Therapy is prescribed to promote comfort by stimulating the circulation to promote localization of purulent matter in tissues. The policy further documented that there will be a physician order for the use of hot pack and will be apply by the Registered Nurse (RN). Hot pack should be covered with a barrier. The hot pack should be removed, and the site assessed. The hot pack should be re-applied every 5minutes. After 20 minutes, terminate treatment and dry the skin. Do not leave patient unattended when pack is in use. Resident #2 was admitted to the facility with diagnoses that include Congenital Malformation of Corpus Callosum, Congenital Deformity of Spine, and Epilepsy. The Minimum Data Set (MDS, a resident assessment tool) dated 10/16/22 documented that Resident #2 had severely impaired cognition. A nursing note dated 09/11/22 at 6:14 PM documented that a warm compress wrapped in wipes was applied to Resident #2's lower abdomen to encouraged voiding. The warm compress caused redness to the lower right abdomen. A Progress Note, written by Registered Nurse (RN) #3, dated 09/11/22 documented that Resident #2 was assessed, and redness was observed to their lower abdomen. Nursing staff will continue to treat with Vitamin A and D Ointment as needed. A Care Plan dated 09/12/22 documented that Resident #2 was observed with a pinkish, reddish, whitish, and blister-like area to the right lower abdomen. A Medical Progress Note (written by Nurse Practitioner) dated 09/12/22 documented that Resident #2 was examined and observed with erythema and peeling skin to the lower right side of their abdomen. Vitamin A and D Ointment to be applied as needed. An Investigation Summary dated 09/13/22 documented that Resident #2 was observed with redness to the right lower abdomen on 09/11/22 at 2:31 PM. The investigation also documented that LPN #1 placed a hot pack wrapped in a washcloth to Resident #2's right lower abdomen and left the room. The investigation also documented that on 09/12/22, there were no signs and symptoms of distress or pain observed. Further assessment revealed a pinkish white/scale like area and the doctor was notified. The investigation concluded that neglect had occurred. A Medical Note (written by Nurse Practitioner) dated 10/25/22 documented that the blistered area of Resident #2's skin is showing improvement and appears to be healing well. The plan includes Dermaphor Ointment to be applied. There was no Physician's Order for the hot compress that was applied to Resident #2's abdomen on 09/11/22. There was no documented evidence that the hot pack was removed, the site was assessed or that the hot pack was re-applied every 5 minutes as needed. There was no documented evidence that the hot pack treatment was terminated after 20 minutes. On 10/19/23 at 1:45 PM, an interview was conducted with CNA #3 who stated that they were assigned to Resident #2 on 09/11/22 on the morning shift (6:00 AM to 2:00 PM) and they observed a blister on Resident #2's lower abdomen and reported it to LPN #1. On 10/19/23 at 2:28 PM, an interview was conducted with the LPN #1 who was assigned to Resident #2 on 09/11/22 on the morning shift (7:00 AM to 2:00 PM). LPN #1 stated that Resident #2 did not void for over 12 hours and that they notified the Nurse Practitioner (NP) #1 who gave LPN #1 a verbal order to apply a hot pack to Resident #2's suprapubic area. LPN #1 could not recall what time they applied the hot pack to Resident #2. LPN #1 stated that the NP did not give them any instructions on how long the hot pack should remain in place, but that they monitored the hot pack every 5 to 10 munities. LPN #1 stated that it is a usual practice at the facility that if a resident does not void after 12 hours, the staff would place a warm compress to the suprapubic area to promote voiding. LPN #1 stated that CNA #3 reported that Resident #2 had redness to the skin, and they reported the redness immediately to the NP. On 10/20/23, at 10:00 AM, an interview was conducted with NP #1 who stated that they gave a one-time verbal order to LPN #1 on 09/11/22. NP #1 stated that it is the practice at the facility to use warm compress on a resident lower abdomen to aide urination. NP #1 stated that the practice is preferred over catheterization to avoid complications. NP #1 stated that there might have been an order prior to the new Electronic Medical Record (EMR) system, however, NP #1 stated that they reviewed the orders and found that there was no order for the hot pack. On 10/31/23 at 10.42 AM, an interview was conducted with Registered Nurse Supervisor (RNS) #3 who stated that a Physician's Order is required for the use of a hot pack. RNS #3 stated that this was the first time Resident #2 sustained a burn from the hot pack. RNS #3 stated that the hot pack should have been wrapped in a paper towel before placing the hot pack on the resident. RNS #3 stated that they assessed Resident #2 the following day (09/12/22) after the incident and Resident #2's lower abdomen was red, puffy, and had a small blister. RNS #3 said that the area was tender to touch, and that Resident #2 flinched when the area was touched. RNS #3 stated that the hot pack was removed from the unit. Resident #3 was admitted to the facility with diagnoses including Congenital Laryngomalacia, Epilepsy, and Dysphagia. The Minimum Data Set (MDS, a resident assessment tool) last quarterly assessments dated 06/20/22 documented that Resident #3 had a severely impaired cognition. A View Order Detail (Physician's Order) dated 09/15/22 documented instructions to apply a warm pack to suprapubic area if no void greater than 12 hours. The order did not indicate the frequency and the duration for the use of the warm pack. An Item Detail (Resident #3's Plan of Care) dated 09/15/22 documented apply warm pack to suprapubic areas if no void greater than 12 hours. The plan documented instructions that the warm pack should be removed after 30 seconds to observe an initial skin response to the therapy. The area should be assessed for tolerance of the warm compress. It is also documented that when the warm compress is in use, it should not be left unattended. The warm pack should have been replaced every 5 minutes as needed and the treatment should have been terminated after 20 minutes. There was no documented evidence that the instructions in the Resident #3's plan of care were followed. An Investigation Summary dated 10/17/22 documented that RN #5 placed a hot pack on Resident #3's upper right thigh at 7:00 AM to elicit elimination. The investigation documented that at 2:57 PM, Resident #3 was observed with a blister on the upper right thigh by CNA #2. The facility concluded that the blister was a result of the hot pack meeting Resident #3's skin. The investigation also concluded that abuse or mistreatment did not occur, and that the incident was an accident. An Item Detail - Plan of Care dated 10/17/22 documented that Resident #3 was observed with a blister to right upper thigh and Bacitracin was started. A Medical Progress Note (written by Nurse Practitioner #2) dated 10/17/22 documented that a Registered Nurse (RN) reported that Resident #3 was observed with a blister on the right thigh and that a hot pack was placed during the morning. Skin assessment revealed a 2x2 centimeter (cm) serous-filled blister at Resident #3 right anterior thigh. The assessment also documented that the blister was likely a second degree burn from the hot pack. The blistered was cleansed and drained and Bacitracin Ointment to apply. On 11/01/23 at 02:27 PM, an interview was conducted with RN #3 who was assigned to Resident #3. RN #3 stated that they applied a hot pack to Resident #1 at around 7:00 AM on 10/17/22 and monitored the hot pack every 10 to 15 minutes. RN #3 stated that they applied and removed the hot pack within 10 to 20 minutes but does not recall what time they removed the hot pack. RN #3 stated that a Physician's Order is required for the use of a hot pack and that the hot pack should be wrapped in a towel before placing it on the resident. RN #5 stated that they wrapped the hot pack in a pillowcase and placed it on Resident #3. On 11/01/23 at 01:47 PM, an interview was conducted with CNA #4. who stated that they worked on 10/17/22 from 2:00 PM to 10:00 PM. CNA #4 stated that they observed a water bubble (blister) on the lower abdomen of Resident #3 and reported it to RN #3. CNA #4 stated that they do not recall the time, but that the hot pack was not on Resident #3's lower abdomen at the time the blister was observed. On 10/31/3 12:02 PM, an interview was conducted with NP #2 who stated that they examined Resident #3 on 10/17/22 and observed a blister on Resident #3's right thigh. NP #2 stated that they believed the warm pack caused the blister. NP #2 said that the hot pack was used to enhance urine output from Resident #3. NP #2 stated that they concluded that the burn appeared to be secondary burn. NP #2 stated that the nurses know how to apply and when to remove the hot pack. NP #2 also said that the hot pack gets cold within 10 minutes after the hot pack is broken. On 10/27/23 at 11:21 AM, an interview was conducted with the Director of Nursing (DON) who stated that Resident #3 had an order for a hot pack, but that Resident #2 did not have an order. The DON stated that the Physician's Order for Resident #3 did not indicate how long the hot pack should have remained in place. The DON stated that Resident #3 had a second degree burn as it was a blister. On 10/31/23 at 2:45 AM, an interview was conducted with the Administrator who is also a RN. The Administrator stated that it is the policy of the facility that the application of heat or cold to treat a designated area must be prescribed by the provider. The administrator stated that the hot pack should be covered with a barrier before applying. The Administrator further stated that they cannot explain why the protocol was not followed. The hot pack should be removed, and the site assessed. The hot pack should also be re-applied every 5minutes and removed after 20 minutes. 10 NYC RR 415.12(h)(1)(2)

Based on observation, record review, and interview conducted during the Recertification Survey, the facility did not ensure that residents were cared for in a manner that maintained or enhanced their dignity. Specifically, a resident's [CONDITION(S)] drainage bag and tubing were observed several times uncovered and exposed to public view in the hallway. This was evident for 1 of 1 resident reviewed for Dignity out of a sample of 28 residents (Resident #106). The finding is: The facility policy dated [CONDITION(S)]/[CONDITION(S)] Care dated 10/2019 documented the following: It is the policy of the facility that the licensed nurse is responsible for the care of the resident who has an ostomy. The Policy also documented that the licensed nurse would provide stoma care while changing the ostomy pouch and provide privacy. Resident #106 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident had an impaired cognition and required total assistance with Activities of Daily Living (ADLs). On 09/02/21, between the hours of 11:43 AM and 12:45 PM, Resident #106 was observed sitting in a wheelchair (w/c) in the hallway, in front of the nurse's station. The resident's [CONDITION(S)] drainage bag and tubing were uncovered and visible. There were feces along the tubing and in the drainage bag attached to lower side of the w/c. On 09/03/21, between the hours of at 10:42 AM and 11:57 AM, Resident #106 was observed being fed by a Certified Nursing Assistant (CNA #1) while sitting in a w/c, in the hallway, in front of the nurse's station. The resident's [CONDITION(S)] drainage bag and tubing were uncovered and visible. There were feces along the tubing and in the drainage bag attached to lower side of the w/c. On 09/07/21 at 09:49 AM, Resident #106 was observed in front of the nursing station,with an unidentified staff member. The [CONDITION(S)] bag was uncovered with feces inside. The Comprehensive Care Plan (CCP) for Bowel Elimination Alteration dated 08/12/21 documented Resident #106 required actual maintenance of any gastrointestinal diversional device attached to the child's body for elimination of waste related to medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The CCP interventions included the following: Perform bowel assessment and abdominal palpation for distention every shift, identify location of gastrointestinal diversion, perform skin assessment every shift, monitor output and frequency, change devices as ordered and PRN (as needed). The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Cleanse with normal saline and dry well. The Physician's note dated 8/27/21 documented the following: Resident has a long history of dysmotility. [CONDITION(S)] was placed 2 years ago. There is a red rubber catheter placed within the ostomy to promote drainage. A series of 8-10 slits made along the length of the catheter to promote drainage and prevent clogging with stool. Catheter is inserted to 75% of its length. Typical drainage is less than 300 ml per shift (q12 h) but if the output is greater than this, it should be replaced 1:1 with [MEDICATION(S)] ringers' solution. On 09/07/21 at 10:44 AM, an interview was conducted with CNA #1. CNA #1 stated that the nurse takes care of the ostomy bag. The CNAs make sure the [CONDITION(S)] bag is cleaned properly and not clogged, and the nurse drains it and measures and documents the output. CNA #1 stated she was never aware of the privacy issues related to the ostomy bag being exposed to the public view. CNA #1 concluded by saying I never received such training that the ostomy or catheter bags have to be covered in public. ] On 09/07/21 at 10:25 AM, an interview was conducted with the Unit Registered Nurse (RN#1) who stated she was not aware of the need for a privacy bag for the [CONDITION(S)]. RN #1 stated that Resident #106 always sits in the hallway, and no one has said anything about the [CONDITION(S)] drainage bag being exposed. On 09/07/21 at 10:53 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the facility does not have privacy bags for the ostomy. The DON stated the facility has a few residents with an ostomy bag. The DON stated that the staff were not trained on the use of a privacy bag to conceal the ostomy from public view. The DON concluded by saying we will work on it. 415.5(a)

Based on observations, record review, and interviews during this recertification survey, the facility did not ensure the dishwashing machine was meeting appropriate temperatures. Specifically, the rinse cycle temperature was not reaching 180 degrees Fahrenheit. This was observed during the Kitchen and Food Service observation task. The finding is: The facility policy and procedure titled, Dishwashing Procedures, (dated 3/14) documented the following. The utility assistance will check the rinse temperature gauges to ensure proper temperature for washing and sanitizing is 180 degrees Fahrenheit for rinse. Multiple observations were made on 11/20/17. At 11:20 AM, the dishwashing machine was observed to be on cycle 2 and the rinse cycle temperatures were 164 and 169 Degrees Fahrenheit. From 1:00 PM to 1:20 PM, the dishwashing machine was observed to be on cycle 4 and the rinse cycle temperatures were 173, 177, and 179 Degrees Fahrenheit. On 11/21/17 at 3:02 PM, the Nutrition Service Utility Worker was interviewed and stated the following. He stated the rinse cycle temperature should be 180 Degrees Fahrenheit. When the machine doesn't reach appropriate temperatures, the dishes are chemically sanitized after it comes out of the machine. The food service manager will be notified afterwards. He further stated he did not have problems with the machine before and it was always meeting temperatures. The utility worker stated the machine has six cycles which are different settings in terms of time frame and different dishware. Regardless of cycle, the temperature should still be meeting 180 Degrees Fahrenheit for the rinse cycle. On 11/20/17 at 1:15 PM and 11/22/17 at 8:09 AM, the Food Service Manager (FSM) was interviewed and stated the following. The dishwasher is a hot water sanitizing machine and the rinse temperature should reach 180 Degrees Fahrenheit. She stated if the machine is not reaching temperature, the dishes will be chemically sanitized and she will call maintenance and then the vendor. She stated the rinse was not meeting temperature because it was on cycle 2 when it should be on cycle 4. The machine has to run on cycle 4 a couple of times so the machine can maintain temperature. The FSM stated she never had this problem before with the dish machine and staff have not reported to her about the machine not meeting temperatures. She stated she does monthly audits of checking the machine temperatures. 415.14(h)

Based on observation and interview it was determined that the facility did not maintain an infection control program to ensure that clean and sterile items were stored under sanitary conditions and in a manner to prevent cross contamination. This was evidenced by clean central supplies being stored adjacent to the septic tank room. The location of the septic tank reeked with a foul odor and was overflowing with dead flies and other insects. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. On 7/22/14 at approximately 11:15 am it was noted that the septic tank for the facility was located in a room within the clean storage room in the basement level of the facility. The septic tank room reeked with a very poignant odor that was noticeable from the storage supply room. The septic tank room was noted to be infested with flies and other insects. The only access to clean and maintain the septic tank was through the clean central storage supply room. This set up would not protect sterile items from cross contamination. In an interview with the maintenance staff on 7/22/14 at approximately 11:30 am he stated that it was how the rooms were located during construction. He also stated that the septic tank is usually cleaned out once monthly by an external sewer company and that access to the septic tank area was through the clean storage room. He also indicated that the exterminator comes into the facility on ce weekly to conduct preventive pest management and that he would point out the location of the pest sightings on his next visit. 483.65

Based on observation and staff interviews, the facility did not ensure that expired medications were removed from the medication refrigerator. Specifically, four boxes of expired Influenza vaccine were observed stored in the medication room refrigerator. This was evident on 1 of 4 units. (Unit 1). This resulted in no actual harm with potential for more than minimal harm. The finding is: On 7/16/2013 at 9:45 AM, during the initial tour, the medication room refrigerator on the first floor contained four boxes of expired Influenza vaccine. One box documented an expiration date of 6/27/2013 and three boxes documented expiration dates of 6/30/2013. The RN (Registered Nurse) was immediately interviewed and stated that she was not aware of who was responsible for checking the stock medications for expiration dates. The RN further stated that she thought the Pharmacist was responsible for checking the stock medications. The Unit RN Manager was interviewed on 7/16/2013 at 11:45AM and stated that the medications were checked by the pharmacist. The RN further stated that the flu vaccines were in the refrigerator from the flu season and added, " the vaccines should not have been there, the flu season is over." The Pharmacy Director was interviewed on 7/17/2013 at 11:30 AM and stated that there is a system in place and this should not have occurred. 415.18 (d)

Based on observation and interview it was determined that the facility did not ensure that corridors were continuously equipped with firmly secured handrails on each side. This was observed in one out of five floors where handrails were noted missing along a 25 feet span of the ground floor corridor. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: During the annual survey conducted on 7/17 between 9:00 am and 12:30 p.m. the following was noted. Opposite the mechanical room on the ground floor along a 25 feet portion of the wall was noted to be missing handrails. The ground floor of the new building has physical/occupational therapy and some program spaces. This corridor connects both the old and new buildings and was noted being used by staff to transport and accompany children to other program areas in the old building. An interview was conducted with the Director of Facility management who indicated that this was the route often travelled by the residents and he did not realize that handrails were needed on both sides. He further indicated that he would bring this concern to administration so that it could be corrected as soon as possible. 415.29

Based on record review and staff interviews the facility did not ensure that Physician's orders were followed. Specifically, a nutritional supplement was not administered as ordered.This was evident for 1 of 19 residents reviewed for Physician's orders. (Residents # 16). This resulted in no actual harm with potential for more than minimal harm. The findings is: 1) Resident # 16 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) 3.0 dated 7/5/12 documented that the resident had severely impaired cognition with no speech. The " Non-Medication Orders " dated 7/9/12 documented " Diet: ...Beneprotien 1 scoop daily. " A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]" Beneprotien 1 scoop daily." The documented time of administration was "10 AM." There is no documented evidence (nurses initials on the MAR) that the nutritional suplement had been administered on 7 days (7/17, 7/19, 7/21, 7/22, 7/23, 7/24 and 7/25/12). On 7/26/12 at 12:00 p.m. an interview was conducted with the unit RN (Registered Nurse) who administers medication. The RN stated that if she didn't sign for the medication "that means it wasn't given...it was overlooked." The RN further stated that she would make sure to read the medication record carefully and sign her initials accordingly. An interview was conducted with the RN/ADNS (Assistant Director of Nursing) on 7/26/12 at 12:15 p.m. The RN/ADNS stated that the assigned medication nurse is responsible for reviewing the Physicians orders at the start of each shift, to ensure that the orders have been transcribed accurately and that the medication is being administered as ordered. The RN further stated that all of the nurses on duty during this time frame will be re-inserviced on medication administration. The RN also stated that the Physician will be called to ask him if it would be ok to administer the medication now ( at 12:15 p.m.). 415.88(c)(3)(ii)

The following waiver (s) is (are) on file with this office. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waive(s) to be continued. Include your request for renewal of this waiver or plan of correction in the space provided on this form. 42 CFR 483.70(a): The maximum number of beds in any bedroom shall be 4 beds. Room #'s 125, 126, 127, and 128 have 5 beds each. NYCRR 713-1.2(b)(1)