Every finding on record at Sunshine Children's Home and Rehab Center

Based on observation, interview, and record review conducted during the recertification survey from 5/29/2025 to 6/4/2025, the facility did not ensure kitchen equipment was maintained in safe working condition. This was observed in 1 (Meat Freezer) of 2 freezers during kitchen review. Specifically, the kitchen meat freezer was observed with ice buildup and a compromised door seal. The findings are: The facility policy titled Food Storage Perishables dated 2/2023 documented frozen products would be stored to enhance the preservation of flavor, quality and nutritive value. The freezer will be cleaned and organized daily. On 5/29/2025 at 10:04 AM, the kitchen meat freezer was observed with ice buildup on multiple boxes of frozen turkey breast, the walls, ceiling, door, and floor. There were 3 areas on the freezer floor where mounds of ice were thicker than and covered the rubber slip mat. The Food Service Director was present during the observation and stated the freezer began icing over a few months prior but has maintained appropriate temperatures for food storage. On 6/03/2025 at 11:59 AM, the kitchen meat freezer was observed with the Food Service Director present. The rubber floor slip mat was covered with a thin sheet of ice creating a slick surface. The surrounding walls and perimeter of the freezer door were covered in ice. The internal thermometer sensor was encased in ice. The Food Service Director attempted to close the meat freezer door and an audible crunch of ice was heard. The seal around the perimeter of the door was covered with ice. Cold air was felt seeping out of the freezer into the kitchen from lower left corner of the closed meat freezer door. On 6/03/2025 at 12:07 PM, the Food Service Director was interviewed and stated the meat freezer started icing over approximately 6 months ago. The Food Service Director stated they contacted a refrigerator repair company and was told the freezer was not very full which caused condensation and ice to buildup inside of the freezer. The freezer maintained appropriate temperatures and has been under close observation. The Food Service Director stated they checked the meat freezer daily to ensure ice buildup did not cause a hazard. Either the Food Service Director of a Utility Worker would use a [NAME] to break up and remove the ice when the buildup became hazardous. The Food Service Director stated they did not inform the Administrator of the ice buildup in the meat freezer. On 6/04/2025 at 1:35 PM, the Administrator was interviewed and stated they were recently made aware the kitchen meat freezer ad some ice buildup but also knew the freezer was holding at appropriate temperatures for food storage. The Administrator stated they did not make first-hand observation of the ice buildup in the meat freezer and that a refrigeration company would be required to determine the cause of the ice buildup. The facility safety officers conducted random environmental rounds of different parts of the facility. 10 NYCRR 415.29

Based on record reviews and interviews conducted during an abbreviated survey (NY00369342) the facility did not ensure that one of three residents (Resident #1) was free from abuse. Specifically, Certified Nurse Assistant #1 with Registered Nurse #1 were in the shower room giving Resident #1 a shower in a shower bed. Resident #1 kicked towards Certified Nurse Assistant #1 and Certified Nurse Assistant #1 smacked Resident #1's upper right leg with an open hand to push Resident #1's leg away from their body. Registered Nurse #1 was startled by the action and immediately called the supervisor to report what had happened. The Findings are: The Facility policy last reviewed 6/24 titled Abuse Prohibition- Freedom from Abuse, Neglect, Exploitation documents that it is the policy of the facility to protect residents from abuse, neglect, mistreatment, exploitation or misappropriation of property in accordance with state and federal regulations. Resident #1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses of multiple congenital malformations, not elsewhere classified, gastro-esophageal reflux disease without esophagitis, and thoracogenic scoliosis of the thoracic region. The Quarterly Minimum Data Set, dated dated dated [DATE] indicated that Resident #1 is severely impaired to make decisions regarding tasks of daily living. Nurse Initial Shift note effective date 1/20/25 at 12:29pm, documents Resident #1's status prior to incident. Documents general: received in the wheelchair, appears comfortable, weights and vitals stable. Cardiovascular: cardiac rate/rhythm within normal limits, capillary refill less than 3 seconds. Skin is intact, warm, no presence of edema, peripheral pulse palpable, and strong blood pressure within normal limits. The rest of assessment/note indicates all was within normal limits. Skin assessment in this same note documents skin is intact, normal pigmentation consistent with residents' baseline, erythema on g-tube site, barrier ointment applied as ordered, bony prominences protected. Physician Interim note effective date 1/20/25 at 5:14pm documents that Resident #1 was assessed related to incident. Awake alert acting as normal and in good mood. Skin in general no redness or lesions. Head and face with scalp and skin intact no swelling or color changes. Abdomen no skin color change, no distension out of his baseline, soft nontender no guarding, G-Tube in place. Extremities with no swelling or color changes. No signs of pain with gentle passive range of motion in all extremities. Right upper thigh area with skin intact no color changes no swelling no tenderness. No trauma or injury noted related to the incident. Follow up as needed. Resident #1 has a care plan-initiated date of 5/11/23 with a focus that reads - the resident has risk factors leaving them vulnerable to potential/actual mistreatment. The goal is that resident will remain safe from any psychological/physical/emotional/verbal abuse and or maltreatment by/though next review date. Interventions listed are: - identify any signs of potential abuse (injuries, poor hygiene, symptoms of anxiety, depression, confusion). - provide resident with safe and meaningful activities. The facility's incident report and the witness statement from the facility's internal investigation documented that on 1/19/25 Registered Nurse #1 was with Certified Nurse Assistant #1 in the shower room giving Resident #1 a shower in the shower bed. The Certified Nurse Assistant #1 was standing on the left side of Resident #1. The resident kicked towards Certified Nurse Assistant #1, and they smacked Resident #1's upper right leg with an open hand to push it down away from themselves. It was a sudden reflexive response. Registered Nurse #1 was startled by the action and immediately called the supervisor to report what had happened. Immediately after the incident the Certified Nurse Assistant #1 was removed from the unit and brought to the lobby. The Director of Nursing was called and notified, Resident #1 was examined, there was no mark or redness, a head-to-toe assessment was completed and showed no unusual bruising, swelling or other sings of injury. The Certified Nurse Assistant #1 was suspended and later terminated. On 1/27/25 at 12:19pm in an interview with Certified Nurse Assistant #2, who frequently provides care for Resident #1, they stated that Resident #1 flails and kicks out often, but what they do to ensure safety is always keep eyes on resident and back up to prevent them from hitting you. Certified Nurse Assistant #2 stated that Resident #1 flails at times, we try to explain what we are doing, and they understand, and they stay more relaxed. Certified Nurse Assistant #2 stated that when Resident #1 kicks, I try to stand back, and when they are tired, they kick more it seems. Certified Nurse Assistant #2 stated that when you explain to them what you are doing, they understand and often are better with cares. On 1/28/25 at 9:15am in a phone interview with Certified Nurse Assistant #1 they stated that they were showering Resident #1, and they were acting up and kicking out as per their usual and their feet were coming near them, it was a reflective action, when something is coming at you; you move it away with no intention to harm. Certified Nurse Assistant #1 stated that normally when they kick, I don't do anything, but on that day, it was just a reflex. Certified Nurse Assistant #1 stated that Resident #1 was not usually on their assignment; they were short staffed, the person that is usually there had called out. Certified Nurse Assistant #1 stated that 1 or 2 times a week they have call outs, the facility tries to find staff to cover, but sometimes they must cover. Certified Nurse Assistant #1 states that evening the weather was bad and there were more call outs than usual. Certified Nurse Assistant #1 stated that Resident #1 acts up all the time. Certified Nurse Assistant #1 was not aware that there could be a 3rd person assist, they had never seen that occur. Certified Nurse Assistant #1 stated they would need to have 2 Certified Nurse Assistants and a Nurse, and there are not 2 Certified Nurse Assistants available to help with cares. Certified Nurse Assistant #1 recalls a presentation on abuse, but it was not something they emphasized. Certified Nurse Assistant #1 stated that at the time they were not sure how to handle the situation. Certified Nurse Assistant #1 stated they love the kids and would never do anything to harm them. Certified Nurse Assistant #1 stated that they had never been given specific instructions on how to take care of Resident #1. On 1/28/24 at 11:32am in an interview with Director of Nursing, they stated that they oversee all resident care and all investigations for abuse, neglect, and mistreatment. Director of Nursing stated that in their [AGE] years working at the facility they recall only 2 abuse cases. Director of Nursing stated that they think that Certified Nurse Assistant #1 responded in a reflexive way to protect themselves from possibly being kicked. Director of Nursing stated they do not think it was done with any malintent and maybe it was just a reflex/instinctive reaction. Director of Nursing stated that Certified Nurse Assistant #1 started working at the facility this past August and they received training at that time. 10NYCRR 415.4(b)

Based on record review and interviews during an abbreviated survey (NY00369342), the facility, regarding an incident of staff-to-resident suspected abuse, did report the incident immediately, but not later than 2 hours, to the State Agency, but did not report the incident immediately, but not later than 2 hours, to local law enforcement. This was identified for one of 3 residents (Resident #1) reviewed for abuse. Specifically, Certified Nurse Assistant #1 with Registered Nurse #1 were in the shower room giving Resident #1 a shower in a shower bed. Resident #1 kicked towards Certified Nurse Assistant #1 and Certified Nurse Assistant #1 smacked Resident #1's upper right leg with an open hand to push Resident #1's leg away from their body. The facility did not report the suspected abuse to local law enforcement. Findings include: The facility policy titled Abuse Prevention- Freedom from Abuse, Neglect, Exploitation revised 6/24 documents that it is the policy of the facility to protect residents from abuse, neglect, mistreatment, exploitation or misappropriation of property in accordance with state and federal regulations. Furthermore, it documents that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law through established procedures. Resident #1 was originally admitted on [DATE] and readmitted on [DATE] with diagnoses of multiple congenital malformations, not elsewhere classified, gastro-esophageal reflux disease without esophagitis, and thoracogenic scoliosis of the thoracic region. The Quarterly Minimum Data Set, dated dated dated [DATE] indicated that Resident #1 is severely impaired to make decisions regarding tasks of daily living. Review of the nursing notes indicates that there is no nursing note from Registered Nurse #1 that reported the incident. Physician Interim note effective date 1/20/25 at 5:14pm documents that Resident #1 was assessed related to incident. Awake alert acting as normal and in good mood. Skin in general no redness or lesions. Head and face with scalp and skin intact no swelling or color changes. Abdomen no skin color change, no distension out of his baseline, soft nontender no guarding, G-Tube in place. Extremities with no swelling or color changes. No signs of pain with gentle passive range of motion in all extremities. Right upper thigh area with skin intact no color changes no swelling no tenderness. No trauma or injury noted related to the incident. Follow up as needed. The facility's incident report and the witness statement from the facility's internal investigation documented that on 1/19/25 Registered Nurse #1 was with Certified Nurse Assistant #1 in the shower room giving Resident #1 a shower in the shower bed. The Certified Nurse Assistant #1 was standing on the left side of Resident #1. The resident kicked towards Certified Nurse Assistant #1, and they smacked Resident #1's upper right leg with an open hand to push it down away from themselves. It was a sudden reflexive response. Registered Nurse #1 was startled by the action and immediately called the supervisor to report what had happened. Immediately after the incident the Certified Nurse Assistant #1 was removed from the unit and brought to the lobby. The Director of Nursing was called and notified, the resident was examined, there was no mark or redness, a head-to-toe assessment was completed and showed no unusual bruising, swelling or other signs of injury. The Certified Nurse Assistant #1 was suspended and later terminated. The Director of Nursing sent in a report to the Department of Health on January 20th by 11:07 AM with the identified allegation type listed as Physical Abuse. In an interview with the Director of Nursing on 1/29/25 at 11:30am they stated they did not call the Local Police department regarding the 01/19/25 incident. The Director of Nursing stated that the Attorney General's office communicated with them (called and emailed) on 01/23/25. The Director of Nursing stated that they did not call the local Police Department because their interpretation was that it was not a crime, there was no injury at all, not even a mark, and Resident #1 was not in any distress - they are hooked up to monitors that register their vitals and the monitors did not indicate any change from the norm. In an interview on 1/29/25 at 11:45am with the Administrator, it was pointed out that the local authorities were not contacted. The Administrator stated that they did not call the local authorities because they knew that the incident was not a crime or in any way suspicious. The Administrator stated that the Certified Nurse Assistant #1 acted reflexively and had absolutely no willful intent. The Administrator stated it was not in their mind a crime. The Administrator stated they also had interactions with the Attorney General's office, who had contacted them, and that the Attorney General had informed them that it was ok that they had not called in the local authorities. In a subsequent interview with the Director of Nursing on 2/27/25 at 1:20pm they stated that it was an oversight, but there is no nursing note regarding the 11/19/25 staff to resident incident. The Director of Nursing stated that Registered Nurse #1, the nurse that reported the incident, wrote only one note on 1/19/25 at 12:09pm, but that note was not about the staff to resident incident. 10 NYCRR 415.4(b)(2)

Based on observations, record reviews and interviews completed during an abbreviated survey (NY00357157 & NY00345502), the facility did not ensure that 2 different residents received treatment and care in accordance with their comprehensive person-centered care plan. Specifically Resident #2 and Resident # 3 had care plans in place, that documented that they required 2 staff members to provide all care. In each identified instance a single Certified Nurse Assistant provided care singlehandedly to each resident. The Finding is: The Facility policy titled Safe Resident Handling that was in effect at the time of the incidents has been effective since 2/1995 and updated and revised multiple times most recently after the 2 incidents with Certified Nurse Assistants providing care alone. The Policy Safe Patient Handling dated 10/2023 documents that the number of staff assistance needed for care is indicated in the care plan/Kardex. The updated policy dated 1/2025, after the two incidents documents: Additionally, all residents that are greater than 35lbs and dependent for Activity of Daily Living performance will be a 2-person assist for Activity of Daily Living care including showering, dressing, diaper changes and positioning, unless otherwise care planned, and this will be indicated with a I take two symbol at residents' bedside and indicated in the care plan/Kardex. Resident #2 originally admitted on [DATE] with diagnoses including, but not limited to, X-linked Myotubular Myopathy (MTM is a rare genetic disorder that affects the muscles, causing weakness and hypotonia - low muscle tone), Pediatric feeding Disorder chronic (PFD is defined as impaired oral intake that is not age-appropriate, and is associated with medical, nutritional, feeding skill, and/or psychosocial dysfunction), and Osteoporosis (a medical condition in which the bones become brittle and fragile from loss of tissue, typically as a result of hormonal changes, or deficiency of calcium or vitamin D). Resident #2 Minimum data set, a resident assessment and screening tool, dated 8/9/2024 indicate that the 8-year-old resident was completely dependent on others for all activities of daily living, Resident #2 is not capable of letting their needs be known. The investigative summary documents that the event occurred on 10/11/2024, at 1:15pm Resident #2 was receiving Occupational Therapy services, and it was noted that there were irregular movements at the left distal femur. Resident #2 had some redness, and they grimaced with manipulation. Therapy was stopped, Registered Nurse #3 was notified, Nurse Practitioner notified, and Nurse Manager. Portable X-Ray ordered, result indicated left mid diaphysis femur fracture (a broken bone in the middle shaft - diaphysis - of the left femur - thigh bone) and Resident #2 was sent to the hospital. Per the facility internal investigation prior to this fracture, Resident #2 had been resting in bed, and was changed 1 time at 5:04am by a single Certified Nurse Assistant (Certified Nurse Assistant #6). Certified Nurse Assistant #6 did not return a call from Department of Health. Certified Nurse Assistant #6's statement in the investigative report is that they changed Resident #2 without assistance because they thought that Resident #2 was only a 2 person assist for transfer and shower and did not realize it was also for diaper changes. Resident #2 is care planned and it is on their Kardex that they are a 2 person assist for all activities of daily living, however, the Certified Nurse Assistant #6 did not check the Kardex prior to providing care. Resident #3 originally admitted on [DATE] with diagnoses including, but not limited to, Aphasia (a language disorder that affects a person's ability to communicate effectively), Metachromatic Leukodystrophy (MLD, a rare, inherited genetic disorder that affects the nervous system and leads to progressive neurological decline), and Osteoporosis. Resident #3's Minimum data set, a resident assessment and screening tool, dated 5/31/2024 indicated that the [AGE] year-old resident was severely cognitively impaired and is completely dependent on others for all activities of daily living, Resident #3 is not capable of letting their needs be known. Reviewing the internal facility investigation summary on 6/16/2024 Certified Nurse Assistant #7 changed Resident #3's diaper without assistance, even though the care plan and Kardex for Resident #3 states 2 person assist. The statement from Certified Nurse Assistant #7 is that they changed Resident #3 alone because the nurse was very busy with a different resident most of the night. The Certified Nurse Assistant #7's statement is that they saw Resident #3's leg and it did not look unusual, red, or swollen ever throughout the night during the times they were in to change Resident #3's diaper. Resident #3 had a straight catheterization at 7am with 2 staff present, Certified Nurse Assistant #6 and Registered Nurse #5. At this time the leg did not have any change in appearance, it was not until 8:30am when the same two staff went in to change Resident #3's diaper that the leg was noticed to be swollen, and there was a noticeable change in the alignment of Resident #3's leg. Protocol was followed and Resident #3 had a stat bed side Xray done and the result indicated a right comminuted mid shaft femur fracture (a comminuted - broken into many pieces - bone in the middle shaft of the right femur - thigh bone) and Resident #3 was transferred to the hospital. Certified Nurse Assistant #7 returned the surveyor's call on 2/7/2025 at 9am and in the interview that followed they stated that they were not aware that the Kardex had changed. Certified Nurse Assistant #7 stated they had often changed the diaper for Resident #3 alone, because they did not check the Kardex. Certified Nurse Assistant #7 stated that when they had gone in to provide cares, Resident #3's leg did not look different in any way. Certified Nurse Assistant #7 stated that since the incident this no longer occurs because there are signs, and the facility changed the assignment process and the assignment sheet; now staff work as a team with every resident. In an interview on 2/6/2025 at 9am with Registered Nurse #5 they stated that they, along with Certified Nurse Assistant #6 had gone in early in the morning to straight catheterize Resident #3 and there were no issues noted with Resident #3's leg. Registered Nurse #5 stated it was not until much later in the morning at around 8:30am that they noticed that Resident #3 had a misalignment with their leg. Registered Nurse #5 stated they were not aware that the Resident #3 had been provided Activities of Daily Living cares alone during the over night shift. 10NYCRR 415.12

Based on record review and interview conducted during an abbreviated survey (NY00315615), the facility failed to ensure the resident's right to be free from abuse for 1 of 3 residents (Resident #1) reviewed for verbal abuse. Specifically, on 04/23/2023 a Licensed Practical Nurse (LPN #1) overheard Certified Nursing Assistant (CNA #1) yelling at Resident #1 to bend their f . knees while providing care to the resident. CNA #1 was also observed by LPN #1 shoving down on the resident's contracted legs and yelling at them while trying to dress them. The findings are: The Policy and Procedure titled Abuse dated 10/2000 and revised 04/2023 documented that it was the policy of the facility to protect residents from abuse, neglect mistreatment, exploitation or misappropriation of property in accordance with state and federal regulations. Abuse is defined as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse. All alleged or suspected abuse will be thoroughly investigated, and findings documented. Mental abuse defined as but is not limited to humiliation harassment threats of punishment or withholding of treatments or services. All employees are responsible to report alleged abuse including those that provide services under contract. Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to Unspecified intellectual disabilities, Spastic Quadriplegic Cerebral Palsy and Aphasia. The Admission Minimum Data Set (MDS, an assessment tool) dated 02/28/2023 documented that the resident had a Brief Interview for Mental Status (BIMS, used to determine attention, orientation, and ability to recall information) score of 99 denoting severe cognitive impairment for daily decision making. The resident required two-person physical assistance for transfer, dressing, and toilet use and bed mobility, total dependence one-person physical assistance for eating, personal hygiene, and bathing. The resident was incontinent of bowel and bladder and used a wheelchair for mobility. The Comprehensive Care Plan documented that the resident has a psychosocial well-being concern which may interfere with their sense of safety updated on 04/28/2023 included interventions that the resident will be provided with the opportunity to meet with Social Worker upon request to support his social and emotional well- being. The Facility Investigative findings documented LPN #1 was in the doorway. LPN#1 heard and saw CNA #1 as they was starting to put Resident #1 pants and CNA#1 was seen shoving their legs down and stated Come on Man straighten your f . legs. LPN #1 asked Resident #1 if they were OK and they stated yes, they then checked their head, body arms and legs for any signs of injury and there was none. When asked why LPN #1 did not report the incident right away, they stated, I should have reported it right away. LPN #1 was reminded they are a mandated reporter. The Facility Investigative Summary regarding the incident on 04/23/2023 documented that the allegation of verbal abuse was substantiated. CNA #1 spoke in a disparaging and derogatory manner and in a manner that made Resident #1 feel threatened. LPN #1 reported CNA #1 had a rough way of physical contact with Resident #1 by shoving their contracted legs while trying to dress them. While no injury was sustained there was a potential for harm. Review of the Physician Progress Note dated 04/28/2023 at 12:32 PM documented Resident #1 was seen and examined at bedside this morning secondary to concerns regarding abuse. Resident is alert and in no acute distress. Review of the Director Social Worker Progress Note dated 04/28/2023 at 2:22 PM revealed that Resident #1 did not report any incident of mistreatment, but confirmed CNA yelled at them recently during care. Team focus will remain on adjustment and sense of personal safety security and well-being of the resident. Review of the Licensed Psychologist evaluation dated 05/01/2023 documented that interview notes (between SW#1 and Resident#1) was reviewed. Resident #1's intellectual and communicative abilities are sufficient for providing accurate reporting when interviewed. During an interview conducted with CNA #1(the accused) on 05/08/2023 at 2:00 PM, CNA #1 stated they worked with Resident #1 on 04/23/2023. CNA #1 stated while they were in the room the Registered Nurse (RN) came in and stated they needed to pick up two extra residents. CNA #1 stated they did tell RN that they were not done with their current assignment and that it was not fair they were assigning two extra residents. CNA #1 stated they may have cursed (not at Resident #1), but it wasn't loud to the point where anyone could hear them from the door. CNA #1 confirmed that LPN #1 was in the room with them and was giving medications to another resident at the time. CNA #1 stated they were trained on abuse and neglect in their training class. CNA #1 stated they understood that they should not be cursing at all. CNA denied rough handling the resident. During an interview conducted with LPN #1 on 05/09/2023 at 12:00 PM, LPN #1 stated while speaking with the Director of Nursing (DON) on 04/27/2023 about the culture on the unit. LPN#1 reported an incident they had witnessed between CNA #1 and Resident #1. LPN #1 stated on 04/23/2023 they were in the doorway of Resident #1's room providing medication to another resident in the room. LPN #1 stated they witnessed CNA #1 dressing Resident #1 and while pushing on the top of their legs to put their pants on they heard CNA #1 say come on man put your f . legs down. LPN #1 stated they asked CNA #1 what they were doing and if they were okay and they stated they were frustrated due to having to take on extra residents. LPN #1 stated CNA #1 did calm down while they were talking to them. During an interview conducted with Registered Nurse(RN #1) on 05/08/2023 at 2:30 PM, RN#1 denied noticing any changes with Resident #1. RN #1 stated they were trained to report any abuse, neglect, or changes in condition to the supervisor immediately. RN #1 denied anyone reporting any allegation to them on 04/23/2022. RN #1 did not have any concerns about CNA #1 regarding abuse or neglect. RN #1 stated they worked with CNA #1 frequently and would have to remind them to be gentle. During an interview with RN #2 on 05/08/2023 at 1:30 PM, RN #2 stated they were the charge nurse on the unit on 04/23/2023. No incident was reported to them during the shift. On 04/28/2023, the DON informed them of the allegation of verbal abuse with Resident #1. During an interview with RN #3 on 05/09/2023 at 1:28 PM, RN #3 stated LPN #1 did not report any abuse or neglect allegations to them. RN #3 stated LPN #1 did say that CNA #1 was very strong in moving residents, but never stated they abused or cursed at Resident #1. RN #3 stated they told LPN #1 to report any concerns to administration if they felt they had something they needed to report. RN #3 stated they could not recall the date they spoke with LPN #1. 415.4(b)(1)(i)

Based on interview and record review conducted during an abbreviated survey (NY00315615), the facility did not ensure an alleged violation involving abuse was reported to the New York State Department of Health (NYSDOH) within 2 hours of occurrence. This was evident for 1 of 3 residents (Resident #1) reviewed for abuse and mistreatment. Specifically, upon witnessing Certified Nursing Aide (CNA #1) of being verbally abusive to Resident #1 on 04/23/2023, a Licensed Practical Nurse (LPN#1) did not report the incident to the facility Administrator until 04/27/2023. Resident #1 confirmed that CNA #1 yelled at them on 04/23/2023 during care. The facility reported to the NYSDOH on 04/28/2023. The findings are: The policy and procedure titled Abuse Prohibition dated effective 10/2000 last revised 04/2023 documented all alleged violations of abuse, including injuries of unknown origin and misappropriation of resident property will be reported immediately to the Director of Nursing (DON) and facility Administrator or his or their designated representative and other officials and in accordance with State Law (NYSDOH) upon having reasonable cause to believe that abuse has occurred. The facility will immediately report any incident and/or violation when there is reasonable cause to believe that abuse has occurred. Resident #1 was admitted to the facility on [DATE] with diagnoses including but not limited to Unspecified intellectual disabilities, Spastic Quadriplegic Cerebral Palsy and Aphasia following unspecified Cerebrovascular Disease. The Quarterly Minimum Data Set (MDS a resident assessment tool) dated 02/28/2023 documented resident is severely impaired. Resident requires extensive assist of two persons physical for bed mobility and transfers, dressing and toilet use. Resident is totally dependent and requires one-person physical assist for eating and hygiene. The Undated Investigation Summary completed by Director of Nursing (DON) documented on 04/27/2023 DON met with LPN #1 at approximately 5:30 PM. LPN #1 reported that during morning care on Sunday 04/23/2023 they were assigned to work on the Chestnut unit in room [ROOM NUMBER] and CNA #1 was the assigned CNA. RN #2 entered the room and informed CNA #1 that they would need to cover two additional residents as one of the other CNAs were late due to car trouble. According to LPN #1, CNA #1 became agitated after hearing they had additional heavy residents. Shortly after RN #2 left the room, LPN #1 was leaving the room and stated I'll be right back. As LPN #1 was in the doorway of the room they heard and saw CNA #1 being excessively rough with Resident #1. CNA #1 was starting to pull up Resident #1's pants and was seen shoving legs down as said through clenched teeth, c'mon man, straighten your f legs! LPN #1 stated they did not report the incident to a manager or supervisor. When asked why, LPN #1 was unable to provide any rational reason other than to say, I should have told right away. Review of the NYS DOH Automated Complaint Tracking System (ACTS) Complaint/Incident Investigation Report documented the date/time of incident was 04/23/2023 at 8:00 AM and a report was submitted by the facility on 04/28/2023 During an interview with RN #2 on 05/08/2023 at 1:30 PM, RN #2 stated they were the charge nurse on 04/23/2023 on the Chestnut unit. No incident was reported to them by any staff during their shift. On 04/28/2023, the DON told them of the allegation of abuse with Resident #1. During an interview conducted with DON on 05/08/2023 at 1:22 PM, the DON stated that on 04/27/2023 a little after 5:00 PM they asked to speak with LPN #1 regarding something unrelated to the abuse allegation. DON stated LPN #1 stated they had witnessed CNA #1 sort of pushing down on resident #1's legs as they were putting their pants on them and made a derogatory comment. DON stated that LPN #1 stated they witnessed the incident as they were leaving the room. The DON stated LPN #1 was asked why they did not report the incident and they stated they knew they were supposed to and were very apologetic. The DON stated both CNA #1 and LPN #1 were suspended. DON denied that LPN #1 reported the incident to anyone else. During an interview conducted with LPN #1 on 05/09/2023 at 11:46 AM, LPN #1 stated they were placed on suspension by the facility on 04/27/2023 pending completion of the investigation. LPN #1 stated while speaking with the DON on 04/27/2023 they reported an incident they had witnessed with CNA #1 and resident #1. LPN #1 stated on 04/23/2023 they were in the doorway of resident #1's room providing medication to another resident in the room. LPN #1 stated they witnessed CNA #1 dressing Resident #1 and while pushing on the top of their legs to put their pants on they heard CNA #1 say come on man put your f legs down. LPN #1 stated the Registered Nurse Supervisor had called out that day so they reported to the next person in charge, RN #3. LPN #1 stated they were under the impression that since they reported to RN #3 who was the preceptor that day that it was sufficient. LPN #1stated they were informed by the DON that RN #3 is not a supervisor, and they should have reported the incident to a supervisor. LPN#1 confirmed the incident occurred on the 6:00 AM to 6:00 PM shift on 04/23/2023. During an interview with RN #3 on 05/09/2023 at 1:28 PM, RN #3 stated LPN #1 did not report any abuse or neglect allegations to them. RN #3 stated LPN #1 informed them that CNA #1 was very strong when moving residents, but did not indicate that CNA #1 abused or cursed at resident #1. RN #3 stated they told LPN #1 to report any concerns to administration if they felt they had something they needed to report. RN #3 stated they could not recall the date they spoke with LPN #1. 415.4(b)

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that food was stored and prepared under sanitary conditions in that, (1.) the temperature of the reach-in freezer was being maintained at zero or below for a prolonged period of time; (2.) the freezer section of a refrigerator was not equipped with a thermometer; and (3.) the hand sanitizer (hand hygiene agent that does not require water) prohibited as a substitute for hand washing was in use in the kitchen. The findings are: 1. During the initial inspection of the kitchen on 11/8/16 between 9:30 AM and 10:30 AM, the thermometer for the reach-in refrigerator showed a temperature of 5 degrees Fahrenheit (F) and was brought to the attention of the Food Service Manger (FSM). During a follow-up visit to the kitchen on 11/10/16, the temperature log for the above freezer showed that since October 16, 2016, the temperature for this freezer was being maintained at 5 degrees F. The temperature log made no reference to what the required temperature should be. (All items were noted to be frozen.) 2. Additionally, during the initial tour of the kitchen, the freezer compartment of the refrigerator in the dining room adjacent to the kitchen did not have a thermometer. The freezer was being used to store menu items. At the time of the observation, the FSM stated that a thermometer was previously present. There was no temperature log for this freezer. During the follow-up visit to the kitchen on 11/10/16, the above freezer was not equipped with a thermometer. At that time the FSM stated that one would be obtained on Monday, 11/14/16. 3. On 11/8/16 a hand sanitizer dispenser was noted to be mounted on the wall in close proximity to the hand washing sink. The hand sanitizer was on the left of the sink and a mounted soap dispenser on the right of the sink. At about 11:00 AM on 11/8/16 a dietary worker was observed to apply the sanitizer to her hands and then proceeded to wash her hands in the same manner as if soap and water were being used. Anti-microbial gel (hand hygiene agent that does not require water) and cannot be used in place of proper hand washing techniques in a food service setting. 415.14 (h)

Based on record review and staff interview, the facility did not ensure that Pre-Admission Screen Resident Reviews(PASRR)were completed prior to admission as required by State and Federal Regulations. This was evident for five of six residents reviewed for PASRR (Residents #54, #56, #58, #59, and #60). This resulted in a potential for more than minimal harm that is not immediate jeopardy. The findings are: The clinical records of five of six residents (Residents #54, #56, #58, #59, and #60) reviewed on 11/20/13 did not contain evidence that PASRR was completed prior to admission to the facility. The PASRR is required by State and Federal Regulations for each resident to determine whether nursing home placement is appropriate for the resident and whether or not specialized services are required to meet the needs of residents with mental [MEDICAL CONDITION] and/or mental illness. The Director of Social Work, who is responsible for the facility's admission process, was interviewed on 11/20/13 at 11:30 AM regarding the lack of PASRR for each of the resident mentioned above. She stated that she completed the screens after the residents' admission to the facility because the pediatric facilities from which these residents were admitted "did not know how to complete the screens". 415.11(e)

Based on observations, record reviews and staff interviews, the facility did not ensure that care and treatments were provided in accordance with the residents' written plan of care. Specifically, a skin protector was not applied for a resident at risk for development of skin breakdown (Resident #1) and a vitamin supplement was not given as ordered by the physician (Resident #12). These were evident for 2 of 13 sampled residents. (Residents #1 and #12). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are: 1. Resident #1 is a [AGE] year old male who was admitted to the facility with [DIAGNOSES REDACTED]. A review of the Non-Medication Orders record which was updated on 11/21/11 revealed skin care orders including turning and positioning every 2 hours, application of barrier cream to diaper area with each diaper change, use of pressure-relief mattress, and application of Allevyn (a type of skin protector). A review of the November 2011 Treatment Record revealed an order for [REDACTED]. Observations on 11/28/11 at 8:00 AM and 10:00 AM and on 11/29/11 at 7:30 AM. revealed that there was no Allevyn applied to the aforementioned areas. Interview with the unit Registered Nurse on 11/29/11 at 8:00 AM revealed that this resident is at risk for development of skin breakdown secondary to the resident's contractures, scoliosis (a spinal deformity), immobility and a history of skin irritation. She further stated that a skin protector was needed to be applied over the bony prominences on the back, buttock, and ischial areas to prevent any further skin breakdown. When asked as to why there was no skin protector over the said areas at the times of observations, she responded that the facility ran out of Allevyn and that she needed to apply a similar product called [MEDICATION NAME]. However, [MEDICATION NAME] was neither found to be applied on the areas susceptible to development of skin breakdown. 2. Resident #12 is a 7-year old female who was admitted to the facility with [DIAGNOSES REDACTED]. A review of the physician's orders [REDACTED]. A review of the November 2011 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview with the Assistant Director of Nursing (ADON) on 11/30/11 at 7:00 AM as to why the medication was not given on those days, she stated that it was not available. During further interview with the ADON as to why the nurses' initials were not encircled on the day 11/24/11 and the days 11/26/11 to 11/28/11, she stated that it appeared that the medication was administered. 415.11(c)(3)(ii)

Based on observation, record review and staff interviews, the facility did not, in all cases, assure that acceptable infection control practices were used by nursing staff to minimize the potential for development and spread of infection. Specifically, the nurse did not follow proper hand washing and gloving techniques when handling contaminated items from a resident who was placed on isolation precautions. This was evident for 1 of 13 sampled residents. (Resident #9) This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The finding is: Resident #9 is a 9-year old male who was admitted to the facility with [DIAGNOSES REDACTED]. (Tracheotomy is a procedure where an airway opening is made into the trachea via an incision on the 2nd or 3rd cartilage ring bypassing the upper airway). A review of the resident's clinical record revealed that the resident has a tracheostomy tube inserted to assist him in breathing. Observations of the resident on 11/29/11 at 10:00 AM. and on 11/30/11 at 10:45 AM revealed that the resident has moderate amount of secretions coming from the tracheostomy tube. The secretions were also noted on the tracheostomy collar that was attached to this tube which assists in providing humidified oxygen to the resident. Further record review revealed that the resident was placed on isolation (contact) precautions secondary to the presence of microorganism in the tracheal secretions and it was necessary that staff use appropriate personal protective equipment such as masks, gowns and gloves when providing direct care to the resident. On 11/30/11 at 9:30 a.m., a Registered Nurse (RN) was observed to wear a mask, a gown and a pair of gloves to assist another nurse in performing tracheostomy care for this resident. This RN removed the tracheostomy collar that was full of secretions. The nurse then proceeded to the bathroom, which is shared with two other residents who are not on isolation precautions. She turned the faucet on to rinse the collar wearing the same glove. After cleansing the collar, she took a paper towel to dry it. She then turned the faucet off using the same paper towel and still wearing the same pair of gloves. She then proceeded back to the resident to replace the collar. When the RN was interviewed on 11/30/11 at 10:15 a.m. as to the proper hand washing and gloving procedure, she stated that she should have removed the gloves and washed her hands accordingly after handling the contaminated collar. She stated that she also should have used her elbows to turn the faucet off to avoid further possible contamination. 415.19(a)(1-3)

Based on observation, record review, and staff interviews, the facility did not ensure that residents were provided adequate supervision and appropriate interventions necessary to prevent elopement from the facility. Specifically, 2 residents were able to leave the facility undetected by staff on 2 separate occasions. This was evident for 2 residents reviewed during an abbreviated survey. (Residents #1, #2) This resulted in the potential for more than minimal harm that is not immediate jeopardy. Findings are: Complaint # NY 547 Complaint # NY 207 Resident #1 is a [AGE] year old male admitted on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS)(a resident assessment tool) dated 5/05/10 revealed the resident has long and short term memory problems and is severely impaired in daily decision making skills. A review of the comprehensive care plan (CCP) revealed on 5/12/10, Resident #1 was observed opening the door to the back hallway that leads to the service driveway. The staff was informed and increased observation was implemented. On 5/29/10 at 9:05 AM, the facility investigation revealed a cab driver came to the front desk and stated a resident was in the driveway. Staff found Resident #1, unsupervised and alone, tipped over in his wheelchair and laying on his right side in the driveway. Resident #1 was alert and responsive with abrasions on the right elbow, right temple and reddened areas on the right chest, leg, and arm. He was able to turn the door handle to the service corridor by pushing down on the lever and pushing his chair forward. The door leads to a service corridor and to a second door with a handle the resident was able to turn. Once out of the building he wheeled approximately 30 feet where his wheelchair tipped over in the driveway. On 7/15/10 a Wanderguard system (alarm system to alert staff to any unsafe wandering) was installed on the back hallway door. There was no Wanderguard alarm installed at the other exit door leading from the dining room to the patio. The facility investigation revealed on 8/08/10, Resident #1 was again found unsupervised by the service driveway outside the building by a dietary employee at 10:30 AM. No staff heard the wanderguard alarm go off. The administrative staff was not made aware of the incident until 8/09/10 at 5:30 PM. None of the staff reported the incident at the time of the occurrence. No injury was noted on the resident. The resident exited the building via the dining room door to the patio that was not wanderguard alarmed although the resident had eloped once before. Furthermore, the dining room door was not locked while there was ongoing construction and machinery outside the building. The resident was able to leave the dining room to go outside undetected and unsupervised. During an interview with the assigned Certified Nursing Assistant (CNA) on 9/21/10 at 9:15 AM, he stated he was caring for another resident and was not aware Resident #1 had left the building. On 8/11/10 at 3:15 PM, Resident #1 was observed self-propelling his wheelchair in the main lobby. He was alert, but unable to communicate verbally. Resident # 2 is a 7 year old female admitted on [DATE] with [DIAGNOSES REDACTED]. The MDS dated [DATE] revealed the resident has long and short term memory problems and is moderately impaired in daily decision making skills. Resident #2 is a non ambulatory child who uses a wheelchair for mobility. As part of her ongoing restorative rehabilitation program she is positioned in a PONY walker (gait trainer for mobility). Her ability to use the PONY walker has increased over the past several months and has become her primary form of mobility. The facility investigation revealed on 9/07/10 at approximately 9:30 AM, Resident #2 was found unsupervised in her PONY walker by the service driveway by a Registered Nurse (RN) who was exiting the building. The RN removed her from the PONY walker and immediately brought her into the building where she was assessed and no injury was noted. The investigation revealed the patio has three openings/exits that allow the residents to move out of the patio area to the playground that leads to the back service driveway. A temporary barrier consisting of 2 large log barriers, approximately 30 lbs each have been placed in the openings to prevent residents from leaving the patio. On 9/21/10, staff had not noticed that the log barriers had been removed. As the children were brought out to the patio for activities, Resident #2 in her PONY walker apparently exited one of these openings. She was not observed by the CNA who was busy settling the other children into the patio. The investigation revealed that Resident #2 left the patio from the right-side opening of the patio that leads to a walk way towards the back service area. It was believed that the landscapers and gardeners had been onsite prior to this event and removed these barriers from the openings. On 9/21/10 at 11:00 AM, Resident #2 was observed in her Pony walker maneuvering at a very fast pace in the patio area followed by a staff member. During an interview on 9/21/10 at 12:45 PM the C.N.A stated she was busy receiving the residents in the patio and did not notice that the log barriers were not in place. At 1:05 PM two Therapeutic Activities Assistants who were transporting the residents also stated they did not notice that the log barriers were not in place allowing Resident #2 to leave the patio undetected and unsupervised. 415.12(h)(2)