Every finding on record at The Hamptons Center for Rehabilitation and Nursing

Based on record review and interviews during survey, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by Center of Medicare and Medicaid Services not less frequently than once every three (3) months. This was identified for four (4) (Resident #25, Resident #35, Resident #36, Resident #184) of ten (10) sampled from 61 residents triggered for the resident assessment task. Specifically, Resident #184's Quarterly Minimum Data Set assessment with Assessment Reference Date of 02/06/2026 was not completed; Resident #35's Quarterly Minimum Data Set assessment was not completed until 77 days after the Assessment Reference Date of 02/06/2026; Resident #25's Quarterly Minimum Data Set assessment was not completed until 71 days after the Assessment Reference Date of 01/21/2026; and Resident #36's Quarterly Minimum Data Set assessment was not completed until 22 days after the Assessment Reference Date of 11/28/2025. The findings include but are not limited to:The facility's policy and procedure titled Minimum Data Set (MDS 3.0) Completion, last reviewed in October 2025, documented the facility will ensure that all Minimum Data Set assessments are completed, signed, and transmitted in accordance with federal requirements and the Resident Assessment Instrument Manual. All required assessments will be scheduled based on Assessment Reference Date and completed within 14 days. The assessment completion is defined as completion of the care area assessment process in addition to the Minimum Data Set items, and a Registered Nurse assessment coordinator has signed and dated both the Minimum Data Set and care area assessment completion attestation. The Center for Medicare and Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1 dated October 2025 documented assessment management requirements for quarterly assessments including the completion date (item Z0500B) must be no later than 14 days after the assessment reference date (ARD + 14 calendar days).Resident #184 was admitted with diagnoses including dementia (a progressive disease that affects memory, thinking and social ability), hypertension (high blood pressure) and hyperlipidemia (elevated lipid level). The Quarterly Minimum Data Set assessment with an assessment reference date of 02/06/2026 documented that Resident #184 had a Brief Interview for Mental Status score of 10, which indicated Resident #184 had moderately impaired cognition. The Quarterly Minimum Data Set assessment did not have a completion date indicated (item Z0500B). Resident #35 was admitted with diagnoses including nontraumatic subarachnoid hemorrhage (bleeding into the space surrounding the brain not caused by head injury), dysphagia (difficulty swallowing), and aphasia (inability to swallow). The Quarterly Minimum Data Set assessment with an assessment reference date of 02/06/2026 documented the Brief Interview for Mental Status was not completed because Resident #35 was unable to understand others. The Quarterly Minimum Data Set assessment was not completed until 04/24/2026, 77 days after the assessment reference date. Resident #25 was admitted with diagnoses including multiple sclerosis (a nervous system disease that affects the brain and spinal cord), tremor, and ulcerative colitis (a condition that cause inflammation and ulcers in the colon). The Quarterly Minimum Data Set assessment with an assessment reference date of 01/21/2026 documented Resident #25 had a Brief Interview for Mental Status score of 15, which indicated Resident #25 had intact cognition. The Quarterly Minimum Data Set assessment was not completed until 04/02/2026, 71 days after the assessment reference date. During an interview on 04/28/2026 at 09:36 AM, the Minimum Data Set Assessor stated that they were responsible for the completion of all Minimum Data Set assessments. The Minimum Data Set Assessor stated the Minimum Data Set booklets should be completed within 14 days of the assessment reference dates. The Minimum Data Set Assessor stated they were unable to complete the assessments on time because they performed other duties such as managing care plan meetings and they have reported their concern to the Minimum Data Set Coordinator and were doing their best at this point. During an interview on 04/28/2026 at 10:30 AM, the Minimum Data Set Coordinator stated that quarterly Minimum Data Set assessments should be completed within 14 days of the assessment reference dates. The Minimum Data Set Coordinator stated they were on track with completing and submitting assessments until a sudden influx of new resident admissions in October 2025. Additionally, the minimum data set system to submit the assessments was changed during the past few months which affected compliance with assessment completion and submission timeline. The Minimum Data Set Coordinator stated the facility Administrator and the Director of Nursing Services were aware of the issues. During an interview on 04/28/2026 at 11:12 AM, the Assistant Director of Nursing Services, former Director of Nursing Services (until 04/20/2026), stated they were aware of late Minimum Data Set assessment completion and were unable to identify the root cause why the assessments were completed late. During an interview on 04/28/2026 at 11:31 AM, the current Director of Nursing Services stated all Minimum Data Set assessments should be completed on time. The Director of Nursing Services stated that timely completion of the Minimum Data Set assessment was crucial to ensure resident care was assessed and provided appropriately. During an interview on 04/28/2026 at 01:14 PM, the Administrator stated they were aware of late Minimum Data Set assessment completion; however, they did not implement any systemic changes that were implemented until the new Director of Nursing Services started. 10New York Code Rules and Regulations 415.11(a)(4)

Based on record review and interviews during survey, the facility failed to ensure that all completed Minimum Data Set assessments were electronically transmitted to the Center for Medicare and Medicaid Services within 14 days of the resident assessment completion. This was identified for three (3) (Resident #36, Resident #43, and Resident #178) of ten (10) residents sampled from 61 residents triggered for the resident assessment task. Specifically, Resident #178's Annual Minimum Data Set assessment was not electronically transmitted to the Center for Medicare and Medicaid Services until 56 days after the completion of the assessment; Resident #43's admission Minimum Data Set assessment was not electronically transmitted to the Center for Medicare and Medicaid Services until 42 days after the completion of the assessment; and Resident #36's Quarterly Minimum Data Set assessment was not electronically transmitted to the Center for Medicare and Medicaid Services until 27 days after the completion of the assessment.The findings include but were not limited to:The facility's policy and procedure titled Minimum Data Set (MDS 3.0) Completion, last reviewed on October 2025, documented the facility will ensure that all Minimum Data Set assessments are completed, signed, and transmitted in accordance with federal requirement and the Resdient Assessment Instrument Manual. All completed Minimum Data Set assessments are transmitted electronically to Center of Medicare and Medicaid Services via the approved submission system. The admission and annual comprehensive assessments and the quarterly assessments are transmitted no later than 14 calendar days from care plan completion date. Resident #178 was admitted with diagnoses including osteoporosis (a bone disease when bone mass and bone density decrease), type 2 diabetes mellitus, and retention of urine. The Annual Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, which indicated that Resident #178 had intact cognition. The Minimum Data Set was completed on 02/10/2026. Resident #43 was admitted with diagnoses including seizures (abnormal electrical activity in the brain), postlaminectomy syndrome (failed back surgery syndrome where patient continues to have pain after spine surgery), and hypertension (high blood pressure). The admission Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 13, which indicated that Resident #43 had intact cognition. The Minimum Data Set was completed on 11/26/2025. Resident #36 was admitted with diagnoses including Guillain-Barre syndrome (an autoimmune condition where the immune system attack the body's nerves), discitis in the thoracic region (infection of the disc space between vertebrae), and chronic obstructive pulmonary disease (a chronic lung condition caused by damages to the lungs). The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated that Resident #36 had intact cognition. The Minimum Data Set was completed on 12/20/2025. A review of the Minimum Data Set (MDS) 3.0 Nursing Home Validation Report revealed the following:-Resident #178's 01/30/2026 admission Minimum Data Set assessment was completed on 02/10/2026, but not transmitted to the Center for Medicare and Medicaid Services (CMS) until 04/07/2026, that is 56 days after the assessment was completed. Additionally, the validation report indicated the assessment was rejected because Section X did not match the corresponding items of an existing record in the database. -Resident #43's 11/19/2025 admission Minimum Data Set assessment was completed on 11/26/2025, but was not transmitted to the Center for Medicare and Medicaid Services until 01/07/2026, that is 42 days after the assessment was completed. -Resident #36's 11/28/2025 Quarterly Minimum Data Set assessment was completed on 12/20/2025, but was not transmitted to the Center for Medicare and Medicaid Services until 01/16/2026, that is 27 days after the assessment was completed. During an interview on 04/28/2026 at 09:36 AM, the Minimum Data Set Assessor stated the Minimum Data Set coordinator and themself were responsible for transmitting the Minimum Data Set assessments to the Center of Medicare and Medicaid Services. The Minimum Data Set Assessor stated they usually transmit the Minimum Data Set assessments the same day they were completed. The Minimum Data Set Assessor stated they were unable to complete and transmitted assessments on time because they performed other duties such as managing care plan meetings. The Minimum Data Set Assessor has reported their concern to the Minimum Data Set Coordinator and was doing their best at this point. During an interview on 04/28/2026 at 10:30 AM, the Minimum Data Set Coordinator stated that quarterly Minimum Data Set assessments should be completed within 14 days of the assessment reference dates. The Minimum Data Set Coordinator stated they were on track with completing and transmitting assessments until a sudden influx of new resident admissions in October 2025. Additionally, the minimum data set system to submit the assessments was changed during the past few months which affected compliance with assessment completion and submission timeline. The Minimum Data Set Coordinator stated the facility Administrator and the Director of Nursing Services were aware of the issues. During an interview on 04/28/2026 at 11:31AM, the Director of Nursing Services stated they expected all Minimum Data Set assessments to be completed and transmitted timely.During an interview on 04/28/2026 at 01:14PM, the Administrator stated that they expected all Minimum Data Set assessments to be completed and transmitted timely. 10 New York Code Rules and Regulations 415.11

Based on observation, record review, and interviews during surveys, the facility failed to ensure that each resident's environment remained free of accident hazards. This was identified for one (1) (Unit G) of seven (7) units reviewed for Accidents. Specifically, a free-standing E-Cylinder oxygen tank (a portable, high-capacity metal cylinder used to store compressed medical grade oxygen) was observed in the Unit G nursing station. The E-Cylinder tank was free standing and was not secured in a safety stand or a rack. The findings include: The facility's policy, titled Oxygen Tank Storage and Handling last revised on 02/2026, documented that all-oxygen tanks must be secured to a wall with a chain or heavy cable. No oxygen tanks will be left unattended on a transport dolly (a small, wheeled platform or cart used to move heavy items). Full oxygen tanks will be separated from empty oxygen tanks and identified as such. During an initial tour of the G Unit on 04/21/2026 at 12:15 PM, an unsecured E-Cylinder tank (a portable, high-capacity metal cylinder used to store compressed medical grade oxygen) was observed freely standing against the wall in the nurse's station. The E-cylinder tank was full and not in use. The E-Cylinder tank was not secure in a rolling caddy or a metal rack. During an interview on 04/21/2026 at 12:20 PM, Licensed Practical Nurse #1 stated they did not see the E-Cylinder tank in the nurse's station. Licensed Practical Nurse #1 stated that they were doing the medication administration for the residents in Unit G and did not notice the E-Cylinder oxygen tank was unsecured. Licensed Practical Nurse #1 stated oxygen tanks must be secured with a chain against the wall and on a dolly (a small, wheeled platform or cart used to move heavy items). During an interview on 04/21/2026 at 12:38 PM, Registered Nurse #2, stated the nurses in the unit for all shifts were responsible for ensuring that all oxygen tanks are secured properly. Registered Nurse #2 stated that oxygen tanks should not be freely standing. Registered Nurse #2 stated that all oxygen tanks must be chained to the wall and secure in a dolly for safety. During an interview on 04/22/2026 at 08:33 AM, Registered Nurse #1, the Unit G Manager, stated they were not aware that an unsecured E-Cylinder tank was in the nurse's station. Registered Nurse #1 stated they checked the tanks when they came in the morning of 04/21/2026 and did not see any tanks freely standing. Registered Nurse #1 stated they did not know who put the unsecured E-Cylinder tank in the nurse's station. Registered Nurse #1 stated that E-Cylinder tanks must be chained to the wall and secure in a dolly. During an interview on 04/22/2026 at 09:51 AM, the Director of Housekeeping stated that they were responsible for transporting the oxygen tanks to the unit. The Director of Housekeeping stated that they did visual rounds around 5:00 AM on 04/21/2026 and saw all the E-Cylinder oxygen tanks secured in a dolly. The Director of Housekeeping stated that an unsecured E-Cylinder oxygen tank is an accident hazard. The Director of Housekeeping stated that an unsecured E-Cylinder oxygen tank can fall and explode. During an interview on 04/27/2026 at 10:32 AM, the Director of Nursing Services stated all staff should be monitoring the oxygen tanks in the unit and resident rooms. The Director of Nursing Services stated all staff should make sure that the oxygen tanks are secure in a dolly and chained against the wall. The Director of Nursing Services stated that an unsecured E-Cylinder oxygen tank can be an accident hazard and cause injury if the tank falls and explodes. 10 New York Code Rules and Regulations 415.12(h)(1)

Based on observations, record review, and interviews during a survey (Complaint #2962369), the facility failed to ensure all residents had the right to be treated with respect and dignity, including the right to retain personal possessions. This was identified for one (1) (Residents #266) of two (2) residents reviewed for resident rights. Specifically, Resident #266 was transferred to the hospital. The facility staff packed Resident 266's belongings. After the resident's was readmitted to the facility from the hospital, the facility did not return the resident's belongings. The findings include: The facility's Policy titled Personal Belongings last reviewed on 10/2025 documented upon discharge of residents to a hospital, the facility will send all valuables to the basement for storage. All clothing and other personal belongings may be left in the room if the door can be locked or the security of the items can be ensured. Property left in the facility for more than 30 days after discharge will be disposed of at the discretion of the facility. The resident was admitted with diagnoses including type two diabetes, cerebral infarction, and essential hypertension. The Minimum Data Set assessment dated [DATE] documented a Brief Interview of Mental Status score of 3, indicating the resident had severely impaired cognition. The resident required assistance with all activities of daily care and was always incontinent. The Facility Grievance form dated 04/13/2026 documented Resident #266's family member reported missing clothing. The resident's clothing could not be located. During an interview on 04/22/2026 at 01:08 PM, Resident #266's family member stated the resident was discharged to the hospital for an evaluation on 01/23/2026 and returned to the facility on [DATE]. The resident's belongings were never returned to the resident or the family after the resident's discharge to the hospital. Resident #266's family member stated the facility knew about the belongings and nobody informed them what happened until today, 04/22/2026 when they heard from the Director of Housekeeping and the Administrator. Resident#266's family stated the missing clothing had sentimental value and getting reimbursement for the belongings cannot compensate for what was lost. Resident #266's family member stated they were informed that the resident's personal possessions were accidentally given to a different resident with same last name. During an interview on 04/23/2026 at 01:24 PM, Certified Nursing Assistant #1 stated when a resident is discharged , they (Certified Nursing Assistant #1) place all the resident's belongings in a box labeled with the resident's name and the room number. Certified Nursing Assistant #1 stated the box is usually stored in the resident's closet until the unit manager tells them (Certified Nursing Assistant #1) to remove the box. Certified Nursing Assistant #1 stated they did not remember if they collected Resident #266's belongings when the resident was transferred to the hospital. During an Interview on 04/23/2026 at 01:26 PM, Housekeeper #1 stated all nurses and certified nursing assistants are responsible for packing the resident's belongings and the housekeepers are responsible for cleaning the rooms. Housekeeper #1 stated the Director of Housekeeping takes the boxes from the rooms to store them in the basement until the resident returns from the hospital, or the resident's family picks up the belongings. During an interview on 04/23/2026 at 03:33PM, the Administrator stated they were not made aware of Resident#266's belongings were missing until 4/13/2026. The Administrator stated they requested receipts of the missing clothing from the resident's family member and they received the receipts on 04/22/2026 and will reimburse the cost of the clothing. During an interview on 04/28/2026 at 12:15 PM, the Director of Housekeeping stated when the resident was discharged to hospital for evaluation on 01/23/2026, Resident #266's belongings were boxed and stored in the basement. The Director of Housekeeping stated there was another resident with the same last name who was assigned to Resident #266's room, and they thought the box belonged to the newly admitted resident. The Director of Housekeeping stated they did not realize until 04/22/2026 that Resident #266's belongings were given to the wrong resident. The Director of Housekeeping stated the resident who received Resident #266's belongings were no longer in the facility, and their belongings were not in the facility. 10 New York Code Rules and Regulations 415.5(h)(1)

Based on record review and interviews during the abbreviated survey (Intake # 2660131) the facility failed to ensure that residents were free from alleged sexual abuse for two (2) of eight (8) residents reviewed. Specifically, Resident#1 and Resident #2, both with intact cognition, reported allegations of sexual abuse. Resident #1 alleged on 08/25/2025 that Certified Nursing Assistant #1 made a sexually inappropriate comment while providing care. Resident #2 alleged Certified Nursing Assistant #1 touched and rubbed their genital area on 08/21/2025 that made them feel unsafe in the facility. Certified Nursing Assistant #1 was suspended for three (3) days without a thorough investigation and returned to work and had access to all 248 residents in the facility. This resulted in Immediate Jeopardy.The findings are:The facility policy titled Abuse Prevention dated 11/02/2022 reviewed 07/2025 documented sexual abuse is the non-consensual sexual contact of any type with a resident and this may include touching intimate body parts. It is a violation of personal rights when anyone interacts with a resident in an inappropriate sexual manner. Residents can be abused without the occurrence of physical injury or sexual penetration.Resident #1 was admitted to the facility on [DATE] with diagnoses that include multiple sclerosis(a chronic autoimmune disease that affects the brain and spinal cord), protein calorie malnutrition (a condition where the body does not receive enough protein and calories) and pseudobulbar affect (a neurological condition that causes sudden, frequent and uncontrollable outburst of crying and laughing that are disproportionate to the situation).The Minimum Data Set (a resident assessment tool) dated 10/03/2025 documented a Brief Interview for Mental Status score of 15 indicating intact cognition.A Grievance Report dated 08/25/2025, documented that on 08/21/2025, Resident #1 told Certified Nursing Assistant #1 they wanted a female certified nursing assistant to give them care, not a male, but then resident #1 told a female certified nursing assistant they were okay with Certified Nursing Assistant #1. Certified Nursing Assistant #1 changed Resident #1's brief and put cream on their vagina and ass and told Resident #1 they never took care of a resident with a shaved vagina. The grievance concluded that Resident #1's family member was made aware that the facility would document in the Electronic Medical Record for Resident #1 not to have male caregivers and Resident #1 would be a two (2)-person approach. There is no documented evidence that an investigation was initiated regarding the incident with Certified Nursing Assistant #1 and Resident #1 on 08/25/2025 when the facility staff became aware. There is no documented evidence that Resident #1 was assessed, or a psychosocial evaluation conducted after they expressed fear due to the incident.During a telephone interview on 11/07/2025 at 4:51 PM, with Resident #1 and Family Member #1, they stated that on 08/21/2025, a day shift male aide, Certified Nursing Assistant #1, asked Resident #1 if they wanted cream on their vagina. Resident stated that Certified Nursing Assistant #1 started to put cream on their buttocks. Certified Nursing Assistant #1 stated that they do not see many women with a shaved vaginal area in the nursing home. Resident #1 stated they waited until their family member came to visit and told them about the incident because they felt embarrassed. Resident #1 stated they were afraid Certified Nursing Assistant #1 would be sexually inappropriate again after the incident. Resident #1 stated they did not agree with allowing the male aide to care for them and told this to Certified Nursing Assistant #1 before they provided care. Resident #1 stated that Certified Nursing Assistant #1 went to get the nurse who told Resident #1 that there was not documentation in their chart that they could not be cared for by a male caregiver. Resident #1 stated they did not feel safe and is no longer in the facility. Family Member #1 stated they shaved Resident#1's genital area for hygiene about a week or two before the incident. They stated they often shave the resident for hygienic purposes since they are unable to do it for themselves. Family Member #1 stated Resident #1 reported the incident to them on 08/25/2025 because the resident felt embarrassed. Family member #1 stated they told the Assistant Director of Nursing about the incident on 08/25/2025. Family Member #1 stated the Assistant Director of Nursing assured them they will take Certified Nursing Assistant #1 off the schedule and start an investigation. Family Member #1 stated they never heard anything regarding the results of the investigation. Family Member #1 stated Resident #1 never felt comfortable staying at the facility and felt they would retaliate against them.A Treatment Administration Record dated 08/21/2025 documented Silvadene 1% topical cream ordered to be applied to the sacrum after cleanse with sterile water and mixed with lidocaine cream followed by abdominal pads and secured with medical tape daily and as needed.There was no documented evidence in Resident #1's electronic medical record of a cream that needed to be applied in the vaginal area. During an interview with Certified Nursing Assistant #1 on 11/07/2025 at 3:40 PM, they stated they work as a float on all units. Certified Nursing Assistant #1 stated on 08/21/2025, they provided care for Resident #1 and denied putting cream on Resident #1's anus or vaginal area. Certified Nursing Assistant #1 stated they do not recall making any statements regarding the resident's vaginal area. Certified Nursing Assistant #1 stated they were suspended for three (3) days because they received a call from the Assistant Director of Nursing that they were conducting an investigation regarding an allegation of abuse. Certified Nursing Assistant #1 stated they received a call from the facility on 08/28/2025 that they were vindicated because another female certified nursing assistant verified that Resident #1 did not have a shaved vaginal area. Certified Nursing Assistant #1 stated they returned to work on 08/29/2025 without restrictions. Certified Nursing Assistant #1 stated they were not given an abuse in-service upon return. Certified Nursing Assistant #1 stated they are no longer working at the facility because they got another position closer to their home.Review of the facility's attendance record for Certified Nursing Assistant #1 documented that Certified Nursing Assistant #1 worked on 08/29/2025 until 10/05/2025. Certified Nursing Assistant #1 had access to all residents in the facility during that time frame.During an interview with the Assistant Director of Nursing on 11/10/2025 at 4:28 PM, they stated they received a complaint from Resident #1 and their family member (Family Member #1) that Certified Nursing Assistant #1 told them they wanted a female aide. Certified Nurse Assistant #1 left the room and returned with a female aide. The female aide offered to stay but they told them it was fine, and they were okay with Certified Nursing Assistant #1. Resident #1 stated Certified Nursing Assistant #1 was changing their brief, cleaned, and put barrier cream on her vagina and ass. The Assistant Director of Nursing stated that Certified Nursing Assistant #1 stated they never gave care to a resident with a shaved vagina but there was no penetration to her anus or vaginal area. Resident #1 denied physical harm but stated that Certified Nursing Assistant #1's statement made her uncomfortable.During an interview with the Administrator on 11/10/2025 at 5:43 PM, they stated the facility conducted a grievance investigation and determined within two (2) hours there was no evidence of abuse. They stated for Resident #1 they ruled in two (2) hours that there was no harm because the family member (family member #1) told them they did not shave Resident #1's vaginal area. The Assistant Director of Nursing completed a grievance on Resident #1. There is no documented evidence that Resident #1 was assessed by a Registered Nurse, or a psychosocial evaluation was conducted after they reported the allegation.2) Resident #2 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus (where the body becomes resistant to insulin and eventually may not produce enough), depression (mental disorder that negatively affects how you feel, think, act, and perceive the world) and anxiety disorder (anxiety that does not go away). The Minimum Data Set, dated [DATE] documented a Brief Interview of Mental Status of 15, indicating intact cognition.During an interview on 11/07/2025 at 5:50 PM with Resident #2, they stated that on 08/21/2025, Certified Nursing Assistant #1 came into their room to change their brief and kept rubbing and rubbing and Resident #2 pointed to their genital area and stated, no one ever did that to them before. Resident #2 stated they reported it to Certified Nursing Assistant #2, who took them to Registered Nurse Supervisor #1 to report it. Resident #2 stated she does not feel safe or comfortable in the facility.There is no documented evidence that the report of sexual abuse was investigated, or that Resident #2 was assessed after this occurred on 08/21/2025.There is no documented evidence that Resident #2 was assessed by a registered nurse or psychosocial evaluation was conducted after expressing fear due to the incident.During an interview with Registered Nurse Supervisor #1 on 11/10/2025 at 2:20 PM, they stated that Resident #2 informed them on 08/21/2025 that Certified Nurse Assistant #1 was inappropriate and took a long time wiping me down there. They also stated Resident #2 requested a room change because she never wanted to see Certified Nursing Assistant #1 again. They reported Resident #2's statement to the Director of Nursing on 08/21/2025. They stated the Director of Nursing said they would discuss it in the morning.A social work progress noted dated 08/22/2025 documented Resident #2 was being transferred to another room on a different unit for roommate incompatibility.There is no documented evidence of an assessment by a registered nurse or that a psychosocial evaluation was conducted for Resident #2 after they reported to the facility that they were uncomfortable after an incident with Certified Nursing Assistant #1 on 08/21/2025.During an interview with Certified Nursing Assistant #2 on 11/10/2025 at 2:37 PM, they stated that Resident #2 told them that Certified Nursing Assistant #1, while providing care, took too long caring for their lower section of their body, wiping down there and they felt uncomfortable. They took long down there to mean the perineum, so they told Resident #2 they were going to take them to the nursing supervisor. Certified Nursing Assistant #2 stated Resident #2 was very upset and due to the nature of Resident #2's comment and they took them to Registered Nurse Supervisor #1.During an interview with Certified Nursing Assistant #3 on 11/10/2025 at 1:42 PM, they stated Resident #2 never fabricated a story to them. They also stated they put barrier cream on Resident #2.During an interview with the Director of Nursing on 11/10/2025 at 4:54 PM, they stated they made the decision not to report this allegation because they did not feel there was any sexual abuse. They stated that Family Member #1 said the vaginal area was not shaved. Certified Nursing Assistant #1 was taken off the schedule out of an abundance of caution. A grievance report was completed and Certified Nursing Assistant #1 was vindicated because Family Member #1 said Resident#1 was not shaved. Certified Nursing Assistant #1 was returned to work. The Director of Nursing stated that Resident #2 only complained that Certified Nursing Assistant #1 took too long providing care, so no formal investigation was conducted.During an interview with the Administrator on 11/10/2025 at 5:43 PM, they stated they did not question Certified Nursing Assistant#1 about Resident #2's statement after the Director of Nursing questioned (Certified Nursing Assistant #1) and stated all Resident #2 stated was Certified Nursing Assistant #1 took too long to care for them. They did not do a formal investigation.During an interview on 11/17/2025 with Social Worker #2 and Resident #2 at 2:15 PM, Resident #2 stated Certified Nurse Assistant #1 was rubbing and rubbing their vagina for a long time; they were putting cream there (pointing to their vagina) and it was uncomfortable. Resident #2 began to cry.During an interview on 11/14/2025 with the Medical Director at 12:01 PM, they stated the staff should report any alleged abuse to leadership (nursing, physicians, administration) in the building immediately, and it should be investigated. If the investigation warrants, it should be reported. They stated during the investigation; the facility should complete a psychosocial exam and a physical exam. They stated any allegations should be reported and recorded immediately. They stated they were the primary doctor for Resident #1 and Resident #2, and they were not informed about the incident until after 11/07/2025.10NYCRR 415.4(b)(1)(ii)

Based on record review and interviews during the abbreviated survey (Intake #2660131) the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of resident property, were reported immediately, but not later than two (2) hours after the allegation is made. This was identified for two (2) of eight (8) Residents (Resident #1 and Resident #2). Specifically, Resident #1 reported an allegation that Certified Nursing Assistant #1 stated to them they did not see many women with a shaved vaginal area in the nursing home and this made Resident #1 not feel safe. Resident #2 reported an allegation that Certified Nurse Assistant #1 touched and rubbed their genital area in a manner that made them feel violated. There was no documented evidence the alleged abuse was reported to local law enforcement or the New York State Department of Health. This resulted in Immediate Jeopardy. The findings are:The facility policy titled Abuse Prevention dated 11/02/2022, reviewed 07/2025 documented: Any case in which abuse neglect mistreatment of a resident has been identified via the investigation or abuse cannot be ruled out, it will be reported promptly to the New York State Department of Health for further investigation. Sexual abuse includes; but it's not limited to sexual harassment or sexual assault residents may be abused by facilities staff this may include touching Intimate body parts, or the clothing covering intimate body parts or the examination of the resident or treatment of the resident for other than [NAME] fide, medical purposes or observation residence can be abused without the occurrence of physical injury or sexual penetration, we must appreciate and recognize residence as a victims when sexual abuse occurs. There was no documented evidence the facility policy contained information regarding reporting to local law enforcement for abuse and reasonable suspicion of a crime.Resident #1 was admitted to the facility on [DATE] with diagnoses that include multiple sclerosis (a chronic autoimmune disease that affects the brain and spinal cord), protein-calorie malnutrition (a condition where the body does not receive enough protein and calories) and pseudobulbar affect (a neurological condition that causes sudden, frequent and uncontrollable outburst of crying and laughing that are disproportionate to the situation).The Minimum Data Set (a resident assessment tool) dated 10/03/2025 documented a Brief I for Mental Status score of 15, indicating intact cognition.A Grievance Report dated 08/25/2025 documented that on 08/21/2025, Resident #1 told Certified Nursing Assistant #1 they wanted a female certified nursing assistant to give them care, not a male, but then told a female certified nursing assistant #2 they were okay with Certified Nursing Assistant #1. Certified Nursing Assistant #1 changed Resident #1's brief and put cream on their vagina and ass and told Resident #1 they never took care of a resident with a shaved vagina. The grievance concluded that Resident #1 and Family Member #1 were made aware that they would document in the Electronic Medical Record for Resident #1 not to have male caregivers, and Resident #1 would be a two (2)-person approach. During a telephone interview on 11/07/2025 at 4:51 PM with Resident #1 and Family Member #1, they stated that on 08/21/2025, a day shift male aide, (Certified Nursing Assistant #1), entered Resident #1's room. Resident #1 stated they requested a female aide but was not provided one. Resident #1 stated Licensed Practical Nurse #1 stated to the resident that Certified Nurse Assistant #1 could care for them because there was not documentation in their chart that they could not be cared for by a male caregiver. During care, Certified Nurse Assistant #1 asked Resident #1 if they wanted cream on their vagina, Resident #1 stated they (Resident #1) could put cream on their own vagina, but Certified Nurse Assistant #1 proceeded to put the cream on Resident #1's buttocks. Resident #1 stated Certified Nursing Assistant #1, said to them that they did not see many women with a shaved vaginal area in the nursing home. Resident #1 stated they did not report the incident until 08/25/2025 because they were embarrassed. Family Member #1 stated they shaved Resident #1 (for hygiene) about a week or two before the incident. Resident #1 reported the incident to them on 08/25/2025. Family Member #1 then made the Assistant Director of Nurses ware on the same day (08/25/2025). Resident #1 stated they did not feel safe because of (Certified Nursing Assistant #1) Resident #1 is no longer residing in the facility. A Treatment Administration Record dated 08/19/2025 through 08/31/2025 documented apply Silvadene (a cream to protect skin during incontinence) followed by abdominal pad to the sacrum and right buttocks daily. During an interview with the Director of Nursing on 11/10/2025 at 4:54 PM, they stated they made the decision not to report this allegation for Resident #1 because they did not feel that this was sexual abuse because Resident #1's vaginal area had not been shaved as per female Certified Nursing Assistance #3 who cared for Resident #1 on 08/22/2025, but Certified Nursing Assistant #1 was taken off the schedule out of an abundance of caution. Upon the completion of the grievance Certified Nurse Assistant #1 was permitted to return to work on 08/29/2025 with no restrictions.During an interview with the Assistant Director of Nurses on 11/10/2025 at 4:28 PM, they stated Resident #1 reported the incident four (4) days later. Assistant Director of Nurses stated they made the grievance report, did not report to local law enforcement or the New York State Department of Health because they did not feel this was sexual abuse. Assistant Director of Nurses stated Resident #1 and Family Member #1 reported that Resident #2 also had the same complaint. Assistant Director of Nurses stated they told Resident #1's family to mind their own business about Resident #2.During an interview with the Administrator on 11/10/2025 at 5:43 PM, they stated the facility conducted a grievance investigation and determined within two (2) hours there was no evidence of abuse for Resident #1. They did not feel there was any sexual abuse because Resident # 1s vaginal area had not been shaved as per Female Certified Nursing Assistant #3 who care for Resident#1 on 08/22/2025.During an interview on 11/14/2025 at 12:01 PM with the Medical Director, they stated the staff should report any alleged abuse to leadership (nursing, physicians, administrator) in the building immediately, and it should be investigated. If the investigation warrants, it should be reported. They stated during the investigation; the facility should complete a psychosocial exam and a physical exam for Resident #1 and Resident #2. They stated any allegations should be reported and recorded immediately. They stated they were not aware of Resident #1 or Resident #2's allegation of abuse until 11/07/2025. There is no documented evidence the alleged abuse reported by Resident #1 was reported to local law enforcement or the New York State Department of Health.Resident #2 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus (where the body becomes resistant to insulin and eventually may not produce enough), depression (mental disorder that negatively affects how you feel, think, act, and perceive the world) and anxiety disorder (anxiety that does not go away).The Minimum Data Set, dated [DATE] documented a Brief Interview of Mental Status of 15, indicating intact cognition.During an interview on 11/07/2025 at 5:50 PM, with Resident #2, they stated that on 08/21/2025, Certified Nursing Assistant #1 came into their room to change their brief, and they kept rubbing and rubbing and Resident #2 pointed to their genital area and stated, no one ever did that to them before. Resident #2 was visibly upset, shaking, and tearful when recalling the incident. Resident #2 stated they reported it to Certified Nursing Assistant #2, who took them to Registered Nurse Supervisor #1 to report it. Resident #2 stated that Registered Nurse Supervisor #1 told them that they would get their room changed so they would never have to see Certified Nursing Assistant #1 again. Resident #2 stated they do not feel safe or comfortable in the facility. There is no documented evidence the allegations were reported to the New York State Department of Health or law enforcement as required.During an interview on 11/17/2025 with Social Worker #2 and Resident #2 at 2:15 PM Resident #2 stated Certified Nurse Assistant #1 was rubbing and rubbing their vagina for a long time; they were putting cream there (pointing to their vagina) and it was uncomfortable. Resident #2 began to cry.During an interview with the Director of Nursing on 11/10/2025 at 4:54 PM they stated Social Worker #1, and the Director of Nursing spoke with Resident #2 on 11/07/2025, Resident #2 stated to them Certified Nursing Assistant #1 took too long with their care, and they did not pursue the statement any further. They stated they did not question Certified Nursing Assistant #1 and did not initiate an Accident/ Incident report.During an interview with the Assistant Director of Nursing on 11/10/2025 at 4:28 PM they stated Resident #2 reported Resident #1 only stated that care took to long so there was no reason to report abuse. During an interview with the Administrator on 11/10/2025 at 5:43 PM they stated Resident #2 stated Certified Nursing Assistant #1 only took too long with their care and some informal information was obtained. Certified Nursing Assistant #1 was not questioned, and an Accident /Incident Investigation was not done because they did not believe it was abuse based on the resident's statement.During an interview on 11/14/2025 with the Medical Director at 12:01 PM, they stated the staff should report any alleged abuse to leadership (nursing, physicians, administration) in the building immediately, and it should be investigated. If the investigation warrants, it should be reported. They stated during the investigation the facility should complete a psychosocial exam and a physical exam for Resident #2. They stated any allegations should be reported and recorded immediately. They stated they were not made aware of the allegation of abuse to Resident #2 until 11/07/2025.10NYCRR 483.12b[5][i](A)(B)(c)[1][4]

Based on record review and interviews during the abbreviated survey (Intake #2660131), the facility failed to ensure that an investigation of alleged sexual abuse was thoroughly and timely investigated to prevent further potential abuse, neglect, exploitation, or mistreatment. This was identified for two (2) of eight (8) residents (Resident #1 and Resident #2) reviewed for accidents/incidents. Specifically, Resident #1 and Resident #2 alleged Certified Nursing Assistant #1 was sexually inappropriate which made them feel unsafe in the facility. There was no documented evidence that an investigation to rule out abuse, neglect, or mistreatment was initiated. This resulted in Immediate Jeopardy.The findings are: The facility policy titled Abuse Prevention dated 11/02/2022 and reviewed 07/2025 documented all allegations of abuse must be immediately reported to the administrator and no later than two (2) hours to the other officials (including to the State Survey Agency) after the allegation is made, if the events that caused the allegation involve abuse or result in serious bodily injury. The facility will investigate all incidents of alleged and actual abuse, complaints/grievances, misappropriation and injury of unknown origin. The investigative process will include statements from staff, witness, residents, interviews with staff, witness, residents, medical record review if applicable, review of employee records. Resident #1 was admitted to the facility on [DATE] with diagnoses that include multiple sclerosis (a chronic autoimmune disease that affects the brain and spinal cord), protein-calorie malnutrition (a condition where the body does not receive enough protein and calories) and pseudobulbar affect (a neurological condition that causes sudden, frequent and uncontrollable outburst of crying and laughing that are disproportionate to the situation). The Minimum Data Set (a resident assessment tool) dated 10/03/2025 documented a Brief Interview for Mental Status score of 15 indicating intact cognition.A Grievance Report dated 08/25/2025 documented that on 08/21/2025, Resident #1 told Certified Nursing Assistant #1 they wanted a female Certified Nursing Assistant to give them care, not a male, but then told a female certified nursing assistant [KN1] [HC2] [KO3] they were okay with Certified Nursing Assistant #1. Certified Nursing Assistant #1 changed Resident #1's brief and put cream on their vagina and ass and told Resident #1 they never took care of a resident with a shaved vagina. The grievance concluded that Resident #1 and their mother were made aware that they would document in the Electronic Medical Record for Resident #1 not to have male caregivers, and Resident #1 would be a two (2)-person approach. During a telephone interview on 11/07/2025 at 4:51 PM with Resident #1 and Family Member #1, they stated that on 08/21/2025, a day-shift male aide, (Certified Nursing Assistant #1), entered Resident #1's room. Resident #1 stated they requested a female aide but was not provided one. Resident #1 stated that Licensed Practical Nurse #1 stated to the resident that Certified Nurse Assistant #1 could care for them because there was no documentation in their chart that they could not be cared for by a male caregiver. During care Certified Nurse Assistant #1 asked Resident #1 if they wanted cream on their vagina, Resident #1 replied they could put cream on their own vagina, but Certified Nurse Assistant #1 proceeded to put the cream on Resident #1's buttocks. Resident #1 stated Certified Nursing Assistant #1 said to them that they did not see many women with a shaved vagina in the nursing home. Resident #1 stated they did not report the incident until 08/25/2025 because they were embarrassed.During a telephone interview on 11/07/2025 at 4:51 PM, Family Member #1 stated they shaved Resident #1 (for hygiene) about a week or two (2) before the incident. Resident #1 reported the incident to them on 08/25/2025. Family Member #1 then made the Assistant Director of Nursing aware on the same day (08/25/2025). Resident #1 stated they did not feel safe because of Certified Nursing Assistant #1. Resident #1 is no longer residing in the facility. During an interview with the Assistant Director of Nursing on 11/10/2025 at 4:28 PM they stated they initiated a grievance report, but they did not feel this was sexual abuse because they believed the resident was making up stories. The Assistant Director of Nursing stated the allegation did not need to be investigated any further. During an interview with the Administrator on 11/10/2025 at 5:43 PM, they stated the facility conducted a grievance investigation and determined within two (2) hours there was no evidence of abuse. They stated for Resident #1 they ruled within two (2) hours that there was no harm because the family member told them they did not shave Resident #1 's vaginal area.Resident #2 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes mellitus (where the body becomes resistant to insulin and eventually may not produce enough), depression (mental disorder that negatively affects how you feel, think, act, and perceive the world) and anxiety disorder (anxiety that does not go away). The Minimum Data Set assessment dated [DATE] documented a Brief Interview of Mental Status of 15, indicating intact cognition.A comprehensive care plan dated 04/30/2025 documented#1 at risk for victimization for psychosocial issues and behavioral indicators with goals that resident's safety and comfort being maintained and free from psychosocial distress.A social worker #1 note dated 08/22/2025 documented Resident #2 had a room change to a different unit. There was no documentation or investigation as to why Resident #2 wanted a room change.During an interview on 11/07/2025 at 5:50 PM with Resident #2, they stated that on 08/21/2025, Certified Nursing Assistant #1 came into their room to change their brief, and they kept rubbing and rubbing and Resident #2 pointed to their genital area and stated, no one ever did that to them before. Resident #2 was visibly upset, shaking, and tearful when recalling the event. Resident #2 stated they reported it to Certified Nursing Assistant #2, who took them to Registered Nurse Supervisor #1 to report it. The Social Worker was also made aware. Resident #2 stated they do not feel safe or comfortable in the facility.During an interview on 11/10/2025 at 2:03 PM with Social Worker #1, they stated Resident #2 had a concern that Certified Nurse Assistant #1 was taking too long to care for them and was tearful. Resident #2 was not used to Certified Nurse Assistant #1 caring for them and requested a room change. Social Worker #1 did not ask any further questions of the resident.During an interview on 11/10/2025 at 2:20 PM with Registered Nurse Supervisor #1, they stated during a conversation with Resident #2 on 08/21/2025, they requested to have their room changed to a different unit the same day the incident occurred. Registered Nurse Supervisor #1 stated the resident wanted the room change because they never wanted to see Certified Nursing Assistant #1 again. Registered Nurse Supervisor #1 reported Resident #2's statement to the Director of Nursing on 08/21/2025.During an interview on 11/10/2025 at 2:37 PM with Certified Nursing Assistant #2, they stated Resident #2 reported to them that Certified Nurse Assistant #1 took too long to care for the lower section of their body, and they felt uncomfortable. Certified Nursing Assistant #2 took Resident #2 to Registered Nurse Supervisor #1 because of the nature of their comment.During an interview with the Director of Nursing on 11/10/2025 at 4:54 PM, they stated they made the decision not to report this allegation because they did not feel there was any sexual abuse. The Director of Nursing stated Resident #2 stated Certified Nursing Assistant #1 took too long with their care which did not need further investigation. During an interview with the Administrator on 11/10/2025 at 5:43 PM, they stated the facility conducted a grievance investigation and determined within two (2) hours there was no evidence of abuse for Resident #2. They stated all Resident #2 stated to them was Certified Nursing Assistant #1 took too long to care for them. The Administrator stated that information did not need an investigation initiated so they did not go any further with questions.During an interview on 11/14/2025 at 12:01 PM with the Medical Director (who is the primary care physician for Resident #1 and Resident #2), they stated the staff should report any alleged abuse to the leadership (nursing, physicians, administration) in the building immediately, and it should be investigated. If the investigation warrants, it should be reported and recorded immediately. They stated they were made aware of the incidents on 11/07/2025. 10NYCRR 415.49(b)(3)

Based on observation, record review, and interviews during an abbreviated survey (NY00368741) on 2/26/2025 the facility did not ensure that all residents were free from physical restraints imposed for the purpose of discipline or convenience and are not required to treat the resident's medical symptoms. This was identified for three residents (Resident #1, Resident #2, and Resident #3) of three residents reviewed for restraints. Specifically, Resident #1, Resident #2 and Resident #3 were observed in their beds with the bed in the lowest position with thick fall prevention mats observed on their side (length wise), pushed up against both sides of the bed restricting the resident's freedom of movement. The findings are: The facility's policy titled, Physical Restraints effective September 2018 and reviewed June 2024 documented it was the policy of the facility to promote and maintain the residents' highest practicable well-being in a restraint free environment and only utilize a physical restraint in a circumstance in which the resident had a medical symptom that may warrant the use of a restraint. The policy defined a physical restraint as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: is attached or adjacent to the resident's body; cannot be removed easily by the resident and restricts the resident's freedom of movement or normal access to their body. 1) Resident #1 had diagnoses that included Parkinson's Disease, Dementia, and Dysphagia. Resident #1's Annual Minimum Data Set assessment dated [DATE] documented Resident #1's Brief Interview for Mental Status was not conducted because Resident #1 was rarely understood and rarely understands. Resident #1's Comprehensive Care Plan titled, Falls/Potential for Falls, effective 3/26/2017 and reviewed on 1/4/2025 documented interventions that included but were not limited to keep the bed low with the wheels in a locked position and bilateral floor mats. Resident #1's Certified Nursing Accountability Record dated February 2025 documented the following protective measures were in place, floor mats and low bed. The Certificated Nursing Accountably record was signed by the assigned Certified Nursing Assistant. During four observations on 2/26/2025 at 8:45 AM, 9:03 AM, 9:36 AM and 9:45 AM, Resident #1 was observed in bed with their bed in the lowest position and thick fall prevention mats were observed on their side, pushed up against both sides of the bed, and nightstands were observed pushed up against the fall prevention mats thereby restricting Resident #1's freedom of movement. During an interview on 2/26/2025 at 9:45 AM, Certified Nursing Assistant #1 who was assigned to Resident #1 stated they did not see Resident #1 today. Certified Nursing Assistant #1 stated they did not place the fall prevention mats on their side, against both sides of the bed with the nightstands pressed up against the mats. Certified Nursing Assistant #1 stated the instruction for the fall prevention mats are they should be placed flat to the floor and next to the bed and are used for fall prevention. Certified Nursing Assistant #1 stated a resident would not to be able to get out of bed if the mats were placed on their side, against the bed with the nightstands against the mats. During an interview on 2/26/2025 at 10:09 AM, Licensed Practical Nurse Manager #1 they stated the fall prevention mats are put in place when a resident is a high fall risk because they widen the surface area of the mattress should the resident fall/roll off the bed. Licensed Practical Nurse Manager #1 stated the fall prevention mats should be laid flat to floor and next to the bed so that if the resident rolled off the bed, they would not fall directly to the floor which can help decrease injuries related to falls. During an interview on 2/26/2025 at 2:41 PM, the Director of Nursing Services stated the correct position for the floor mats is to be laid flat on the floor next to the resident's bed and if they were higher than the bed it could restrict the resident's freedom of movement. The Director of Nursing Services stated the fall prevention mats should not be placed on their side and against the bed and to be an effective fall prevention intervention the mats had to be laid flat and next to the bed. 2) Resident #2 had diagnoses that included Cerebral Infarction (ischemic stroke), Hemiplegia (paralysis that affects only one side of your body), and Dementia. Resident #2's Minimum Data Set assessment dated [DATE] documented Resident #2's Brief Interview for Mental Status was not conducted because Resident #2 was rarely/never understood. Resident #2's Comprehensive Care Plan titled, Falls/Potential for Falls, effective 2/16/2024 and reviewed on 11/24/2024 documented an intervention to keep the bed in the lowest position. Resident #2's Certified Nursing Accountability Record dated February 2025 documented the following protective measures were in place, floor mats and low bed. The Certificated Nursing Accountably record was signed by the assigned Certified Nursing Assistant. During three observations on 2/26/2025 at 8:47 AM, 9:05 AM, and 9:37 AM, Resident #2 was observed in bed with their bed in the lowest position and thick fall prevention mats were observed on their side pushed up against both sides of the bed. Additionally, one nightstand was observed pushed up against the fall prevention mat on the right side of the bed thereby restricting Resident #2's freedom of movement. During an interview on 2/26/2025 at 9:37 AM, Certified Nursing Assistant #2, who was Resident #2's assigned Certified Nursing Assistant stated they checked in on Resident #2 this morning but had not provided care yet. Certified Nursing Assistant #2 stated they could not recall what position the fall prevention mats were in when they looked in on Resident #2. Certified Nursing Assistant #2 stated the fall prevention mat should be placed flat on the floor and next to Resident #2's bed as they are used to prevent the resident from hurting themselves if they fell out of bed. Certified Nursing Assistant #2 stated if the mats are on their side the resident would not be able to get out of bed. During an interview on 2/26/2025 at 1:24 PM, Certified Nursing Assistant #3 stated they were the assigned Certified Nursing Assistant for Resident #2 on the 11:00 PM to 7:00 AM shift. They stated when their shift ended at 7:00 AM the fall prevention mats were laid flat to the floor and next to Resident #2's bed. During an interview on 2/26/2025 at 2:27 PM, Licensed Practical Nurse #2 stated they gave Resident #2 medication at about 5:00 AM and observed Resident #2 in bed but did not observe the floor mats on their side and up against Resident #2's bed. Licensed Practical Nurse #2 stated a restraint would be anything that prevents a resident from moving freely. Additionally, the floor mats on their side and up against Resident #2's bed would be considered a restraint and should not be placed that way. During an interview on 2/26/2025 at 2:41 PM, the Director of Nursing Services stated the correct position for the floors mats is to be laid flat on the floor next to the resident's bed. The Director of Nursing Services stated if the mats are placed on their sides, and they were higher than the bed and items were placed up against mats then it could restrict the resident's freedom of movement. The Director of Nursing Services stated the fall prevention mats should not be placed on their side and against the bed and to be an effective fall prevention intervention the mats had to be laid flat and next to the bed. 3) Resident #3 had diagnoses including Dementia, Alzheimer's Disease, and Aphasia (a language disorder that affects a person's ability to communicate effectively.) Resident #3's Annual Minimum Data Set assessment dated [DATE] documented Resident #3's Brief Interview for Mental Status was not conducted because Resident #3 was rarely understood and rarely understands. Resident #3's Comprehensive Care Plan titled, Falls/Potential for Falls, effective 11/7/2017 and reviewed on 2/1/2025 documented interventions including but were not limited to placing bed in lowest position and high floor mats. Resident #3's Certified Nursing Accountability Record dated February 2025 documented the following protective measures were in place, floor mats and low bed. The Certificated Nursing Accountably record was endorsed by the assigned Certified Nursing Assistant. During an observation on 2/26/2025 at 8:49 AM Resident #3 was observed in bed with their bed in the lowest position and thick fall prevention mats were observed on their side, pushed up against both sides of the bed, with both nightstands pushed up against the fall prevention mats. Additionally, a Broda chair (a supportive positioning device) was pushed up against the fall prevention mat on the left side of the bed thereby restricting Resident #3's freedom of movement. During an observation on 2/26/2025 at 9:08 AM Resident #3 was observed in an elevated bed receiving assistance with breakfast by Certified Nursing Assistant #1 who was on the left side of the bed. The fall prevention mat on the left side of the bed was removed and the nightstand on the left side was pushed off to the side. The Broda chair was positioned at the end of the bed. The fall prevention mat on the right side of the bed was on its side and pushed up against the bed with a nightstand pressed up against the fall prevention mat. During an observation and interview on 2/26/2025 at 9:21 AM with Certified Nursing Assistant #1, Resident #3 was observed in bed with their bed in the lowest position and thick fall prevention mats were observed on their side, pushed up against both sides of the bed, nightstands were observed pushed up against the fall prevention mats. Certified Nursing Assistant #1 stated they assisted Resident #3 with breakfast this morning and the fall prevention mats were on their sides against both sides of the bed with nightstands up against them. A Broda chair was also against the left fall prevention mat. Certified Nursing Assistant #1 stated they moved the items away from the left side of the bed so they could assist Resident #3 but did not place the left fall prevention mat on its side against the bed with the nightstand against it. They stated they do not know who placed the fall prevent mats in that way but should be flat on the floor. During an interview on 2/26/2025 at 10:09 AM, Licensed Practical Nurse Manager #1 stated the fall prevention mats are put in place when a resident is a high fall risk because they widen the surface area of the mattress should the resident fall/roll off the bed. Licensed Practical Nurse Manager #1 stated the fall prevention mats should be laid flat to floor and next to the bed so that if the resident rolled off the bed, they would not fall directly to the floor which can help decrease injuries related to falls. During an interview on 2/26/2025 at 1:24 PM, Certified Nursing Assistant #3 stated when their shift ended at 7:00 AM the fall prevention mats were laid flat to the floor and next to Resident #3's bed. Certified Nursing Assistant #3 stated the fall prevention mats are used for safety because if a resident fell out of bed the fall prevention mats would stop the resident from falling to the floor. During an interview on 2/26/2025 at 2:41 PM, the Director of Nursing Services stated the correct position for the floors mats is to be laid flat on the floor next to the resident's bed. The Director of Nursing Services stated if the mats are placed on their sides, and they were higher than the bed and items were placed up against mats then it could restrict the resident's freedom of movement. The Director of Nursing Services stated the fall prevention mats should not be placed on their side and against the bed and to be an effective fall prevention intervention the mats had to be laid flat and next to the bed. 483.10(e)(1)

Based on observations, record reviews, and interviews conducted during an abbreviated survey (NY00368741) on 2/26/2025 the facility did not ensure call systems were accessible to each resident while the resident were in their rooms. This was identified for three residents (Resident #1, Resident #2, and Resident #3) of three residents reviewed for call systems. Specifically, Resident #1, Resident #2 and Resident #3 were observed, multiple times in their beds, with no access to use their call bells preventing them to be able to call for assistance. The findings are: The facility's policy titled, Call Bell and Alarm Response effective October 2019 and reviewed September 2024 documented call bells and alarms will be answered promptly by all staff and to ensure the call bell has a clip for placement. The policy did not include where the resident's call bell should be placed. 1) Resident #1 had diagnoses that included Parkinson's Disease, Dementia, and Dysphagia. Resident #1's Annual Minimum Data Set assessment dated [DATE] documented Resident #1's Brief Interview for Mental Status was not conducted because Resident #1 was rarely understood and rarely understands. Resident #1's Comprehensive Care Plan titled, Falls/Potential for Falls, effective 3/26/2017 and reviewed on 1/4/2025 documented an intervention to keep the call bell within reach. During four observations on 2/26/2025 at 8:45 AM, 9:03 AM, 9:36 and 9:45 AM Resident #1 was observed in bed and the resident's call bell was observed hanging on the knob of the nightstand to the right of Resident #1's bed. The call bell was out of reach of Resident #1. The final observation at 9:45 AM was conducted with Certified Nursing Assistant #1. Certified Nursing Assistant #1 observed the call bell positioned hanging on the knob of the nightstand, and then left the room without placing the call bell within reach of Resident #1. During an interview on 2/26/2025 at 9:45 AM, Certified Nursing Assistant #1, who was assigned to Resident #1, stated they did not see Resident #1 today and they were not aware that the call bell was out of reach of Resident #1 but that the call bell should be where the resident can reach it. During an interview on 2/26/2025 at 2:41 PM, with the Director of Nursing Services they stated they didn't know why the call bell for Resident #1 was behind the residents headboard but they (the call bells) should be clipped to the bed sheet and with-in reach of the resident. 2) Resident #2 had diagnoses that included Cerebral Infarction (ischemic stroke), Hemiplegia (paralysis that affects only one side of your body), and Dementia. Resident #2's Minimum Data Set assessment dated [DATE] documented Resident #2's Brief Interview for Mental Status was not conducted because Resident #2 was rarely/never understood. Resident #2's Comprehensive Care Plan titled: Falls/Potential for Falls, effective 2/16/2024 documented an intervention for the call bell to be within reach. During three observations on 2/26/2025 at 8:47 AM, 9:05 AM, and 9:37 AM Resident #2 was observed in bed and Resident #2's call bell was observed hanging from the call bell jack in the wall, down behind the headboard and on the floor and out of the resident's reach restricting the resident from calling for assistance During an observation and interview on 2/26/2025 at 9:37 AM, with Certified Nursing Assistant #2 they stated they checked in on Resident #2 this morning but had not provided care yet. Certified Nursing Assistant #2 stated they could not recall where the call bell was when they checked on Resident #2. During this observation with the surveyor and Certified Nursing Assistant #2 stated they observed the call bell on the floor behind Resident #2, s headboard. They stated the call bell was not in reach of the resident and should always be. During an interview on 2/26/2025 at 9:54 AM, Licensed Practical Nurse #1, they stated they saw Resident #2 this morning but could not recall the location of the call bell. Licensed Practical Nurse #1 stated the call bell should be within arm's reach of the resident and not have been on the floor behind the headboard. Licensed Practical Nurse #1 stated that the call bell accessibility was the responsibility of all staff to check. During an interview on 2/26/2025 at 1:24 PM, Certified Nursing Assistant #3 stated they worked the overnight shift that ended at 7:00 AM. Certified Nursing Assistant #3 stated they provided care for Resident #2 at about 5:00 AM and they could not recall where the call bell was. Certified Nursing Assistant #3 stated the call bell should always be within the reach of a resident. During an interview on 2/26/2025 at 2:27 PM, Licensed Practical Nurse #3 stated they gave Resident #3 medication at about 5:00 AM and observed Resident #3's call bell on the resident's bed, within reach of the resident. During an interview on 2/26/2025 at 2:41 PM, with the Director of Nursing Services they stated they didn't know why the call bell for Resident #2 was behind the residents headboard but they (the call bells) should be clipped to the bed sheet and with-in reach of the resident 3) Resident #3 had diagnoses including Dementia, Alzheimer's Disease, and Aphasia. Resident #3's Annual Minimum Data Set assessment dated [DATE] documented Resident #3's Brief Interview for Mental Status was not conducted because Resident #3 was rarely understood and rarely understands. Resident #3's Comprehensive Care Plan titled, Falls/Potential for Falls, effective 11/7/2017 and reviewed on 2/1/2025 documented an intervention for the call bell to be within reach. During three observations on 2/26/2025 at 8:49 AM, 9:08 AM, and 9:21 AM Resident #2 was observed in bed and their call bell was observed hanging from the call bell jack in the wall, down behind the headboard and on the floor and out of the resident's reach. During the 9:08 AM observation Certified Nursing Assistant #1 was bedside assisting Resident #3 with breakfast. During an interview on 2/26/2025 at 9:21 AM Certified Nursing Assistant #1, stated they checked on Resident #3 before breakfast and then returned to assist Resident #3 with their meal. Certified Nursing Assistant #1 stated they could not recall where the call bell was at those two times or that the call bell was out of reach. Certified Nursing Assistant #1 stated the call bell should always be where the resident could reach it. During an interview on 2/26/2025 at 1:24 PM, Certified Nursing Assistant #3 they stated they worked the overnight from 11:00 PM to & 7:00 AM. Certified Nursing Assistant #3 stated they provided care for Resident #3 at about 5:30 AM and they placed the call bell across the chest of Resident #3. During an interview on 2/26/2025 at 2:41 PM, with the Director of Nursing Services they stated they didn't know why the call bell for Resident #1 was behind the residents headboard but they (the call bells) should be clipped to the bed sheet and with-in reach of the resident. 10NYCRR 415.29

Based on observation, record review, and interviews during the Recertification Survey initiated on 9/23/2024 and completed on 9/30/2024, the facility did not ensure that each resident was treated with respect and dignity and in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life. This was identified for one (Resident #5) of three residents reviewed for Dignity. Specifically, on 9/23/2024 Resident #5's room was observed with a strong urine odor. A disposable bed pad with a large urine stain was observed on the floor adjacent to the resident's bed with three urinals one of which was full. Resident #5 stated they wanted the area to be clean. The finding is: The facility's policy titled Dignity, last reviewed May 2024, documented it is the policy of the facility to promote an environment in which the resident's dignity is evident in all interactions between caregivers and residents. Dignity means staff carry out activities that assist the resident to maintain and enhance their self-esteem and self-worth. Resident #5 was admitted with diagnoses including Asperger's Syndrome, Depression, and Cerebrovascular Accident. The 9/19/2024 Quarterly Minimum Data Set assessment documented a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. The Minimum Data Set assessment documented the resident required substantial/maximal assistance for toileting and had functional limitation in range of motion to the upper and lower extremities. On 9/23/2024 at 11:43 AM, Resident #5 was observed in bed. The resident appeared to be sleeping but was easily arousable. There was a disposable bed mat on the floor with three urine bottles on it. One of the urine bottles was full and the other two were empty. The bed mat on the floor was soiled with a large urine stain and there was a strong urine odor in the room. The resident stated the staff needed to empty the full urine bottle. Certified Nursing Assistant #1 was notified of the observation on 9/23/2024 at 11:45 AM. Certified Nursing Assistant #1 observed the soiled bed mat on the floor and the full bottle of urine and stated the resident does not like to get out of bed until after lunch. Certified Nursing Assistant #1 stated it is difficult for the resident to use the bathroom because the resident has to wear braces on their legs, and having the urine bottles on the floor next to the bed is the resident's preference. Certified Nursing Assistant #1 stated they would get the resident out of bed after lunch and then they left the room without emptying the urine bottle or removing the soiled bed mat. During an observation on 9/23/2024 at 12:45 PM, Resident ##5's room was observed with a soiled bed mat that was placed on the floor. A full urinal was still present next to the resident's bed. The resident was sitting up in their bed and had just finished their lunch meal. This observation was brought to the attention of Licensed Practical Nurse #1 (unit manager). Licensed Practical Nurse #1 stated the urinal should have been emptied when the full urinal was observed by Certified Nursing Assistant #1 an hour ago and the disposable bed mat should have been removed. The Director of Nursing Services was interviewed on 9/26/2024 at 1:46 PM and stated having the urinals on the floor is the resident's preference and we have to honor their wishes, but the resident area should be kept clean and odor-free. Resident #5 was interviewed On 9/26/2024 at 2:26 PM and stated the urinals are kept on the floor because they are easy to reach that way and they urinate a lot. The resident stated it is difficult for them to get out of bed and the aides are too busy to get them up. The resident stated, I want the area to be clean. 10NYCRR 415.3(d)(1)(i)

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00354353) initiated on 9/23/2024 and completed on 9/30/2024, the facility did not ensure that each resident's primary representative was immediately informed when a resident had an accident resulting in injury that had the potential for requiring Physician intervention. This was identified for one (Resident #230) of four residents reviewed for Accidents. Specifically, on 9/17/2024 Resident #230 fell from the bed and sustained bruising to their face. The resident's representative was not informed of the fall. The finding is: The facility's policy titled Change in Condition, last reviewed 10/2023, documented any deterioration in health, mental, or psychosocial status causing either life-threatening conditions or clinical complications, as well as any deviation from the resident's baseline medical condition, which constitutes an abnormal condition, will be reported to the Nursing Supervisor and Physician. Criteria for reporting a change in condition include incident/accident with or without injury. At the time the change in condition is identified, the nurse will notify families/next of kin. Resident #230 was admitted with diagnoses including Cerebral Palsy, Quadriplegia, and Seizure Disorder. The 9/3/2024 Admission Minimum Data Set assessment documented no Brief Interview for Mental Status score because the resident had severely impaired cognitive skills for daily decision-making. An Accident and Incident report dated 9/17/2024 at 1:00 PM documented the resident fell from the bed and was found on the floor adjacent to their bed by a housekeeper. The resident was non-verbal and could not explain what happened. The resident sustained a 3-centimeter round ecchymotic (bruise) abrasion to the right forehead and an abrasion to the right cheek. The Physician and the resident's group home manager were notified. A review of the electronic medical record revealed that the resident's family member was listed as the primary contact and the group home was listed as the secondary contact. The resident's family member (primary contact) was interviewed on 9/27/2024 at 12:32 PM and stated the facility did not notify them when the resident fell from the bed on 9/17/2024. The family member stated they found out about the fall the next day when they were notified by another organization that supports the group home. On 9/27/2024 and 9/30/2024 multiple calls were made to Registered Nurse #1 (nursing supervisor) who prepared the accident and investigation report. Calls were not returned. During an interview on 9/30/2024 at 9:37 AM, Assistant Director of Nursing Services #1 (Risk Manager) stated the group home was providing care to the resident before the resident was admitted to the facility for short-term treatment. The facility staff did not call or notify the family member who was listed as the primary contact instead, they called the group home regarding the resident's fall. Assistant Director of Nursing Services #1 stated that the facility should have notified the family member of the resident's fall on 9/17/2023. During an interview on 9/30/2024 at 10:14 AM, Licensed Practical Nurse #2 (unit nurse) stated they did not notify the resident's family to inform them of the resident's fall on 9/17/2024. Licensed Practical Nurse #2 stated when the resident fell , they contacted the group home staff because the group home staff were the ones who were visiting the resident. During an interview on 9/30/2024 at 10:22 AM, the Director of Nursing Services stated that the facility staff should have called the resident's family member first because the resident's medical record contact list documented the family member as the first contact. 10 NYCRR 415.3(f)(2)(ii)(a)

Based on observations, record review, and interviews during the Recertification Survey initiated on 9/23/2024 and completed on 9/30/2024, the facility did not ensure that each resident was provided a safe, clean, comfortable, and homelike environment. This was identified for one (Unit E) of four units observed during the environmental task. Specifically, during an environmental tour of Unit E, Resident#144's bathroom door was observed with broken hinges and was not able to be closed; Resident#56's privacy curtains were observed with dark brown and yellow stains, and the bathroom floor was soiled with dark grayish stains. The findings are: The facility's policy for Cleaning Resident Bathrooms and Public Bathrooms, dated February 2024, documented that daily cleaning will ensure optimum levels of cleanliness and sanitation, prohibit the spread of infection, and maintain the outward appearance of the facility. The facility's policy for Cleaning Resident Rooms, dated March 2024, documented the purpose of this policy was to provide a detailed description of the steps that are to be completed daily in the cleaning of a resident room. The steps included cleaning and dusting all vertical surfaces including doors, door trim, molding, walls, light switch plates, and curtains using a clean cloth soaked in or sprayed with disinfectant cleaner. -Resident#144 had diagnoses that included Dementia, Arthritis, and Depression. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 12, which indicated the resident had moderately impaired cognition. The resident utilized a walker and wheelchair as a mobility device. During an environmental tour of Unit E on 9/23/2024 at 12:41 PM, Resident #144's bathroom door was observed with a loose upper hinge and was unable to be closed. During an observation on 9/30/2024 at 10:00 AM, Resident #144's bathroom door was observed with a loose upper hinge and was unable to be closed. During an interview on 9/30/2024 at 10:42 AM, Certified Nursing Assistant #9 stated Resident #144's bathroom door had been broken for months and the broken door concern was reported by them in the maintenance log book approximately seven months ago. During an interview on 9/30/2024 at 11:37 AM, Maintenance Worker#1 stated they always check the resident rooms after the resident gets discharged and before a new resident gets admitted to make sure that all maintenance concerns are addressed. Maintenance Worker#1 observed Resident#144's bathroom door and stated the door hinge was broken and needed to be fixed. Maintenance Worker#1 stated that according to the maintenance book Resident#144's bathroom door was fixed on 9/11/2024 and the door hinges must have broken again after it got fixed on 9/11/2024. During an interview on 9/30/2024 at 2:40 PM, Unit Manager #3 stated Resident#144's bathroom door had been broken for a while and the concern was documented in the maintenance log book. -Resident#56 had diagnoses including Cardiomegaly, Major Depression, and Type 2 Diabetes Mellitus. The Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 15, which indicated the resident was cognitively intact. The resident required supervision and contact guard assistance with toileting and was frequently incontinent of bowel and bladder. During an observation on 9/23/2024 at 12:19 PM, Resident #56's privacy curtain was observed to have multiple yellowish-brown stains all over the curtain, and the bathroom floor was observed with grayish-brown stains. Resident #56 was interviewed immediately after the observation on 9/23/2024 and stated It would be nice to have clean curtains. During an observation on 9/30/2024 at 3:08 PM, Resident #56's privacy curtain was observed with multiple yellowish-brown stains all over the curtain, and the bathroom floor was observed with grayish-brown stains. During an interview on 9/30/2024 at 11:07 AM, Certified Nursing Assistant #10 stated the housekeepers were responsible for cleaning the bathroom floors and the privacy curtains. The housekeepers were cleaning the bathrooms every day and they did not know why there were stains on the curtains. During an interview on 9/30/2024 at 11:45 AM, Housekeeper #1 stated the privacy curtain in Resident #56's room was changed last week, the curtain is not dirty it is just stained. Housekeeper #1 stated Resident #56's bathroom floors needed cleaning. During an interview on 9/30/2024 at 4:17 PM, the Director of Housekeeping stated the residents should not have stained privacy curtains and dirty bathroom floors and they will make sure that Resident #56's privacy curtain is changed and the bathroom floors are cleaned. During an interview on 9/30/2024 at 4:35 PM, the Director Of Nursing Services stated it was not acceptable to have dirty, stained bathroom floors, broken bathroom doors, and or stained privacy curtains in any resident room. 10 NYCRR 415.5(h)(2)

Based on record review, and interviews during the Recertification Survey and Abbreviated Survey (NY 00351219) initiated on 9/23/2024 and completed on 9/30/2024, the facility did not ensure that accidents were thoroughly investigated to rule out abuse, neglect, or mistreatment. This was identified for one (Resident #161) of four residents reviewed for Accidents. Specifically, Resident #161 was found on the floor in their room near the bed on 7/28/2024 and sustained a six-centimeter laceration (cut or tear) with bruising to the left side of their face. The facility did not obtain statements from each staff member involved with the resident to identify the root cause of the accident. The finding is: The facility's Accident and Incident policy and procedure reviewed on 8/2024 documented that the charge nurse or supervisor will initiate the collection of statements from staff. The statement will be collected from Certified Nursing Assistants, caregivers, Licensed nurses working that shift, and all others assigned to the unit that day, including other departments. The resident's roommate, other residents, or visitor's statements should be obtained as applicable. As necessary, statements are obtained from staff involved with the resident in the last 24 hours. The statements should be obtained from necessary personnel prior to the end of the shift on which the accident was first noted. Resident #161 was admitted with diagnoses that included Dementia, Difficulty walking, and Left Femur (leg bone) Fracture. The Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status score of 5, which indicated the resident had severe cognitive impairment. The resident required moderate assistance from staff for transfers, and ambulation and had one fall with injury prior to this assessment. A Comprehensive Care Plan for falls dated 7/15/2023 and last updated on 7/28/2024 documented the resident was at risk for falls related to falls in the last six months. Since admission, the resident has fallen on 2/17/2024, 4/3/2024, 6/20/2024, and 7/28/2024. The resident with impaired balance, impaired gait, muscle weakness, impulsiveness, and poor safety awareness. The interventions included keeping the call bell and personal items within reach, encouraging the use of proper footwear, and reminding the resident to ask for assistance for difficult maneuvers. An Accident and Incident Report dated 7/28/2024 documented that at 7:15 PM the Certified Nursing Assistant #6 checked on the resident and observed the resident sitting upright on the floor next to their bed. The resident was unable to recall how the incident happened due to baseline confusion. The resident sustained a 6-centimeter laceration with bruising on the left side of their face and bleeding was noted. A nursing progress note dated 7/28/2024 documented the resident was found on the floor near the bedside, physical assessment revealed a 6-centimeter laceration with bruising to the left side of the resident's face. During an interview on 9/30/2024 at 10:21 AM, Certified Nursing Assistant #6 stated they were assigned to care for Resident #161 on 7/28/2024. Certified Nursing Assistant #6 stated the Kitchen transporter first observed the resident on the floor and called them. Certified Nursing Assistant #6 stated when they went to the resident's room, the resident was sitting on the floor in an upright position next to the bed. Certified Nursing Assistant #6 stated when they provided a statement regarding the accident, they did not tell the Nursing Supervisor that the Kitchen transporter was the one who found the resident on the floor. During an interview on 9/30/2024 at 10:55 AM, the Risk Manager stated the Registered Nurse Supervisor was responsible for interviewing the staff and obtaining statements that included all relevant information regarding the fall. The Risk Manager stated that Certified Nursing Assistant #6 should have reported to the Supervisor that the Kitchen transporter identified the resident on the floor. The Risk Manager stated that the Kitchen transporter's statement should have been obtained and included in the Accident and Incident Report. During an interview on 9/30/2024 at 11:15 AM, Registered Nurse #2 stated they were responsible for obtaining statements from all staff that were involved with the care of the resident. Registered Nurse #2 stated Resident #161 was found on the floor on 7/28/2024; however, they did not recall obtaining a statement from the Kitchen transporter and did not recall that it was the Kitchen transporter that first identified the resident on the floor. Registered Nurse #2 stated that if they knew they would have obtained a statement and included it in the Accident and Incident Report. During an interview on 9/30/2024 at 1:22 PM, the Director of Nursing Services stated that the Registered Nurse Supervisors were responsible for starting the Accident Incident Report and following up with obtaining statements from all involved staff. The Director of Nursing Services stated that if the Kitchen transporter identified the resident on the floor and brought it to the nursing staff's attention, a statement should have been obtained from the Kitchen transporter. 10 NYCRR 415.4 (b) (3)

Based on record review and interview during the recertification survey initiated on 9/23/2024 and completed on 9/30/2024, the facility failed to ensure that a Minimum Data Set Assessment was completed within the prescribed time frames. This was evident during the Resident Assessment task. Specifically, Resident #486 was admitted to the facility on [DATE]. The admission Minimum Data Set Assessment was completed on date 7/25/2024. The Minimum Data Set assessment was completed six days beyond the required timeframe. The finding is: The facility policy titled Minimum Data Set Version 3.0, last reviewed March 2024, documented the facility will conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. Resident #486 was admitted on [DATE] with diagnoses of Congestive Heart Failure and Diabetes Mellitus. An admission Minimum Data Set assessment was initiated on 7/7/2024 and was completed on 7/25/2024. The Minimum Data Set Coordinator was interviewed on 9/30/2024 at 9:44 AM and stated the Minimum Data Set assessment for each resident should be completed within 14 days after the resident's admission to the facility. The Minimum Data Set Coordinator stated that Resident #486's assessment was not completed on time and was six days late. The Minimum Data Set Coordinator stated they were responsible for ensuring the timely completion of each Minimum Data Set assessment and were not sure why the admission assessment for Resident #486 was late. During an interview on 9/30/2024 at 3:27 PM, the Administrator stated the Minimum Data Set Coordinator is responsible for ensuring the Minimum Data Set assessments are completed on time. The Administrator stated they were not aware that the Minimum Data Set assessments were not being completed timely. 10 NYCRR 415.11

Based on observation, record review, and interviews conducted during a Recertification and Abbreviated survey (NY 00326995) completed on 9/30/24, the facility did not ensure a resident who required respiratory care, including tracheostomy (an opening into the windpipe to help air reach the lungs) care, provided such care consistent with professional standards of practice. This was identified for one (Resident #129) of one resident reviewed for respiratory care. Specifically, 1) during observation of Resident #129's tracheostomy care on 9/27/2024, Registered Nurse #6 did not change the inner tracheostomy tube (cannula) as ordered by the Physician and 2) there was no documented evidence the resident's tracheostomy outer cannula was routinely being changed as per the manufacturer's specifications from March 2023 to October 2023. The finding is: The policy and procedure titled Tracheostomy Care, revised May 2023, documented that the tracheostomy cannula, stomas, and surrounding areas shall be aseptically cleaned. Nurses may change the inner cannula. Only physicians may change/replace the outer cannula. Universal precautions are indicated with all tracheotomy procedures. The facility policy did not indicate a timeframe for changing the outer tracheostomy cannula. Resident #129 was admitted with a tracheostomy and Anoxic Brain Damage (a disorder of the brain caused by decreased oxygen). The Quarterly Minimum Data Set assessment dated [DATE], documented that the resident had severe cognitive impairment and was dependent on staff for all care. The Minimum Data Set assessment documented the resident required tracheostomy care. The Comprehensive Care Plan titled Respiratory: Tracheostomy, revised on 8/24/2024, documented Resident #129 was to receive tracheostomy care every shift and as needed. The Comprehensive Care Plan did not include directions related to changing the inner or outer cannula for the tracheostomy tube. The tracheostomy tube (utilized by Resident #129) manufacturer brochure documented under the warning section: The disposable inner cannula is designed for single use and should not be cleaned or reused and the outer cannula should be changed every 28 days. Under the cautions section: The tracheostomy tube and obturator are single patient-use medical devices. Duration of single-patient use should not exceed 29 days. The manufacturer does not recommend and has not substantiated the use of these devices beyond the 29-day time frame. Decisions about tracheostomy tube changes should be made by the responsible physician or designate using accepted medical techniques and judgment. A review of the resident's medical records indicated there were no physician orders to change the outer cannula from March 2023 to October 2023. A Nursing progress note dated 10/27/2023 documented the resident was seen on 10/25/2023 by the Ear Nose and Throat Specialist and the outer cannula was changed. A Physician's order dated 2/18/2024 (original order date 1/26/2024) documented to schedule an appointment with the Ear Nose and Throat consult for a tracheostomy change on 04/10/2024 at 10:00 AM. The physician's orders dated 9/25/2024 documented Resident #129 had a tracheostomy tube; and to change the disposable tracheostomy inner cannula daily and as needed for secretion maintenance. During an observation on 9/27/2024 at 10:20 AM, Registered Nurse #6 performed tracheostomy care for Resident #129 with the assistance of Registered Nurse #5. Registered Nurse #6 performed hand hygiene and gathered supplies. Registered Nurse #6 did not include a new disposable inner cannula while gathering the supplies. Registered Nurse #6 removed the dirty inner cannula and placed the dirty inner cannula in a tray to rinse with sterile saline. Registered Nurse #6 stated they would reuse the rinsed inner cannula and would place it back into the resident's tracheostomy. Registered Nurse #6 stated they did not know that there was a physician's order to change the inner cannula daily. During an interview on 9/27/2024 at 11:34 AM, Nurse Practitioner # 1 stated the tracheostomy inner cannula is disposable and should not have been washed and re-used. The disposable inner cannula should have been replaced. The resident can develop respiratory infections if the inner cannula is not replaced daily. The outer tracheostomy tube should also be changed every three months and there should have been a physician's order in 2023. The Respiratory Therapist is now responsible for tracheostomy tube changes every 3 months since January 2024. Nurse Practitioner #1 stated when the resident returned from the hospital in December 2023, we ensured the outer tracheostomy tube was changed as per protocol. During an interview on 9/30/2024 at 11:26 AM, the Medical stated Registered Nurse #6 should have changed the inner cannula as per the physician's orders. The resident is at risk for infections if the inner cannula is not changed daily or if the tracheostomy tube is not changed every 3 months. The tracheostomy tube should have been changed every 3 months. The attending physician should have ordered the tracheostomy tube replacement every 3 months. During an interview on 9/30/24 at 1:41 PM, the Director of Nursing Services stated cleaning the inner cannula and reinserting it back into the tracheostomy tube is not acceptable. The Director of Nursing Services stated that reusing the disposable inner cannula would increase the risk of infection. Resident #129's tracheostomy was not being changed on a routine basis in 2023 and this was identified when the resident went out to the Ear Nose and Throat Specialist in October 2023. The Director of Nursing Services stated the tracheostomy tube should have been changed on a routine basis. During a telephone interview with the Respiratory Therapist on 9/27/2024 at 1:20 PM, they stated Registered Nurse # 6 should have removed the disposable inner cannula and replaced it with a new inner cannula as per physician orders. The Respiratory Therapist stated reusing the disposable inner cannula places the resident at high risk for infection. The Respiratory Therapist stated they have been taking care of Resident #129 since January 2024 and have been changing their tracheostomy tube every 90 days. The Respiratory therapist stated they did not care for the resident before January 2024 and that the tracheostomy tube should have been changed every three months. 10NYCRR 415.12(k)(4)

Based on observation, record review, and interviews during the Recertification Survey initiated on 9/23/2024 and completed on 9/30/2024, the facility did not ensure that all residents were free of significant medication errors. This was identified for one (Resident #106) of 25 residents reviewed during medication pass observation. Specifically, Resident #106 had a physician's order for Ampicillin 1 Gram (antibiotic) Intravenous solution every 6 hours at 12:00 AM; 6:00 AM; 12:00 PM; and 6:00 PM for Cellulitis (skin infection). The Medication Administration Record lacked documented evidence that Resident #106 received their 12:00 AM and 6:00 AM dosage of the Physician-ordered antibiotic on 9/23/2024. The finding is: The facility's policy for Medication Administration and Documentation, last reviewed 10/2023, documented administering medication at the time it is prepared. If there are any missed doses, notify the Physician and or the Nurse Practitioner immediately and follow the recommendations/orders. Upon completion of the medication pass and before the end of the shift, the medication nurse will check the electronic medical record dashboard to ensure all medications and monitoring are completed. Resident #106 was admitted with diagnoses of Acute Osteomyelitis (bone infection) of the left ankle and foot and Cellulitis (skin infection). The Minimum Data Set assessment dated [DATE] documented that Resident #106 had severely impaired cognitive skills for daily decision-making. The Minimum Data Set documented the resident received antibiotic therapy during the assessment look-back period. The Comprehensive Care Plan for Antibiotic Therapy dated 8/21/2024 documented the resident needs intravenous antibiotics therapy due to Cellulitis. The interventions included administering intravenous medication via a pump as per the physician's orders and documenting the administration on the resident's Medical Administration Record. The physician's order dated 8/22/2024 documented to administer Ampicillin 1 Gram solution with Sodium Chloride 0.9 % (flush). Infuse 1 Gram by injection route every 6 hours for 6 weeks every day at 12:00 AM; 6:00 AM; 12:00 PM; and 6:00 PM for 6 Weeks for Cellulitis. During a medication pass observation on 9/23/2024 at 11:20 AM, Resident #106 was observed lying in their bed. An intravenous pole was observed by the resident's bedside with an empty Ampicillin 1 Gram vial attached to an intravenous solution bag containing 50 milligrams of normal saline. The Ampicillin vial or the normal saline intravenous bag did not include a label indicating when the medication was reconstituted (mixed with normal saline) and the time the medication was supposed to be administered. A review of the Medication Administration Record dated 9/23/2024 indicated Ampicillin 1 Gram intravenous medication was not signed for as administered at 12:00 AM and at 6:00 AM. During an interview on 9/23/2024 at 11:22 AM, Nurse Manager #3 stated they work on another unit and came to Resident #106's unit to administer the 12:00 PM intravenous antibiotic dose for the resident. Nurse Manager #3 confirmed an empty Ampicillin 1 Gram vial was attached to the 50 milligrams normal saline intravenous bag and the Ampicillin vial or the normal saline intravenous bag had no label that indicated when the medication was reconstituted and the time the medication was supposed to be administered. Nurse Manager #3 stated that the observed medication was most likely the 6:00 AM Ampicillin antibiotic dose not administered to the resident and did not know why. During an interview on 9/30/2024 at 10:13 AM, Registered Nurse Supervisor#1 stated they worked during the 9/22/2024 to 9/23/2024 night shift. They prepared the antibiotic medication for Resident #106 on 9/23/2024 at 6:00 AM; however, they forgot to administer the medication to Resident#106. Registered Nurse Supervisor#1 stated they administered the 12:00 AM intravenous antibiotic to Resident #106 and forgot to sign the Medication Administration Record. During an interview on 9/30/2024 at 11:57 AM, the Director of Nursing Services stated Nurse Manager #3 informed them that the 6:00 AM antibiotic medication dose was not administered to Resident #106 and that the 12:00 AM and 6:00 AM doses were not signed for as administered on the Medication Administration Record. The Director of Nursing Services stated that it is extremely important that antibiotics are administered as per the physician's orders. During an interview on 9/30/2024 at 1:00 PM, Medical Doctor#1 stated that residents should not miss any antibiotic doses to maintain the effectiveness of the medication and the staff must sign for the medication administration. 10 NYCRR 415.12(m)(2)

Based on observations, interviews, and record review during the Recertification Survey initiated on 9/23/2024 and completed on 9/30/2024, the facility did not ensure that food was prepared and served in accordance with professional standards for food service safety. This was identified during the Kitchen observation task. Specifically, Dietary Aide #1 was observed handling peeled, hard-cooked eggs wearing the same gloves that were used while entering and exiting the walk-in refrigerator; and the cold food temperatures were above the safety zone. The finding is: The undated facility policy and procedure for Food Service Hand Washing, documented that hands are frequently and properly washed throughout the day. The purpose is to remove bacteria that may cause infection. Employees must always wash their hands before starting work in the kitchen, after handling soiled dishes and utensils, before and after performing cleaning procedures, and before and after handling food. The facility's policy and procedure for Food Service Department Infection Control Procedures, last reviewed February 2024, documented the facility maintains strict sanitary conditions in the food service department to eliminate food contamination and prevent the growth of disease-producing organisms and the production of bacterial toxins. All employees are required to wash their hands for the following: start of a new work assignment or procedure and when come into contact with any soiled object or matter. For glove use, if preparation requires direct food contact, put gloves on after hand washing. Change gloves as necessary such as if the employee is interrupted and required to perform another task. The facility's policy and procedure for Food temperatures, last reviewed in March 2024, documented that foods will be maintained at temperatures sufficient to preserve nutritive value and avoid bacterial growth before and during meal service. All foods, being held for any length of time, will be kept above 135 degrees Fahrenheit or below 41 degrees Fahrenheit. During a Kitchen observation on 9/23/2024 at 10:02 AM, with the Food Service Director, Dietary Aide #1 was observed entering a walk-in refrigerator wearing a pair of gloves. Dietary Aide #1 was observed exiting the refrigerator with the same gloves and then handling peeled, hard-cooked eggs. Dietary Aide #1 was immediately interviewed and stated they should have washed their hands and put on new gloves before handling any food. Dietary Aide #1 stated there was an increased risk of food contamination since they did not change their gloves. During a lunch meal tray line observation on 9/23/2024 at 11:21 AM with the Food Service Director, food temperatures were taken by the Food Service Supervisor. The egg salad sandwich temperature measured 60 degrees Fahrenheit, and the health shake temperature measured 45 degrees Fahrenheit. The Food Service Supervisor was interviewed immediately after the observation on 9/23/2024 and stated the temperature of cold food items should be at or below 40 degrees Fahrenheit. The Food Service Supervisor stated that food temperatures over 40 degrees Fahrenheit have increased potential for bacterial growth and the residents could potentially get sick. The Food Service Supervisor stated they do not take the temperature of the cold food items before meal services. The facility tray line temperature log reflected only hot food temperatures. The Food Service Director was interviewed on 9/30/2024 at 9:37 AM and stated Dietary Aide #1 was in training on 9/23/2024 and was not supposed to be handling food. The Food Service Director stated if the food got contaminated, it potentially could spread illness to the residents. The Food Service Director further stated that they were not taking the temperatures of the cold food items on the tray line as they were using the temperature of the refrigerator as the basis for the food temperature, assuming that the cold food would remain as cold as the refrigerator temperature. 10 NYCRR 415.14(h)

Based on record review and interviews during the Recertification Survey and Abbreviated Survey (NY 00354353) initiated on 9/23/2024 and completed on 9/30/2024, the facility did not ensure that timely arrangements were made for outside services that met professional standards. This was identified for one (Resident #230) of four residents reviewed for Accidents. Specifically, Resident #230 with severely impaired communication was transferred to the Neurologist's office for a medical appointment on 9/11/2024. The resident was not accompanied by the facility staff or the resident representative who could speak on behalf of the resident; therefore, the appointment was canceled and the resident was returned to the facility. There was no documentation in the resident's medical record that the appointment was canceled; no documentation regarding how to coordinate future medical appointments; and no documentation from the resident's primary care provider regarding the missed medical appointment. The finding is: The facility policy titled Transport Policy for Medical Appointments, last reviewed March 2024, documented a qualified staff member or family member/designated representative will accompany residents during transport to provide assistance if needed and ensure comfort and safety; all transport requests, confirmations, and incidents must be documented in the resident's medical record; staff will record details of each transport, including date, time, destination, and any issues encountered during the transport; compliance with state and federal regulations regarding resident transport must be maintained at all times. Resident #230 was admitted with diagnoses including Cerebral Palsy, Quadriplegia, and Seizure Disorder. The 9/3/2024 Admission Minimum Data Set assessment documented no Brief Interview for Mental Status score because the resident had severely impaired cognitive skills for daily decision-making. A Social Work progress note dated 9/2/2024 documented that Resident #230 was non-verbal and was admitted to the facility for short-term intravenous antibiotic treatment. The discharge plan was for the resident to return to the group home setting. A physician's order dated 8/30/2024 documented Phenytoin (antiseizure medication) 50-milligram tablet, one tablet by oral route once daily for unspecified convulsions. A nursing progress note, written by Licensed Practical Nurse #1 (unit manager), dated 9/11/2024 at 9:14 AM documented the resident left the unit in stable condition via stretcher to a Neurology appointment. There was no further documentation in the medical record regarding the Neurology appointment. During an interview on 9/25/2024 at 11:01 AM, Receptionist #1 from the Neurologist's office stated Resident #230 came to the office for a Neurology consult on 9/11/2024. The resident was nonverbal and was not accompanied by the facility staff or a family member; therefore, the appointment was canceled. During an interview on 9/25/2024 at 11:50 AM, Resident #230's group home representatives including the house manager, the Director of Nursing, and the Assistant Director of Nursing, stated the resident's family member did not want the group home staff to accompany the resident for any outside consultant appointments. The group home house manager stated they told the resident's family member that the group home staff was not going to accompany the resident on 9/11/2024 for the Neurology appointment. During an interview on 9/25/2024 at 12:17 PM, Licensed Practical Nurse #1 (unit manager) stated the hospital recommended a Neurology consult for Resident #230 for seizure management. Licensed Practical Nurse #1 made an appointment for 9/11/2024. Licensed Practical Nurse #1 stated they spoke to the resident's group home manager on 9/10/2024, who said that the group home staff would not accompany the resident to the appointment as per the resident's family's direction. Licensed Practical Nurse #1 stated they had also told the resident's family member about the appointment; however, they could not recall when. Licensed Practical Nurse #1 stated to their knowledge, the family member was going to be at the appointment on 9/11/2024. Licensed Practical Nurse #1 stated they did not document their discussion with the resident's family member or the group home in the resident's medical record. Licensed Practical Nurse #1 stated they did not know the facility's policy for sending a non-verbal resident out for an appointment. During an additional interview on 9/26/2024 at 11:03 AM, Licensed Practical Nurse #1 stated when Resident #230 returned from the Neurologist's office on 9/11/2024, they (Licensed Practical Nurse #1) did not document in the resident's medical record and did not inform the resident's family of the appointment cancellation. Licensed Practical Nurse #1 stated they did not reschedule the appointment. Licensed Practical Nurse #1 stated the Nurse Practitioner was aware of the appointment cancellation. During an interview on 9/26/2024 at 1:50 PM, the Director of Nursing Services stated all conversations with the group home and the resident's family should have been documented including the appointment cancellation. The Director of Nursing Services stated that they expected staff to follow up regarding rescheduling the Neurology consult. During an interview on 9/27/2024 at 12:32 PM, the resident's family member stated they were not informed of the resident's 9/11/2024 Neurology appointment. They became aware of the appointment when they got a call from the Neurologist's office that the resident was brought in and was alone. The resident's family member stated they would have never agreed to the Neurology appointment because the transport would have been painful and distressing for the resident. During an interview on 9/30/2024 at 9:03 AM, Nurse Practitioner #1 stated they knew that Resident #230's Neurology appointment was canceled and the resident's family member did not want to reschedule the appointment. Nurse Practitioner #1 stated they could not recall if they documented their communication with the resident's family member in the resident's medical record. 10 NYCRR 415.26(e)(1)(i-iv)

Based on interviews and record review during the Recertification Survey initiated on 9/23/2024 and completed on 9/30/2024, the facility did not ensure that all completed Minimum Data Set assessments were electronically transmitted to the Centers for Medicare and Medicaid Services within the required timeframe. This was identified for six (Residents #52, #148, #13, #105, #206, and 486) of 12 residents reviewed for the Resident Assessment Facility Task. Specifically, the Minimum Data Set assessment for Residents #52, #148, #13, #105, #206, and #486 were not transmitted to the Centers for Medicare and Medicaid Services within 14 days of the assessment completion date. The finding is: The facility's policy titled Minimum Data Set Version 3.0, last reviewed March 2024, documented the facility will conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. A review of the Minimum Data Set (MDS) 3.0 Nursing Home Validation Report dated 9/26/2024 documented the following Minimum Data Set assessments were transmitted to Centers for Medicare and Medicaid Services on 9/26/2024: -Resident #52's quarterly Minimum Data Set assessment, with an assessment reference date of 7/17/24, was completed on 7/25/2024. The assessment was transmitted and accepted on 9/26/2024. Resident #52's Minimum Data Set assessment was transmitted 63 days late. -Resident #148's quarterly Minimum Data Set assessment, with an assessment reference date of 7/17/24, was completed on 7/23/2024. The assessment was transmitted and accepted on 9/26/2024. Resident # 148's Minimum Data Set assessment was transmitted 65 days late. -Resident #13's quarterly Minimum Data Set assessment, with an assessment reference date of 7/17/24, was completed on 7/23/2024. The assessment was transmitted and accepted on 9/26/2024. Resident #13's Minimum Data Set assessment was transmitted 65 days late. -Resident #105's quarterly Minimum Data Set assessment, with an assessment reference date of 8/1/24, was completed on 8/11/2024. The assessment was transmitted and accepted on 9/26/2024. Resident #105's Minimum Data Set assessment was transmitted 46 days late. -Resident #206's quarterly Minimum Data Set assessment, with an assessment reference date of 7/26/24, was completed on 8/3/2024. The assessment was transmitted and accepted on 9/26/2024. Resident #206's Minimum Data Set assessment was transmitted 54 days late. -Resident #486's admission Minimum Data Set Assessment, with an assessment reference date of 7/7/2024, was completed on 7/25/2024. The assessment was transmitted and accepted on 9/26/2024. Resident #486's Minimum Data set assessment was transmitted 63 days late. The Minimum Data Set Coordinator was interviewed on 9/30/2024 at 1:28 PM and stated the Minimum Data Set assessment for each resident should be transmitted to the Centers for Medicare and Medicaid Services within 14 days of the assessment completion. The Minimum Data Set Coordinator stated they thought had previously submitted the Minimum Data Set assessment for all six residents; however, they did not receive the validation report. The Minimum Data Set Coordinator stated that based on not having the validation report, the assessments had not been previously submitted. The Minimum Data Set Coordinator stated they then resubmitted the Minimum Data Set assessments again on 9/26/2024. During an interview on 9/30/2024 at 3:27 PM, the Administrator stated the Minimum Data Set Coordinator is responsible for ensuring the Minimum Data Set assessments are completed and transmitted to the Centers for Medicare and Medicaid Services on a timely basis. The Administrator stated they were not aware that the Minimum Data Set assessments were not being transmitted timely. 10 NYCRR 415.11

Based on record review and interviews during the Recertification Survey initiated on [DATE] and completed on [DATE], the facility did not ensure that the Minimum Data Set (MDS) assessments accurately reflected each resident's current status. This was identified for one (Resident #115) of two residents reviewed for Resident Assessment and one (Resident #145) of one resident reviewed for Physician's Services. Specifically, 1) Resident #115 expired on [DATE] while out of the facility and a Discharge MDS assessment was not completed. 2) Resident #145's Admission MDS assessment did not include that the resident had a Pacemaker and an Automatic Implantable Cardioverter Defibrillator (AICD) device under Section I for active diagnosis. The finding is: The facility undated policy for Completion of the Resident Assessment Instrument (RAI) Process documented that the assessments will be completed within the guidelines outlined in the RAI manual and to track changes in the resident's status. 1) Resident #115 was admitted to the facility with the diagnoses of Malignant Neoplasm of Prostate, Hepatic Failure, and Malnutrition. The Admission MDS assessment dated [DATE] documented Resident #115 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. The Nursing Note dated [DATE] documented that Resident #115 was on the way to a transplant team appointment with family members and collapsed while in the car. Resident #115 was taken to the emergency room , intubated and expired shortly afterwards. Review of the electronic medical record system revealed that the facility initiated a Death in facility tracking record and had suspended the Death in facility tracking record on [DATE] at 2:00 PM. There were no subsequent MDS entries for Resident #115. MDS Coordinator #2 was interviewed on [DATE] at 1:17 PM. MDS Coordinator #2 stated that the Death in Facility MDS was done in error and was suspended because Resident #115 died outside of the facility. MDS Coordinator #2 was not aware of who had completed the Death in facility MDS tracking record, it may have been MDS Coordinator #1. MDS Coordinator #2 stated that the facility should have completed a Discharge MDS instead a Death in facility tracking log. MDS Coordinator #1 was interviewed on [DATE] at 2:00 PM. MDS Coordinator #1 stated that the death in facility record was automatically generated in the system when Resident #115 was discharged from the electronic medical record. MDS Coordinator #1 stated that MDS Coordinator #2 was on vacation on [DATE] and that they (MDS Coordinator #1) just suspended the Death in Facility MDS because Resident #115 did not die in the facility. MDS Coordinator #1 stated that it was a mistake not to do the Discharge MDS at that time and they should have done one when they suspended the Death in Facility MDS. The Director of Nursing Services (DNS) was interviewed on [DATE] at 2:15 PM. The DNS stated that they (DNS) were not familiar with the MDS protocol when a resident expires less than 24 hours at the hospital. The DNS stated that they (DNS) were not sure if Resident #115's MDS should have been completed as a discharge MDS or as a Death in Facility MDS since Resident #115 was not discharged or transferred to the hospital. 44925 2) Resident #145 was admitted on [DATE] with diagnoses that include Anoxic brain damage, Hemiplegia and Hemiparesis following Cerebral Infarction and Essential (primary) Hypertension. The Minimum Data Set (MDS) assessment dated [DATE] documented that a Brief Interview for Mental Status (BIMS) was not performed because the resident had severely impaired cognition. The MDS assessment did not include that the resident had a Pacemaker and an Automatic Implantable Cardioverter Defibrillator (AICD) device under Section I for active diagnosis. The MDS coordinator #1 was interviewed on [DATE] at 2:04 PM and stated that the permanent pacemaker and AICD should have been documented on the MDS under active diagnosis section. The Director of Nursing Services (DNS) was interviewed on [DATE] at 11:24 AM and stated that the diagnoses of Permanent Pacemaker and AICD should have been captured on the MDS assessment. 10 NYCRR 415.11(b)

Based on observations, interviews, and record review, during an abbreviated survey (Complaint # NY 595) the facility failed to protect the resident's(s') right to be free from Sexual abuse, potential physical and psychosocial harm by a staff member. This was evident for one (Resident #1) of 3 residents reviewed for Sexual Abuse. Specifically, Certified Nurse's Assistant (CNA) #1 witnessed Recreation Aide (RA) #1 in Resident #1's bed lying behind the resident on their left side and appeared that RA #1 was having sexual intercourse with Resident #1. CNA #1 did not intervene to protect the resident and left Resident #1 alone with RA #1 in the room for approximately 3 minutes failing to ensure the resident was safe and free from further abuse. Additionally, the facility failed to protect all other residents by allowing the alleged perpetrator (RA #1) access to all 191 residents in the facility. The facility did not immediately remove RA #1 from the facility's premises. This resulted in actual harm with the likelihood for more than minimal harm that is Immediate Jeopardy to resident health and safety. This had the potential to affect all 191 residents in the facility. The finding is: The Facility's policy titled Abuse Prohibition and Prevention dated 6/24/2022 documented each resident of the facility shall be free from abuse, neglect, mistreatment, and exploitation and misappropriation of property. Abuse shall include physical harm, mental anguish, verbal abuse, sexual abuse, and involuntary seclusion of any source. Sexual abuse was defined as non-consensual intrusion or penetration, touching intimate body parts or the clothing covering intimate body parts, examination, or treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . During the investigation, the Resident must be protected from additional harm. It is the facility's policy that the individual (s) named and/or involved in any alleged abuse be removed from the facility setting (including grounds) immediately and suspended until such abuse has been ruled out or verified for the duration of the investigation to protect the Resident from any type of retaliation or further abuse. Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly Minimum Data Set (MDS-an assessment tool) dated 10/12/2022 documented a Brief Interview for Mental Status (BIMS) score of 3 indicating severely impaired cognition. The Resident was dependent with 2 staff members for bed mobility. The Comprehensive Care Plan (CCP) dated 6/1/2016 and updated on 10/30/2022 titled Potential for Victimization documented that Resident #1 was at risk for victimization related to presence of behavioral, functional, cognitive or psycho-social issues and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The Nurse's Progress Notes (NPN) dated 10/30/2022 at 10:31 PM documented at approximately 4:30 PM, Certified Nursing Assistant CNA #1 reported to Registered Nurse Supervisor # 1 (RNS #1) that they observed another person in Resident#1's bed. As CNA #1 approached Resident'#1s bed they (CNA#1) saw the Recreation Aide (RA) #1 in the bed lying behind the Resident#1 and (both Resident #1 and RA#1 were lying on their left sides) and that RA #1 had their right leg over the resident. RA #1 pants were unzipped, and they were having sexual intercourse with Resident #1. Resident#1 was transferred to the hospital for an assessment and rape examination. The Emergency Medical Services (EMS) report dated 10/30/2022 documented EMS was dispatched to the facility for a reported sexual assault. Nursing home staff stated that a recreation aide was found with their pants down behind a patient in the patient' room between 3:30 PM and 4:30 PM on 10/30/2022. The emergency room Department Discharge Instructions dated 10/30/2022 at 7:23 PM documented that Resident#1 was evaluated due to a report of Sexual Assault. The facility's investigative summary undated documented on 10/30/2022, at approximately 3:50 PM CNA #1 was returning to Resident #1's room and observed Recreation Aide (RA #1) lying behind the resident. The resident was on their left side and RA #1 was also on their left side both facing the window. CNA #1 reported that resident's brief was twisted to the side of hip bone, however CNA #1 could not see between RA #1 and resident's backside. CNA #1 reported that RA #1's black pants and shoes were on the bed, the pants were open in the front and pulled down along with RA #1's underwear exposing the butt crack. RA #1 was moving back and forth thrusting motion like having sex and RA #1's right leg was on top of resident's right leg, RA #1's left leg (knee) was on the bed, but their foot was partially hanging over the side of the bed. CNA #1 reported that they exclaimed, Jesus wept then RA #1 turned to look at CNA #1 and did not say anything. CNA #1 reported that they felt panic and immediately called out for help and left. CNA #1 stated that at the same time of the occurrence, a code blue had been called on another unit and most staff had responded to help. CNA #1 reported to LPN #1 what they observed. Licensed Practical Nurse (LPN) #1 and CNA #1 went to resident's room and saw the resident's blankets had been pulled up neatly. And the resident was facing the window (side lying). LPN #1 and CNA #1 lifted the blanket and moved the incontinent brief slightly to check for blood but did not want to disturb potential evidence. RNS #1 was notified and reported to Director of Nursing (DON) that CNA #1 as unable to locate RA#1 from 4:30 PM through 6:00 PM. then at approximately 6:15 PM on 10/30/2022, Assistant Director of Nursing (ADON) reported to DON that RA #1 was at the reception desk and was brought to the police station for questioning. The facility's investigative report also documented that RA #1 was scheduled to work on 10/30/2022 between 9:30 AM to 7:30 PM and that their break schedule was between 5:00 PM to 5:30 PM. Additionally, the investigative report documented that RA #1 was not assigned to Resident #1 for a one to one visit or to provide ADL assistance. The facility concluded that there was credible evidence of abuse. Resident #1 was observed on 11/1/2022 at 2:00 PM and 11/3/2022 at 10:39 AM. Resident is non-verbal and did not respond when name was called. A review of the video surveillances conducted on 11/1/2022 at 2:40 PM with Maintenance Director, ADON and Administrator revealed that on 10/30/2022 at: 3:48:26 PM- RA #1 walked down the Unit B hallway, was looking in each room, looked at Resident #1's room and went pass Resident #1's room and went out of video surveillance 3:48:46 PM RA #1 reappeared in the video frame and entered into Resident#1's room. 3:50:31 PM CNA #1 entered Resident #1's room. 3:50:44 PM CNA #1 exited Resident #1's room and walked down the hallway and out of video surveillance. 3:53:01 PM RA #1 exited Resident #1's room and walked the hallway and out of video surveillance. 3:53:57 PM RA #1 passed by Unit B nurses' station and appeared to have something in their hand and opened the bathroom door near the station and quickly closes it. Then went down a hallway and out of video surveillance. 3:54:23 PM RA#1 entered Unit C (same floor as Unit B) passed the nurses' station and went out of video surveillance. 3:56:18 PM RA#1 was seen at front desk and picked up two boxes and left -went out of video surveillance. 3:57:11 PM RA #1 was holding two boxes by elevators and assisted Resident #2 with their rolling walker and went out of video surveillance with Resident #2. 4:01:59 PM RA#1 carrying boxes and with Resident #2 at the elevator. 4:04:36 PM RA #1 was at the elevator with RA #2 and went out of video surveillance 4:13:10 PM RA#1 was seen in the lobby at the front desk and exited the building. 6:10:14 PM RA #1 re-entered into the building and sat at the front desk. 6:12 PM-ADON approached RA#1 sitting at front desk and went into the DON's office. 6:21:58PM RA #1 was handcuffed by two police officers and exited the building at 6:22 PM. During an interview with CNA #1 on 11/1/2022 at 4:59 PM they stated on 10/30/2022 they worked from 7:00 AM to 11:00 PM and was assigned to Resident #1. CNA #1 checked on the resident at approximately 2:00 PM and left the resident wearing a blouse and incontinent pad with no bottom and was covered with a flat sheet and blanket lying on their back. A code blue was called on another unit at approximately 3:30 PM. CNA #1 went to check the resident at approximately 3:50 PM and saw a shoe, black pants, a leg over resident's legs moving and thought it was another resident. CNA #1 stated when they were about 6-7 feet away, they could see that it was not a resident. CNA #1 saw someone's butt crack, their pants were undone, the resident was on their side, and the side of the resident's incontinence brief was twisted. CNA #1 said they screamed Jesus wept. The guy that was in the bed turned their face around and they saw it was RA #1. CNA #1 said they could see RA #1's leg over the resident's leg moving back and forth but did not see RA #1's penis. RA #1's right leg was over Resident's leg and the blanket and sheet were down at the foot of the bed. RA #1's pants were undone. CNA #1 stated they knew they should have stayed with the resident and should have put the call light on. CNA #1 reported that they told CNA#2 and CNA#3 what they saw because they could not locate LPN #1, who was responding to the code blue. CNA #1 informed LPN #1 and they observed the resident lying on their side and was covered. LPN #1 checked the resident's brief and directed them to report the incident to RNS #1. During an interview with CNA #2 on 11/2/2022 at 8:43 AM they stated that on 10/30/2022 they worked 7:00 AM-11:00 PM. CNA #2 stated that CNA #1 informed them they saw RA #1 having sex with Resident #1. CNA #2 stated they went to check the resident and did not see RA #1 in the room. CNA #2 left the residents room to find LPN #1. During an interview with Registered Nurse Supervisor (RNS) #1 on 11/2/2022 at 11:43 AM RNS#1 stated that on 10/30/2022 a 3:45 PM there was an emergency stat code. The LPNs responded to the stat until about 4:15 PM. RNS #1 stated that CNA#1 described that they saw RA#1 having sexual intercourse with Resident#1. RNS #1 asked CNA #1 for a statement and asked the whereabouts of RA #1. RNS #1 called the ADON then called the police and reported a possible sexual assault involving a staff and a resident. RNS #1 immediately activated a page to locate RA #1. LPN #1 informed RNS #1 that they checked the resident, and their incontinence brief was closed and there was no evidence of any trauma or bleeding and the incontinence brief was dry. RNS #1 stated they could not really assess the incontinent brief because they did not want to touch the resident. RNS #1 stated the resident appeared to have no signs and symptoms of pain or discomfort. Police officers (PO) arrived but they could not locate RA #1. When RA #1 walked back into the building at approximately 6:00 PM, the police arrested RA. RNS #1 stated CNA #1 should not have left Resident #1's room with RA #1 still in there. RNS #1 stated it is not the protocol to leave the resident alone with the perpetrator in the room. During an interview with LPN #1 on 11/2/2022 at 12:41 PM stated on 10/30/20 that they worked between 7AM to 7:40 PM. LPN #1 responded to a code blue on another unit around 3:00 PM. CNA #1 told LPN #1 that they saw RA #1 was in bed with the resident. CNA #1 stated they did not know the whereabouts of RA#1. LPN #1 went to resident's room with LPN #2, CNA #1, and CNA #3. LPN #1 saw the resident was lying on their left side and was covered with their blanket. LPN #1 looked inside the residents incontinent brief and did not go any further because they did not want to disturb any possible evidence. The resident was awake and did not show signs and symptoms of discomfort. LPN #1 paged RNS #1 and told another CNA #1 to make sure no one comes on the unit, and to look out for RA #1. LPN #1 and CNA #1 went to RNS #1's office and CNA #1 reported the incident to RNS #1. RNS #1 came to the unit to assess the resident. LPN #1 stated they did not have in-service on finding someone in bed with someone and this was a different situation. During an interview with the Director of Recreation (DOR) on 11/2/2022 at 1:09 PM they stated that RA #1 worked on 10/30/2022 from 9:30 AM to 3:30 PM. RA #1 and was not assigned to do any 1:1 activity to Resident #1 or any resident. RA #1 goes on break from 5-5:30 PM to cover the break of the security guard or receptionist. RA #1 was assigned to help units A and B in the dining rooms to keep resident's safe. DOR was made aware of the incident at 6PM on 10/30/2022. DOR was informed that RA #1 was involved in a sexual assault and was arrested by the Police and was terminated. During an interview with the DON on 11/2/2022 at 3:14 PM they stated that ADON told them that CNA #1 witnessed RA #1 in the resident's room lying in the bed with resident#1 with their pants down. DON instructed ADON to call 911. DON stated that when they arrived at the facility at 5:25 PM the police were already present. ADON and Maintenance Director reviewed the video footage. DON stated RA #1 entered resident's room after an immediate emergency situation call was announced. The DON stated that the CNA #1 told them they left the room to look for LPN #1. The ADON informed them that they saw RA #1 at the reception desk. The DON conducted an interview with RA #1 who stated, I was sitting, and I know it looks bad, I positioned the resident. I sat on resident's bed, and I was on my phone and sent a text that is all. The DON stated, they asked the RA #1 if it was necessary to sit on resident's bed and text and RA #1 stated I know it looks bad. The DON stated RA #1 was profusely and profoundly sweating. The Suffolk County Police Detective arrived and took RA #1 custody after RA #1 wrote their statement. DON stated the staff are expected to stay with the resident if they witness an abuse. The staff can always pull a call bell, or emergency bell in the restroom. DON stated the video surveillance appears RA #1 went into the room at 3:48 PM and CNA #1 went in at 3:50 PM. Then someone left the room at 3:52 PM. DON stated they did not know who left the room. The resident was sent to the hospital for rape kit and the facility did not have result of rape kit. The facility changed the secure door code and terminated RA #1 on 10/30/2022 and called to Criminal History Record Check (CHRC). Resident #1 was assessed for psychological service. An updated intervention was initiated have a male staff member provide them care. DON found out later after viewing the video surveillance that RA #1 interacted with another resident (Resident #2) by assisting them to the elevator. RA #1 came back to the facility and was relieving a security guard when they were told RA #1 had left and thought the danger is gone. During an interview with ADON on 11/2/2022 at 7:24 PM they stated that on 10/30/2022 they were called by RNS #1 at approximately 4:30 PM. The ADON stated that CNA #1 walked into Resident #1's room and observed RA #1 their pants down behind the resident. ADON was in the building at 5:12 PM and the RNS #1 called the police around 5:15 PM. The ADON stated that the DON arrived at the facility by 5:20 PM-5:25 PM. The ADON stated when they came out from RNS office, they saw RA #1 behind the reception desk. ADON stated the staff should have stayed in the resident's room and protected the resident. The ADON reviewed the video surveillance with maintenance, and it showed RA #1 walking around the facility and had contact with another resident. The ADON stated that the staff should have known RA #1's whereabouts and place RA #1 in a contained room with supervision. CNA #1 could use the call bell in the room and the emergency call bell in the bathroom. In a reasonable person standard, ADON stated that they would feel violated if they were the resident, especially since the resident could not express themselves. The family was notified and was weepy on the phone. During an interview with the Administrator (Adm) on 11/2/2022 at 8:57 PM they stated that they were notified that RA #1 was found by CNA #1 lying in bed with Resident #1 and that the RA #1's legs were over Resident #1's legs. The Adm stated that CNA #1 stated they saw RA #1's feet and legs in motion like having sex with the resident. Adm said they went to Maintenance and viewed the cameras. They said they arrived in the building around 6:40 PM and RA #1 was already taken into police custody. Adm stated that CNA #1 should have never left Resident #1's room. The Administrator stated the staff need education on how to deal with situation such as resident's abuse. The Administrator stated that the RA #1 should have been contained in one area until the police arrived. The family was very upset and distraught. The facility concluded that the situation could have been handled differently like staying with the resident. 10NYCRR 415.4(b)(1)(i)