Central Queens Rehabilitation & Nursing Center
February 12, 2025 Complaint Survey

Standard Health Citations

FF15 483.12(b)(5)(i)(A)(B)(c)(1)(4):REPORTING OF ALLEGED VIOLATIONS

REGULATION: 483. 12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: 483. 12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. 483. 12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 12, 2025
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews during an abbreviated survey (NY 419 and NY 391), the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, and mistreatment, are reported immediately, but not later than 2 hours after the allegation is made to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities). This was evident in three (3) out of five (5) residents sampled (Residents #1, Resident #2 and Resident #3). Specifically, on 04/11/2024 at 12:50 PM, Registered Nurse #1 documented while monitoring residents at the start of their shift 7:00 AM to 3:00 PM, Resident #1 complained of pain in their private area and stated they think someone might have touched their private area because it hurts. Resident #1 was transferred to the hospital for further evaluation. The facility reported the incident to the New York State Department of Health on 04/16/2024 at 4:17 PM. On 05/15/2024 at 5:45 PM, Resident #2 was sitting in the dining room when Resident #3 suddenly hit Resident #2 on their head with a soda can. Resident #2 was transferred to the hospital for further evaluation. The facility reported the incident to the New York State Department of Health on 05/16/2024 at 3:01 PM. The findings are: The facility's Policy and Procedure titled Abuse, Mistreatment, Neglect, Misappropriation of Resident 's Property, revised 01/ 2025. Number 6: Reporting and Response (pg.17) documented it is the facility's policy to report abuse allegations per Federal and State Law. The policy documented the facility will ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool), dated 03/22/2024, documented Resident #1 had a Brief Interview of Mental Status (used to determine attention, orientation, and ability to recall information) score of 14 associated with intact cognition. An Incident/Accident Report dated 04/10/2024, documented Resident #1 reported their private area was hurting because they think the nurse on the 11:00 PM-7:00 AM shift touched their private area. The facility's investigation dated 04/16/2024, concluded there was no credible evidence to suggest that abuse occurred. Resident #1 has history of confabulation and manipulation. Resident #1 initially denied seeing someone enter their room and touching them. The 11:00 PM- 7:00 AM shift reported that Resident #1 was observed sleeping throughout the shift. Resident #1 was transferred to the hospital and was evaluated for alleged sexual abuse and treated [MEDICATION NAME]. Resident #1 is no longer residing at the facility, several attempts made to interview Resident #1 was unsuccessful. During a telephone interview on 02/11/2025 at 1:15 PM, Assistant Director of Nursing stated any allegation of abuse should be reported within two hours to the New York State Department of Health. They stated they did not report the incident because Resident #1 denied the allegation when they were re-interviewed. Assistant Director of Nursing stated they reported the incident to the New York State Department of Health five days later because they wanted to complete their investigation and have concrete details before reporting the allegation. During a telephone interview on 02/12/2025 at 9:05 AM, the Administrator stated on 04/11/2024 at 9:30 AM, during morning meeting, Resident #1's concern was discussed, and an investigation was started, and Resident #1 was transferred to the hospital for further evaluation. Administrator stated abuse allegation are supposed to be reported to the New York State Department of Health within 2 (two) hours, however, this incident was not reported because Resident #1 recanted their statement, and the facility staff wanted to have concrete details before reporting the incident to the New York State Department of Health. Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated [DATE], documented Resident #2 had a Brief Interview of Mental Status score of 14 associated with intact cognition. Resident #3 was admitted to the facility with [DIAGNOSES REDACTED]. The Minimum Data Set, dated dated [DATE], documented Resident #3 had a Brief Interview of Mental Status score of 7 associated with severely impaired cognition. An Incident/Accident Report dated 05/15/2024 at 5:45 PM, documented Resident #3 approached Resident #2 in the dining room hit Resident #2's head with a soda can. Staff were present in the dining room and were unable to prevent the occurrence. The facility's investigation dated 05/20/2024, concluded the altercation was unavoidable and unpredictable. Staff responded appropriately and separated the residents. Resident #2 and Resident #3 were transferred to the hospital for further evaluation. Resident #2 no longer resides at the facility. Resident #3 no longer resides at the facility. During a telephone interview on 02/11/2025 at 2:25 PM, Director of Nursing stated after an incident was discussed with the team, the Assistant Director of Nursing is responsible for reporting the incident to the New York State Department of Health. The Director of Nursing stated any allegation of abuse is supposed to be reported within 2 (two) hours. The Director of Nursing stated the Resident-to-Resident incident was reported on 05/16/24 because Resident #3 was confused and did not have capacity, and they did not assume this incident fell under the category to report within two hours. During a telephone interview on 02/12/2025 at 9:14 AM, the Administrator stated they were informed by the Director of Nursing that Resident #3 hit Resident #2 on their head with a soda can (cannot recall the time or date they were informed). Resident #2 refused assessment, 911 was called and Resident #2 transferred to the hospital. The Administrator stated the incident was reported to the New York State Department of Health the following day because there were no serious bodily injury and Resident #2 refused assessment. 10 NYCRR 415. 4(b)

Plan of Correction: ApprovedMarch 4, 2025

I. IMMEDIATE CORRECTIVE ACTIONS 1. Residents #1, #2, and #3 no longer reside at the facility. 2. The Director of Nursing, Assistant Director of Nursing, and the Administrator were re-educated on: a. Gaps in practice cited by the NYSDOH at F 609. b. The key points in F609 c. The facilitys Abuse, Mistreatment, Neglect, and Misappropriation of Resident Property. d. The requirements for reporting resident incident/accidents timely (F609), e. Identification criteria for reportable accident/incidents as per F 609. f. Appropriate timelines/timeframes for reporting (F609), g. Reporting whether the resident is confused, does not have capacity, or unable/unwilling to verbalize the occurrence h. Having a mental disorder or cognitive impairment does not automatically preclude a resident from engaging in deliberate or non-accidental actions. i. The facilitys accountability and responsibility for reporting alleged abuse, neglect, and mistreatment. j. Review of F609 definition of ?ôalleged violation and ?£serious bodily injury. 3. Attendance sheets and lesson plans are filed for reference and validation. II. IDENTIFICATION OF OTHER RESIDENTS: 1. All Accidents and Incidents occurring during the last 30 days were reviewed to confirm timely initial reporting and submission as required under F 609. 2. No other deficient practices were found. III. MEASURES/SYSTEMATIC CHANGES TAKEN 1. The QAPI Committee will convene to examine the deficiency cited under Fed-F-609 483. 12(c)(1)(4) Reporting of Alleged Violations: 10 NYCRR 415. 4(b) a. Perform an assessment of the possible causative factors that may have contributed to the issues identified in the above deficiency. b. Identify the specific steps/interventions that must be initiated to eliminate and correct the causative factors identified during the assessment phase. c. Identify any routine triggers or parameters the facility will implement for F609 that will signal or alert all staff of an evolving problem or deficient practice situation. d. Indicate how this system will be implemented and sustained by the facility. e. Specify how the facility will measure whether efforts are successful or unsuccessful in maintaining compliance. 2. The QAPI committee reviewed the facilitys Abuse, Mistreatment, Neglect, and Misappropriation of Resident Property. a. No deviation from regulations under F609 or current standards of practice was identified. 3. Nurse Managers/Supervisors and Department Heads will receive re-education on a. The Abuse, Mistreatment, Neglect, and Misappropriation of Resident Property policy and procedure with an emphasis placed on the facilitys responsibility to report the initial accident/incidents that fit the criteria and reporting requirements with F609 in a timely manner. 4. Attendance records and lesson plans will be filed for reference and validation IV. HOW CORRECTIVE ACTION WILL BE MONITORED 1. The QAPI Committee developed an audit tool with measurable goals designed to review Accident and Incidents to determine reportability to the State Survey Agency. 2. The Director of Nursing/designee will utilize the audit tool to monitor and review the timeliness of all reportable resident accident and incidents to the State Survey Agency. 3. Audits will be performed weekly for four weeks, monthly for four months, and quarterly thereafter to sustain 100% compliance with the Abuse, Mistreatment, Neglect, and Misappropriation of Resident Property policy and procedure and F 609. 4. Audits with negative findings will have immediate corrective actions including reporting per F609 and re-education for employees involved. 5. The Director or Nursing/designee will prepare a quarterly audit, summarizing the facilitys accident/incident report findings and corrective plans implemented (if applicable) to the QAPI Committee for needed revisions to the action plan, improvement of our delivery of care services, resident outcomes, and compliance with F 609. 6. The Director of Nursing/designee will review Accident/Incidents daily to ensure the timely submission of all reportable accident/incidents to the State Survey Agency. V.TITLE OF PERSON RESPONSIBLE FOR CORRECTION OF DEFICIENCY: 1. Director of Nursing. 2. (MONTH) 14, 2025.