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Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: December 26, 2023
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interviews during an Abbreviated Survey (Complaint # NY 617), the facility failed to ensure that two allegations of sexual abuse were investigated. This was evident for two (Resident #1 and Resident #2) of three residents reviewed for sexual abuse. Specifically, Resident #1 reported on 12/2/2023 to Certified Occupational Therapist Assistant #1 that Certified Nursing Assistant #1 asked the resident to remove their clothes and play a game. Resident #2 reported to Social Worker #1 on 12/07/2023 that Certified Nursing Assistant #1 touched their thigh while resident was in their bed and asked to take them to dinner which scared and upset the resident. This resulted in Immediate Jeopardy for Resident #1 and Resident #2 and a potential to affect 104 other facility residents. The findings are: The facility's undated policy titled. Abuse Prevention documented under the Reporting portion of the policy and reads in part: Reporting- All employees are required to immediately report any information which leads them to believe abuse has occurred. Reports can be made to chain of command: to the nurse, a supervisor, department head, Social Services, Nursing Administration, Administration, or to the New York State Department of Health. The policy did not address the reporting timeframe and the requirement to inform the local law enforcement of any allegations of abuse. 1) Resident #1 was admitted with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented a Brief Interview for Mental Status score of 6 indicating severe cognitive impairment. A grievance report dated 12/07/2023 documented that on 12/2/2023 that Resident #1's family reported to Social Worker #2 that Resident #1 told them that someone molested (to make unwanted or improper sexual advances towards someone) Resident #1 the night of 12/1/ 2023. There was no documented evidence that the facility investigated the reported sexual abuse. During an interview on 12/20/2023 at 11:41 A.M., Certified Occupational Therapist Assistant #1 stated?Resident #1 told them on 12/02/2023 that Certified Nursing Assistant #1 asked Resident #1 to remove their clothes to play a game and inappropriately touched them the day before. Certified Occupational Therapist Assistant #1 stated they reported the allegations to a nursing staff member (could not recall the name). Certified Occupational Therapist Assistant #1 stated they did not document the allegations in the residents' records. During an interview on 12/21/2023 at 11:07 AM with Resident #1,?they stated that a male staff member was in their room and told them to take off their clothes so they could play a game. Resident #1 was crying during the interview.? Resident #1 stated they did not recall the name of the staff member. The resident was unable to give any further description of the alleged perpetrator or further account of their encounter with the alleged perpetrator. During an interview with Social Worker #2 on 12/21/2023 at 1:01 PM, they stated someone (did not recall the name and date) from the rehabilitation department told them that Resident #1 reported that a Certified Nursing Assistant (did not give a specific name) told Resident #1 to take off their clothes and do a dance. Social Worker #2 stated they interviewed Resident #1 on 12/07/2023 with Resident #1's family present. Social Worker #2 stated that Resident #1 was confused at the time of the interview and did not have a recollection of the alleged abuse. Social Worker #2 stated Resident #1's family told them that Resident #1 identified Certified Nursing Assistant #1 as the individual who had the alleged encounter with Resident # 1. Social Worker #2 stated they reported the sexual abuse allegation to Social Worker # 1. During an interview with Social Worker #1 on 12/22/2023 at 12:13 PM they stated they became aware of an allegation of sexual abuse made by Resident #1 involving Certified Nursing Assistant #1 on 12/07/ 2023. Social Worker #1 was made aware of the allegation by Social Worker # 2. Social Worker #1 stated they interviewed Resident #1 about the sexual abuse allegation but Resident #1 was confused and was not able to disclose any information about the alleged abuse. Social Worker #1 stated they were unsuccessful at getting any information from Resident #1 hence they did not do anything further. Social Worker #1 stated they were in-serviced on abuse in the past. Social Worker #1 stated they documented on the grievance report and informed the Director of Nursing on 12/8/ 2023. During an interview on 12/21/2023 at 11:05 AM, Registered Nurse #1 stated that they became aware that an allegation was made by Resident #1 that Certified Nursing Assistant #1 told Resident #1 to take off their clothes to do a dance. Registered Nurse #1 stated they could not recall the date they became aware or how they became aware. Registered Nurse #1 stated they did not assess Resident #1 after being informed of the allegation because they did not think it was necessary. Registered Nurse #1 stated they did not document the allegation in the resident's medical record or the nurses' daily report. Registered Nurse #1 stated they did not report the allegation to anyone because they were aware the allegation was being investigated by the social worker. During an interview on 12/22/2023 at 10:03 AM, Registered Nurse #2 stated that Social Worker #2 told them on 12/6/2023 of an allegation of sexual abuse. Registered Nurse #2 stated that Certified Nursing Assistant #1 asked Resident #1 to take off their gown and dance. Registered Nurse #2 stated they did not do an assessment on Resident#1 after they were made aware of the allegation. Registered Nurse #2 stated they believed that Social Worker #1 initiated an investigation related to the sexual abuse allegation. Registered Nurse #2 stated they notified the Director of Nursing of the alleged abuse?via an e-mail on 12/06/ 2023. ? During an interview with the Director of Nursing on 12/22/2023 at 11:02 AM they stated they received an e-mail on 12/06/2023 from Registered Nurse #2 informing them that Certified Nursing Assistant #1 should no longer be assigned to Resident # 1. The Director of Nursing stated the e-mail from Registered Nurse #2 did not allege abuse and that the e-mail only documented removing Certified Nursing Assistant #1 from Resident #1's assignment. The Director of Nursing further stated on 12/08/2023 that they were informed of a grievance report regarding an allegation of sexual abuse made by Resident #1 involving Certified Nursing Assistant # 1. The Director of Nursing stated they did not do an investigation because they were out sick and thought that the incident was already investigation. During an interview on 12/22/2023 at 11:36 AM with the Administrator, they stated they were aware of a grievance report alleging sexual abuse reported by Resident #1 involving Certified Nursing Assistant # 1. The Administrator did not recall the date they became aware of the allegation. The Administrator stated that an investigation was not initiated because they believed it was sexual abuse discrimination against Certified Nursing Assistant # 1. The Administrator further stated that Certified Nursing Assistant #1 was not suspended and continued to perform their regular duties. The Administrator stated that Certified Nursing Assistant #1 was removed from Resident #1's assignment. During an interview on 12/22/2023 at 3:36 PM Certified Nursing Assistant #1 stated they were interviewed about the allegation made by Resident #1, however, they did not recall who interviewed them or the date of the interview. Certified Nursing Assistant #1 stated they were told they could not care for Resident # 1. Certified Nursing Assistant #1 stated they were not suspended or re-educated on abuse and denied the allegation. 2) Resident #2 was admitted with [DIAGNOSES REDACTED]. The Quarterl | Plan of Correction: ApprovedJanuary 19, 2024 F- 610 Investigate/Prevent/Correct Alleged Violation I. The following actions were accomplished for the residents identified in the sample: Resident #1 An incident report was initiated by the DON on 12/22/2023 and an investigation was completed on 1/5/24 regarding the abuse allegation reported by a family member. The Administrator reported the allegation of abuse to the NYSDOH, local police and the Attorney General's Office on 12/22/ 2023. An incident report was initiated on 12/26/2023 based on additional information provided by the resident regarding sexual misconduct. The facility reported this new allegation of abuse to the NYSDOH, local police and Attorney General's Office on 12/26/2023 related to additional information provided by the resident. On 12/27/2023 the Administrator/designee counseled and reeducated Certified Occupational Therapist Assistant #1, who initially was informed by Resident #1 of the alleged abuse, on her responsibilities related to abuse prevention and reporting any allegation of abuse that she has knowledge of promptly and if action not taken to report to another administrative staff member. Resident #2 An incident report was initiated on 12/22/2023 by the DON and an investigation was completed on 01/05/2024 regarding the allegation. The DON reported the allegation of abuse to NYSDOH, local police and the Attorney General's Office on 12/22/ 2023. Resident #1 & Resident #2 CNA #1 was suspended on 12/22/2023 and remains off duty. On 12/27/2023, the Administrator/designee counseled and reeducated Social Workers #1 & #2 regarding the facilitys Abuse Prevention, Reporting and Investigation protocols to follow when an allegation of abuse is made so that protecting the resident, reporting per mandated timeframes, timely investigating and other necessary actions can be implemented. This reeducation for Social Worker #1 reinforced their responsibility to follow-up with the Administrator if a report to the DNS is not promptly acted on as well as reinforcing timely reporting so that required notifications can be made to the NYSDOH and local law enforcement. On 01/04/2024, Registered Nurse #1, Registered Nurse #2 & RN Supervisor #2 were counseled and reeducated by the Acting DON regarding the facilitys Abuse Prevention, Reporting and Investigating protocols, including protocols for promptly reporting all abuse allegations to Administration for prompt follow-up reporting and investigating. This reeducation reinforced the RNs responsibility to assess the resident following an abuse allegation and documenting such an assessment in the medical record as well as protecting a resident who voiced an allegation of abuse by removing the identified staff member from duty until an investigation is completed. The Administrator provided counselling and reeducation to the Director of Nursing, who was in the DON position when the allegations of abuse were made, regarding the importance of timely reporting all alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and reporting abuse allegation to the proper authorities, including law enforcement and the NYSDOH, within prescribed timeframes and responsibility for conducting a comprehensive investigation so that needed corrective actions can be implemented. On 01/03/2024 the Administrator identified the ADON/MDS Coordinator as the Acting Director of Nursing, and the prior Director was assigned other duties. On 12/22/2023 the facilitys Abuse Prevention Policy was reviewed and revised to include information regarding the 2-hr. timeframe for reporting an allegation of abuse and notifying local law enforcement of any allegation of abuse. Education was initiated by the inservice coordinator with all staff related to abuse prevention, investigation and reporting on 12/22/2023 and approximately 95% compliance was met as of 12/30/ 23. An outside consultant was hired to provide assistance and was onsite on 01/02/2024 01/03/2024 & 01/04/ 2024. The Abuse Prevention, Investigation and Reporting Policy was reviewed and revised again on 01/03/2024 with the assistance of the outside consultant to comply with NYS and Federal Regulations. The lesson plan for abuse prevention/reporting and investigations was revised on 01/02/2024 and the consultant provided additional staff education starting 01/02/ 2024. As of 01/03/2024 approximately 50% compliance was reached. An educational session was recorded for ongoing use by the facility. Education will continue until compliance is met for all staff. A post-test was developed to validate staff knowledge of the content of the material. A lesson plan was developed by the outside consultant for abuse investigation and reporting with content directed to administrative staff who have responsibility for investigation and reporting of resident incident/accidents. An education session was conducted by the outside consultant with Administrative and Nursing Supervisory staff on 01/02/ 2024. On 01/03/24, the outside consultant met with the Administrator to review their responsibilities for oversight of the facilitys Abuse Prevention, Reporting and Investigation protocols, including reporting to the NYSDOH and local law enforcement per mandated timeframes. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practices. Between 01/03/2024 and 01/19/2024 all occurrence reports related to allegations of abuse, neglect, exploitation, or mistreatment from 09/01/2023 to present were reviewed by the Administrator and Acting Director of Nursing to determine if investigations were thoroughly completed, that a resident was protected during the investigation and that incidents that met NYSDOH reporting requirements were reported. No additional findings were noted; no additional reporting to the NYSDOH was necessary. The facilitys QAPI Committee and Outside Consultant participated in a Direct Plan QAPI meeting on 01/18/2024, to discuss the deficiency findings identified at F-610 and conducted a Root Cause Analysis. Based on the Root Cause Analysis that was part of the DP(NAME) QAPI meeting on 01/18/2024, the following issues were identified that required corrective actions: The facilitys policy on Abuse would benefit from additional review. The facility policy on Incident Reporting would benefit from review. The facility policy on Investigations would benefit from review. All HCPs would benefit from additional education related to incident/accident reporting and investigations inclusive of the steps to follow to communicate and respond to changes in a residents condition/behavior. Please refer to corrective actions outlined in Sections II, III and IV of this DP(NAME). Effective 01/22/2024 education will be provided by the Outside Consultant to all facility staff on investigating all allegations of abuse, neglect and mistreatment, preventing further abuse neglect and mistreatment during the investigation and reporting the results of all investigations as per established protocols to the administrator and to other officials in accordance with Federal and State law. Education will include the importance of caregiver responsibilities related to prompt reporting of resident events including unusual behaviors so that follow-up can be completed for an event that may be indicative of abuse, neglect or mistreatment is promptly investigated including follow-up completed related to a change in condition. This education will continue to be provided until all facility and agency staff receive this mandatory education. III. The following system changes will be implemented to assure continuing compliance with regulations: On 01/22/2024, the outside consultant along with the Administrator and Acting Director of Nursing will conduct an additional review and revision of the policies and procedures related to Abuse Prevention Investigation and Reporting to ensure |
Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: December 26, 2023
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and resident interviews during an Abbreviated Survey (Complaint # NY 617), the facility failed to ensure that two allegations of sexual abuse were reported to the Department of Health and Local Law Enforcement within two hours. This was evident for two (Resident #1 and Resident #2) of three residents reviewed for sexual abuse. Specifically, Resident #1 reported on 12/2/2023 to Certified Occupational Therapist Assistant #1 that Certified Nursing Assistant #1 asked the resident to remove their clothes and play a game. Resident #2 reported to Social Worker #1 on 12/07/2023 that Certified Nursing Assistant #1 touched their thigh while resident was in their bed and asked to take them to dinner which scared and upset the resident. This resulted in Immediate Jeopardy for Resident #1 and Resident #2 and a potential to affect 104 other facility residents. The findings are: The facility's undated policy titled. Abuse Prevention documented under the Reporting portion of the policy and reads in part: Reporting- All employees are required to immediately report any information which leads them to believe abuse has occurred. Reports can be made to chain of command: to the nurse, a supervisor, department head, Social Services, Nursing Administration, Administration, or to the New York State Department of Health. The policy did not address the reporting timeframe and the requirement to inform the local law enforcement of any allegations of abuse. 1) Resident #1 was admitted with [DIAGNOSES REDACTED].The Minimum (MDS) data set [DATE] documented a Brief Interview for Mental Status score of 6 indicating severe cognitive impairment. A grievance report dated 12/07/2023 documented that on 12/2/2023 Resident #1's family reported to Social Worker #2 that Resident #1 told them that someone molested (to make unwanted or improper sexual advances towards someone) Resident #1 the night of 12/1/ 2023. There was no documented evidence that the facility reported the alleged abuse to the Local Law Enforcement or the New York State Department of Health. During an interview on 12/20/2023 at 11:41 A.M.,Certified Occupational Therapist Assistant #1 stated?Resident #1 told them on 12/02/2023 that Certified Nursing Assistant #1 asked Resident #1 to remove their clothes to play a game and inappropiately touched them the day before. Certified Occupational Therapist Assistant #1 stated they reported the allegations to a nursing staff member (could not recall the name). Certified Occupational Therapist Assistant #1 stated they did not document the allegations in the residents' records. During an interview on 12/21/2023 at 11:07 AM with Resident #1,they stated that a male staff member was in their room and told them to take off their clothes so they could play a game. Resident #1 was crying during the interview. Resident #1 stated they did not recall the name of the staff member. The resident was unable to give any further description of the alleged perpetrator or further account of their encounter with the alleged perpetrator. During an interview with Social Worker #2 on 12/21/2023 at 1:01 PM, they stated someone (did not recall the name and date) from the rehabilitation department told them that Resident #1 reported that a Certified Nursing Assistant (did not give a specific name) told Resident #1 to take off their clothes and do a dance. Social Worker #2 stated they interviewed Resident #1 on 12/07/2023 with Resident #1's family present. Social Worker #2 stated that Resident #1 was confused at the time of the interview and did not have a recollection of the alleged abuse. Social Worker #2 stated Resident #1's family told them that Resident #1 identified Certified Nursing Assistant #1 as the individual who had the alleged encounter with Resident # 1. Social Worker #2 stated they reported the sexual abuse allegation to Social Worker # 1. During an interview with Social Worker #1 on 12/22/2023 at 12:13 PM they stated they became aware of an allegation of sexual abuse made by Resident #1 involving Certified Nursing Assistant #1 on 12/07/ 2023. Social Worker #1 was made aware of the allegation by Social Worker # 2. Social Worker #1 stated they interviewed Resident #1 about the sexual abuse allegation but Resident #1 was confused and was not able to disclose any information about the alleged abuse. Social Worker #1 stated they were unsuccessful at getting any information from Resident #1 hence they did not do anything further. Social Worker #1 stated they were in-serviced on abuse in the past. Social Worker #1 stated they documented on the grievance report and informed the Director of Nursing on 12/8/ 2023. During an interview on 12/21/2023 at 11:05 AM, Registered Nurse #1 stated they became aware an allegation was made by Resident #1 against Certified Nurse Assistant #1, where in Certified Nursing Assistant #1 told Resident #1 to take off their clothes to do a dance. Registered Nurse #1 stated they could not recall the date they became aware or how they became aware. Registered Nurse #1 stated they did not assess Resident #1 after being informed of the allegation because they did not think it was necessary. Registered Nurse #1 stated they did not document the allegation in the resident's medical record or the nurses' daily report. Registered Nurse #1 stated they did not report the allegation to anyone because they were aware the allegation was being investigated by the social worker. During an interview on 12/22/2023 at 10:03 AM, Registered Nurse #2 stated that Social Worker #2 told them on 12/6/2023 of an allegation of sexual abuse. Registered Nurse #2 stated that Certified Nursing Assistant #1 asked Resident #1 to take off their gown and dance. Registered Nurse #2 stated they did not do an assessment on Resident#1 after they were made aware of the allegation. Registered Nurse #2 stated they believed that Social Worker #1 initiated an investigation related to the sexual abuse allegation. Registered Nurse #2 stated they notified the Director of Nursing of the alleged abuse via an e-mail on 12/06/ 2023. During an interview with the Director of Nursing on 12/22/2023 at 11:02 AM they stated they received an e-mail on 12/06/2023 from Registered Nurse #2 informing them that Certified Nursing Assistant #1 should no longer be assigned to Resident # 1. The Director of Nursing stated the e-mail from Registered Nurse #2 did not allege abuse and that the e-mail only documented removing Certified Nursing Assistant #1 from Resident #1's assignment. The Director of Nursing further stated on 12/08/2023 they were informed of a grievance report regarding an allegation of sexual abuse made by Resident #1 involving Certified Nursing Assistant # 1. The Director of Nursing stated they did not report the sexual abuse allegations to Local Law Enforcement or the New York State Department of Health because they were out sick and thought that the incident was already reported. During an interview on 12/22/2023 at 11:36 AM with the Administrator, they stated they were aware of a grievance report alleging sexual abuse reported by Resident #1 involving Certified Nursing Assistant # 1. The Administrator did not recall the date they became aware of the allegation. The Administrator stated they did not report the allegation to the Local Law Enforcement or the Attorney General because they believed it was sexual abuse discrimination against Certified Nursing Assistant # 1. The Administrator further stated that Certified Nursing Assistant #1 was not suspended and continued to perform their regular duties. The Administrator stated that Certified Nursing Assistant #1 was removed from Resident #1's assignment. During an interview on 12/22/2023 at 3:36 PM Certified Nursing Assistant #1 stated they were interviewed about the allegation made by Resident #1, however, they did not recall who interviewed them or the date of the interview. Certified Nursing Assistant #1 stated they were told they could not care for Resident # 1. Ce | Plan of Correction: ApprovedJanuary 19, 2024 F- 609 I. The following actions were accomplished for the residents identified in the sample: Resident #1 An incident report was initiated by the DON on 12/22/2023 and an investigation was completed on 1/5/24 regarding the allegation. The DON reported the allegation of abuse to the NYSDOH, local police and the Attorney General's Office on 12/22/ 2023. A full body check was conducted on 12/22/2023 by the unit nurse. No visible injuries were identified. A CCP related to the resident being at At Risk for Abuse was initiated on 12/22/2023 by the IDCP Team. The IDCP Team rereviewed the ?ôAt Risk for Abuse?Ø care plan on 12/26/2023 and the interventions were revised. Resident was placed on 1 : 1 monitoring on 12/24/ and the intervention remains active as of 1/3/ 24. The need for ongoing 1:1 was reviewed at the CCP meeting and maintained until discharge home on 01/09/ 2024. A psychiatric consultation was conducted on 12/26/ 2023. No medication changes were recommended by the psychiatrist. A psychology consult was conducted on 12/26/ 2023. There were no findings of emotional distress documented in the psychology consult. An incident report was initiated on 12/26/2023 based on additional information provided by the resident regarding sexual misconduct. The facility reported this new allegation of abuse to the NYSDOH, local police and Attorney General's Office on 12/26/2023 related to additional information provided by the resident. Ongoing monitoring of resident's general mood, behaviors with focus on any changes in customary routine are documented when observed. Resident continues to be visited on a frequent basis by his Social Worker who is providing emotional support. The IDCP Team is encouraging the family to continue daily visitation. On 12/27/2023 the Administrator/designee counseled and reeducated Certified Occupational Therapist Assistant #1, who initially was informed by Resident #1 of the alleged abuse, on her responsibilities related to abuse prevention and reporting any allegation of abuse that she has knowledge of promptly and if action not taken to report to another administrative staff member. Resident #2 An incident report was initiated on 12/22/2023 by the DON and an investigation was completed on 1/5/24 regarding the allegation. The DON reported the allegation of abuse to NYSDOH, local police and the Attorney General's Office on 12/22/ 2023. A full body check was attempted on 12/22/2023 by the RN but was declined. A CCP related to the resident being at At Risk for Abuse and trauma was initiated on 12/22/2023 by the IDCP Team. The IDCP Team rereviewed the ?ôAt Risk for Abuse?Ø care plan on 12/22/2023 and the interventions were revised on12/26/ 2023. Resident was placed on 1:1 monitoring on 12/24/ 2023. The intervention was discontinued on 12/27/2023 per resident request. A psychiatric consult was conducted on 12/26/ 2023. There were no recommendations for medication. Psychotherapy sessions were recommended to continue and are active. Ongoing monitoring of the resident's general mood, behaviors with a focus on any changes in customary routine documented when observed. Resident continues to be visited on a frequent basis by her Social Worker who is providing emotional support. Resident #1 & Resident #2 CNA #1 was suspended on 12/22/2023 and remains off duty. If a decision is made for the CNA to return to work, he will be counseled and reeducated on the facilitys Abuse Prevention protocol prior to returning to duty. On 12/27/2023 the Administrator/designee counseled and reeducated Social Workers #1 & #2 regarding the facilitys Abuse Prevention, Reporting and Investigation protocols to follow when an allegation of abuse is made so that protecting the resident, reporting per mandated timeframes, timely investigating and other necessary actions can be implemented. This reeducation for Social Worker #1 reinforced their responsibility to follow-up with the Administrator if a report to the DNS is not promptly acted on as well as reinforcing timely reporting so that required notifications can be made to the NYSDOH and local law enforcement. On 12/27/2023, Registered Nurse #1, Registered Nurse #2 & Nursing Supervision #2 were counseled and reeducated by the Administrator/designee regarding the facilitys Abuse Prevention, Reporting and Investigating protocols, including protocols for promptly reporting all abuse allegations to Administration for prompt follow-up reporting and investigating. This reeducation reinforced the RNs responsibility to assess the resident following an abuse allegation and documenting such an assessment in the medical record as well as protecting a resident who voiced an allegation of abuse by removing the identified staff member from duty until an investigation is completed. Licensed nurses completed full house body checks on 12/26/ 2023. No physical findings were identified and there were no verbal allegations of abuse by any additional residents. ?ôAt Risk for Abuse?Ø care plans were initiated for all residents on 12/26/ 2023. The Administrator provided counselling and reeducation to the Director of Nursing, who was in the DON position when the allegations of abuse were made, regarding the importance of reporting all alleged violations related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source and misappropriation of resident property and reporting abuse allegation to the proper authorities, including law enforcement and the NYSDOH, within prescribed timeframes. On 01/03/2024 the Administrator identified the ADON/MDS Coordinator as the Acting Director of Nursing, and the prior Director was assigned other duties. On 12/22/2023 the facilitys Abuse Prevention Policy was reviewed and revised to include information regarding the 2-hr. timeframe for reporting an allegation of abuse and notifying local law enforcement of any allegation of abuse. Education was initiated by the inservice coordinator with all staff related to abuse prevention, investigation and reporting on 12/22/2023 and approximately 95% compliance was met as of 12/30/ 2023. An outside consultant was hired to provide assistance and was onsite on 01/02/2024 and 01/03/ 2024. The Abuse Prevention, Investigation and Reporting Policy was reviewed and revised again on 01/03/2024 with the assistance of the outside consultant to include compliance with all state and federal regulations. The lesson plan for abuse prevention/reporting and investigations was revised on 01/02/2024 and the consultant provided additional staff education starting 01/02/ 2024. As of 01/03/2024 approximately 50% compliance was reached. An educational session was recorded for ongoing use by the facility. Education will continue until compliance is met for all staff. A post-test was developed to validate staff knowledge of the content of the material. A lesson plan was developed by the outside consultant for abuse investigation and reporting with content directed to administrative staff who have responsibility for investigation and reporting of resident incident/accidents. An education session was conducted by the outside consultant with Administrative and Nursing Supervisory staff on 01/02/ 2024. On 01/02/2024, the outside consultant met with the Administrator to review their responsibilities for oversight of the facilitys Abuse Prevention, Reporting and Investigation protocols, including reporting to the NYSDOH and local law enforcement per mandated timeframes. II. The following corrective actions will be implemented to identify other residents who may be affected by the same practice: All residents have been identified as potentially being affected by the same practices. All occurrences or accident/incident reports related to allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property from 09/01/2023 to present were reviewed by the Administrator and/or Acting Director of Nursing to determine if the 2-hr. reporting requirement was met. No additional occurrences related to reporting of allegat |