A Holly Patterson Extended Care Facility
May 23, 2025 Complaint Survey

Standard Health Citations

FF16 483.12(b)(1)-(5)(ii)(iii):DEVELOP/IMPLEMENT ABUSE/NEGLECT POLICIES

REGULATION: §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, §483.12(b)(4) Establish coordination with the QAPI program required under §483.75. §483.12(b)(5) Ensure reporting of crimes occurring in federally-funded long-term care facilities in accordance with section 1150B of the Act. The policies and procedures must include but are not limited to the following elements. §483.12(b)(5)(ii) Posting a conspicuous notice of employee rights, as defined at section 1150B(d)(3) of the Act. §483.12(b)(5)(iii) Prohibiting and preventing retaliation, as defined at section 1150B(d)(1) and (2) of the Act.

Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: May 23, 2025
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview during an abbreviated survey (NY 105), the facility failed to implement Abuse/Neglect policies to prevent, protect and report an incident of physical abuse for one (1) resident (Resident #1) out of three (3) residents reviewed for abuse. Specifically, on 05/04/2025 at 3:59 PM, the facility failed to protect Resident #1 from Certified Nursing Assistant #1 who was observed restraining both hands of Resident #1 and hitting them in the head. This incident was observed by Certified Nursing Assistants #2 and #3 who were in the hallway at the time of the incident and did not identify, correct, intervene or report the occurrence of abuse. Additionally, the incident was reported by a visitor on 05/06/2025 to Unit Liaison #1 who did not report the incident to their supervisor (Unit Liaison #2) until 05/07/2025. This allowed Certified Nursing Assistants #1, #2, and #3 to have continued access to Resident #1 and the other 436 Residents in the facility. Using the reasonable person concept, this resulted in actual psychosocial harm that was Immediate Jeopardy. The findings are: Resident #1 had a medical [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score- 99 indicating severe impairment for decision making. The review of the facility policy entitled, Abuse, with a revision date of 03/2024, documented it is the policy of the facility to ensure that every resident is free from abuse and that their rights, dignity and respect are maintained. The policy further documented all staff are responsible for reporting abuse, intervene immediately to safeguard resident if abuse, neglect, mistreatment or misappropriation of property has been observed. Report incident of actual or alleged abuse, neglect or mistreatment to charge Nurse or Supervisor immediately. Review of the facility video surveillance with the Administrator, Director of Nursing and Risk Manager on 05/19/2025 at 10:28 AM, revealed that on 05/04/2025 at 3:59 PM Resident #1was in the hallway sitting in a wheelchair outside of a resident room. Certified Nursing Assistant #2 is observed standing at the nurse's station and Certified Nursing Assistant #3 was observed in the hallway taking vital signs of another resident. Certified Nursing Assistant #1 was observed pointing their finger in the face of Resident #1. Resident #1 responded by striking the hand of Certified Nursing Assistant #1 twice. Certified Nursing Assistant #1 responded by striking Resident #1 across the head and proceeds to hold both of the resident's hands down towards the wheelchair. Review of the Resident Accident/Incident Report dated 05/07/2025 at 10:30 AM documented that on 05/06/2025 an anonymous visitor reported to Unit Liaison #1 that they witnessed Staff had an inappropriate encounter with Resident #1 on 05/04/2025. The Accident Incident Report further documented Unit Liaison #1 did not report this information to Unit Liaison #2 until the morning of 05/07/2025. The Accident/Incident Report further documented while reviewing the camera, it was observed that Certified Nursing Assistant #1 had inappropriate contact with Resident #1. It was also noted that two (2) additional staff members were in the hallway at the time of the incident looking towards the incident. The facility investigation documented that Certified Nursing Assistants #2 and #3 denied seeing the occurrence. During an interview on 05/19/2025 at 12:53 PM with Unit Liaison #1, they stated they received a call on 05/06/2025 at approximately 5:30PM-6:00PM from an unidentified caller who stated that on Sunday 05/04/2025, when the caller was visiting the facility, they heard screaming and when they came out of the room they were in, they observed staff hitting Resident #1 in the head. Unit Liaison #1 stated on the morning of 05/07/2025, they reported this to Unit Liaison #2. They further stated that they should have notified the supervisor immediately about the incident. Multiple telephone call attempts to reach Certified Nursing Assistant #1 on 05/19/2025 at 1:30 PM and 2:00 PM, as well as on 05/20/2025 between 10:30 AM and 2:00 PM were unsuccessful. Phone call messages were not returned, and a letter was sent, with no response to the letter. Multiple telephone call attempts to reach Certified Nursing Assistant #2 on 05/20/2025 at 2:00 PM and 3:00 PM were unsuccessful. A letter was sent with no response. During an interview with Certified Nursing Assistant #3 on 05/19/2025 at 3:16 PM, they stated that on 05/04/2025 they worked 3:00 PM - 11:00 PM as their regular assignment and they stated Resident #1 was on their assignment. They further stated Resident #1 is not combative and does not hit staff during care. They stated on 05/04/2025 they were taking vital signs for another Resident and did not notice Certified Nursing Assistant #1 hit Resident #1. They stated they heard Resident #1 yelling but did not look to see what was going on. When asked about the video surveillance where they were observed looking in the direction of Resident #1, Certified Nursing Assistant #3 stated they did not recall. During a telephone interview with Licensed Practical Nurse #1 on 05/19/2025 at 1:51 PM, they stated that on 05/04/2025 at approximately 4:00 PM, while at the nurse's station, they heard screaming in the hallway and saw Certified Nurse Aide #1 removing a resident away from Resident #1. Licensed Practical Nurse #1 stated they did not see anyone hitting Resident #1 and this was not reported by any staff in the hallway. Licensed Practical Nurse #1 stated if the staff saw any abuse, such as anyone hitting a resident, they should have informed the Nursing Supervisor immediately. When asked about the video surveillance not showing another resident in the proximity at that time, Licensed Practical Nurse #1 stated they did not see the video and could not recall. During an interview conducted on 05/19/2025 at 3:08 PM with the Director of Nursing, they stated the incident was reported by Unit Liaison #1 on 05/07/2025. The incident should have been reported as soon as the visitor reported what they saw. They stated during the investigation and review of the video surveillance they could see Certified Nursing Assistant #1 strike Resident #1. They further stated during the investigation Certified Nursing Assistant #2 and Certified Nursing Assistant # 3 were seen facing the direction of the incident, however both denied seeing anything, and did not report any incident to the floor nurse or the supervisor. The investigation summary documented abuse did occur to Resident #1. During an interview conducted on 05/19/2025 at 4:30 PM with the Facility Administrator they stated the incident should have been reported immediately. They further stated Certified Nursing Assistant #2 and #3 denied seeing abuse however are observed facing the direction of the incident. The Administrator stated the facility has a zero-tolerance policy for abuse. They further stated the staff should have intervened and protected the resident and reported immediately. 10 NYCRR 415.4(b)(2)

Plan of Correction: ApprovedJune 19, 2025

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident 1 was assessed by a License nurse on 5/7/2025 and showed no signs and symptoms of injury or change of condition and MD assessment was also conducted on 5/7/2025, no sign of any visible injury, no change in behavior and no change in mental status. Care plans were updated to ensure interventions are in place to prevent abuse. Resident was assessed by Social Services on 5/8/2025 and noted with no apparent distress, talking, laughing, and smiling. The CNAs involved were taken off duty immediately. CNA #1 was terminated, CNA#2 and CNA #3 were suspended without pay. Police were called by the Administrator and DON met with the family member to provide information and reassurance/emotional support. Report number was assigned. The Abuse policy was updated, and Abuse posters were updated. Staff were educated by the in-service department about the updated policy and abuse poster and this was completed by 5/23/2025. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken All residents have the potential to be affected by this finding. The QA Committee updated and approved the revision of Abuse and Neglect Policy and Procedure to include ?Ç£See Something, Do Something, Report Immediately?Ç¥. The QA Committee also met on 6/11/2025 to discuss root cause analysis of possible reasons why they deficient practice occurred, and Consultant advised on findings. The Abuse poster was updated and written in different languages and posted throughout the facility, so employees, residents, and visitors are aware of the policy. Anyone who does not follow abuse policy and procedures will face disciplinary action up to and /or including termination. Guardian Angel Department Head unit rounds will be conducted once per week to help prevent identify problems that may lead to potential abuse and report any negative findings during morning report will also be implemented. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur All staff were educated by the in-service department using the revised policy and procedures on Abuse, neglect, exploitation, and Misappropriation of resident property by 5/23/2025. The facility obtained an outside consultant not employed by the facility to help develop an acceptable directed plan of correction and in service by 6/12/2025. Enhanced training on how to handle behavioral situations with residents who have cognitive impairment/Dementia and in-service about Abuse will be provided by the outside consultant 6/18/2025 ?Çô 6/20/2025 and additional zoom trainings will be provided on 7/1/2025 and 7/2/2025 for staff on vacation or leave based on the findings of the QAPI Committee. Anonymous suggestion box for employees and families was also created. Nursing assignment is now rotating every 6 months. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice DON or designee will monitor compliance to the revised policy on ?Ç£Preventing Abuse, neglect, exploitation, and misappropriation of resident property?Ç¥ and the DP(NAME) to ensure staff are properly addressing and promptly reporting abuse or allegations of abuse following facility Policy and Procedures. DON or designee will report progress of this QAPI to the QA Committee until significant compliance is achieved. Nurse Supervisors will continue auditing the residents in all units. Audit tool #1 and #2 will be utilized. It will be done weekly for a period of one month. Then once a month for a period of three months and then quarterly check will be in place until significant compliance is achieved. DON or designee will report findings to the QA committee for monitoring until significant compliance is achieved. Administrator or designee will monitor the anonymous Suggestion Box and address anything placed inside the box. This will continue for a period of one year. Guardian Angel Department Head room rounds will occur once a week to help prevent and identify problems that may lead to potential abuse and report any negative findings during morning report was also implemented. This will be monitored by the Administrator or designee for a period of one year in QA Committee. The date for correction and the title of the person responsible for correction of each deficiency The Administrator, Director of Nursing, Nursing Supervisors or designee will be responsible for the correction, and they will be completed by 7/2/2025.

FF16 483.12(a)(1):FREE FROM ABUSE AND NEGLECT

REGULATION: §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion;

Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: May 23, 2025
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews during an abbreviated survey (NY 105), the facility failed to prevent and protect an incident of physical abuse for one (1) resident (Resident #1) out of three (3) residents reviewed for abuse. Specifically, on 05/04/2025 at 3:59 PM, Certified Nursing Assistant #1 was observed on facility surveillance video restraining both hands of Resident #1 and hitting them in the head two (2) times. Using the reasonable person concept, this resulted in actual psychosocial harm that was Immediate Jeopardy. The findings are: Resident #1 had a medical [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score- 99, Resident #1 is not understood and does not understand, indicating severe impairment for decision making. Review of the facility policy entitled, Abuse with a revision date of 03/2024, documented it is the policy of the facility to ensure that every resident is free from abuse and that their rights, dignity and respect are maintained. The policy further documented all staff are responsible for reporting abuse, intervene immediately to safeguard resident if abuse, neglect, mistreatment or misappropriation of property has been observed. The policy further documents that staff are to report incidents of actual or alleged abuse, neglect or mistreatment to charge Nurse or Supervisor immediately. Review of the facility surveillance video with the Administrator, Director of Nursing, and Risk Manager on 05/19/2025 at 10:28 AM revealed that on 05/04/2025 at 3:59 PM, Resident #1 was in the hallway sitting in a wheelchair outside of a resident room. Certified Nursing Assistant #2 was observed standing at the nursing station and Certified Nursing Assistant #3 was observed in the hallway taking vital signs of another resident. Certified Nursing Assistant #1 was observed pointing their finger in the face of Resident #1. Resident #1 responded by striking the hand of Certified Nursing Assistant #1 two (2) times. Certified Nursing Assistant #1 responded by striking Resident #1 across the head and proceeded to hold both resident's hands down towards the wheelchair. Certified Nursing Assistant #2 and #3 were observed in the hallway facing the direction of the incident. Review of the Resident Accident/Incident Report dated 05/07/2025 at 10:30 AM documented that on 05/06/2025 an anonymous visitor reported to Unit Liaison #1, they had witnessed staff having an inappropriate encounter with Resident #1 on 05/04/2025. On 05/06/2025 between approximately 5:30 PM and 6:00 PM, the visitor notified Unit Liaison #1 that on Sunday 05/04/2025, when the visitor was present on the unit, they heard screaming and observed staff hitting Resident #1 in the head. The Accident Incident Report further documented Unit Liaison #1 did not report this information to Unit Liaison #2 until the morning of 05/07/2025. The Accident/Incident Report further documented while reviewing the camera it was observed two (2) additional staff members were in the hallway at the time of the incident looking towards the incident. The facility investigation documented Certified Nursing Assistants #2 and #3 denied seeing the occurrence. On 05/19/2025 at 10:30 AM during observation and an attempt to interview, Resident #1 was observed sitting in the wheelchair in the hallway, the resident began yelling and waving appearing fearful. During an interview on 05/19/2025 at 12:53 PM with Unit Liaison #1, they stated they received a call on 05/06/2025 at approximately 5:30PM-6:00 PM from an unidentified caller who stated that on Sunday 05/04/2025, when the caller was visiting the facility, they heard screaming and when they came out of the room they were in, they observed staff hitting Resident #1 in the head. Unit Liaison # 1 stated on the morning of 05/07/2025 they reported this to Unit Liaison #2. Unit Liaison #1 further stated that they should have notified the supervisor immediately. Multiple telephone call attempts to reach Certified Nursing Assistant #1 on 05/19/2025 at 1:30 PM and 2:00 PM, as well as on 05/20/2025 between 10:30 AM and 2:00 PM were unsuccessful. Phone call messages were not returned, and a letter was sent, with no response to the letter. Multiple telephone call attempts to reach Certified Nursing Assistant #2 on 05/20/2025 at 2:00 PM and 3:00 PM were unsuccessful. A letter was sent with no response. During an interview with Certified Nursing Assistant #3 on 05/19/2025 at 3:16 PM, they stated that on 05/04/2025 they worked 3:00 PM - 11:00 PM as their regular assignment and they stated Resident #1 was on their assignment. They stated Resident #1 is not combative and does not hit staff during care. They stated on 05/04/2025, they were taking vital signs for another Resident and did not notice Certified Nursing Assistant #1 hit Resident #1. They stated they heard Resident #1 yelling but did not look to see what was going on. When asked about the surveillance video where they were observed looking in the direction of Resident #1, Certified Nursing Assistant #3 stated they did not recall. During a telephone interview with Licensed Practical Nurse #1 on 05/19/2025 at 1:51 PM, they stated that on 05/04/2025 at approximately 4:00 PM, while at the nurse's station they heard screaming in the hallway and saw Certified Nurse Aide #1 removing a resident away from Resident #1. Licensed Practical Nurse #1 stated they did not see anyone hitting Resident #1 and this was not reported by any staff in the hallway. Licensed Practical Nurse #1 stated if the staff saw any abuse going on, such as anyone hitting a resident, they should have informed the Nursing Supervisor immediately. When asked about the video surveillance not showing another resident in the proximity at that time, Licensed Practical Nurse #1 stated they did not see the video and could not recall. During an interview on 05/19/2025 at 3:08 PM with the Director of Nursing, they stated the incident was reported by Unit Liaison #1 on 05/07/2025. The incident should have been reported as soon as the visitor reported what they saw. They stated during the investigation and review of the surveillance video they could see Certified Nursing Assistant #1 strike Resident #1. They further stated during the investigation, Certified Nursing Assistant #2 and Certified Nursing Assistant #3 can be seen facing the direction of Certified Nursing Assistant #1 and Resident #1 however, they denied seeing anything , and did not report any incident to the nurse or the supervisor. The investigation summary documented abuse did occur to Resident #1. During an interview on 05/20/2025 at 2:00 PM with the Medical Director, they stated Resident #1 was assessed with [REDACTED]. They further stated Resident #1, or any other resident, should not be hit by staff. The Medical Director stated the facility has a zero tolerance for abuse. 10 NYCRR 415.4 (b)(1)(i)

Plan of Correction: ApprovedJune 19, 2025

What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident 1 was assessed by a License nurse on 5/7/2025 and showed no signs and symptoms of injury or change of condition and MD assessment was also conducted on 5/7/2025, no sign of any visible injury, no change in behavior and no change in mental status. Care plans were updated to ensure interventions are in place to prevent abuse. Resident was assessed by Social Services on 5/8/2025 and noted with no apparent distress, talking, laughing, and smiling. The CNAs involved were taken off duty immediately. CNA #1 was terminated; CNA #2 and CNA #3 were suspended without pay. Police were called by the Administrator and DON met with the family member to provide information and reassurance/emotional support. Report number was assigned. The Abuse policy was updated, and Abuse posters were updated. Staff were educated by the in-service department about the updated policy and abuse poster and this was completed by 5/23/2025. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents have the potential to be affected by this finding. Risk manager screened all residents in the unit where Resident #1 resides, completed on 5/8/2025. No signs and symptoms of abuse noted. Then, two audit tools were created and utilized to assess random residents in all units. It was completed on (MONTH) 23, 2025. Alert residents that can be interviewed were interviewed using the audit tool #1 to check for abuse and the ones cannot be interviewed were checked for any sign / symptoms of abuse using audit tool #2. If identified, an investigation will take place, and disciplinary action will be imposed. There were no other residents found to have similar findings. There was no indication of any abuse as a result of the audits. Administrator reviewed facility Self-Reported Accident / Incident Log and noted all were reported and investigations completed. All staff were in service on ?Ç£Abuse, Neglect, Exploitation and Misappropriation of property.?Ç¥ By 5/23/2025. Staff who are on leave or vacation will be in-serviced upon return. The facility also obtained an outside consultant not employed by the facility to help develop and implement an acceptable directed plan of correction and in-service. Enhanced training on how to handle behavioral situations with residents who have cognitive impairment/Dementia and additional education on abuse, neglect and mistreatment will also be provided by an outside Consultant 6/18/2025-6/20/2025 and additional zoom trainings will be provided on 7/1/2025 and 7/2/2025 for staff on vacation or leave based on the findings of the QAPI Committee. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur. The QA Committee updated and approved the revision of Abuse and Neglect Policy and Procedure to include ?Ç£See something, Do something, Report immediately?Ç¥ and the Abuse poster updated as well. The message is written in different languages for all residents/ visitors of the facility. All staff were given an in-service using the revised policy and procedures on ?Ç£Abuse, neglect, exploitation, and misappropriation of resident property?Ç¥. Anonymous suggestion box for employees and families was created. Nursing assignment is now rotating every 6 months. Guardian Angel Department Head room rounds will occur once a week by managers or designees to help prevent and identify problems that may lead to potential abuse and report any negative findings during morning report was also implemented. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice DON or designee will monitor compliance to the revised policy on ?Ç£Preventing Abuse, neglect, exploitation, and misappropriation of resident property?Ç¥ and the Directed Plan of Correction to ensure staff are properly addressing and promptly reporting abuse or allegations of abuse following facility Policy and Procedures. Administrator will report progress of this QAPI to the QA Committee until significant compliance is achieved. Nurse Supervisors will continue auditing the residents in all units. Audit tool #1 and #2 will be utilized. It will be done weekly for a period of one month. Then once a month for a period of three months and then quarterly check will be in place until significant compliance is achieved. All findings will be reported by the DON or designee to QA committee for monitoring and ensuring significant compliance. Administrator or designee will monitor the anonymous Suggestion Box and address anything placed inside the box. This will continue for a period of one year. Guardian Angel Department Head room rounds will occur once a week to help prevent and identify problems that may lead to potential abuse and report any negative findings during morning report was also implemented. This will be monitored by the Administrator or designee for a period of one year in QA Committee. The date for correction and the title of the person responsible for correction of each deficiency The Administrator, Director of Nursing, Nursing Supervisors or designee will be responsible for the correction, and they will be completed by 7/2/2025.