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Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: February 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case #'s NY 986, NY 919, NY 950, and NY 114), the facility failed to ensure the residents' right to be free from abuse and neglect for four (4) (Resident #'s 1, 2, 3, and 4) of four (4) residents reviewed for abuse and neglect, which included physical, verbal and mental abuse. Specifically, (1.) Video footage documented Resident #1 was pushed to the floor on 2/02/2025 at 5:03 PM by Shahbaz (Certified Nurse Aide) #1, transferred off the floor by Licensed Practical Nurse #1 without an assessment by a Registered Nurse, and suffered a broken hip. (2.) Resident #2 was left unattended in the bathroom by Shahbaz #5 for one hour and twenty minutes on 11/04/2024. Resident #2 attempted to get themselves off the toilet and subsequently fell and suffered an injury to their right shoulder. (3.) On 11/05/2024, Resident #3 attempted to stand from the table after finishing their meal; Shahbaz #5 yelled at the resident to sit the F*** down. (4.) On 11/08/2024 at 3:00 AM, Resident #4 used their call bell requesting assistance, Shahbaz #6 entered the room and pushed the resident down on the pillow. This resulted in Immediate Jeopardy and substandard quality of care to resident health and safety and had the potential to affect all 177 residents in the facility. The immediate Jeopardy was lifted on 2/13/2025. This is evidenced by: Cross-referenced to: F609: Reporting, F610: Investigate/Prevent/Correct Alleged Violations. Review of the facility Abuse Prevention & Investigation Policy, dated 10/14/2022, documented the following: - Residents have the right to be free from verbal, sexual, physical, and mental abuse; neglect, mistreatment, corporal punishment, involuntary seclusion, exploitation, and misappropriation of property (thereafter abuse shall be understood to include all of the above. - All employees have an obligation to report such abuses when they have reasonable cause to believe that such an incident has occurred. The facility shall follow guidelines as outlined in federal/state regulations, Dear Administrator Letters (DALs), Centers for Medicaid and Medicare State Operations Manual Appendix PP, and Trinity Health/St. Peter's Health Partners policies and procedures. The staff shall report any incident or allegation/suspicion of abuse as outlined above to the Administrator, Director of Nursing Services or their designee immediately. In cases where a crime is suspected, the facility leadership is expected to report the same to local law enforcement under the Elder Justice Act. Resident #1 Resident #1 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/29/2024 documented the resident had severely impaired cognition and could usually be understood and could usually understand others. Review of video surveillance footage on 02/11/2025 at 4:00 PM revealed that on 02/02/2025 at 5:00 PM: 1. Shahbaz #1 was with Resident #1 in the hallway. 2. Resident #1 was ambulating with their hands behind their back, without the need of an assistive device. Resident #1 walked over to the dining table and was stopped by Shahbaz #1, who blocked the resident from going to the table, pushing the resident in a backward motion. 3. Shahbaz #1 grabbed Resident #1 by the arm. Resident resisted, and Shahbaz #1 placed their hands on the resident's arms, spun the resident by pulling them around, and pushed the resident backward while the resident was trying to prevent the Shahbaz from grabbing them. 4. Once Resident #1 was up against the wall in a backward position, the resident attempted to steady themselves by grabbing for the handrail but was unable to hold on to the rail. 5. Shahbaz #1 let go of Resident #1 with a push, and the resident began to fall to the ground. 6. Shahbaz #1 made no attempts to stop or break the resident's fall. 7. Resident #1 fell against the wall; resident's legs appeared to buckle or twist. The resident reached for the handrail again but could not hold on to it and fell on their right hip. 8. Shahbaz #1 looked at Resident #1, who had fallen, and walked away from the resident. Resident #1 was then alone on the floor as Shabazz #1 transported other residents to the dining table. 9. Resident #1 was transferred off the floor by Licensed Practical Nurse #1, Shahbaz #1 and Shahbaz #3 without the use of a mechanical lift. Record review of an undated facility document titled Termination revealed the following: on 02/03/2025, the facility investigated a resident fall that resulted in a fracture (bone break) and hospitalization . The investigation produced credible evidence to support Shahbaz #1 physically abused and neglected the resident. Camera review showed Shahbaz #1 held Resident #1's hands while they proceeded to move them away from the table by pushing and pulling them across the hallway towards the handrail, approximately 10-15 feet. Shahbaz #1 pushed Resident #1 against the wall, their body leaning, and their gait unsteady, then they let go of the resident's hands, causing the resident to fall backwards. The undated facility document noted that based on the video footage, it was uncertain whether the resident was pushed; Shahbaz #1 proceeded to walk away from Resident #1 and left them on the floor until the nurse responded to evaluate Resident #1. The document noted Shahbaz #1 was terminated, and the document was signed by Guide #1 (Guides oversee the Shahbaz in the homes) and Assistant Director of Nursing #1 with no date or time. Termination of Shahbaz #1 was documented as being done verbally by telephone. Nursing progress note dated 02/02/2025 at 6:13 PM, completed by Registered Nurse #1, documented that Registered Nurse #1 was called to House 16 for a witnessed fall. It documented the following: Shahbaz #1 reported that they were taking Resident #1 to their room when Resident #1 let go of the side rail and fell to the floor. Upon arrival, Resident #1 was observed sitting on the floor in the dining room. On assessment, Resident #1 was observed to be in pain with some guarding to their right thigh and was unable to stand. Resident #1 was assisted off the floor with a mechanical lift and two-person assist, then placed in a wheelchair. Physician was made aware and ordered an x-ray of the right hip, pelvis and femur. Mobile imaging was called to be in. Resident #1's family was notified and came in to visit. Vital Signs: Temperature 97.8, Pulse 83, Respirations 20 per minute, Blood Pressure 160/84. Record review of Mobile X-ray imaging report of Resident #1's right hip, dated 02/02/2025 at 6:45 PM, revealed Resident #1 sustained a [MEDICAL CONDITION] femur (long leg bone located from hip to knee) that suggested subacute timing (that indicated it had recently occurred). During an interview on 02/11/2025 at 9:01 AM, Assistant Director of Nursing #1 stated Resident #1 had a fall with an injury on 02/02/2025, and video of the incident was reviewed with Guide #1 on 02/03/2025 at 10:50 AM, when abuse was discovered. They stated that Shahbaz #1 was interviewed by telephone and suspended when their recounting of the events that occurred did not match the actual events documented in the video recorded on 02/02/2025 at 5:00 PM. Assistant Director of Nursing #1 stated they then reported it to New York State Department of Health. During an interview on 02/11/2025 at 1:00 PM, Assistant Director of Nursing #1 stated Licensed Practical Nurse #1 called them on 02/02/2025 at 7:39 PM, to report that Resident #1 had fallen, had a fracture (bone break), and was being transferred to the hospital. Assistant Director of Nursing #1 stated they were aware Shahbaz #1 had completed their shift and left for the day, and Guide #1 confirmed with them via text message on 02/02/2025 that Shahbaz #1 was not scheduled to work on 02/03/2025 (the next day). Assistant Director of Nursing #1 stated that they (Assistant Director of Nursing #1) did not come into the facility on [DATE] and had not reported the incident to Administrator #1 or started an investigation until 02/03/2025. They stated that the video of the 02/02/2025 incident was not reviewed until 02/03/2025 because they were unable to access the video from home. They further stated that Shahbaz #1 was not suspended on 02/02/2025 because they had no concerns of abuse. During an interview on 02/11/2025 at 9:05 AM, Administrator #1 stated that they became aware of the incident on 02/03/2025 at 10:50 AM, when Assistant Director of Nursing #1 notified them that abuse had occurred, and the investigation was not started on 2/02/2025. During an interview on 02/11/2025 at 11:35 AM, Guide #1 stated they were contacted by Assistant Director of Nursing #1 at approximately 9:30 PM on 02/02/2025 about a fall in the house where Resident #1 resided and where Shahbaz #1 worked. Guide #1 stated Assistant Director of Nursing #1 wanted to know if Shahbaz #1 was working on 02/03/2025. Guide #1 stated they informed Assistant Director of Nursing #1 that Shahbaz #1 was not working the next day, and both decided to not review the video until 02/03/2025. Guide #1 stated they and Assistant Director of Nursing #1 reviewed the video on 02/03/2025 at approximately 10:30 AM and found that Shahbaz #1 had abused Resident #1. Guide #1 further stated that they interviewed Shahbaz #1 about the incident by phone; the account given by Shahbaz #1 was not consistent with the video. Guide #1 stated Shahbaz #1 was suspended pending the outcome of the investigation and subsequently terminated. During an interview on 02/11/2025 at 2:17 PM, Shahbaz #2 stated they were afraid and intimidated by Shahbaz #1. Shahbaz #2 stated they saw Shahbaz #1 grab Resident #1 and pull them away from the table. Shahbaz #2 stated that they thought Shahbaz #1 was taking the resident to their room and did not intervene. They stated that they heard Resident #1 talk loudly and heard Resident #1 fall but did not see it. The resident fell hard; I didn't report it until later because I was scared; I reported it to Licensed Practical Nurse #2 later that night on 02/02/2025 when they arrived at 7:00 PM. The Shahbaz said that Licensed Practical Nurse #2 called the Assistant Director of Nursing #1 and insisted I tell them I had concerns about the fall, and thought they should look at the video because something was not right. Shahbaz #2 stated that the resident could be easily redirected but that was not the way Shahbaz #1 dealt with Resident #1. They stated Shahbaz #2 had reported Shahbaz #1 for bullying them in the past, and this had been reported to both Guide #1 and the Assistant Director of Nursing #1, but nothing was done. Shahbaz #2 reported feeling intimidated because of this and did not stop what they felt was abuse. They stated Shahbaz #1 could be rough with the residents and had done things the way they wanted to, and that Shahbaz #1 worked at the facility a long time. Shahbaz #2 stated no investigation had been started at the time of the fall by Registered Nurse #1 and that they (Shahbaz #2) were interviewed on 02/03/2025 by Assistant Director of Nursing #1. During an interview on 02/11/2025 at 2:42 PM, Licensed Practical Nurse #1 stated they saw Resident #1 on the floor on 02/02/2025 after being called to respond to House #16 for a fall. Licensed Practical Nurse #1 stated they called Registered Nurse #1, who arrived at the house at 5:00 PM on 02/02/2025. Licensed Practical Nurse #1 stated Registered Nurse #1 did not assess the resident and instructed Licensed Practical Nurse #1 to use a mechanical lift to pick Resident #1 up off the floor. Licensed Practical Nurse #1 stated that with the help of Shahbaz #3, they lifted Resident #1 off the floor without using the mechanical lift and could see the resident's leg was injured. They stated Resident #1 was placed in a wheelchair and taken to the office where Registered Nurse #1 was located. They stated Registered Nurse #1 called the physician and completed paperwork. They stated they called the family and when the family arrived, they brought the resident to their room and placed the resident in their bed using a gait belt (a belt used to assist with ambulating). Licensed Practical Nurse #1 further stated that Registered Nurse #1 never went to the room to perform any further evaluation of the resident. During an interview on 02/11/2025 at 3:37 PM, Medical Director #1 stated Resident #1 should have been assessed prior to being picked up; they also stated what a proper assessment was and how a resident should be handled after a fall which would help to prevent further injury to a resident and that abuse needed to be investigated and reported. During a telephone interview on 02/11/2025 at 5:11 PM, Licensed Practical Nurse #2 stated they arrived for their 02/02/2025 7:00 PM shift and were given report of Resident #1's fall by Licensed Practical Nurse #1. They stated that no abuse was reported until Shahbaz #2 told them that they (Shahbaz #2) were afraid and that things were 'not right.' During a telephone interview on 02/12/2025 at 6:49 AM, Registered Nurse #1 stated they did not assess or perform range of motion on Resident #1 prior to telling staff to transfer the resident off the floor. They stated that upon receiving the x-ray report on 02/02/2025 prior to the resident being transferred to the hospital, they became concerned with Shahbaz #1's accounting of the fall. They stated that they were not present when the fall occurred, but Shahbaz #1 was still interacting with the resident. Registered Nurse #1 stated they called Assistant Director of Nursing #1 to verbalize concerns, and requested the video be reviewed to determine what happened and ensure the resident hadn't hit their head, as neurological checks had not been done and abuse needed to be ruled out. They stated that they felt something did not seem right. Registered Nurse #1 stated that Assistant Director of Nursing #1 relayed to them that Shahbaz #1 had worked at the facility for a long time, they had no concerns that Shahbaz #1 would abuse a resident, but they would look at the video. Registered Nurse #1 stated that Assistant Director of Nursing #1 dismissed the concerns. Registered Nurse #1 stated they were interviewed by Assistant Director of Nursing #1 and asked about assessing Resident #1 when they responded to the incident on 02/02/2025. They stated that the video demonstrated no range of motion or full assessment of Resident #1 had been done prior to Resident #1 being lifted from the floor. Registered Nurse #1 stated they were not aware that the leg was fractured; that a full assessment including range of motion should have been done; and that they had not asked or interviewed anyone about the fall other than Shahbaz #1. They stated that Shahbaz #1 worked their regular schedule from 02/02/2025 until they were suspended as of 02/11/2025. Registered Nurse #1 stated that their progress note of Resident #1 being transferred off the floor for this incident was not accurate because they had written it as staff were actively moving Resident #1 off of the floor, and they had thought staff were using the hoyer lift as they instructed. They stated they had not corrected their documentation/progress note on the incident since recording it on 02/02/2025. Registered Nurse #1 stated Shahbaz #1 had been one of the staff members assisting the resident off the floor. During an interview on 02/18/2025 at 3:45 PM, Shahbaz #3 stated Registered Nurse #1 and Licensed Practical Nurse #1 told them to help get Resident #1 off the floor. The resident was crying and holding their right leg, they appeared to be in pain. They stated that Resident #1 was assisted up by Shahbaz #1 and Shahbaz #3 while Licensed Practical Nurse #1 got a wheelchair. They stated that Registered Nurse #1 was not present when the staff got the resident off the floor without using the mechanical lift. They further stated that Shahbaz #1 had been sometimes aggressive with staff members, but Shahbaz #3 had not seen Shahbaz #1 abuse residents. During a telephone interview on 2/20/2025 at 9:08 AM, Guide #1 stated they had been aware of staff concerns with Shahbaz #1; a counselling meeting was provided to Shahbaz #1 in (MONTH) 2024 after a staff confrontation. During an interview on 2/24/2025 at 3:38 PM, Guide #1 stated after the investigation was completed, Human Resources informed them that Shahbaz #'s 2, 3 and 5 were all terminated. Several attempts to reach Shahbaz #1 from 02/13/2025 to 02/24/2025 by telephone were unsuccessful. Resident #2 Resident #2 was admitted with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented resident could usually be understood and could usually understand others, with severely impaired cognition for daily decision making. Review of a Facility Reported Incident received by the New York State Department of Health on 11/08/2024 revealed the following: Resident #2 was placed on the toilet on 11/04/2024 at 6:05 PM by Shahbaz #5 and never checked on until 7:25 PM when the resident was found to have fallen on the floor. Shahbaz #5 stated that they placed Resident #2 on the toilet and left them for approximately 10 minutes, however, video camera footage did not corroborate this recounting. The facility determined this when they reviewed surveillance camera footage three (3) days later on 11/07/2024 at 2:50 PM. Shahbaz #5 was placed on suspension pending continued investigation of potential neglect, and Administrator #1 was notified of the event. Facility investigation dated 11/07/2024 documented the following: Shahbaz #5 left Resident #2 unattended on the toilet for 1 hour and 20 minutes on 11/04/2024 and supported by review of the video surveillance footage that the facility viewed three days after the event on 11/07/2024 at 02:50 PM. It identified Shahbaz #5's recounting of the fall was not consistent with the times they were observed going in and out of the resident's room on the evening of the event. Resident #2's Comprehensive Care Plan documented the resident was a fall risk and the resident's care card documented Resident #2 required assistance with toileting to and from the bathroom, was unreliable with using a call bell or pendant for safety, and required all needs to be anticipated. The resident should not have been left unattended on the toilet, and Shahbaz #5 was terminated. The resident sustained [REDACTED]. A nursing progress note dated 11/04/2024 at 9:35 PM documented the following: Resident #2 was found on the floor that day and had a full range of motion to all extremities. Registered Nurse Supervisor #3 was called, and using a mechanical lift, Resident #2 was moved off the floor and placed in a wheelchair. The supervisor and family were notified and note of the event placed in the Medical Director's log. A nursing progress note dated 11/04/2024 at 9:32 PM documented the following: Registered Nurse Supervisor #3 documented they were called to House #12 for a resident fall. Resident #2 was laying on their left side in the bathroom. The Physician and family were notified. A nursing progress note dated 11/05/2024 at 9:06 AM documented the following: Resident #2 reported experiencing pain in their right arm and right leg following a fall. The resident was unable to lift their right arm in front of them. X-rays were ordered and were pending. The resident had no memory of the fall. A medical provider progress note dated 11/06/2024 at 11:08 AM documented further x-rays were requested to follow up on the right shoulder and clavicle (neck) areas because of pain and bruising on the chest. A rehabilitation progress note dated 11/06/2024 at 12:28 PM documented that the resident was no longer able to feed themselves as a result of the fall. Staff reported the resident was right-handed, and staff had begun assisting with feeding for Resident #2 during meals. Resident #3 Resident #3 was admitted with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented resident could usually be understood and usually understand others, with severely impaired cognition for daily decision making. Review of a Facility Reported Incident received by the New York State Department of Health on 11/08/2024 revealed the following: On 11/05/2024 at 7:30 PM, Resident #3 was sitting at the dining room table, stood up from the chair, and Shahbaz #5 stated Can you just sit the f*** down. It further documented that staff were first made aware of the incident on 11/07/2024 at 4:00 PM. Record review revealed Shahbaz #5 continued to work on 11/05/2024, and that this incident occurred one day after Shahbaz #5 had left Resident #2 unattended on the toilet for 1 hour and 20 minutes on 11/04/2024. In an email dated 11/12/2024 at 8:27 AM, Director of Nursing #1 documented the following to Human Resource officer regarding abuse and neglect allegations against Shahbaz #5: We are asking for termination since there was definite neglect and even though we were unable to substantiate the profanity, it probably did happen. During an interview on 02/19/2025 at 4:07 PM, Shahbaz #4 stated they reported verbal abuse of Resident #3 by Shahbaz #5 on 11/05/2024. They stated that when Resident #3 tried to stand up from the dining table, Shahbaz #5 yelled at them saying, Could you sit the F*** down. They stated that they reported the verbal abuse to Guide #1 on 11/05/2024, but it was days later before Assistant Director of Nursing #1 interviewed them. They further stated that Shahbaz #5 was not removed from resident care while the investigation was ongoing. During an interview on 02/24/2025 at 12:07 PM, Director of Nursing #1 stated the following: When the verbal abuse was reported, there had been an ongoing investigation regarding abuse and neglect towards another resident by Shahbaz #5. On 02/11/2025, Shahbaz #5 had not been truthful about the neglect of Resident #2 and gave a different recounting of the events which was proven false by watching the video. The video of the incident for Resident #3 demonstrated Shahbaz #5 was interacting with Resident #3 and could not hear as no sound was recorded. They stated that they didn't know why audio was not recorded, and none of the videos record sound. They further stated that Shahbaz #4 had reported what they heard but had not seen the incident. Resident #4 Resident #4 was admitted with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented resident could be understood and understand others with intact cognition. Review of a Facility Reported Incident received by the New York State Department of Health on 11/11/2024 revealed the following: Resident #4 reported to a staff member on 11/09/2024 at 11:00 AM that Shahbaz #6 pushed them down hard onto the bed and left without providing help on 11/08/2024 at 3:00 AM. It documented Administrator #1 was first made aware of the incident on 11/11/2024 at 11:25 AM. An email dated 11/10/2024 at 12:08 PM, sent to Guide #1 from Licensed Practical Nurse #3, documented they received a complaint from Resident #4 concerning Shahbaz #6 who turned off the call bell at approximately 11/08/2024 at 3:00 AM and did not assist them. The second time the call bell was turned on, Shahbaz #6 came in, turned off the light and pushed the resident down on the bed hard. The resident reported Shahbaz #6 left without providing any help and that Resident #4 sat up for two hours worried about it. Resident #4 stated they were old but knew what they were talking about and would not make this up. Licensed Practical Nurse #3 assured the resident it would be addressed with Shahbaz #6's supervisors. Investigation dated 11/11/2024 at 11:20 AM, documented the following: Verbal abuse and neglect had occurred by Shahbaz #6. This was determined through interviews with Resident #4, that Shahbaz #6 had abused the resident and was terminated. This was supported by review of the video that identified Shahbaz #6's accounting of the events was not consistent with the times they were observed going in and out of the resident's room on the evening of the event (night shift 11/07/2024 PM into 11/08/2024 AM). The Investigation documented Guide #1 was notified via email by Licensed Practical Nurse #3 on 11/10/2024 at 12:00 PM that Resident #4 had reported abuse by Shahbaz #6. The investigation was initiated on 11/11/2024 by Assistant Director of Nursing #1. During the investigation, other residents reported concerns with Shahbaz #6 and care they received. During surveillance camera review of the investigation, Shahbaz #6 was noted to be sitting for large portions of their shift, did not provide resident care, and did not enter seven (7) resident rooms on their shift that night. During an interview on 02/24/2025 at 12:07 PM, Director of Nursing #1 stated that in the facility's Greenhouse Models (a specific living environment), the Guide is the one who would address concerns with the Shahbaz and would bring it to administration's attention. During an interview on 02/24/2025 at 12:26 PM, Licensed Practical Nurse #3 stated during morning medication pass on 11/10/2024, Resident #4 reported they had been abused by Shahbaz #6 during care given during the night shift. They stated that Resident #4 was worried about being cared for by Shahbaz #6. They stated that they (Licensed Practical Nurse #3) sent an email to Guide #1 immediately. They stated that there was no interview or investigation done regarding the reported abuse of Resident #4 by Shahbaz #6 until 11/11/2024, when they were interviewed by Assistant Director of Nursing #1. During an interview on 02/24/2025 at 3:38 PM, Guide #1 stated after the investigation was completed, they were informed Shahbaz #5 was to be terminated for abuse and neglect. They stated that per facility procedure, Guides would inform the Shahbaz if/when they were terminated. They further stated that Human Resources had notified them (Guide #1) of the need to terminate Shahbaz #5. New York Codes, Rules and Regulations 415.4(b)(1)(i) | Plan of Correction: ApprovedMarch 26, 2025 Plan of correction not approved or not required |
Scope: Isolated
Severity: Immediate jeopardy to resident health or safety
Citation date: February 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case #s NY 986, NY 919, NY 950, and NY 114), the facility failed to ensure all allegations of abuse were thoroughly investigated for three (3) (Resident #'s 1, 2, and 3) of four (4) residents reviewed for abuse investigation. Specifically, (1.) video surveillance footage revealed Shahbaz (Certified Nurse Aide) #1 pushed Resident #1 to the floor on 2/02/2025 at 5:03 PM. There was no documented evidence the facility initiated an investigation on 2/02/2025 (2.) Resident #2 was left unattended in the bathroom by Shahbaz #5 for one hour and twenty minutes on 11/04/2024. Resident #2 attempted to get themselves off of the toilet and subsequently fell and suffered an injury to their right shoulder. (3.) On 11/05/2024, Resident #3 attempted to stand from the table after finishing their meal; Shahbaz #5 yelled at the resident to sit the F*** down. This resulted in Immediate Jeopardy and substandard quality of care to resident health and safety with the likelihood to affect all 177 residents in the facility. The immediate Jeopardy was lifted on 2/13/2025. This is evidenced by: Cross-referenced to: F600: Abuse Prohibition, F609: Reporting. Review of the facility Abuse Prevention & Investigation Policy, dated 10/14/2022, documented the following: - Residents have the right to be free from verbal, sexual, physical, and mental abuse; neglect, mistreatment, corporal punishment, involuntary seclusion, exploitation, and misappropriation of property (thereafter abuse shall be understood to include all of the above). - All employees have an obligation to report such abuses when they have reasonable cause to believe that such an incident has occurred. The facility shall follow guidelines as outlined in federal/state regulations, Dear Administrator Letters (DALs), Centers for Medicaid and Medicare State Operations Manual Appendix PP, and Trinity Health/St. Peter's Health Partners policies and procedures. The staff shall report any incident or allegation/suspicion of abuse as outlined above to the Administrator, Director of Nursing Services or their designee immediately. In cases where a crime is suspected, the facility leadership is expected to report the same to local law enforcement under the Elder Justice Act. Resident #1 Resident #1 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/29/2024 documented the resident was cognitively impaired, could be understood, and understand others. Video surveillance footage revealed that on 2/02/2025 at 5:00 PM, Shahbaz #1 pushed Resident #1 and walked away. Resident #1 fell and sustained a fractured (broken) hip. Nursing progress note dated 02/02/2025 at 6:13 PM, completed by Registered Nurse #1, documented that Registered Nurse #1 was called to House 16 for a witnessed fall. It documented the following: Shahbaz #1 reported that they were taking Resident #1 to their room when Resident #1 let go of the side rail and fell to the floor. Upon arrival, Resident #1 was observed sitting on the floor in the dining room. On assessment, Resident #1 was observed to be in pain with some guarding to their right thigh and was unable to stand. Resident #1 was assisted off the floor with a mechanical lift and two-person assist, then placed in a wheelchair. Physician was made aware and ordered an x-ray of the right hip, pelvis and femur. The x-ray was ordered to be completed by a Mobile / portable, bedside unit Resident #1's family was notified and came in to visit. Vital Signs: Temperature 97.8, Pulse 83, Respirations 20 per minute, Blood Pressure 160/84. Record review of Mobile X-ray imaging report of Resident #1's right hip, dated 02/02/2025 at 6:45 PM, revealed Resident #1 sustained a [MEDICAL CONDITION] femur (long leg bone located from hip to knee) that suggested subacute timing (that indicated it had recently occurred). There was no documented evidence the facility initiated an investigation on 2/02/2025 to rule out abuse. Additionally, there was no documented evidence the facility completed a thorough investigation of the alleged violation, and no documented evidence that the facility informed law enforcement. Facility 5-day Investigation Report created 02/07/2025 and changed 02/11/2025 documented the following: There was reasonable cause to believe that abuse, neglect, or mistreatment occurred on 02/02/2025. Resident representative was reported of the incident on 02/05/2025 at 1:30 PM (three days later). Summary of interview(s) with staff responsible for oversight and supervision of the location where the alleged victim resides listed as, ' NA. ' Summary of interview(s) with staff responsible for oversight and supervision of the alleged perpetrator, if staff or a resident, listed as, ' NA. ' The facility corrective action noted only the termination of employment for Shahbaz #1. During an interview on 02/11/2025 at 9:01 AM, Assistant Director of Nursing #1 stated Resident #1 had a fall with an injury on 02/02/2025, and video of the incident was reviewed with Guide #1 on 02/03/2025 at 10:50 AM, when abuse was discovered. They stated that Shahbaz #1 was interviewed by telephone and suspended when their recounting of the events that occurred did not match the actual events documented in the video recorded on 02/02/2025 at 5:00 PM. Assistant Director of Nursing #1 stated they then reported it to New York State Department of Health. During an interview on 02/11/2025 at 9:05 AM, Administrator #1 stated that they became aware of the incident on 02/03/2025 at 10:50 AM, when Assistant Director of Nursing #1 notified them that abuse had occurred, and the investigation was not started on 2/02/2025. During an interview on 02/11/2025 at 2:17 PM, Shahbaz #2 stated they were afraid and intimidated by Shahbaz #1. Shahbaz #2 stated they saw Shahbaz #1 grab Resident #1 and pull them away from the table. Shahbaz #2 stated that they thought Shahbaz #1 was taking the resident to their room and did not intervene. They stated that they heard Resident #1 talk loudly and heard Resident #1 fall but did not see it. The resident fell hard; I didn't report it until later because I was scared; I reported it to Licensed Practical Nurse #2 later that night on 02/02/2025 when they arrived at 7:00 PM. The Shahbaz said that Licensed Practical Nurse #2 called the Assistant Director of Nursing #1 and insisted I tell them I had concerns about the fall, and thought they should look at the video because something was not right. During an interview on 02/11/2025 at 11:35 AM, Guide #1 stated they were contacted by Assistant Director of Nursing #1 at approximately 9:30 PM on 02/02/2025 about a fall in the house where Resident #1 resided and where Shahbaz #1 worked. Guide #1 stated Assistant Director of Nursing #1 wanted to know if Shahbaz #1 was working on 02/03/2025. Guide #1 stated they informed Assistant Director of Nursing #1 that Shahbaz #1 was not working the next day, and both decided to not review the video until 02/03/2025. Guide #1 stated they and Assistant Director of Nursing #1 reviewed the video on 02/03/2025 at approximately 10:30 AM and found that Shahbaz #1 had abused Resident #1. Guide #1 further stated that they interviewed Shahbaz #1 about the incident by phone; the account given by Shahbaz #1 was not consistent with the video. Guide #1 stated Shahbaz #1 was suspended pending the outcome of the investigation and subsequently terminated. There was no documented evidence the facility took measures to prevent further potential abuse by Shahbaz #1 on 02/02/2025. Based on observations, interview and record review cross referenced, when Shahbaz #2 heard the incident as it unfolded, they did not intervene and did not share the status of what had happened with responding staff (Licensed Practical Nurse # 1, Registered Nurse #1, and Shahbaz #3) while the resident was on the ground. Video surveillance footage revealed that after the fall, Resident #1 was animated whenever Shahbaz #1 approached the resident. Shahbaz #1 was allowed to provide continued assistance with staff when Resident #1 was removed from the floor. During an interview on 02/11/2025 at 1:00 PM, Assistant Director of Nursing #1 stated Licensed Practical Nurse #1 called them on 02/02/2025 at 7:39 PM, to report that Resident #1 had fallen, had a fracture (bone break), and was being transferred to the hospital. Assistant Director of Nursing #1 stated they were aware Shahbaz #1 had completed their shift and left for the day, and Guide #1 confirmed with them via text message on 02/02/2025 that Shahbaz #1 was not scheduled to work on 02/03/2025 (the next day). Assistant Director of Nursing #1 stated that they (Assistant Director of Nursing #1) did not come into the facility on [DATE] and had not reported the incident to Administrator #1 or started an investigation until 02/03/2025. They stated that the video of the 02/02/2025 incident was not reviewed until 02/03/2025 because they were unable to access the video from home. They further stated that Shahbaz #1 was not suspended on 02/02/2025 because they had no concerns of abuse. During a telephone interview on 02/12/2025 at 6:49 AM, Registered Nurse #1 stated they did not assess or perform range of motion on Resident #1 prior to telling staff to transfer the resident off the floor. Registered Nurse #1 stated that they documented their progress note of Resident #1 being transferred off the floor for this incident was not accurate because they had written it as staff were actively moving Resident #1 off of the floor, and they had thought staff were using the hoyer lift as they instructed. They stated they had not corrected their documentation/progress note on the incident since recording it on 02/02/2025. Registered Nurse #1 stated Shahbaz #1 had been one of the staff members assisting the resident off the floor. There was no documented evidence the facility took corrective action for other staff members involved in the incident including but not limited to Licensed Practical Nurse #1, Registered Nurse #1, Guide #1, and Assistant Director of Nursing #1 following the verification of the allegation. Resident #2 Resident #2 was admitted with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented resident could usually be understood and could usually understand others with severely impaired cognition for activities of daily living. Review of a Facility Reported Incident received by the New York State Department of Health on 11/08/2024 revealed the following: Resident #2 was placed on the toilet on 11/04/2024 at 6:05 PM by Shahbaz #5 and never checked on until 7:25 PM when the resident was found to have fallen on the floor. Shahbaz #5 stated that they placed Resident #2 on the toilet and left them for approximately 10 minutes, however, video camera footage did not corroborate this recounting. The facility determined this when they reviewed surveillance camera footage three (3) days later on 11/07/2024 at 2:50 PM. Shahbaz #5 was placed on suspension pending continued investigation of potential neglect, and Administrator #1 was notified of the event. Facility investigation dated 11/07/2024 documented the following: Shahbaz #5 left Resident #2 unattended on the toilet for 1 hour and 20 minutes on 11/04/2024 and supported by review of the video surveillance footage that the facility viewed three days after the event on 11/07/2024 at 02:50 PM. It identified Shahbaz #5 ' s recounting of the fall was not consistent with the times they were observed going in and out of the resident's room on the evening of the event. Resident #2's Comprehensive Care Plan documented the resident was a fall risk and the resident ' s care card documented Resident #2 required assistance with toileting to and from the bathroom, was unreliable with using a call bell or pendant for safety, and required all needs to be anticipated. The resident sustained [REDACTED]. There was no documented evidence the facility took measures to prevent further potential abuse by Shahbaz #5 on 11/04/2024. Additionally, there was no documented evidence of a Facility 5-day Investigation Report submittal to the New York State Department of Health. Resident #3 Resident #3 was admitted with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented resident could usually be understood and usually understand others with severely impaired cognition for daily decision making. Review of a Facility Reported Incident received by the New York State Department of Health on 11/08/2024 revealed the following: On 11/05/2024 at 7:30 PM, Resident #3 was sitting at the dining room table, stood up from the chair, and Shahbaz #5 stated Can you just sit the f*** down. It further documented that staff were first made aware of the incident on 11/07/2024 at 4:00 PM. There was no documented evidence the facility took measures to prevent this verbal abuse by Shahbaz #5 on 11/05/2024 after the 11/04/2024 allegation of abuse (see Resident #2). Additionally, there was no documented evidence of a Facility 5-day Investigation Report submittal to the New York State Department of Health. Facility Investigation dated 11/07/2024, documented the following: On 11/05/2024, verbal abuse to Resident #3 by Shahbaz #5 was not conclusive. Shahbaz #3 reported verbal abuse had occurred to Resident #3 by Shahbaz #5. Director of Nursing #1 deemed the allegation to be likely. During an interview on 02/19/2025 at 4:07 PM, Shahbaz #4 stated they reported verbal abuse of Resident #3 by Shahbaz #5 on 11/05/2024. They stated that when Resident #3 tried to stand up from the dining table, Shahbaz #5 yelled at them saying, Could you sit the F*** down. They stated that they reported the verbal abuse to Guide #1 on 11/05/2024, but it was days later before Assistant Director of Nursing #1 interviewed them. They further stated that Shahbaz #5 was not removed from resident care while the investigation was ongoing. During an interview on 2/24/2025 at 12:07 PM, Director of Nursing #1 stated there had been an ongoing investigation regarding abuse and neglect of another resident by Shahbaz #5 when the verbal abuse was reported. They felt it could not be supported, and the investigation of neglect was the reason Shahbaz #5 was terminated. The video of the incident for Resident #3, demonstrated the Shahbaz was interacting with Resident #3 but no sound was recorded. During an interview on 2/24/2025 at 12:26 PM, Licensed Practical Nurse #3 stated they reported concerns to Administration and was told to report concerns to the Guide, Administration did not interview Licensed Practical Nurse #3 regarding allegations of abuse by Resident #2 or Resident #3 regarding Shahbaz #5. During an interview on 02/24/2025 at 3:38 PM, Guide #1 stated after the investigation was completed, they were informed Shahbaz #5 was to be terminated for abuse and neglect. They stated that per facility procedure, Guides would inform the Shahbaz if/when they were terminated. They further stated that Human Resources had notified them (Guide #1) of the need to terminate Shahbaz #5. There was no documented evidence the facility took corrective action for other staff members involved in the incident including but not limited to Licensed Practical Nurse #3 and Guide #1 following the verification of the allegation. 10 New York Codes, Rules and Regulations 415.4(b)(2) | Plan of Correction: ApprovedMarch 26, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is part of a directed plan of correction Element 1 Resident 1 was provided with medical intervention at time of incident. Resident is being monitored for any psychosocial stressors related to this event. The residents medical record was reviewed to determine if any changes to routine patterns were documented none identified. Law enforcement notified of event. Resident 2 Resident discharged on [DATE]. Staff involved no longer at facility. Full investigation completed during the on-site New York State Department of Health complaint survey on 2/12/25-2/13/25 Resident 3 Resident is being monitored for any psychosocial stressors related to this event. The residents medical record was reviewed on 3/19/25 to determine if any changes to routine patterns were documented none identified. Full investigation completed during the on-site New York State Department of Health complaint survey on 2/12/25-2/13/25 Element 2 All residents have potential to be affected by stated deficiency. All Residents that reside in the facility will be interviewed by social work to determine if they feel safe in the facility. Any concerns will be investigated and reported as required. Nursing and social work will monitor the identified residents for potential adverse effects related to allegations IE. mood/behavioral changes, changes in daily routine, etc. The past 30 days of Incident Reports were reviewed by the Director of Nursing to determine thoroughness of investigation and identification of causes, contributing factors, and/or documented corrective actions to prevent reoccurrence. Review will be completed by 3/27/25 No follow-up action required All staff were in serviced by the nursing educators on 2/12/25 - 2/13/25 on Investigation of allegations of abuse, neglect and mistreatment. Element 3 Measures taken to ensure the problem does not recur: The Abuse Reporting/Investigation policy and procedure were reviewed by the Administrator, Director of Nursing and Nursing Administration. The abuse reporting/investigation policy changed to reflect need to report immediately but not more than two hours all allegations of abuse, neglect and mistreatment. Supervisors have been educated to the process to report and given standard work instructions outlining process. This includes the following: *Notify Administrator *Notify Director of Nursing *Submit report to Department of Health *Notify Law Enforcement Social work, nursing supervisor, nurse manager, assistant director of nursing, director of nursing and administrator were educated on completing the Investigation Checklist for Allegation of Resident Abuse, Neglect, or Mistreatment contained in the Abuse Reporting Policy. By completing all elements of the checklist, it will provide a thorough review of incident and ability for staff to make appropriate corrective actions to prevent reoccurrence of event. The review of the Investigation Checklist includes but not limited to the following: Notification of Administrator and Director of Nursing Accused removed from assignment/suspended until investigation complete Incident Report/Resident Statement Statement of accused/witness statements Face sheet/[DIAGNOSES REDACTED]. Residents most recent History and physical Current physician's orders [REDACTED]. progress notes Care plan related to incident/Kardex reviewed or revised Brief interview for mental status assessment Most recent Minimum data set X-ray reports Staffing assignments Copy of acknowledgement of submission to Department of Health ?ÇóA record of interviews ?ÇóAn explanation of evidence reviewed * Police report if appropriate per Elder Justice Act ?ÇóThe conclusion reached based on above elements and data points collected during the investigation. The conclusion is drawn following a thorough and complete investigation where critical thinking is used to review investigation and determine actions that need to be taken to prevent reoccurrence of the incident. The above education will be repeated yearly and is part of onboarding for previously identified staff. All open investigations will have a shift-to-shift hand off to next senior leader (supervisor, director of nursing, administrator, or designee) to continue investigation until all elements complete to ensure investigation is completed and closed. Any step in process missed by staff involved in investigation will receive immediate re-education by administrator or designee. Element 4 The Facility will monitor its performance to ensure that solutions are sustained by taking the following measures: Administrator or designee will update and maintain Investigation Log at the time of each event to ensure that facility appropriately responds and investigates allegations of potential misconduct per policy. Log will document elements including but not limited to the following: 1 Date incident reported 2. Resident demographics 3. type of event 4. If reportable reported within time frame 5. Investigation checklist completed 6. Conclusion 7.If any deficient practice identified remediation/education provided Log will be audited by Executive Director or designee Monday - Friday to monitor compliance. Any break in policy will be corrected immediately, and reeducation provided. Audits will continue weekly for three months. Log will be brought to Quality Assurance Performance Improvement Committee Meeting monthly. All resident investigations will continue to come to the Quality Assurance Committee as part of the standing agenda items pursuant to current regulation. Quality Assurance Performance Improvement Committee will make recommendations for change in plan, policy or education based on results of audits. Committee will make recommendations for continued monitoring and frequency of audits. The Administrator will be responsible for ongoing compliance |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 24, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during an abbreviated survey (Case #s NY 986, NY 919, NY 950, and NY 114), the facility did not 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 for 4 (Resident # ' s 1, 2, 3 and 4) of 4 residents reviewed for abuse and neglect. Specifically, (1) an allegation of abuse of Resident #1 ?Çô overheard by staff and that resulted in a broken leg ?Çô on 02/02/2025 at 5:00 PM was not reported to the New York State Department of Health until 02/03/2025 at 12:55 PM. (2) An allegation of abuse of Resident #2 ?Çô that resulted in a broken shoulder ?Çô on 11/04/2024 was not reported to the New York State Department of Health until 11/08/2024. (3) An allegation of verbal abuse on Resident #3 that was witnessed by staff on 11/05/2024 was not reported to the New York State Department of Health until 11/08/2024. (4) An allegation of physical abuse on Resident #4 that was first made known to staff on 11/09/2024 was not reported to the New York State Department of Health until 11/11/2024. This is evidenced by: Cross-referenced to: F600: Abuse Prohibition, F610: Investigate/Prevent/Correct Alleged Violations. Review of facility Abuse Prevention & Investigation Policy dated 10/14/2022, documented the following: - Residents have the right to be free from verbal, sexual, physical, and mental abuse; neglect, mistreatment, corporal punishment, involuntary seclusion, exploitation, and misappropriation of property (thereafter abuse shall be understood to include all of the above). - All employees have an obligation to report such abuses when they have reasonable cause to believe that such an incident has occurred. The facility shall follow guidelines as outlined in federal/state regulations, Dear Administrator Letters (DALs), Centers for Medicaid and Medicare State Operations Manual Appendix PP, and Trinity Health/St. Peter's Health Partners policies and procedures. The staff shall report any incident or allegation/suspicion of abuse as outlined above to the Administrator, Director of Nursing Services or their designee immediately. In cases where a crime is suspected, the facility leadership is expected to report the same to local law enforcement under the Elder Justice Act. - a. A report to the New York State Department of Health must be made immediately, but no later than 2 hours after forming the suspicion that an allegation meets the following criteria: Serious bodily injury occurred (regardless of infraction type, e.g., neglect, exploitation, misappropriation, etc.) and/or if there is suspicion that abuse has occurred. b. A report to the New York Department of Health must be made no later than 24 hours after forming the suspicion that an allegation has occurred that: Serious bodily injury did NOT occur, and the allegation involves neglect, exploitation, mistreatment, and misappropriation that does not result in serious bodily injury. c. Failure to report such incidents is considered a violation of regulations and policies governing resident abuse and compromises the facility ' s ability to provide a safe and secure environment for residents. Resident #1 Resident #1 was admitted with [DIAGNOSES REDACTED]. The Minimum Data Set (an assessment tool) dated 11/29/2024 documented the resident could usually be understood and could usually understand others with severely impaired cognition. Video surveillance footage revealed that on 02/02/2025 at 5:00 PM, Shahbaz #1 pushed Resident #1 and walked away. Resident #1 fell and sustained a fractured (broken) hip. Record review of Mobile X-ray imaging report of Resident #1's right hip, dated 02/02/2025 at 6:45 PM, revealed Resident #1 sustained a [MEDICAL CONDITION] femur (long leg bone located from hip to knee) that suggested subacute timing (that indicated it had recently occurred). During a telephone interview on 2/12/2025 at 6:49 AM, Registered Nurse #1 stated upon receiving the report of the x-ray on 2/02/2025, they became concerned with Shahbaz #1's accounting of the fall. They stated they had not been present when the fall occurred, but Shahbaz #1 was interacting with the resident. Registered Nurse #1 stated they called the Assistant Director of Nursing #1 to verbalize concerns, and requested the video be reviewed. Registered Nurse #1 stated they did not interview any staff. During an interview on 02/11/2025 at 1:00 PM, Assistant Director of Nursing #1 stated Licensed Practical Nurse #1 called them on 02/02/2025 at 7:39 PM, and they (Assistant Director of Nursing #1) did not come into the facility on [DATE] and had not reported the incident to Administrator #1 or started an investigation until 02/03/2025. During an interview on 2/13/2025 at 4:08 PM, Administrator #1 stated the complaint with abuse that occurred on 2/02/2025 to Resident #1 was reportable and had not been investigated or reported per regulation by Assistant Director of Nursing #1. They further stated Assistant Director of Nursing #1 had not notified them and had not followed the procedure in place to protect the resident; Reporting should have been completed on 2/02/2025 two hours after it the allegation was made that abuse was suspected; The video should have been viewed when the concern was raised by the staff especially given the serious injury. There was no documented evidence that the facility notified law enforcement. Record review revealed the facility submitted the Reportable Incident to the New York State Department of Health one day after the event, on 02/03/2025 at 12:55 PM. Resident #2 Resident #2 was admitted with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented resident could usually be understood and could usually understand others with severely impaired cognition for activities of daily living. Review of a Facility Reported Incident received by the New York State Department of Health on 11/08/2024 revealed the following: Resident #2 was placed on the toilet on 11/04/2024 at 6:05 PM by Shahbaz #5 and never checked on until 7:25 PM when the resident was found to have fallen on the floor. Shahbaz #5 stated that they placed Resident #2 on the toilet and left them for approximately 10 minutes, however, video camera footage did not corroborate this recounting. The facility determined this when they reviewed surveillance camera footage three (3) days later on 11/07/2024 at 2:50 PM. Shahbaz #5 was placed on suspension pending continued investigation of potential neglect, and Administrator #1 was notified of the event. Facility investigation dated 11/07/2024 documented the following: Shahbaz #5 left Resident #2 unattended on the toilet for 1 hour and 20 minutes on 11/04/2024 and supported by review of the video surveillance footage that the facility viewed three days after the event on 11/07/2024 at 02:50 PM. It identified the resident sustained [REDACTED]. During a telephone interview on 2/20/2025 at 9:08 AM, Guide #1 stated videos were to be reviewed if there was a fall or injury or any questionable situation immediately, and that was not being done. Guide #1 further stated investigations and reporting were done by the Assistant Director of Nursing, Director of Nursing, or Administration. Resident #3 Resident #3 was admitted with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE] documented resident could usually be understood and usually understand others with severely impaired cognition for daily decision making. Review of a Facility Reported Incident received by the New York State Department of Health on 11/08/2024 revealed the following: On 11/05/2024 at 7:30 PM, Resident #3 was sitting at the dining room table, stood up from the chair, and Shahbaz #5 stated Can you just sit the f*** down. It further documented that staff were first made aware of the incident on 11/07/2024 at 4:00 PM. During an interview on 02/19/2025 at 4:07 PM, Shahbaz #4 stated they reported verbal abuse of Resident #3 by Shahbaz #5 on 11/05/2024. They stated that when Resident #3 tried to stand up from the dining table, Shahbaz #5 yelled at them saying, Could you sit the F*** down. They stated that they reported the verbal abuse to Guide #1 on 11/05/2024, but it was days later before Assistant Director of Nursing #1 interviewed them. They further stated that Shahbaz #5 was not removed from resident care while the investigation was ongoing. Resident #4 Resident #4 was admitted with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], documented resident could be understood and understand others with intact cognition for daily decision making. Review of a Facility Reported Incident received by the New York State Department of Health on 11/11/2024 revealed the following: Resident #4 reported to a staff member on 11/09/2024 at 11:00 AM that Shahbaz #6 pushed them down hard onto the bed and left without providing help on 11/08/2024 at 3:00 AM. During an interview on 02/24/2025 at 12:26 PM, Licensed Practical Nurse #3 stated during morning medication pass on 11/10/2024, Resident #4 reported they had been abused by Shahbaz #6 during care given during the night shift. They stated that Resident #4 was worried about being cared for by Shahbaz #6. They stated that they (Licensed Practical Nurse #3) sent an email to Guide #1 immediately. They stated that there was no interview or investigation done regarding the reported abuse of Resident #4 by Shahbaz #6 until 11/11/2024, when they were interviewed by Assistant Director of Nursing #1. During an interview on 2/13/2024 at 5:45 PM, Director of Nursing #1 stated the reporting and investigating of complaints had not been completed timely by Assistant Director of Nursing #1. New York Codes, Rules and Regulations 415.4(b)(1)(i) | Plan of Correction: ApprovedMarch 26, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This is part of a directed plan of correction Element 1 Resident 1 was provided with medical intervention at time of incident. Resident is being monitored for any psychosocial stressors related to this event. The residents medical record was reviewed on (MONTH) 21, 2025, to determine if any changes to routine patterns were documented none identified. Social work will continue to monitor the resident to ensure no [MEDICATION NAME] psychosocial impact ( i.e. withdrawal. decrease appetite, change in sleep patterns) due to this event. Resident 2 Resident discharged on [DATE] Resident 3 Resident is being monitored for any psychosocial stressors related to this event. The residents medical record was reviewed on 3/19/25 to determine if any changes to routine patterns were documented none identified. Social work will continue to monitor the resident to ensure no [MEDICATION NAME] psychosocial impact ( i.e. withdrawal. decrease appetite, change in sleep patterns) due to this event. Resident 4 Resident 4 was interviewed on 3/20/25 to determine if they feel safe in the facility. Resident stated she does. Resident will be monitored and observed for any signs of psychosocial stressors related to this incident. Social work will continue to monitor the resident to ensure no [MEDICATION NAME] psychosocial impact ( i.e. withdrawal. decrease appetite, change in sleep patterns) due to this event. Staff cited in deficiency are no longer employed by the facility and appropriate referrals made to law enforcement and/or Office of professional discipline Element 2 All residents have the potential to be affected by stated deficiency. All residents that reside in the facility will be interviewed by social work or designee to determine if they feel safe in the facility. Any concerns will be investigated and reported as required under New York State Department of Health reporting requirements. Interviews will be completed by (MONTH) 26,2025. For any resident who is unable to be interviewed the responsible party will be contacted to determine any concerns. These contacts will be completed by (MONTH) 26, 2025. Nursing and social work will monitor the identified residents for potential adverse effects related to the to the stated deficient practice The past 30 days of incident reports will be reviewed by the Director of nursing or designee to determine thoroughness of investigation and identification of causes, contributing factors, and/or documented corrective actions to prevent reoccurrences Review will be completed by (MONTH) 26, 2025. If any areas are identified as being inconsistent with policy further investigation will be completed at time of review and if required incident reported to regulatory body per regulation and policy. All staff were educated on 2/12/25 -2/13/25 on abuse reporting requirements and abuse reporting policy Element 3 Measures taken to ensure the practice does not reoccur: *The abuse reporting/investigation policy was reviewed by the administrator, Director of nursing, and nursing administration. The policy was revised. Policy updated to state all staff have responsibility to immediately report any abuse/allegation of neglect, mistreatment or misappropriation. Policy also updated to clarify need to report all allegations within 2 hours to New York State Department of Health and as appropriate other regulatory entities. Education provided to Social work, nursing supervisor, nurse managers, and administrator and all staff by a third party consultant as part of a directed Inservice plan. Education included but not limited to the following: Definitions of abuse, neglect and mistreatment Reporting timeline Reporting obligations Investigation. The above education will be repeated yearly and is part of onboarding. All investigations will have a shift-to-shift hand off to the next senior leader (Supervisor, Director of Nursing, administrator, designee) to continue the investigation until all elements are complete to ensure investigation is completed and closed. Any steps in process missed by staff completing the investigation will receive immediate re-education by administrator or designee. Review of the Centers for Medicare and Medicaid (CMS) Critical Element Pathway with the Registered Nurse Supervisory staff to ensure full understanding of the reporting requirements. Standard work instruction developed for use by the supervisor to ensure he/she have the tools needed to report all allegations/suspected/actual incidents of abuse per policy (Immediately but no later than 2 hours) and to assist in the thorough investigation of all incidents. Element 4 The Facility will monitor its performance to ensure that solutions are sustained by taking the following measures: Audits will be completed on 5 elders and 5 staff per week. Elders will be asked if they feel safe and if they have any concerns regarding staff or care. Audits will be completed by social work or designee. Staff will be audited on his/her knowledge of abuse reporting requirements. Staff audits will be done by Nurse Manager or designee on varying shifts. Any areas identified that require follow-up or education will be done immediately. Audits be completed weekly for the first three months. Audits will be brought to the Quality Assurance Committe monthly. Committee will make recommendations based on audit results. Administrator or designee will update and maintain Investigation Log at the time of each event to ensure that facility appropriately respond and reports allegations of abuse, neglect or mistreatment. Log will document elements including but not limited to the following: 1 Date incident reported 2. Resident demographics 3. type of event 4. If reportable reported within time frame 5. Conclusion 6. If any deficient practice identified remediation/education provided Log will be audited by Executive Director or designee Monday - Friday to monitor compliance. Any break in policy will be corrected immediately, and reeducation provided. Audits will continue weekly for three months. Log will be brought to Quality Assurance Performance Improvement Committee Meeting monthly. All resident investigations will continue to come to the Quality Assurance Committee as part of the standing agenda items pursuant to current regulation. Quality Assurance Performance Improvement Committee will make recommendations for change in plan, policy or education based on results of audits. Committee will make recommendations for continued monitoring and frequency of audits. The Administrator will be responsible for ongoing compliance |