**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Complaint investigation (Complaint #NY00355221) during the Standard survey completed on 6/27/2025, the facility failed to protect residents from resident-to-resident sexual abuse for one (1) (Resident #34) of four (4) residents reviewed for abuse. Specifically, Resident #28, who had a history of exhibiting inappropriate sexual behavior in front of other residents, was observed by Certified Nurse Aide #1 on 9/21/2024 self-gratifying with their genitalia exposed in front of Resident #34, who was nonverbal and lacked the capacity to consent. There was no documented evidence interventions were put into place, Resident #28 had continued access to Resident #34, and exhibited inappropriate sexual behavior in front of Resident #34 again on 9/22/2024. Using the reasonable person concept, as referenced in the Centers for Medicare and Medicaid Services Psychosocial Outcome Severity guide, it was determined psychosocial harm occurred that is not Immediate Jeopardy. The findings include:The policy titled Abuse Investigation, last revised 7/2016, documented reporting of resident abuse and mistreatment shall be properly and thoroughly investigated. Allegations of suspected abuse shall be immediately reported to the nurse manager who shall promptly notify the Director of Nursing. The Director of Nursing would speak with the individuals involved and interview every person on duty if possible. Residents would be protected from harm during the investigation. The Director of Nursing and Administrator would review all details of the investigation to determine if there was sufficient evidence to believe abuse occurred and appropriate authorities would be notified. State Operation Manual dated 03/10/2025 documented sexual abuse was defined at 42 CFR S483.5 as non-consensual sexual contact of any type with a resident and included but was not limited to: forced observation of masturbation.Resident #28 had diagnoses including obstructive and reflux uropathy (blockage in the urinary tract hindering the normal flow of urine), hypertension (high blood pressure), and alcohol abuse. The Minimum Data Set (a resident assessment tool) dated 08/27/2024 documented Resident #28 was cognitively intact, was understood, understands, and was independent for wheelchair mobility of at least 150 feet on the unit. There were no behaviors documented during the assessment period.The comprehensive care plan dated 08/20/2024 revealed Resident #28 had a history of urinary tract infections, with intervention to irrigate catheter every shift, change catheter monthly, and encourage fluids throughout the day. Resident #28 also had a history of alcohol abuse with interventions to monitor mood patterns and determine if problems were related to external causes.Resident #34 had diagnoses including dementia with behavioral disturbances, depression, and history of cerebral infarction without residual deficits (stroke). The Minimum Data Set, dated [DATE] documented Resident #34 was severely cognitively impaired, was sometimes understood, usually understands, and required a substantial/maximal assist of one staff member for transfers, was dependent on staff for wheelchair mobility, and was non-ambulatory. The comprehensive care plan dated 07/17/2024 documented Resident #34 had a communication problem related to expressive aphasia (difficulty speaking) and was unable to verbalize needs, staff to anticipate and meet all needs and ensure/provide a safe environment. There was no documented evidence interventions were put into place to protect Resident #34 from further abuse following the incident on 09/21/2024.Review of a nursing progress note dated 07/21/2024 at 4:01 PM, Licensed Practical Nurse #1 documented that they observed Resident #28 touching themself in the hallway in front of an unidentified resident and was reminded that they need to be in the privacy of their room if they wished to do those things. There was no documented follow-up or investigation to this incident. Review of a nursing progress note dated 08/08/2024 at 5:45 PM, Licensed Practical Nurse #1 documented while assisting Resident #28 into their wheelchair with a Certified Nurse Aide, Resident #28 grabbed Certified Nurse Aide's buttocks and would not let go when told to do so. Once Resident #28 was seated in the wheelchair, the Certified Nurse Aide was able to pull themselves away from the resident. There was no documented evidence Resident #28's care plan was updated following this incident.Review of a nursing progress note dated 09/21/2024 at 5:20 PM, Licensed Practical Nurse #3 documented they were informed by Certified Nurse Aide #1 that Resident #28 was self-gratifying themselves in the hallway in front of Resident #34's room while staring into the room. Resident #28 was removed from the hallway. Resident #28 was educated that activities involving self-pleasure should only be done in their room and never in public. Review of the 24-hour report sheet dated 09/21/2024 documented Resident #28 had inappropriate behaviors; Resident #34's section was blank. There was no documented evidence that any interventions were put into place following inappropriate sexual behavior by Resident #28 towards Resident #34 on 09/21/2024. Review of a nursing progress note dated 09/22/2024 at 3:36 PM, Licensed Practical Nurse #4 documented Resident #28 was observed sitting in front of Resident #34's room with their right hand in their shorts moving up and down in a fast motion. When approached, they removed their hand. When asked what they were doing, Resident #28 stated they were just watching Resident #34. Resident #28 was removed from the hallway and educated on doing their personal duty in their room and not in front of Resident #34 because it made them uncomfortable. Review of the 24-hour report sheet dated 09/22/2024 documented Resident #34's room was changed to a room closer to the nurse's station. Resident #28 was placed on 15-minute checks after a fall at 11:30 PM and multiple attempts to get up.There was no documented evidence relating to Resident #28's inappropriate sexual behaviors towards Resident #34 or that any interventions were put into place. Review of a nursing progress note dated 09/22/2024 at 6:23 PM, Licensed Practical Nurse #5 documented Resident #34 appeared red in the face, was in a decreased mood with sad expressions. Review of facility Incident Investigation dated 90/23/2024, indicates, Registered Nurse #4 (the former Director of Nursing) documented it was reported by nursing staff that on 09/21/2024 Resident #28 was noted to be sitting outside of Resident #34's room touching themselves inside of their shorts while Resident #34 was looking at them through the open door. Resident #28 was alert, oriented, and aware of their actions. Resident #34 was non-verbal and unable to express themselves or move from the area. There was no physical contact, but staff felt that Resident #34 may have been saddened by witnessing Resident #28's behavior. The reporting nurses were interviewed and Licensed Practical Nurse #3 stated it was reported to them that Resident #28 was inappropriately touching themself in front of Resident #34. When they approached Resident #28, they were not exposed but were aggressively stroking their hand up and down in their shorts. Licensed Practical Nurse #3 removed Resident #28 from Resident #34's view and counseled them not to engage in that behavior outside of their private space. The following afternoon (09/22/2024), Licensed Practical Nurse #4 observed Resident #28 with their hand in their pants looking into Resident #34's room but could not say for certain if they were acting in a sexual manner. Resident #28 was interviewed and denied any sexual behavior, and stated they were just itching. Resident #28 also stated they remembered Resident #34 from a prior admission when they could communicate, and they were trying to get a verbal response from Resident #34, they were curious if they had helped Resident #34 in their gains with their interactions with them. Resident #34 was non-verbal with little expression, but staff noted they seemed more down yesterday (09/22/2024) following the incident.Review of a signed witness statement dated 09/24/2024, Certified Nurse Aide #1 documented on 09/21/2024 they were walking towards another resident's room when they observed Resident #28 exposing their genitalia to another resident (Resident #34), they ran and got a nurse (Licensed Practical Nurse #3) and told them about the situation. Review of a physician progress note dated 10/04/2024, revealed the Medical Director documented Resident #34 was not feeding themself well and their weight had gradually declined over the last few weeks by a few pounds. The Medical Director documented Resident #34 had an extremely flat affect and was nonverbal, but they believed Resident #34 was able to comprehend more than they were able to express.During an observation and interview on 06/23/2025 at 1:16 PM, Resident #34 was seated in their high back wheelchair and was nonverbal. Resident #34's Health Care Proxy stated Resident #34 would not have welcomed another person exposing their genitalia to them and/or self-gratifying, it would have made them very uncomfortable, and they felt that this was sexual abuse towards Resident #34. During an observation and interview on 06/25/2025 at 9:06 AM, Resident #28 was laying in their bed and stated they had no recollection of the incidents on 07/21/2024 or 09/21/2024 and 09/22/2024 involving Resident #34 and had never exposed themselves to any another resident. Resident #28 stated they had rashes in their groin occasionally and that could have been a time where a rash was active, and they were itching.During a telephone interview on 06/25/2025 at 9:47 AM, Licensed Practical Nurse #4 stated on 9/22/2024, they observed Resident #28 from behind, making a fast up and down motion with their right hand/arm, it looked like they were attempting to self-gratify while staring into Resident #34's room, who was seated in their recliner facing the doorway. Licensed Practical Nurse #4 stated that when they approached Resident #28, they pulled their hand out of their shorts and looked surprised that someone caught them; they removed Resident #28 from the area and educated them on doing their private duty in their own room. Licensed Practical Nurse #4 stated they were often Resident #28's nurse, and they did not have an active rash in their groin at the time and did not mention anything about being itchy or itching down there when asked what they were doing. Licensed Practical Nurse #4 stated they were not aware Resident #28 had been observed doing a similar behavior in front of Resident #34 the day prior, but they were aware of Resident #28 having a history of making sexually inappropriate comments to staff and self-gratifying behaviors in their room. Licensed Practical Nurse #4 stated it appeared to them that Resident #28 was self-gratifying themself in the hallway in front of Resident #34 on 09/22/2024, and when they thought about it throughout the night, they felt what Resident #28 did was abuse. During a telephone interview on 06/25/2025 at 10:05 AM, Licensed Practical Nurse #3 stated that on 09/21/2024, they were informed by Certified Nurse Aide #1 that Resident #28 was exhibiting sexually inappropriate behavior in front of Resident #34. They approached Resident #28 and saw their hand in their pants making a jerking motion up and down aggressively and did not see any genitalia exposed. Licensed Practical Nurse #3 stated Resident #28 stated they were waiting for their roommate and was adamant on staying where they were but eventually agreed to come down the hallway away from Resident #34's room. Licensed Practical Nurse #3 stated following the incident they told staff to increase their monitoring of Resident #28 and #34 for the rest of the shift, documented on the 24-hour report sheet that Resident #28 had inappropriate behavior, and educated Resident #28 on self-gratifying only in their private space, but they did not put any other interventions into place. Licensed Practical Nurse #3 stated Resident #34 did not have capacity to consent, was nonverbal and relied on staff to anticipate all needs. Licensed Practical Nurse #3 stated they were unaware of the abuse policy, so they did not report anything to anyone, but they felt this was abuse after being reeducated on abuse and abuse reporting. During an interview on 06/25/2025 at 12:20 PM, Licensed Practical Nurse #1 reviewed their progress note from 07/21/2024 and stated they did not recall the incident specifically or who the other resident involved was, but felt that Resident #28 was being sexually inappropriate in front of another resident, which they felt was sexual abuse and reported it to the Unit Manager at the time (current Director of Nursing #1). Licensed Practical Nurse #1 stated they educated Resident #28 right away and there were no further instances until 09/21/2024, but Resident #28 did have a history of being sexually inappropriate towards staff. During an interview on 06/25/2025 at 12:44 PM, Director of Nursing #1 (who was the Unit Manager at the time of the incidents on 07/21/2024, 09/21/2024 and 09/22/2024) reviewed the progress note from 07/21/2024 and stated they were never made aware of that incident and should have been so that an investigation could have been initiated. Director of Nursing #1 stated if they were made aware of the 07/21/2024 incident then the incidents on 09/21/2024 and 09/22/2024 could have possibly been prevented because they would have been more aware of Resident #28's sexually inappropriate behaviors and could have put interventions into place sooner. During a telephone interview on 06/25/2025 at 1:12 PM, Certified Nurse Aide #1 stated that on 09/21/2024 they were walking out of another resident's room after finishing care when they observed Resident #28 sitting in their wheelchair, half in the hallway and half in the doorway looking into Resident #34's room, with their genitalia exposed self-gratifying, aggressively. Certified Nurse Aide #1 stated Resident #34 was seated in their recliner approximately 10 feet away, facing the doorway, unable to speak or move and staring directly at Resident #28. Certified Nurse Aide #1 stated they were in shock and their first reaction was to run and alert Licensed Practical Nurse #3, who was at the nurse's station. Licensed Practical Nurse #3 arrived within one (1) minute and Resident #28 was removed from the area. Certified Nurse Aide #1 stated they felt as though the incident they witnessed was sexual abuse so that is why they reported it right away. They stated a reasonable person would not be okay with something like that (self-gratifying) happening in front of them, it was sexual abuse, and it should not be happening.During an interview on 06/25/2025 at 2:49 PM, Director of Nursing #1 and the Administrator reviewed the facility investigation and witness statements. Both stated they were unaware of the documented exposure incident on 09/21/2024. Both stated they agreed that this was sexual abuse and using the reasonable person concept, there was a potential for psychosocial harm to have occurred to Resident #34 from the sexually inappropriate behavior from Resident #28 on 09/21/2024 and 09/22/2024. Director of Nursing #1 and the Administrator stated the incidents on 09/21/2024 and 09/22/2024 should have been reported so that interventions could have been put into place immediately to prevent any further incidents. Director of Nursing #1 stated Resident #28 had continued access to Resident #34, and it was important to keep all residents safe. During an interview on 06/26/2025 at 9:36 AM, Director of Social Work stated they evaluated both Resident #28 and Resident #34 following the incidents on 09/21/2024 and 09/22/2024. Resident #28 denied any sexually inappropriate behavior and stated they were just itching themselves. Director of Social Work stated using the reasonable person concept, there was the potential for Resident #34 to have suffered from psychosocial harm during the incidents with Resident #28 and interventions should have been put into place following the first incident on 09/21/2024 and it should have been reported to administration. During an interview on 06/26/2025 at 9:46 AM, Licensed Practical Nurse #5 stated on 09/22/2024 Resident #34 was sitting in the hallway near the nurse's station in the late afternoon after the incident with Resident #28, and just looked off. They could not say for certain what was going on with Resident #34 because they were nonverbal, but they did not appear themselves.During a telephone interview on 06/26/2025 at 9:54 AM, Registered Nurse #4 (the former Director of Nursing) stated they were made aware on 09/23/2024 that Resident #28 exhibited inappropriate sexual behavior in front of Resident #34 on 09/21/2024 and 09/22/2024 and they initiated an investigation. They were made aware Resident #28 exposed themselves to Resident #34 and was self-gratifying, but when they spoke with Resident #28, Resident #28 denied the act and stated they were itching their groin. Registered Nurse #4 stated they were unaware Resident #28 had a previous incident where they were exhibiting inappropriate sexual behavior on 07/21/2024, and that should have been reported to them. Registered Nurse #4 stated they were aware of the alleged exposure of genitalia by Resident #28 in front of Resident #34 but could not say for certain that it occurred because they did not interview the witness. Registered Nurse #4 stated that the plan put into place following the 09/22/2024 incident was successful, so they did not feel it was abuse.During an interview on 06/26/2025 at 10:20 AM, the Medical Director stated they were not aware that Resident #28 had exposed their genitalia to Resident #34 on 09/21/2024. They were under the impression Resident #28 only had their hand in their shorts and was engaging in inappropriate sexual behavior on 09/21/2024 and 09/22/2024. Medical Director stated Resident #34 was nonverbal, had moments of clarity and some level of awareness, but did not have capacity to consent. Resident #28 had capacity and was capable of making decisions and they had enough cognition to know what they were doing but just may not have been aware of the social inappropriateness of it. The Medical Director stated Resident #34 would probably not be accepting of the interaction, it would not have been welcomed and using the reasonable person concept, there was a potential for Resident #34 to have suffered psychosocial harm from the sexual behavior exhibited by Resident #28 on 09/21/2024 and again on 09/22/2024. Interventions should have been put into place and facility administration should have been made aware immediately after the incident on 09/21/2024. The Medical Director stated they were aware Resident #28 had a history of being sexually inappropriate towards staff on occasion, but they were not aware of Resident #28 having a history of being sexually inappropriate in public areas in front of other residents and should have been made aware. 10 NYCRR 415.3(d)(1)(vii)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint investigation (#NY00355221) during the Standard survey completed on 06/27/2025, the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than two (2) hours after the allegation is made if the events that cause the allegation involve abuse, to the administrator and to other state officials (including to the State Survey Agency) for two (2) (Residents #28 and #34) of four (4) residents reviewed. Specifically, there were three (3) documented incidents in which staff observed Resident #28 exhibiting inappropriate sexual behaviors in front of two (2) different residents which were not reported to Administration. On 07/21/2024, Resident #28 was observed touching themselves in front of an unknown resident, on 09/21/2024 and 09/22/2024 Resident #28 was observed self-gratifying themselves in front of Resident #34 who was nonverbal and lacked capacity to consent. These incidents were not reported to Administration until 09/23/2024. Additionally, there was a delay in reporting the alleged abuse allegations to the New York State Department of Health. This resulted in, or had the likelihood for, psychosocial harm that is not Immediate Jeopardy for Resident #34.The findings are:The policy titled Abuse Investigation, last revised 07/2016, documented reporting of resident abuse and mistreatment shall be properly and thoroughly investigated. Allegations of suspected abuse shall be immediately reported to the nurse manager who shall promptly notify the Director of Nursing. The Director of Nursing would promptly initiate an investigation. Resident would be protected from harm during the course of the investigation. The Director of Nursing or Administrator would notify the State Health Department as soon as possible, not to exceed 24 hours after the discovery of the incident. For any instances resulting in serious bodily injury, reporting must be done within two (2) hours. 1. Resident #28 had diagnoses including obstructive and reflux uropathy (blockage in the urinary tract hindering the normal flow of urine), hypertension (high blood pressure), and alcohol abuse. The Minimum Data Set (a resident assessment tool) dated 08/27/2024 documented Resident #28 was cognitively intact and independent for wheelchair mobility of at least 150 feet on the unit.The comprehensive care plan dated 08/20/2024 revealed Resident #28 had a history of urinary tract infections, with intervention to irrigate catheter every shift, change catheter monthly, and encourage fluids throughout the day. Resident #28 also had a history of alcohol abuse with interventions to monitor mood patterns and determine if problems were related to external causes.Review of a nursing progress note dated 07/21/2024 at 4:01 PM, Licensed Practical Nurse #1 documented staff observed Resident #28 touching themself in the hallway with an unidentified resident present and was reminded they needed to be in the privacy of their room if they wished to do those things. There was no documented evidence this was reported to the Nurse Manager, Director of Nursing or the Administrator. Review of the 24-hour report sheet dated 07/21/2024 revealed no documentation regarding the sexually inappropriate behavior exhibited by Resident #28 or that Administration was notified. The facility could not provide any additional documented evidence the sexually inappropriate behavior exhibited by Resident #28 on 07/21/2024 was reported to the Administrator or Director of Nursing.During an interview on 06/25/2025 at 12:20 PM, Licensed Practical Nurse #1 reviewed their progress note from 7/21/2024 and stated they did not recall the incident specifically or who the other resident involved was, but felt that Resident #28 was being sexually inappropriate in front of another resident, which they felt was sexual abuse and reported it to the Unit Manager at the time (current Director of Nursing #1). Licensed Practical Nurse #1 stated any suspected allegation of abuse should be reported right away to Administration. 2. Resident #34 had diagnoses including dementia with behavioral disturbances, depression, and history of cerebral infarction without residual deficits (stroke). The Minimum Data Set, dated [DATE] documented Resident #34 was severely cognitively impaired, was sometimes understood, usually understands, and required a substantial/maximal assist of one (1) staff member for transfers, was dependent on staff for wheelchair mobility, and was non-ambulatory. The comprehensive care plan dated 07/17/2024 documented Resident #34 had a communication problem related to expressive aphasia (difficulty speaking) and was unable to verbalize needs, staff to anticipate and meet all needs and ensure/provide a safe environment. There was no additional documentation related to the incidents.Review of nursing progress notes revealed the following:-On 09/21/2024 at 5:20 PM, Licensed Practical Nurse #3 documented they were informed by Certified Nurse Aide #1 that Resident #28 was self-gratifying in front of Resident #34, Resident #28 was educated and removed from the area. -On 09/22/2024 at 3:36 PM, Licensed Practical Nurse #4 documented Resident #28 was observed self-gratifying in front of Resident #34, Resident #28 was educated and removed from the area. There was no documented evidence the inappropriate sexual behavior incidents were reported to the Director of Nursing or Administrator. Review of 24-hour report sheets revealed the following:-On 09/21/2024 during the 7:00 AM - 7:00 PM shift, Resident #28 had inappropriate behaviors; Resident #34's section was blank. -On 09/22/2024 during the 7:00 AM - 7:00 PM shift, Resident #34's room was changed to a room closer to the nurse's station. Resident #28 was placed on 15-minute checks after a fall at 11:30 PM and attempts to get up multiple times. There was no documented evidence the inappropriate sexual behavior incidents were reported to the Director of Nursing or Administrator. Review of the New York State Department of Health Complaint Tracking System Complaint/Incident Investigation Report revealed the date/time of the alleged incident was 09/21/2024 at 3:00 PM. The date/time the Administrator was first made aware of the incident was 09/23/2024 at 9:30 AM. It was submitted by the facility on 09/23/2024 at 12:22 PM.Review of facility Incident Investigation dated 09/23/2024 at 8:00 AM, Registered Nurse #4 (the former Director of Nursing) documented it was reported by nursing staff that on 09/21/2024 at 3:00 PM Resident #28 was noted to be engaging in inappropriate sexual behavior while Resident #34 was looking at them through the open door. Resident #28 was alert, oriented, and aware of their actions. Resident #34 was non-verbal and unable to express themselves or move from the area, but staff felt that Resident #34 may have been saddened by witnessing Resident #28's behavior. The following afternoon (09/22/2024 at 3:30 PM) Licensed Practical Nurse #4 observed Resident #28 with their hand in their pants looking into Resident #34s room. Resident #34 was non-verbal with little expression, but staff noted they seemed more down yesterday (09/22/2024) following the incident. Both incidents were reported to Registered Nurse #4 on 09/23/2024 at 8:00 AM. During a telephone interview on 06/25/2025 at 9:47 AM, Licensed Practical Nurse #4 stated that on 09/22/2024 they observed Resident #28 from behind, making a fast up and down motion with their right hand/arm, looked like they were attempting to self-gratify while staring into Resident #34s room; they removed Resident #28 from the area and educated them on doing their private duty in their own room. Licensed Practical Nurse #4 stated they were not aware Resident #28 had been observed doing a similar behavior in front of Resident #34 the day prior and they did not report anything to Administration because they did not want to accuse Resident #28 of doing something they might not have been doing. Licensed Practical Nurse #4 stated it appeared to them that Resident #28 was self-gratifying themself in the hallway in front of Resident #34 on 09/22/2024, and when they thought about it throughout the night, they felt what Resident #28 did was abuse and reported it to the Director of Nursing on 09/23/2024.During a telephone interview on 06/25/2025 at 10:05 AM, Licensed Practical Nurse #3 stated that on 09/21/2024 they were informed by Certified Nurse Aide #1 that Resident #28 was exhibiting sexually inappropriate behavior in front of Resident #34. They approached Resident #28 and saw their hand in their pants making a jerking motion up and down aggressively and did not see any genitalia exposed. Licensed Practical Nurse #3 stated they did not report the incident to the Administrator or Director of Nursing because they were unaware of the abuse policy; they should have reported the incident right away to Administration. During an interview on 06/25/2025 at 12:44 PM, Director of Nursing #1 (who was the Unit Manager at the time of the incidents on 07/21/2024, 09/21/2024 and 09/22/2024) reviewed Licensed Practical Nurse #1's progress note from 07/21/2024 regarding Resident #28's sexually inappropriate behavior in front of another resident and stated they were never made aware of that incident, and should have been so that an investigation could have been initiated. Director of Nursing #1 stated if they were made aware of the 07/21/2024 incident then the incidents on 09/21/2024 and 09/22/2024 could have possibly been prevented because they would have been more aware of Resident #28's sexually inappropriate behaviors. Director of Nursing #1 stated in order to ensure all residents safety, all suspected allegations of abuse should be reported to administration immediately so that an investigation can be initiated. Director of Nursing #1 stated all suspected allegations of abuse should be reported to the Department of Health within two (2) hours. During a telephone interview on 06/25/2025 at 1:12 PM, Certified Nurse Aide #1 stated that on 09/21/2024, they observed Resident #28 sitting in their wheelchair, half in the hallway and half in the doorway looking into Resident #34's room, with their genitalia exposed self-gratifying themself aggressively, while Resident #34 was seated in their recliner, facing the doorway, unable to speak or move and staring directly at Resident #28. Certified Nurse Aide #1 stated they were in shock and their first reaction was to run and alert Licensed Practical Nurse #3, who was at the nurse's station. Licensed Practical Nurse #3 arrived within one (1) minute and Resident #28 was removed from the area. During an interview on 06/25/2025 at 2:49 PM, Director of Nursing #1 and the Administrator stated the incidents on 07/21/2024, 09/21/2024, and 09/22/2024 should have been reported right away to Administration so that interventions could have been put into place to prevent any further incidents. Director of Nursing #1 and the Administrator stated all suspected allegations of sexual abuse should be reported within two (2) hours to the Department of Health. These incidents were considered sexual abuse, they should have been reported immediately so that Administration could have reported in the required time frame. Director of Nursing #1 stated Resident #28 had continued access to Resident #34, and it was important to keep all residents safe. During an interview on 06/26/2025 at 9:36 AM, the Director of Social Work stated any allegations of abuse should be reported to Administration right away so that they could be reported to the appropriate authorities within two (2) hours. They stated the incident involving Resident #28 and Resident #34 on 09/21/2024 should have been reported immediately to Administration so that an investigation could have been initiated. They stated the incident on 07/21/2024 should have been reported to Administration so that it could have been investigated.During a telephone interview on 06/26/2025 at 9:54 AM, Registered Nurse #4 (the former Director of Nursing) stated they were made aware on 09/23/2024 of Resident #28 exhibiting inappropriate sexual behavior in front of Resident #34 on 09/21/2024 and 09/22/2024 and should have been made aware immediately following the incidents. Registered Nurse #4 stated they were unaware Resident #28 had a previous incident where they were exhibiting inappropriate sexual behavior on 07/21/2024 and that should have been reported to them. During an interview on 06/26/2025 at 10:20 AM, the Medical Director stated all suspected allegations of abuse should be reported to administration immediately so that an investigation can be initiated. The Medical Director stated all suspected allegations of abuse should be reported to the Department of Health within two (2) hours. 10 NYCRR 415.4(b)(2)