Based on observation, record review and interview during the recertification and abbreviated (NY00314754, NY00319010, NY00320020, NY00327419, NY00331182, and NY00334923) surveys conducted 3/18/2024-3/29/2024 the facility failed to provide adequate supervision to prevent accidents for 4 of 10 residents (Residents #114, #174, #191, and #213) reviewed. Specifically, Residents #114, #191, and #213 were subjected to physical aggression and sexually abusive behaviors by Resident #174 and the facility failed to develop or implement strategic interventions for Resident #174 to protect other residents from victimization. Subsequently, Resident #174 pushed Resident #114 causing Resident #114 to sustain a hip fracture; Residents #174 and #213 were found in sexually inappropriate situations three times; and Resident #174 pushed Resident #191 causing them to hit their head against a wall causing an abrasion. This resulted in harm to Residents #191 and #114 that was not immediate jeopardy. Findings include: The facility policy Abuse Prevention modified 3/2019 documents the facility would not permit residents to be subjected to abuse by other residents. Residents will be provided with appropriate clinical care and treatment and will be cared for according to the individualized care plan. Incidents of resident-to-resident altercations must be reported to the Administrator and addressed by the interdisciplinary team members and care planned accordingly. In such instances the resident that is the perpetrator and all residents who may be vulnerable to the perpetrating resident must have their care documented with immediate safety action taken. The facility policy Behavior Protocol-Handling Problem Behaviors modified 2/2019 documents that all disciplines will implement appropriate strategies to eliminate problem behaviors which may cause emotional and physical problems to both residents and staff. Staff will document in the electronic medical record interventions which were used to attempt to eliminate the behavior, indicating if the interventions were successful. The attending physician/nurse practitioner will be consulted for further recommendations and/or interventions/orders. Resident #174 had diagnoses including frontotemporal neurocognitive disorder (dementia caused by damage to neurons in the frontal and temporal lobes of the brain), aphasia (difficulty expressing themself), and wandering. The 3/15/2023 Minimum Data Set documented the resident had severe cognitive impairment and did not exhibit physical or verbal behavioral symptoms directed toward others. The 9/5/2023 Minimum Data Set assessment documented the resident had intact cognition, verbal behaviors directed toward others for 1-3 of 7 days, other behavioral symptoms not directed toward others for 1-3 of 7 days, wandered for 1-3 of 7 days, was independent with most activities of daily living, received a daily antidepressant, and used a wander alarm. Resident #174's comprehensive care plan initiated 10/10/2022 and updated 2/27/2023 documented the resident had confusion, wandered, had potential to be verbally aggressive, liked to kiss peers on the forehead and rub back/shoulders, had dementia, had potential for physical aggressiveness, and had behavior problems. Interventions included remind of socially acceptable behaviors, invite to small groups, music in room, 1:1 supervision if needed, independent activity materials provided, walk, TV, care magazines, movies, assess for fall risk, wander risk tool at admission/quarterly/as needed, distract, redirect, wander detection device on right ankle, intervene immediately, encourage to visit peers in public areas, avoid taking inappropriate behaviors lightly, separate residents if sexually inappropriate behaviors noted, medications as ordered, remove from situation, and close door if masturbating. Resident #114 had diagnoses including impulsiveness, emotional lability (rapid, often exaggerated changes in mood), and aphasia (difficulty speaking). The 3/21/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, did not exhibit behavioral symptoms, did not wander, and required supervision when walking in the corridor and locomotion on the unit. Resident #191 had diagnoses including dementia, anxiety, and insomnia. The 6/1/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, had physical and verbal behavioral symptoms directed toward others for 1-3 of 7 days, wandered for 4-6 of 7 days, required supervision of 1 for walking in the corridor and locomotion on the unit, did not use mobility devices, and used a wander alarm daily. Resident #213 had diagnoses including Alzheimer's disease, restlessness and agitation, and wandering. The 11/15/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, did not exhibit behavioral symptoms, did not wander, required partial/moderate assistance with walking, and did not use a wander alert device. Nursing progress notes for Resident # 174 documented: - from 1/9/2023 -2/19/2023, the resident exhibited aggressive behaviors including throwing items, slamming, and kicking their door, standing in the hall naked, wandering the unit, becoming impatient and agitated with other residents, swinging at staff, touching other residents, and allowing other residents to touch them, - on 1/20/2023 the resident was examined by the physician with a new order for Celexa (antidepressant). - on 2/24/2023 at 5:04 PM, staff witnessed Resident #174, and another resident enter Resident #174's room and close the door. Staff entered and witnessed the other resident rubbing Resident #174's genitals, both residents were fully clothed. The residents were separated, and Resident #174 was placed on 1:1 supervision, monitored for 72 hours, and the physician was notified. - on 2/27/2023 at 2:10 PM, the physician was updated on the resident's behaviors and a new order was to discontinue Celexa and start Prozac 20 milligrams daily for inappropriate sexual behaviors. - from 2/24/2023-3/1/2023, documented 1:1 supervision continued - on 3/1/2023 at 11:00 AM, 1:1 supervision was completed. Resident #174's comprehensive care plan was revised on 2/27/2023. Another resident was witnessed rubbing Resident #174's genitals over their pants, both residents were fully clothed. Interventions included avoid taking inappropriate behaviors lightly or dismissing as a fluke. Provide 1:1 supervision if indicated. A 3/2/2023 psychiatric nurse practitioner #21 progress note documented the resident was seen per request of staff for frontotemporal dementia with behaviors and sexually inappropriate behaviors. Staff reported sexually inappropriate behaviors of masturbating, and giving attention to other residents, including rubbing their backs. The resident had not touched anyone on private areas of the body. Otherwise, staff did not report any aggression. There was an episode where staff found the resident with a female in their room who was rubbing the resident's genitals over their pants, but both residents were fully clothed, and they were separated. Selective serotonin reuptake inhibitors (antidepressants) can help manage behaviors associated with dementia. If sexually inappropriate behaviors continue, they would recommend starting Tagamet twice a day. The resident would be followed in 2-4 weeks. Nursing progress notes documented: -on 3/4/2023 at 9:43 PM, staff were watching the resident with females as the resident had been petting their hands all day. Staff made sure the resident was not taking anything further. - on 3/12/2023 at 1:08 PM, the resident was following another resident around attempting to play with their hair, at one point staff intervened with gentle direction. - on 3/15/2023 at 1:16 PM, the physician increased Prozac to 30 milligrams daily. - on 3/17/2023 at 2:19 PM, walking around trying to get another resident to go in their room. They proceeded to follow the resident around and was redirected back to their room. - from 3/18/2023-4/13/2023 episodes of slamming and hitting the door, throwing things in their room, and becoming agitated with other residents. A 4/5/2023 physician #18 progress note documented the resident had frontotemporal dementia with negative behaviors and poor impulse control. The increased dose of Prozac would be continued. The resident was definitely doing better according to aides with regards to negative behaviors and mood lability. A 4/14/2023 Accident/Incident Report for Resident #174 completed by registered nurse Unit Manager #24 documented at 7:00 AM, staff heard a thud and found Resident #114 on the floor against the closet of Resident #174's room. Resident #174 was standing near Resident #114 and stated they pushed Resident #114 because they were in their room. Immediate interventions included registered nurse assessment and aggressive behavior monitoring for 72 hours. A 4/14/2023 Accident/Incident Report for Resident #114 completed by Registered Nurse Unit Manager #24 documented at 7:00 AM, Resident #114 was found in Resident #174's room on the floor. Resident #114 stated Resident #174 pushed them. Neuro checks were at baseline, no injury to head, moving all extremities, and without pain. Transferred with assistance of 2 and resident complained of left hip/leg pain once weight bearing. The resident was transported to bed in a wheelchair and was awaiting transport to hospital for evaluation. A 4/14/2023 at 12:44 PM, Registered Nurse Unit Manager #24's progress note documented they called the hospital to check on the status of Resident #114 and was told the resident had a left hip fracture and was waiting for orthopedics. Resident #114's comprehensive care plan initiated 8/23/2022 documented the resident had potential to be physically aggressive related to anger at placement may strike at others. Interventions included to intervene when agitated before escalation and guide away from source of distress. A 4/14/2023 at 2:36 PM, social worker #26 progress note documented they spoke to Resident #174 following the incident with their peer. The resident reported they pushed Resident #114 out of their room. Resident #174 was reminded to ask staff for help if they were bothered or concerned. Resident #174's 4/14/2023 updated comprehensive care plan documented the resident had potential for physical aggressiveness and pushed a peer who wandered into their room causing a fall. Interventions included move peers out of harm's way, remind resident they could cause harm, privacy curtain on doorway, stop sign across door to prevent peers from entering room, may close door for privacy and to keep peers from entering room. Resident #114's comprehensive care plan initiated 4/14/2023 documented the resident had potential to be a victim of abuse related to another resident's intrusive behavior. Resident was found on the floor of Resident #174's room. Interventions included provide environmental barriers to ensure safety-stop sign placed in doorway of Resident #174 to deter Resident #114 from entering. A 4/15/2023 physician #18 progress note documented Resident #174 had aggressive behaviors and poor impulse control, at times. The resident was more mellow with increased dose of Prozac. The plan was to continue the present dose of Prozac 30 milligrams daily and the resident was doing better with negative behaviors and mood lability. A 5/10/2023 physician #18 progress note documented the resident had occasional issues with poor impulse control, verbally and physically. The resident was not perceived as a danger to staff or others. The increase in Prozac seemed to have helped. Nursing notes for Resident #174 documented: - on 5/10/223 at 3:16 PM, the resident was redirected by staff for trying to remove other residents from their room. The resident was reminded to seek staff assistance. The stop sign in doorway was replaced as the resident kept removing and placing it in their closet. - on 5/18/2023 at 10:22 PM the resident was observed trying to kiss another resident on the mouth. Typically, the resident would kiss on the cheek. - on 5/28/2023 at 9:50 PM, the resident became agitated with another resident when they took the stuffed animals they were playing with. Resident #174 followed the resident and raised their arms toward them, but staff quickly intervened and separated the residents. - on 5/30/2023 at 3:14 PM the resident threw a stuffed animal at another resident A 7/4/2023 Accident/Incident Report completed by illegible name and title documented at 7:15 PM, Resident #191 was in Resident #174's room. Resident #174 was telling Resident #191 to leave the room. Resident #191 left the room and Resident #174 pushed Resident #191 on the upper back, causing Resident #191 to shuffle forward. Resident #191 did not fall. Resident #191 was assessed without injury and redirected away from Resident #174. Resident #191 was redirected to their room without further issues. Both residents would be monitored for a minimum of 72 hours for signs of fearfulness or change in behavior. Resident #191 would be monitored for a minimum of 72 hours for aggressive behavior. The plan of care was followed. Resident #191's care plan was updated on 7/4/2023 to include the resident was subject to physical aggression from peers. Interventions included resident would be free of physical aggression by peers. The care plan did not identify new interventions to ensure the resident was free from aggression by peers. Resident #174's care plan was revised on 7/4/2023 to include the resident had potential to be physically aggressive (initiated 2/27/2023) and pushed a peer up against the wall. There were no additional documented interventions. The 7/7/2023 physician #18 progress note documented Resident #174 had their own room and occasionally had negative behaviors with other residents wandering into their room. Staff did their best to avoid the situation. Resident #174 was usually peaceful but became agitated when others wandered into their space. A gradual dose reduction of medication was not currently indicated. Nursing notes for Resident #174 documented: - on 7/27/2023 at 9:17 PM the resident attempted to hit another resident and was redirected. - on 8/4/2023 at 10:46 PM the resident kept throwing a book across the room and ripping out pages. When asked by staff to go to their room they started slamming and kicking the door and kicked a staff in the legs. - on 8/7/2023 psychiatric nurse practitioner #21 was updated on the resident's aggressive behavior and ordered gabapentin 100 milligrams three times daily for agitation. - No negative behaviors were documented from 8/8/2023-8/31/2023. - on 9/1/2023 at 10:32 PM the resident was yelling at another resident, was asked to go to their room, and began kicking the door of their room. - on 9/11/2023 at 7:40 PM the resident had a verbal altercation with another resident. - on 10/5/2023 at 6:31 AM, note states, at 1:30 AM the resident was sitting next to a female resident who was sleeping. The resident attempted to place their hands inside of the female resident's inner thigh. A 10/9/2023 Accident/Incident Report completed by Registered Nurse Unit Manager #24 documented at 3:15 PM Resident #191 was witnessed in Resident #174's room falling to the floor, hitting the right side of their head on the wall as they fell. Resident #174 was standing over Resident #191 then walking away. Resident #191 was crying and would not give a statement. The nurse practitioner examined Resident #191. The resident had a small abrasion on the right ear that required treatment. The resident was wandering per usual shortly thereafter. The care plan was followed, and the plan was to monitor for 72 hours. An unsigned narrative included with the report documented Resident #174 stated they pushed Resident #191 because they were in their room. Both residents would be monitored for a minimum of 72 hours for signs of fearfulness, change in behavior, and aggression. Resident #174 was placed on aggressive behavior charting for a minimum of 72 hours. Resident #191's care plan was revised to include pushed by peer on 10/9/2023. There were no documented revised interventions to ensure the resident remained free of accident hazards. Resident #174's care plan was revised to include they pushed their peer on 10/9/2023. There were no documented revised interventions to protect other residents from aggressive behaviors. On 11/3/2023 at 9:54 PM the resident was reported to be standing over a peer while sleeping and was redirected. The 11/8/2023 nurse practitioner #20 progress note documented Resident #174 could be easily irritable and agitated with staff and other residents. The resident was currently on gabapentin and Prozac. Typically, the resident was easily redirected. The plan was to continue gabapentin and Prozac and non-pharmaceutical interventions. No gradual dose reduction of medication was indicated. A 12/10/2023 Accident/Incident Report completed by illegible name and title documented at 3:45 PM the Supervisor and unit nurse notified them Resident #213 was observed in the dining room sitting on Resident #174's lap. Resident #174 was fondling Resident #213's breasts. The residents were separated. There were no signs of physical or emotional trauma. The included unsigned narrative documented Resident #174 had demonstrated physical behaviors directed toward others as evidence by masturbating with their door open, mutual touching of genitals, had potential to be physically aggressive, went into other resident's rooms, and was exit seeking. Both residents would be monitored for a minimum of 72 hours for any change in behaviors, fearfulness, or aggression. Resident #213's care plan initiated 12/12/2023 documented the resident had the potential for being a victim of abuse related to another resident's behavior, inappropriate closeness, and intrusive behavior. Interventions included redirect resident away from male peers with known history of sexually inappropriate behavior, discourage from rubbing and kissing peers, encourage, and praise appropriate interactions with peers, and encourage attendance at activities to prevent boredom. Resident #174's care plan was revised on 12/10/2023 to include resident was noted rubbing Resident #213 on the outside of their shirt while sitting on their lap. There were no revised interventions to protect other residents from inappropriate behaviors. A nursing progress noted dated 12/11/2023 at 3:31 PM document Resident #174 was agitated. The resident was given space and left alone to calm down. The resident went to their room and returned for breakfast. The resident was seen touching a peer and staff intervened. The 1/3/2024 physician #19 progress note documented Resident #174 had increased outbursts and behaviors with staff and other residents. Staff had stated they have not noted any changes in resident behaviors that would be detrimental. The resident was easily redirected and able to maintain independence. The resident had good behavioral control with Prozac 10 milligrams daily and gabapentin 100 milligrams three times a day for agitation. The resident followed directions and was primarily aphasic (did not speak clearly). Aggressive behaviors had been controlled with current medication dosages. Nursing staff had no concerns with overall behaviors. An Accident/Incident Report dated 2/20/2024 completed by illegible registered nurse documented at 2:15 PM Resident #174 was found with a peer laying across them fully clothed on Resident #174's bed. Resident #174's hand was on the resident's groin. Staff immediately separated the residents. Immediate interventions included registered nurse assessment, separation of the residents, and behavior forms were initiated. A nursing note dated 2/22/2024 at 10:34 AM documented Resident #174 was rubbing a couple of residents' knees while sitting on the couch in the TV area. The residents were asleep on the couch. A nursing note dated 2/24/2024 at 9:51 PM documented Resident #174 was lying in their bed with another resident who was fully clothed. Resident #174 had their pants down with an erect penis. The residents were separated. Resident #174 was placed on 30-minute safety checks. An Accident/Incident Report dated 2/24/2023 at 8:15 PM completed by illegible licensed practical nurse documented they were called to the unit for witnessed sexually inappropriate behavior. Resident #213 was in Resident #174's room. Resident #174 had their pants down with an erect penis. The residents were separated immediately, and Resident #213 denied pain or discomfort. Immediate interventions included the residents were separated, 15-minute checks, registered nurse assessment and transfer to appropriate unit when available (did not indicate which resident would be transferred). There was no documented evidence Resident #174's comprehensive care plan was revised to include interventions to keep other resident's safe from aggression and sexual contact by Resident #174. A nursing progress note dated 2/25/2024 at 9:24 PM documented the resident exited the dining room with their pants halfway down and had an erection. At 9:35 PM the resident was found standing in another resident's room while the other resident was sleeping. The other resident's blanket was pulled down and their brief was exposed. Resident #174 was redirected and encouraged not to go in other's rooms. During an interview on 3/20/2024 at 9:47 AM, certified nurse aide #22 stated for a resident-to-resident incident, staff tried to keep them away from each other post incident. They received dementia training about 3 months ago and were taught to redirect using various methods, try to deescalate the situation, remove the residents from the situation, and walk with the residents. Those techniques were also used to prevent residents from wandering into others' rooms. The facility had used stop signs in the past, but the facility stopped using them on the dementia unit. The aide did not know why the stop sign usage stopped. Resident specific interventions were listed on a resident's care instructions. The dementia unit had multiple residents that wandered. Resident #174 was sexually inappropriate at times and the facility implemented a door sensor in the room doorway about 3 weeks ago. The aide stated that Resident #114 was wandering the unit the morning of 4/14/2023. The aide was providing care to another resident on 4/14/2023 when they heard a thud in Resident #174's room, entered the room, saw Resident #114's feet as they were leaning against the wall by the closet, and Resident #114 was moaning. Resident #174 stepped out of the room after Resident #114 stated Resident #174 pushed them and left the room. There was no stop sign on the door prior to the incident. Resident #174 had not been aggressive with any residents prior to that incident. Resident #174 usually exited their room to get a staff member to deal with the situation. Staff tried to supervise the resident's room at least every 20-30 minutes. Staff used a 1:1 intervention frequently on the unit. Resident #174 could be sexual and had a door sensor on their room. Resident #213 also had sexual behaviors and they were moved for that reason. When the door sensor alarm went off, they checked to see if another resident went into Resident #174's room. The door sensor was implemented about a month ago. They tried to keep eye on the door and check but there were no set times and tried every 20-30 minutes. During an interview on 3/21/2024 at 12:11 PM, certified nurse aide #23 stated resident-specific interventions were documented in the care instructions. The main interventions used were reapproach, redirect, offer food/fluids, and intervene. Resident #191 was frequently in other residents' spaces and wandered the unit. Staff tried to keep a close eye on residents but that depended on staffing numbers. Resident #174 was a younger resident who still had a lot of sexual urges/needs. Prior to putting a door sensor on Resident #174's room door recently, staff frequently rounded the unit and tried to keep an eye on their room. Resident #174 only lashed out if certain residents went into their room. Resident #174's room door was usually kept closed and they previously had a stop sign across the doorway. The aide did not know what happened to it. Resident #213 was moved off the unit as they had liked to get intimate with male residents, particularly Resident #174. During an interview on 3/21/2024 at 1:10 PM, Registered Nurse Manager #24 stated there were independent activities kept on the dementia unit to use as distraction for some residents. Unit staff tried to keep known aggressive residents away from residents they tended to target. Staff had tried stop signs and curtains as deterrents from wanderers going into others' rooms. The residents took them down. Staff checked on each resident at least every hour. Door sensors were also implemented. Resident #174 had behaviors of verbal and physical aggression and was sexually inappropriate at times. The resident attended a lot of supervised activities. Resident #174 did not like other residents in their room and pushed them when they entered. Resident #174 removed barriers that staff put across their doorway to deter others from entering. Staff encouraged Resident #174's door to be closed until Resident #213 was found in the room in inappropriate manners. Resident #114 sustained a fractured hip when Resident #174 pushed them in their room. Resident #174 admitted to pushing the resident. The Manager thought that was the first time Resident #174 was physically aggressive with another resident. Staff attempted to supervise Resident #174 and their room but could not always be in the hallways as they had to provide resident care. Resident #174 now had a door sensor to alert staff that someone was going in or out of their room. Resident #174 was impulsive in the moment and quickly reverted to calmness post incident. Behavioral interventions were discussed as needed as an interdisciplinary team during morning reports. During an interview on 3/21/2024 at 3:53 PM, the Director of Nursing stated when there were resident-to-resident interactions on the dementia unit, they expected staff to use a lot of activities, keep residents in sight as much possible, engage the resident, and constant rounds when providing care. Staff were expected to redirect each resident before an incident could occur. Alarms were to alert staff of a potential situation and nurses were usually in the hallway giving medications. Staff were not able to be in the hallway at all times. Behavioral interventions were in the care plan and care instructions. Resident #114 broke their hip when they entered Resident #174's room and was pushed. That could have been prevented if staff saw Resident #114 ambulating on the unit and enter the room. Resident #191 sustained an abrasion when they were pushed and hit their head while in Resident #174's room. The incidents with Resident #174 and Resident #213 could have been prevented if staff saw them together prior to being inappropriate. In each instance, the residents were placed on hourly checks for 72 hours. Resident #213 was moved to a different unit to prevent reoccurrences. During an interview on 3/21/2024 at 4:41 PM, physician #4 stated Resident #114 sustained harm of a fractured hip and Resident #191 sustained an abrasion when they were pushed by Resident #174. 10 NYCRR 483.25(d)