On June 28, 2023 a
Exhibit,Appendix
was filed
involving a dispute between
People Of The State Of New York, By Letitia James, Attorney General Of The State Of New York,
and
Abraham Operations Associates Llc Dba Beth Abraham Center For Rehabilitation And Nursing,
Aharon Lantzitsky,
Amir Abramchik,
Aron Gittleson,
Beth Rozenberg,
Bis Funding Capital Llc,
Centers For Care Llc Dba Centers Health Care,
Cfsc Downstate Llc,
Daryl Hagler,
David Greenberg,
Delaware Operations Associates Llc Dba Buffalo Center For Rehabilitation And Nursing,
Delaware Real Property Associates Llc,
Elliot Kahan,
Hollis Operating Co Llc Dba Holliswood Center For Rehabilitation And Healthcare,
Hollis Real Estate Co Llc,
Jeffrey Sicklick,
Jonathan Hagler,
Kenneth Rozenberg,
Leo Lerner,
Light Property Holdings Ii Associates Llc,
Mordechai Moti Hellman,
Reuven Kaufman,
Schnur Operations Associates Llc Dba Martine Center For Rehabilitation And Nursing,
Skilled Staffing Llc,
Sol Blumenfeld,
for Commercial - Other - Commercial Division
in the District Court of New York County.
Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023
NYSCEF BOC. NO. 570 RECEIVED NYSCEF: 06/28/2023
PETTIGREW EXHIBIT 134
INDEX NO. 451549/2023
NYSCEF DOC. NO. 570 RECEIVED NYSCEF 06/28/2023
Department of Health & Human Services Printed: 07/25/2022
Form Approved OMB.
Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. Building
335503 B. Wing 12/06/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
195 44 Woodhull Avenue
Holliswood Ctr for Rehabilitation and Healthcare
Hollis, NY 11423
For information on the nursing home's planto correct this deficiency, please contact the nursing home or the state survey agency.
(x4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES.
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody,
Level of Harm - Minimal harm
or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Residents Affected - Few Based on observations, interviews, and record review conducted during an abbreviated survey (NY 687) on
10/27/2021, the facility did not ensure that a resident was free from Sexual Abuse. This was evident in 1 out
6 residents sampled (Resident #3). Specifically, on 07/18/2020, a staff member observed Resident #1 with
his/her hand inside of Resident #3's, who was sitting in the dining room, diaper that was ripped opened. A
few minutes prior to incident, Resident #1 was observed with his/her hands on the midsection of Resident #2
the resident was sitting in the dining room. Resident #1 was not removed from the dining room immediately
when he/she was observed touching Resident #2 inappropriately. The facility did not protect Resident #3
from sexual abuse,
The findings are:
Review of the facility's policy and procedure entitled Abuse last revised in 02/2019 documented:
The facility prohibits the mistreatment, neglect, and abuse of resident/patients and misappropriation of
resident/patient property by anyone. The facility has designed and implemented processes, which strive to
ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment ,
and/or misappropriation of property. The facility will ensure that prevention techniques are implemented in
the facility, not limited to, ongoing supervision of employees through visual observation of care delivery and
recognition of signs of burnout, frustration, and stress. The facility will identify, correct, and intervene in
situations where abuse, neglect, and/or mistreatment are more likely to occur which includes secluded areas
of the facility. The facility will have sufficient staffing on each shift to meet the needs of the residents/patients
and reinforce staff education, with emphasis on reporting of concerns, incidents, and grievances.
A Facility's Investigation Form dated 07/20/2020 documented that on 07/18/2020 at approximately 11:08 AM,
Resident #1 was observed in the far corner of the dining room next to Resident #3 who was laying in his/her
Geri-chair. As per the Home Health Aide (HHA), Resident #1 had his/her hand inside the front of Resident #3
diaper. As per the HHA, Resident #1 pulled back the cover sheet and the HHA saw Resident #1 moving
his/her hand under Resident #3 diaper. The HHA immediately separated the residents and informed the
charge nurse. When Resident #1 was asked what he/she was doing, Resident #1 said that he/she was
touching Resident #3's vagina. Resident #3 was evaluated with no visible injury. The Physician, Nurse
Practitioner (NP), the Police and family were informed. Resident # 1 was transferred to the emergency room
(ER) for Psychiatric evaluation. The Investigation concluded that abuse occurred
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (x6) DATE
REPRESENTATIVE'S SIGNATURE
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet
Previous Versions Obsolete 335503 Page1 of 4
INDEX NO. 451549/2023
NYSCEF DOC. NO. 570 RECEIVED NYSCEF 06/28/2023
Department of Health & Human Services Printed: 07/25/2022
Form Approved OMB
Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (XI) PROVIDER/SUPPLIER/CLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. Building
335503 B. Wing 12/06/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
195 44 Woodhull Avenue
Holliswood Ctr for Rehabilitation and Healthcare
Hollis, NY 11423
For information on the nursing home's planto correct this deficiency, please contact the nursing home or the state survey agency.
(x4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600 1) Resident #1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR
PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 05/06/2020
Level of Harm - Minimal harm or documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention,
potential for actual harm orientation, and ability to recall information) score of 06/15, associated with severely impaired cognition.
Residents Affected - Few Resident #1's At Risk for Abuse Care Plan was initiated on 06/01/2016, last updated 05/20/2020. The
interventions documented to assess the resident for signs and symptoms of abuse and investigate all
allegations of abuse promptly.
Resident #1's Psychiatry Consult dated 07/06/2020 at 9:37 AM documented that Resident #1 was seen for
follow up. Resident #1 was alert and oriented x 2, calm, cooperative and sexually preoccupied. Resident #1
had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . As per staff, the resident seemed to be
paranoid with aggressive behavior towards other residents. Resident #1 denied side effects from
medications. Support and counselling provided as well as psych education, Recommended medication
change: start [MEDICATION(S)] 1 MG orally twice a day.
The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .
The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER]
Resident #1's Assessment Note dated 07/18/2020 at 9:35 PM documented that at approximately 11:05 AM,
the charge nurse reported that Resident #1 was observed with his/her hand near the midsection of Resident
#2, CNA approached and Resident #1 quickly moved away. Within a few seconds after, Resident #1 was
observed with his/her hands in Resident #3 's diaper. The CNA intervened and removed Resident #1. The
residents were separated and body checks were done on Resident #2 and Resident #3. No evidence of
vaginal trauma noted. Resident #1 stated that he/she was touching Resident #3's vagina and Resident #3
liked it. The Physician, Nurse Practitioner (NP) and Police were made aware. Resident #1 was transferred to
the hospital for psychiatric evaluation,
Resident #1's NP's Progress Note dated 07/18/2020 at 9:38 PM documented that the NP was called by the
RN to assess Resident #1 who was observed touching a female inappropriately. Resident #1 was seen post
Emergency Department (ED) visit. Resident #1 was calm and cooperative. No emotional trauma or harm
noted. No new recommendations from the ED. Continue with care and current medication regimen.
Resident #1's Nursing Progress Note dated 07/18/2020 at 11:53 PM documented that Resident #1 was alert
and responsive to all stimuli. The resident returned from hospital at 9:50 PM in stable condition. Resident #1
was transferred to the 4th floor unit. No new recommendation from the hospital. The NP was informed.
2) Resident #2 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR
PHYSICIAN ORDER] . The MDS dated [DATE] identified the resident with long/short-term memory problems
and severely impaired decision-making ability
3) Resident #3 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR
PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #3 had short/long-term memory
problems. Resident #3 had severely impaired decision-making ability
(continued on next page)
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet
Previous Versions Obsolete 335503 Page 2 of 4
INDEX NO. 451549/2023
NYSCEF DOC. NO. 570 RECEIVED NYSCEF 06/28/2023
Department of Health & Human Services Printed: 07/25/2022
Form Approved OMB
Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (XI) PROVIDER/SUPPLIER/CLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. Building
335503 B. Wing 12/06/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
195 44 Woodhull Avenue
Holliswood Ctr for Rehabilitation and Healthcare
Hollis, NY 11423
For information on the nursing home's planto correct this deficiency, please contact the nursing home or the state survey agency.
(x4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600 Resident #3's Risk for Abuse related to cognitive impairment and dependence on others for Activities of Daily
Living Care Plan was initiated on 07/25/2016, last updated 06/11/2020. The interventions documented to
Level of Harm - Minimal harm or assess Resident #3 for signs and symptoms of abuse/neglect, investigate all allegations of abuse and
potential for actual harm neglect promptly. One-one visits from all departments as needed.
Residents Affected - Few Resident #3's Assessment Note dated 07/18/2020 at 10:23 PM documented that at approximately 11:08 AM,
the writer was called to the unit by the charge nurse. The CNA stated that he/she observed Resident #1 with
his/her hand in Resident # 3's diaper. The residents were separated and body check was done on Resident
#3, No evidence of vaginal trauma or any other skin issues observed. No pain or discomfort noted. When
asked about the incident, Resident #1 stated that he/she was touching Resident #3's vagina and that
Resident #3 liked it. The Physician, NP and the Police were made aware.
During interviews on 10/27/2021 and 12/06/2021, Licensed Practical Nurse (LPN) #1 stated that he/she was
the charge nurse of unit at the time of the incidents involving Resident #1, Resident #2, and Resident #3.
LPN #1 said that he/she was called after Resident #1 touched Resident #3 inappropriately. LPN #1 said that
he/she told one of the CNAs to remove Resident #1 from the dining room and he/she informed the
Registered Nurse Supervisor (RNS). LPN #1 added that Resident #1 had no prior incidents of sexually
inappropriate behavior. LPN #1 stated that he/she could not recall if there were other residents in the dining
room apart from Resident #2 and Resident #3. LPN #1 also stated that he/she did not assign any staff
member to monitor the dining room, but a staff member was monitoring the hallway and was stationed
opposite the dining room. The staff member was able to see the residents in the dining room
During an interview on 10/28/2021 at 11:45 AM, the Home Health Aide (HHA) stated that on 07/18/2020
around 11:00 AM, he/she was assigned to hallway watch on the unit. The HHA was stationed at the end of
the hallway in front of the dining room. There was no other staff monitoring the dining room. The HHA stated
that he/she observed Resident #1 wheeled himself/herself into the dining room and shortly afterwards,
he/she saw Resident #1 with his/hands above the midsection of Resident #2. The HHA stated that Resident
# 2 was sitting in his/her Geri-chair in the dining room. The HHA stated that he/she went into the dining room
and Resident #1 pulled his/her hand away from over Resident #2's midsection and went to another corner of
the dining room. The HHA stated that within a minute, he/she observed Resident #1 sitting close to Resident
#3 and Resident #3's cover sheet was pulled down and his/her diaper was ripped apart. The HHA stated that
he/she observed Resident #1 with his/her hand inside of Resident #3's diaper. Resident #1's hand was
moving in Resident #3's diaper. The HHA stated that he/she separated the residents and shouted for LPN.
#1
During interviews on 11/01/2021 at 10:45 AM and 12/06/2021 at 11:47 AM, the Registered Nurse Supervisor
(RNS) stated that he/she was called to unit on 07/18/2020 after Resident #1 was observed with his/her hand
in Resident #3's diaper. The RNS stated that the residents were already separated when he/she responded
to the unit. The RNS verbalized that he/she informed the Director of Nursing. The RNS stated that Resident
#1 was taken to another unit and was placed on 1:1 observation until he/she was transferred to the ER for
evaluation. The RNS stated that he/she assessed Resident #3 and there was no evidence of vaginal trauma
and no changes in mental status. The RNS said he/she did not recall if there were other residents in the
dining room but there was a staff member monitoring the dining room when he/she responded to the unit
(continued on next page)
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet
Previous Versions Obsolete 335503 Page 3 of 4
INDEX NO. 451549/2023
NYSCEF DOC. NO. 570 RECEIVED NYSCEF: 06/28/2023
Department of Health & Human Services Printed: 07/25/2022
Form Approved OMB
Centers for Medicare & Medicaid Services No. 0938-0391
STATEMENT OF DEFICIENCIES (XI) PROVIDER/SUPPLIER/CLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. Building
335503 B. Wing 12/06/2021
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
195 44 Woodhull Avenue
Holliswood Ctr for Rehabilitation and Healthcare
Hollis, NY 11423
For information on the nursing home's planto correct this deficiency, please contact the nursing home or the state survey agency.
(x4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0600 During an interview on 11/10/2021 at 12:15 PM, the Director of Nursing (DON) stated that Resident #1 and
Resident #3 were on routine monitoring during care (every 2-3 hours or more frequent). In addition, two staff
Level of Harm - Minimal harm or members always monitored the hallway when residents are out of bed. The DON stated that residents are
potential for actual harm only in the dining room during meals and activities. The DON stated that one staff member monitors the end
of the hallway near the dining room, The DON said that the facility investigation concluded that sexual abuse
Residents Affected - Few occurred to Resident #3 since Resident #1 was observed with his/her hand inside of Resident #3's diaper.
The DON stated that the HHA redirected Resident #1 away from Resident #2 after the HHA was uncertain of
what Resident #1 was doing near to Resident #2 priorto Resident #1 putting his/hand in Resident #3's
diaper. The DON stated that the HHA was inadvertently identified as a CNA in the investigation and notes.
415.4(b)(1)(i)
FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet
Previous Versions Obsolete 335503 Page 4 of 4
Preview
iD: YORK OUN PK 06 DM INDEX NO. 451549/2023 NYSCEF BOC. NO. 570 RECEIVED NYSCEF: 06/28/2023 PETTIGREW EXHIBIT 134 INDEX NO. 451549/2023 NYSCEF DOC. NO. 570 RECEIVED NYSCEF 06/28/2023 Department of Health & Human Services Printed: 07/25/2022 Form Approved OMB. Centers for Medicare & Medicaid Services No. 0938-0391 STATEMENT OF DEFICIENCIES (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335503 B. Wing 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 195 44 Woodhull Avenue Holliswood Ctr for Rehabilitation and Healthcare Hollis, NY 11423 For information on the nursing home's planto correct this deficiency, please contact the nursing home or the state survey agency. (x4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES. (Each deficiency must be preceded by full regulatory or LSC identifying information) F 0600 Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody, Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Residents Affected - Few Based on observations, interviews, and record review conducted during an abbreviated survey (NY 687) on 10/27/2021, the facility did not ensure that a resident was free from Sexual Abuse. This was evident in 1 out 6 residents sampled (Resident #3). Specifically, on 07/18/2020, a staff member observed Resident #1 with his/her hand inside of Resident #3's, who was sitting in the dining room, diaper that was ripped opened. A few minutes prior to incident, Resident #1 was observed with his/her hands on the midsection of Resident #2 the resident was sitting in the dining room. Resident #1 was not removed from the dining room immediately when he/she was observed touching Resident #2 inappropriately. The facility did not protect Resident #3 from sexual abuse, The findings are: Review of the facility's policy and procedure entitled Abuse last revised in 02/2019 documented: The facility prohibits the mistreatment, neglect, and abuse of resident/patients and misappropriation of resident/patient property by anyone. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment , and/or misappropriation of property. The facility will ensure that prevention techniques are implemented in the facility, not limited to, ongoing supervision of employees through visual observation of care delivery and recognition of signs of burnout, frustration, and stress. The facility will identify, correct, and intervene in situations where abuse, neglect, and/or mistreatment are more likely to occur which includes secluded areas of the facility. The facility will have sufficient staffing on each shift to meet the needs of the residents/patients and reinforce staff education, with emphasis on reporting of concerns, incidents, and grievances. A Facility's Investigation Form dated 07/20/2020 documented that on 07/18/2020 at approximately 11:08 AM, Resident #1 was observed in the far corner of the dining room next to Resident #3 who was laying in his/her Geri-chair. As per the Home Health Aide (HHA), Resident #1 had his/her hand inside the front of Resident #3 diaper. As per the HHA, Resident #1 pulled back the cover sheet and the HHA saw Resident #1 moving his/her hand under Resident #3 diaper. The HHA immediately separated the residents and informed the charge nurse. When Resident #1 was asked what he/she was doing, Resident #1 said that he/she was touching Resident #3's vagina. Resident #3 was evaluated with no visible injury. The Physician, Nurse Practitioner (NP), the Police and family were informed. Resident # 1 was transferred to the emergency room (ER) for Psychiatric evaluation. The Investigation concluded that abuse occurred (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (x6) DATE REPRESENTATIVE'S SIGNATURE FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 335503 Page1 of 4 INDEX NO. 451549/2023 NYSCEF DOC. NO. 570 RECEIVED NYSCEF 06/28/2023 Department of Health & Human Services Printed: 07/25/2022 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391 STATEMENT OF DEFICIENCIES (XI) PROVIDER/SUPPLIER/CLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335503 B. Wing 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 195 44 Woodhull Avenue Holliswood Ctr for Rehabilitation and Healthcare Hollis, NY 11423 For information on the nursing home's planto correct this deficiency, please contact the nursing home or the state survey agency. (x4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information) F 0600 1) Resident #1 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS, a resident assessment tool) dated 05/06/2020 Level of Harm - Minimal harm or documented that Resident #1 had a Brief Interview for Mental Status (BIMS, used to determine attention, potential for actual harm orientation, and ability to recall information) score of 06/15, associated with severely impaired cognition. Residents Affected - Few Resident #1's At Risk for Abuse Care Plan was initiated on 06/01/2016, last updated 05/20/2020. The interventions documented to assess the resident for signs and symptoms of abuse and investigate all allegations of abuse promptly. Resident #1's Psychiatry Consult dated 07/06/2020 at 9:37 AM documented that Resident #1 was seen for follow up. Resident #1 was alert and oriented x 2, calm, cooperative and sexually preoccupied. Resident #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . As per staff, the resident seemed to be paranoid with aggressive behavior towards other residents. Resident #1 denied side effects from medications. Support and counselling provided as well as psych education, Recommended medication change: start [MEDICATION(S)] 1 MG orally twice a day. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] Resident #1's Assessment Note dated 07/18/2020 at 9:35 PM documented that at approximately 11:05 AM, the charge nurse reported that Resident #1 was observed with his/her hand near the midsection of Resident #2, CNA approached and Resident #1 quickly moved away. Within a few seconds after, Resident #1 was observed with his/her hands in Resident #3 's diaper. The CNA intervened and removed Resident #1. The residents were separated and body checks were done on Resident #2 and Resident #3. No evidence of vaginal trauma noted. Resident #1 stated that he/she was touching Resident #3's vagina and Resident #3 liked it. The Physician, Nurse Practitioner (NP) and Police were made aware. Resident #1 was transferred to the hospital for psychiatric evaluation, Resident #1's NP's Progress Note dated 07/18/2020 at 9:38 PM documented that the NP was called by the RN to assess Resident #1 who was observed touching a female inappropriately. Resident #1 was seen post Emergency Department (ED) visit. Resident #1 was calm and cooperative. No emotional trauma or harm noted. No new recommendations from the ED. Continue with care and current medication regimen. Resident #1's Nursing Progress Note dated 07/18/2020 at 11:53 PM documented that Resident #1 was alert and responsive to all stimuli. The resident returned from hospital at 9:50 PM in stable condition. Resident #1 was transferred to the 4th floor unit. No new recommendation from the hospital. The NP was informed. 2) Resident #2 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] identified the resident with long/short-term memory problems and severely impaired decision-making ability 3) Resident #3 was initially admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS dated [DATE] documented that Resident #3 had short/long-term memory problems. Resident #3 had severely impaired decision-making ability (continued on next page) FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 335503 Page 2 of 4 INDEX NO. 451549/2023 NYSCEF DOC. NO. 570 RECEIVED NYSCEF 06/28/2023 Department of Health & Human Services Printed: 07/25/2022 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391 STATEMENT OF DEFICIENCIES (XI) PROVIDER/SUPPLIER/CLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335503 B. Wing 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 195 44 Woodhull Avenue Holliswood Ctr for Rehabilitation and Healthcare Hollis, NY 11423 For information on the nursing home's planto correct this deficiency, please contact the nursing home or the state survey agency. (x4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information) F 0600 Resident #3's Risk for Abuse related to cognitive impairment and dependence on others for Activities of Daily Living Care Plan was initiated on 07/25/2016, last updated 06/11/2020. The interventions documented to Level of Harm - Minimal harm or assess Resident #3 for signs and symptoms of abuse/neglect, investigate all allegations of abuse and potential for actual harm neglect promptly. One-one visits from all departments as needed. Residents Affected - Few Resident #3's Assessment Note dated 07/18/2020 at 10:23 PM documented that at approximately 11:08 AM, the writer was called to the unit by the charge nurse. The CNA stated that he/she observed Resident #1 with his/her hand in Resident # 3's diaper. The residents were separated and body check was done on Resident #3, No evidence of vaginal trauma or any other skin issues observed. No pain or discomfort noted. When asked about the incident, Resident #1 stated that he/she was touching Resident #3's vagina and that Resident #3 liked it. The Physician, NP and the Police were made aware. During interviews on 10/27/2021 and 12/06/2021, Licensed Practical Nurse (LPN) #1 stated that he/she was the charge nurse of unit at the time of the incidents involving Resident #1, Resident #2, and Resident #3. LPN #1 said that he/she was called after Resident #1 touched Resident #3 inappropriately. LPN #1 said that he/she told one of the CNAs to remove Resident #1 from the dining room and he/she informed the Registered Nurse Supervisor (RNS). LPN #1 added that Resident #1 had no prior incidents of sexually inappropriate behavior. LPN #1 stated that he/she could not recall if there were other residents in the dining room apart from Resident #2 and Resident #3. LPN #1 also stated that he/she did not assign any staff member to monitor the dining room, but a staff member was monitoring the hallway and was stationed opposite the dining room. The staff member was able to see the residents in the dining room During an interview on 10/28/2021 at 11:45 AM, the Home Health Aide (HHA) stated that on 07/18/2020 around 11:00 AM, he/she was assigned to hallway watch on the unit. The HHA was stationed at the end of the hallway in front of the dining room. There was no other staff monitoring the dining room. The HHA stated that he/she observed Resident #1 wheeled himself/herself into the dining room and shortly afterwards, he/she saw Resident #1 with his/hands above the midsection of Resident #2. The HHA stated that Resident # 2 was sitting in his/her Geri-chair in the dining room. The HHA stated that he/she went into the dining room and Resident #1 pulled his/her hand away from over Resident #2's midsection and went to another corner of the dining room. The HHA stated that within a minute, he/she observed Resident #1 sitting close to Resident #3 and Resident #3's cover sheet was pulled down and his/her diaper was ripped apart. The HHA stated that he/she observed Resident #1 with his/her hand inside of Resident #3's diaper. Resident #1's hand was moving in Resident #3's diaper. The HHA stated that he/she separated the residents and shouted for LPN. #1 During interviews on 11/01/2021 at 10:45 AM and 12/06/2021 at 11:47 AM, the Registered Nurse Supervisor (RNS) stated that he/she was called to unit on 07/18/2020 after Resident #1 was observed with his/her hand in Resident #3's diaper. The RNS stated that the residents were already separated when he/she responded to the unit. The RNS verbalized that he/she informed the Director of Nursing. The RNS stated that Resident #1 was taken to another unit and was placed on 1:1 observation until he/she was transferred to the ER for evaluation. The RNS stated that he/she assessed Resident #3 and there was no evidence of vaginal trauma and no changes in mental status. The RNS said he/she did not recall if there were other residents in the dining room but there was a staff member monitoring the dining room when he/she responded to the unit (continued on next page) FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 335503 Page 3 of 4 INDEX NO. 451549/2023 NYSCEF DOC. NO. 570 RECEIVED NYSCEF: 06/28/2023 Department of Health & Human Services Printed: 07/25/2022 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391 STATEMENT OF DEFICIENCIES (XI) PROVIDER/SUPPLIER/CLIA (x2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 335503 B. Wing 12/06/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 195 44 Woodhull Avenue Holliswood Ctr for Rehabilitation and Healthcare Hollis, NY 11423 For information on the nursing home's planto correct this deficiency, please contact the nursing home or the state survey agency. (x4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information) F 0600 During an interview on 11/10/2021 at 12:15 PM, the Director of Nursing (DON) stated that Resident #1 and Resident #3 were on routine monitoring during care (every 2-3 hours or more frequent). In addition, two staff Level of Harm - Minimal harm or members always monitored the hallway when residents are out of bed. The DON stated that residents are potential for actual harm only in the dining room during meals and activities. The DON stated that one staff member monitors the end of the hallway near the dining room, The DON said that the facility investigation concluded that sexual abuse Residents Affected - Few occurred to Resident #3 since Resident #1 was observed with his/her hand inside of Resident #3's diaper. The DON stated that the HHA redirected Resident #1 away from Resident #2 after the HHA was uncertain of what Resident #1 was doing near to Resident #2 priorto Resident #1 putting his/hand in Resident #3's diaper. The DON stated that the HHA was inadvertently identified as a CNA in the investigation and notes. 415.4(b)(1)(i) FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete 335503 Page 4 of 4