Delaware Oaks Center For Rehabilitation And Nursi

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to facility staff that they had witnessed Resident #12 standing in front of Resident #51, who was seated in their wheelchair and that Resident #51 had their left hand under Resident #12's shirt and was rubbing Resident #12's left breast. During an observation on 09/16/2025 at 9:51 AM, Resident #51 was in bed, and was not able to be interviewed. During an observation on 09/15/2025 at 10:56 AM, Resident #12 was dressed and resting on their bed and was not able to be interviewed. During an interview on 09/18/2025, Resident #61 stated they witnessed Resident #51 touch Resident #12 in an inappropriate manner. Resident #12 was standing close Resident #51, making noises, and Resident #51 was running their hands all over Resident #12. They reported this immediately to the Administrator. Review of an Employee Statement Form completed by Certified Nurse Aide #3 and dated and signed 09/10/2025 documented that on 08/22/2025

they witnessed Resident #51 put their hand up Resident #12's bra. A call was placed to Certified Nurse Aide #3 for interview without success. During a telephone interview on 09/19/2025 at 11:44 AM, Certified Nurse Aide #1 stated they worked during the evening shift on 08/22/2025 and Resident #51 had been brought back from an activity and was seated in their wheelchair near the elevator. Resident #12 had kept approaching #51, staff would intervene. Resident #51 was then moved to a different location. During an

interview on 09/19/2025 at 9:00 AM, Registered Nurse #2 Unit Manager stated on 8/22/2025 Resident #12 was especially attention-seeking with Resident #51. Resident #51 was moved to another floor. The intervention immediately implemented was to keep Resident #12 away from male residents (within arm's length) and staff education. Resident #12 was seen by the facility medical provider for an acute visit the next day related to their behaviors, as needed medications were administered, and the resident was transferred to the hospital for a psychiatric evaluation. During an interview on 09/18/2025, the Administrator stated Resident #61 came to their office and reported they had observed Resident #51 touching Resident #12. The Administrator stated they immediately called the Nurse Supervisor (Registered Nurse #5) and instructed them to separate the two residents and initiate an investigation into the allegation. 10 NYCRR 415.4(b)(4)

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Delaware Oaks Center for Rehabilitation and Nursi

1205 Delaware Avenue Buffalo, NY 14209

For information on the nursing home's plan to 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on interview and record review conducted during Complaint investigation (2598732) during the Standard Survey completed on 09/19/2025, the facility did not ensure that all alleged violations involving abuse are reported immediately, but not later than 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 #12 and #51) of three (3) residents reviewed. Specifically, the Administrator was notified of an allegation of resident-to-resident abuse and it was not reported to the State Agency within the required time frame.The finding is:Refer to F 600 Freedom from Abuse and NeglectThe policy titled Prevention, Investigation & Reporting Resident Abuse, Mistreatment, Injury of Unknown Source, Neglect & Misappropriation of Resident Property Effective 5/2024 and last reviewed 7/2024 documented that it was the facility's policy to prevent abuse and any suspected or actual violation required immediate reporting to the Administrator, Director of Nursing, Social Worker, Nursing Supervisor or House Charge Nurse on duty. Immediate action was to be taken to report any incident to the New York State Department of Health. It further documented the New York State Department of Health required immediate reporting of suspected or actual abuse to the Administrator of the facility and, when required by law or regulation to the New York State Department of Health via the Health Commerce System Network Incident Reporting Form or the Abuse Hotline. The New York State Department of Health must be contacted about alleged abuse if someone tells you they saw abuse. When reasonable cause is established that abuse may have occurred, the incident must be reported to the New York State Department of Health within 24 hours.

The investigation does not need to be completed before reasonable cause is established.The Complaint/Incident Investigation Report 2598732 submitted by the facility to the Internet Quality Improvement and Evaluation System on 08/23/2025 at 1:15 PM documented that on 08/22/2025 at 5:34 PM, Resident #61 reported they observed Resident #12 standing in front of Resident #51, at which time Resident #51 had placed their left hand under Resident #12's shirt and rubbed Resident #12's left breast.

During an interview on 09/18/2025, Resident #61 stated they witnessed Resident #51 touch Resident #12

in an inappropriate manner. Resident #12 was standing close to Resident #51, making noises, and Resident #51 was running their hands all over Resident #12. They reported this immediately to the Administrator. During an interview on 09/18/2025 at 11:45 AM, the Administrator stated that Resident #61 reported what they had observed to them immediately. The Administrator stated they immediately called the nurse supervisor (Registered Nurse #5) and instructed them to go to the unit to intervene. The Administrator stated they believed the nurse supervisor informed the Director of Nursing of the allegation and was instructed to start an investigation. The Administrator stated the abuse allegation should have been reported to the State Agency immediately and thought the Director of Nursing had completed the reporting. During an interview on 09/18/25 at 12:32 PM, the Director of Nursing stated they knew these types of abuse allegations needed to be reported to the New York State Department of Health immediately and no later than two (2) hours after an allegation was made. They stated they had not reported this on time, because they had not completed their investigation and had not determined if it had happened. 10 NYCRR 415.4(b)(4)

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