Monroe Community Hospital

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an Abbreviated Survey (Incident ID: 2640065) from 10/15/2025 to 10/24/2025, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (1) (Resident #1) of three (3) residents reviewed. Specifically, Resident #1 had no documented bowel movement from 09/24/2025 through 10/03/2025 and there was no documented evidence any as needed medications for constipation were administered. Resident #1 was hospitalized on [DATE] and found to have severe rectal stool burden (excessive amount of stool in the colon or rectum) requiring manual disimpaction (a procedure used to remove stool from the rectum) and stercoral colitis (an inflammatory condition of the large bowel caused by substantial stool burden). Following return from the hospital on [DATE], Resident #1 had no documented bowel movement through 10/16/2025, and there was no evidence any as needed bowel medications were administered until 10/15/2025. This facility's failure to implement an effective bowel management protocol, to follow care plan interventions, and act on documented alerts and bowel movement reports resulted in actual harm for Resident #1 and a likelihood for serious injury, serious harm, serious impairment, or death for all residents in the facility (census 403), that was Immediate Jeopardy and Substandard Quality of Care. The findings include: The facility policy titled Provision of Resident Care, revised 05/15/2023, included after care such as incontinence and bowel care is performed it is entered into the electronic medical record. The electronic medical record is programmed to provide alerts and reports for specific care-related documentation, including alerts and tasks that would prompt receiving users to initiate proper follow-up. Programmed alerts included, but are not limited to, absent bowel movements. Receiving users are expected to review and act upon alerts each shift. Programmed reports include bowel tracking and receiving users were expected to review and act upon the reports each shift.An undated facility document Bowel Movement (BM) Alert Training included if a resident has not had a documented bowel movement, an alert would trigger under the To Do list in the electronic medical record. Clinical nurse managers, administrative nurse managers, assessment nurses, supervisors, registered nurses, and nursing administration would see these alerts. Nursing should implement an appropriate bowel movement protocol and once the appropriate protocol was in place, the alert should be cleared. The facility could not provide a written bowel regimen policy, procedure, or protocol that provided monitoring timeframes or the parameters for administering as needed bowel medications. Resident #1 had diagnoses including multiple sclerosis (a disease that affects the central nervous system), depression, and generalized weakness. The Minimum Data Set (a resident assessment tool) dated 09/05/2025 included the resident was cognitively intact.Review of the comprehensive care plan last revised on 09/15/2025, revealed the resident had hypothyroidism (a condition where the thyroid gland is underactive) and a history of constipation with the use of laxatives (medications or substances that promote bowel movements) daily. Interventions included, but were not limited to, monitor bowel movements, check bowel sounds as indicated, assess abdomen for distention, and bowel management per medical orders.Review of September 2025 and October 2025 Physician Order Sheets revealed an order dated 08/29/2025 for polyethylene glycol 17 grams oral powder as needed two (2) times daily for constipation and an order dated 10/21/2024 for milk of magnesium 400 milligrams oral suspension once a day as needed for constipation. The physician orders did not specify after how many days without a bowel movement to administer as needed medications or the order in which as needed medications were to be administered.Review of the Activities of Daily Living Verification Worksheet (part of the electronic medical record used to track resident care) revealed Resident #1 had no documented bowel movement from 09/24/2025 through 10/03/2025.Review of bowel movement reports (includes the number of times residents had no bowel movement recorded or had missed documentation during the previous three (3) days), revealed Resident #1 was listed on reports dated 09/26/2025, 09/29/2025, 10/01/2025, and 10/03/2025. There was no documented evidence the reports had been reviewed or acted upon. Review of September 2025 and October 2025 Medication Administration Records revealed the as needed medications prescribed to Resident #1 for constipation were not administered from 09/24/2025 through 10/03/2025.Review of medical provider visit notes from 09/24/2025 to 10/03/2025 did not include evidence Resident #1's bowel status had been addressed. In a progress note dated 10/02/2025, Licensed Practical Nurse #4 documented Resident #1 was found wearing multiple urine-soaked briefs with a stool-contaminated dressing to the sacrum. There was no documented evidence of the size, amount, color, or consistency of the stool.In a Provider Acute Visit note dated 10/03/2025, Physician Assistant #1 documented Resident #1 had developed a fever and tachycardia (rapid heart rate) and there was concern the resident was having a septic response (a life-threatening condition that occurs when the body's immune system overreacts to an infection) to a deeper infection. Resident #1 would be sent to the hospital for further evaluation. There was no documented evidence the resident's abdomen or bowel status were assessed at that time. Resident #1 was hospitalized from [DATE] to 10/09/2025. The Hospital Discharge summary dated [DATE], documented Resident #1 had imaging (a medical technique used to see inside the body to diagnose conditions and plan treatment) on 10/03/2025 with results including severe rectal stool burden. Resident #1 had sepsis secondary to potential intra-abdominal (within the abdominal cavity) infection from stercoral colitis and experienced a high fever and tachycardia following manual disimpaction. Resident #1 was readmitted to the facility on [DATE]. Review of the Activities of Daily Living Verification Worksheet from 10/09/2025 through 10/16/2025 revealed Resident #1 had no documented bowel movement(s).Review of bowel movement reports revealed Resident #1 was listed on reports dated 10/10/2025 and 10/13/2025. There was no documented evidence the reports had been reviewed or acted upon. Review of the Medication Administration Record from 10/09/2025 to 10/14/2025 revealed as needed medications prescribed for constipation had not been administered. A nursing progress note dated 10/15/2025, by Licensed Practical Nurse #5, documented as needed milk of magnesium and polyethylene glycol were administered to Resident #1 at 4:39 PM.During an interview on 10/15/2025 at 11:41 AM, Licensed Practical Nurse #5 stated they were not aware Resident #1 had been treated in the hospital for bowel impaction and most residents had as needed medications ordered for constipation. In a follow-up interview at 3:16 PM, Licensed Practical Nurse #5 stated a report was generated from the electronic medical record listing residents who had not had a bowel movement in three (3) days, and they would follow the bowel protocol which included administering as needed medications for those residents with orders. During an interview on 10/15/2025 at 3:31 PM, Certified Nursing Assistant #1 stated they documented bowel movements in the electronic medical record. They stated printed reports identifying residents with no bowel movement in three (3) days were reviewed during shift huddles to verify whether any documentation of bowel movements was missed.During an interview on 10/15/2025 at 4:06 PM, Medical Director #1 stated they expected nursing staff to administer as needed bowel medications if there was no bowel movement in three (3) days and notify a provider if medications were not effective or not ordered. Medical Director #1 stated they believed there was a bowel alert report listing residents without bowel movements available to nursing staff. They stated if a resident had multiple medications ordered, the orders should specify which medication to administer first. Medical Director #1 stated the facility did not have a written bowel management protocol. During an interview on 10/15/2025 at 4:30 PM, Director of Nursing #1 stated bowel movement reports were printed on Mondays, Wednesdays, and Fridays (automatically by the electronic medical record) and listed residents without a bowel movement. They stated the reports were intended to alert staff for follow-up.During an interview on 10/15/2025 at 5:33 PM, Licensed Practical Nurse #6 stated bowel movement lists were printed daily, identified residents without a bowel movement in three (3) days, and were reviewed during morning report. They stated they would administer bowel medications or notify the provider if no medications were ordered, and certified nursing assistants were instructed to notify them when a bowel movement occurred so it could be documented.During an interview on 10/16/2025 at 1:43 PM, Registered Nurse Manager #1 stated bowel movement reports were printed three (3) times per week and reviewed with certified nursing assistants. They stated the electronic medical record would generate alerts at 24, 48, and 72 hours for residents without a bowel movement. Registered Nurse Manager #1 stated most residents were on bowel regimens and the bowel management process involved the use of as needed medications. They were unable to locate a written bowel protocol upon request.During an interview on 10/16/2025 at 2:56 PM with Director of Nursing #1 and Director of Nursing #2, Director of Nursing #1 stated if a resident had several as needed medications for constipation, the nurse should review the medication indication to determine which medication to use. Director of Nursing #2 stated the nurse should start with the least restrictive medication. Director of Nursing #1 stated there were no bowel movement entries for Resident #1 from 09/24/2025 through 10/03/2025 and believed someone may have forgotten to document a bowel movement. Director of Nursing #1 stated they had no explanation for how this was not identified despite bowel alerts and reports.During a follow-up interview on 10/21/2025 at 11:32 AM, Medical Director #1 stated a resident could have leakage of stool around a bowel impaction. They stated Resident #1's bowel impaction was likely preventable because interventions were not implemented. They stated Resident #1 was at high risk for constipation due to immobility and a neurologic condition and would have expected bowel management to be addressed when Resident #1 returned from the hospital.During a telephone interview on 10/24/2025 at 11:49 AM, Licensed Practical Nurse #2 stated bowel movement reports had been printed daily until a system upgrade six (6) months earlier. After the upgrade, reports were printed every other day and then only on Mondays, Wednesdays, and Fridays. Licensed Practical Nurse #2 stated they had been serving as an interim charge nurse since 08/06/2025 and had not understood the bowel alerts in the electronic medical record until recently receiving education. They were not aware Resident #1 had not had a bowel movement from 09/24/2025 through 10/03/2025 and would have expected to be informed.During a telephone interview on 10/24/2025 at 10:40 AM, Nurse Practitioner #1 stated they expected staff to notify them if a resident had not had a bowel movement in more than two (2) days or was experiencing discomfort. They stated the facility did not have a bowel protocol and most residents were on bowel regimens. Nurse Practitioner #1 stated they specified the order bowel medications were to be administered when prescribing the medications. They stated they were unaware Resident #1 had not had a bowel movement from 09/24/2025 through 10/03/2025 or from 10/09/2025 through 10/16/2025.The survey team identified Immediate Jeopardy, and the facility Administrator was notified on 10/17/2025 at 2:30 PM.On 10/20/2025 at 10:45 AM, the survey team determined the Immediate Jeopardy was removed based on the following corrective actions taken by the facility:The facility provided a copy of the defined Bowel Management Regimen policy and procedure, dated 10/17/2025. The bowel regimen policy was observed in binders on each residential unit along with current bowel movement reports. The facility provided supporting documentation for 85.5% of nursing staff educated on the formal bowel management policy and procedure with an attestation that all remaining nursing staff would receive education prior to their next scheduled shift. Interviews with several staff revealed appropriate knowledge of the bowel management process.A list of all facility residents who did not have a documented bowel movement in three (3) days was provided. Supporting evidence of as needed medications offered and provided was reviewed with no identified concerns. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review conducted during an Abbreviated Survey (Incident ID: 2640065) from 10/15/2025 to 10/24/2025, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) of three (3) residents (Resident #1) reviewed. Specifically, the facility failed to assess, treat and prevent deterioration of Resident #1's sacral pressure ulcer from 08/30/2025 through 09/22/2025 which resulted in severe pain to the wound and the wound required sharp debridement during a hospitalization. This resulted in actual harm for Resident #1 and a likelihood for serious injury, serious harm, serious impairment, or death for 29 residents in the facility (census 403) identified as having pressure ulcers that was Immediate Jeopardy and Substandard Quality of Care. The findings include:The facility policy Skin Care Program revised 03/04/2025 included, but was not limited to, comprehensive skin assessments are completed by the registered nurse upon admission and with any significant change of condition, skin checks will be performed once weekly by the registered nurse or licensed practical nurse, daily visual checks during routine care should be completed by the certified nursing assistants and if a new area is identified the staff nurse should be notified. The staff nurse should complete an electronic incident report once a new open area is identified which triggers notification to the wound care team. The wound care team will assess the site and recommend an appropriate course of treatment. An individualize skin care plan will be developed and tailored to the resident's clinical condition and risk profile. Resident #1 had diagnoses including multiple sclerosis (a disease that affects the central nervous system), depression, and generalized weakness. The Minimum Data Set (a resident assessment tool) dated 09/05/2025 included the resident was cognitively intact.Review of the Comprehensive Care Plan revised 09/15/2025 revealed Resident #1 had the potential for alterations in their skin related to decreased mobility. Interventions included, but not limited to, assess for new skin breakdown, turn and reposition per policy, keep the skin dry and clean, and provide appropriate skin barriers.There was no documented evidence the care plan included documentation of conversations related to the resident's condition, treatment options, expected outcomes, and consequences of refusing treatment. The Resident Care Summary Assessment (care plan used by certified nursing assistants) reviewed on 10/15/2025, revealed Resident #1 required the limited assistance of one (1) staff for bed mobility, had a specialty mattress, and staff were to apply barrier cream or gel to the intact skin of the buttocks two (2) times a day, and notify the nurse for redness or irritation.The September 2025 Physician Order Sheet included an order dated 12/14/2023 to apply a thick layer of barrier cream to the right and left buttocks two (2) times a day. Resident #1 was hospitalized from [DATE] to 08/30/2025 for evaluation of stroke-like symptoms. In a hospital consult note dated 08/25/2025, Wound Care Registered Nurse #2 documented the resident had a partial thickness/Stage 2 (a type of skin injury that involves damage to the outer layer of skin) wound to their sacrum (the bony area at the top of the buttocks) related to friction and moisture and complicated by pressure and immobility. The wound measured 1.5 centimeters (length) by 0.5 centimeters (width) by 0.1 centimeters (depth). The periwound (skin surrounding the wound) had hyperpigmented (darkened) scar tissue likely related to continuous irritation or friction on the skin.The hospital After-Visit Summary dated 08/30/2025, included wound care instructions to cleanse the sacral wound bed with normal saline moistened gauze, allow to dry, and cover with a foam dressing every three (3) days and as needed. There is no documented evidence new wound care orders were entered for Resident #1 from 08/30/2025 through 09/22/2025.Resident #1 returned to the facility on [DATE]. In a Provider Visit Note dated 09/02/2025, Nurse Practitioner #1 documented Resident #1 was admitted to the hospital on [DATE] with acute encephalopathy (a change in brain function due to injury or disease), underwent a stroke workup, and was treated for a urinary tract infection. There is no documented evidence Nurse Practitioner #1 assessed Resident #1's sacral wound or reviewed the wound care recommendations from the hospital.In a nursing progress note dated 08/30/2025, Licensed Practical Nurse #2 documented the resident's arrival to the facility and an area on the sacrum measuring 2.0 centimeters by 2.0 centimeters with soft, pink, friable (thin, delicate, and easily tears or breaks) skin. A sacral foam dressing was replaced.There is no documented evidence of dressing changes from 08/31/2025 to 09/21/2025. In a Skin Check dated 09/02/2025, Registered Nurse Assistant Director of Nursing #1 documented Resident #1 had a Stage 1 pressure ulcer to the sacrum measuring 2.0 centimeters by 2.0 centimeters. There is no documented evidence additional skin checks were completed until 09/23/2025.In a progress note dated 09/11/2025, Licensed Practical Nurse #1 documented nursing staff found an open area on Resident #1's sacrum, notified the nursing supervisor, and entered a note in the communication log (used by staff to communicate resident status and changes in condition to medical providers). In an incident report (used to trigger notification to the wound care team of a new open skin area) dated 09/11/2025, Licensed Practical Nurse #1 documented the discovery of an open area to the sacrum during care, Nursing Supervisor #1 was notified, and a medical provider was notified via the communication log. The report included it was reviewed at morning report on 09/12/2025.In a Communication Log entry dated 09/11/2025, Licensed Practical Nurse #1 documented Resident #1 had an open area to the sacrum. The provider response section had 'In hospital' handwritten and did not include a date or initials.In a progress note dated 09/12/2025 at 3:41 AM, Licensed Practical Nurse #7 documented Resident #1 was sent to the hospital. The resident returned to the facility on [DATE].In a Communication Log entry dated 09/16/2025, Licensed Practical Nurse #2 documented an open area noted 9/11 by nurse via incident report. The provider response section was initialed by Nurse Practitioner #1 and dated 09/16/2025.The documented evidence revealed the wound was not seen by or documented by a provider until 09/23/2025.In a progress note dated 10/15/2025, documented as a late entry (an addition to the medical record made after the original event, to document information that was missed or forgotten), Wound Care Registered Nurse #1 documented Resident #1 was not seen on 09/12/2025 after initial notification of possible skin breakdown because the resident was out at the hospital and they were unable to assess the resident's skin on 09/17/2025 because the resident was up in a wheelchair and declined to return to bed for assessment. In a progress note dated 09/21/2025, Licensed Practical Nurse #3 documented they were called to change a dressing found on Resident #1's sacrum. The wound measured 1.75 to 2.0 centimeters (length) by 0.5 centimeters (width) by 0.25 centimeters (depth). Licensed Practical Nurse #3 was informed the wound had been brought to other nurses' attention five (5) days earlier and they notified Registered Nurse #2.In an incident report dated 09/21/2025, Licensed Practical Nurse #3 documented the dressing change to Resident #1's sacral wound, Registered Nurse #2 was notified, and a medical provider was notified via the communication log. The report included it was reviewed at morning report on 09/22/2025.In a Communication Log entry dated 09/21/2025, Licensed Practical Nurse #3 documented Resident #1 had an open area to the sacrum. The provider response section had 'Wound to see' handwritten, was initialed by Medical Director #1 and dated 09/22/2025.In a progress note dated 09/21/2025, Registered Nurse #2 documented they were notified Resident #1 had an open area on their sacrum, measured the wound, and placed a dressing. Resident #1 reported they had pain in the sacral area that rated a 5 (moderately strong pain) out of 10 (worst pain possible). The incident was written in the Communication Log for further follow-up.In a Wound Assessment note dated 09/23/2025, Wound Care Registered Nurse #1 documented Resident #1 had a 2.0 centimeter (length) by 2.0 centimeter (width) unstageable (a type of pressure injury where the wound bed is fully or partially covered with dead tissue) sacral wound with slough (dead tissue within a wound) and recommended daily treatment with gelling fiber (a wound dressing) and a foam dressing for autolytic debridement (a wound care technique that breaks down and removes dead tissue) and a pressure-relieving mattress.Review of medical orders dated 09/23/2025 included wound care orders for the sacral pressure ulcer to be completed daily and as needed, and a specialty (ROHO) mattress. In a provider Acute Visit Note dated 09/29/2025, Nurse Practitioner #1 documented Resident #1's sacral wound measured approximately 2.0 centimeters by 3.0 centimeters with surrounding erythema (redness) and tenderness and the resident had severe pain to the wound with no as needed pain medication available. There was no documented evidence a medical provider saw Resident #1 or addressed their sacral wound and related pain from 08/30/2025 to 09/28/2025.In a Wound Assessment note dated 10/02/2025, Wound Care Registered Nurse #1 documented a Stage 4 (a severe pressure injury with full-thickness skin loss and tissue damage that extends into muscle, bone, or tendons) sacral pressure injury measuring 4.5 centimeters (length) by 3.5 centimeters (width) by 1.0 centimeter (depth) with a larger area of periwound erythema and non-blanchable skin (areas of skin that do not turn white when pressure is applied) and recommended a daily Vashe (skin cleanser used for debriding and irrigating wounds) moistened gauze dressing.In a Provider Acute Visit note dated 10/03/2025, Physician Assistant #1 documented the resident was followed for a Stage 4 sacral wound and received one (1) dose of Ceftriaxone (an antibiotic) intramuscularly the previous night. Resident #1 had developed a fever and tachycardia (rapid heart rate) and there was concern the resident was having a septic response (a life-threatening condition that occurs when the body's immune system overreacts to an infection). Resident #1 would be sent to the hospital for further evaluation. Resident #1 was hospitalized from [DATE] to 10/09/2025.Review of a hospital surgical consult note dated 10/08/2025, Physician #2 documented the sacral wound bed was covered with fibrinopurulent exudate (a type of inflammatory fluid that is typically found in areas of infection) and necrotic (dead tissue that has lost its blood supply and is no longer able to function) skin and had sharp debridement (a medical procedure that involves removing dead, infected, or damaged tissue from a wound with sharp instruments such as a scalpel or forceps) at the bedside.During an interview on 10/15/2025 at 11:30 AM, Resident #1 stated they do not get out of bed unless they have an appointment because if they get up, they will have to wait until the next shift to get back in bed. Resident #1 stated sitting for long periods of time is painful at the wound site.During an observation on 10/15/2025 at 12:30 PM, Licensed Practical Nurse #5 performed wound care as ordered. Resident #1 yelled out you are hurting me during the dressing change. Licensed Practical Nurse #5 proceeded with the dressing change and did not address Resident #1's pain.During an interview on 10/20/2025 at 1:55 PM, Registered Nurse Assistant Director of Nursing #1 stated weekly skin checks were required, and certified nursing assistants were expected to report changes so licensed nurses could evaluate the wound, with registered nurses verifying any identified skin concerns. They stated wound issues should be entered in the communication log or referred to the wound team and nursing supervisors complete skin and pain assessments on new admissions or readmissions on weekends and after hours. Registered Nurse Assistant Director of Nursing #1 stated they completed a skin check on 09/02/2025, identifying a Stage 1 (an early-stage skin injury caused by prolonged pressure) wound, applied barrier cream, and did not apply a dressing to the area since the skin was intact. There was no documented evidence a provider was notified of the Stage 1 pressure injury, or an incident report initiated. During an interview on 10/20/2025 at 2:44 PM, Wound Care Occupational Therapist #1 stated the wound team reviewed incident reports daily, attempted to assess residents as scheduling allowed, and prioritized those residents with newly reported skin concerns. Wound Care Occupational Therapist #1 stated if a resident declined to return to bed for a wound assessment, the wound team attempted later the same day or scheduled them first for the next day if still unable to see them.During an interview on 10/20/2025 at 3:49 PM, Wound Care Registered Nurse #1 stated weekly skin checks were expected. They were not informed of Resident #1's skin findings from 08/30/2025 or 09/02/2025 but would have expected to be notified so they could advise on any skin treatments and make a plan to see the resident. Wound Care Registered Nurse #1 stated they attempt to educate residents who refuse evaluations and may document additional notes when needed. Wound Care Registered Nurse #1 stated they recalled a skin concern entered for Resident #1 on 09/11/2025, but Resident #1 was out of the facility on 09/12/2025, and the resident later declined assessment on 09/17/2025. They stated after receiving a second incident report on 09/21/2025 they evaluated the wound on 09/23/2025. The sacral wound had significant slough and drainage, and they ordered daily dressing changes and a specialty mattress. Wound Care Registered Nurse #1 stated they examined the wound again on 10/02/2025 and the dressing was heavily soiled with urine and stool. They stated a day or two (2) prior, Nurse Practitioner #1 informed them the wound was worsening, and Wound Care Registered Nurse #1 was advised by Nurse Practitioner #1 assessment of the wound could wait until the next scheduled wound rounds.During a telephone interview on 10/21/2025 at 8:45 AM, Licensed Practical Nurse #1 stated day shift nurses typically complete weekly skin checks and certified nursing assistants report concerns. They stated new open areas require cleaning, measurements, application of a dressing, supervisor notification, communication log entry, and incident reporting. They recalled a certified nursing assistant reporting Resident #1's open sacral area in September 2025, after which they documented it and notified the provider.During a telephone interview on 10/21/2025 at 11:00 AM, Licensed Practical Nurse #3 stated they were called by a certified nursing assistant to see Resident #1's wound on 09/21/2025. Licensed Practical Nurse #3 stated there was a dressing in place. They cleansed the wound, applied barrier film, used silver gelling fiber, and placed a foam dressing without a provider order, and stated the certified nursing assistant reported notifying another nurse four (4) to five (5) days earlier.During an interview on 10/21/2025 at 11:32 AM, Medical Director #1 stated they expect nursing staff to assess new skin issues, document open wounds with an incident report, and notify the wound team for pressure concerns. They stated Stage 1 wounds do not usually require provider notification, but the wound team should be notified to monitor. Medical Director #1 stated they learned of Resident #1's wound on 09/22/2025, was informed the wound team would see the resident, and documented Wound to see in the communication log. They stated early interventions should occur when a wound is first identified but believed the wound was likely unavoidable due to Resident #1's immobility and inability to tolerate being off the area.During an interview on 10/21/2025 at 9:29 AM with Director of Nursing #1 and Director of Nursing #2, Director of Nursing #1 stated weekly skin checks are expected but not strictly done every seven (7) days. Director of Nursing #1 stated new skin issues should prompt a supervisor check, progress note, and provider communication for pressure wounds, but would not expect an incident report to be created for Stage 1 wounds. Director of Nursing #1 stated the wound team receives alerts in the electronic health record for new pressure wounds and attends morning reports where incident reports are reviewed. Director of Nursing #2 stated Resident #1 returned from the hospital on [DATE], with a fragile skin area covered by a dressing, and an open area was entered in the communication log on 09/11/2025. Director of Nursing #2 stated an open area is not always considered a pressure ulcer and could be moisture associated skin damage (MASD, inflammation or skin erosion caused by long-term exposure to moisture). Director of Nursing #2 stated the wound team first saw Resident #1 for their sacral pressure ulcer on 09/23/2025.During a telephone interview on 10/24/2025 at 10:40 AM, Nurse Practitioner #1 stated they review hospital information and see residents upon return but do not always document the visit. They stated nurses report new concerns through the communication log, which Nurse Practitioner #1 initialed when reviewed, and assessed the resident as needed. Nurse Practitioner #1 stated they recalled seeing Resident #1 for pain and observing a small open area on their sacrum, applying barrier cream, and alerting the wound team; they could not recall the date of the visit. They later saw the worsening wound at the wound team's request; they could not recall the date of the visit. Nurse Practitioner #1 stated they may not document every resident visit and were not aware Resident #1 missed wound assessments on 09/12/2025 and 09/17/2025. They expected the wound team to notify them if the wound team was unable to see a resident.The survey team identified Immediate Jeopardy, and the facility Administrator was notified on 10/21/2025 at 4:38 PM.On 10/21/2025 at 8:15 PM, the survey team determined the Immediate Jeopardy was removed based on the following corrective actions taken by the facility: All residents with pressure ulcers were reassessed and treatment plans were reviewed for appropriateness. The survey team reviewed additional residents with no identified concerns. The Skin Care Program policy and procedure was revised to include all new admissions and readmissions would be screened by a member of the wound care team to ensure appropriate skin care treatment plan was initiated.100% of Wound Care staff received re-education on the revised policy and procedure. The survey team verified the education through staff interviews. 10 NYCRR 415.12(c)(1)(2)

Based on observations, interviews and record review conducted during an Abbreviated Survey (Complaint #: NY00368800/Intake ID: 466508) from 08/26/2025 to 09/12/2025, the facility failed to ensure residents received the necessary care, treatment, and services, consistent with professional standards of practice, to promote healing and prevent new pressure ulcers from developing for one (1) of three (3) residents (Resident #8) reviewed. Specifically, the facility failed to ensure Resident #8's specialty mattress was in place from 01/04/2025 to 01/10/2025, and the resident was later found to have a stage two (2) (partial-thickness skin loss) and stage three (3) (full-thickness skin loss) pressure ulcer to their buttocks. This resulted in actual harm to Resident #8 that is not Immediate Jeopardy. The findings are:The facility policy, Skin Care Program, with a revision date of 10/01/2023, included all residents with a history of pressure injuries within the past 12 months should be considered to be in the high risk category for prophylactic (preventative) interventions. All wounds will be offloaded (the process of reducing or eliminating pressure on a wound site to promote healing) and advanced wound therapies will be utilized to promote wound healing in accordance with best practices. The undated facility document, How To Check the Proper Placement of ROHO (mattress overlay system for people who require skin or soft tissue protection) and Low Air Loss (LAL) Mattresses for Residents, included specialty mattresses are specifically designed to reduce pressure over the body in order to help prevent and treat pressure injuries (pressure ulcers). All specialty mattresses need to be checked by the nurse every shift to ensure they are in place and functioning properly for the safety of residents. If a resident has an order for a specialty mattress and the mattress is not in place or is malfunctioning, the nursing supervisor should be immediately notified. Resident #8 had diagnoses that included diabetes, pressure ulcers, and muscle weakness. The Minimum Data Set (a resident assessment tool) dated 10/10/2024 included the resident had moderate cognitive impairment, was at risk for developing pressure ulcers, had two (2) unhealed pressure ulcers, was receiving pressure ulcer care, and had pressure reducing devices for their bed and chair. Review of physician orders included an order dated 09/27/2024 for a specialty 42 inch ROHO mattress and to check that the mattress is in place and inflated every shift.In a Wound Assessment form dated 11/13/2024, Wound Care/Registered Nurse #1 documented the left buttock, stage three (3) pressure ulcer was healed with recommendations to continue treatment with barrier cream (adds a protective layer to skin to help prevent damage) and ROHO cushion for prophylaxis. In a Skin Check form dated 01/08/2025, Licensed Practical Nurse #4 documented Resident #8's skin was clear and intact. Review of the Comprehensive Care Plan dated 01/09/2025, revealed Resident #8 was at risk for pressure ulcers. Interventions included but were not limited to: check skin and report any signs of breakdown, use pillows, pads, or wedges to reduce pressure, and to turn and reposition. Additionally, as of 01/10/2025, the care plan included Resident #8 had new wounds, was transferred to another unit without the specialty mattress, and sustained pressure areas to their right and left buttocks. Review of an undated Facility Investigation included during skin rounds on 01/10/2025, Resident #8 was found to have new skin loss over their bilateral buttocks. Resident #8 was transferred on 01/04/2025 from Friendship 3 [NAME] to Friendship 4 East and their ROHO mattress was not transferred with them. Additionally, a statement documented by Licensed Practical Nurse #2 included the resident did not have the ROHO mattress while on Friendship 4 East.In an undated, signed statement, Registered Nurse Supervisor #1 documented they were told on the evening of 01/04/2025 Resident #8 needed to move to another unit after their roommate tested positive for COVID-19. Resident #8 was transported to the receiving unit by wheelchair and Registered Nurse Supervisor #1 was unable to find any staff to help them transfer the resident's bed. Registered Nurse Supervisor #1 reported to the night staff that Resident #8 had been moved but did not have their bed with specialty mattress. In a Witness Statement form dated 01/04/2025 to 01/05/2025, Licensed Practical Nurse #1 documented there was no ROHO mattress, and they notified Licensed Practical Nurse Supervisor #1. Licensed Practical Nurse #1 documented 'not administered' on the Treatment Administration Record for the 01/04/2025 night shift and informed the oncoming day shift nurse. The January 2025 Treatment Administration Record from 01/04/2025 to 01/10/2025 included to check that the specialty mattress was in place and inflated and a review of the documentation revealed the following: The ROHO mattress was documented by nursing staff as 'not administered' on 01/04/2025 night shift, 01/05/2025 evening and night shift. The ROHO mattress was documented by nursing staff as 'administered' on 01/04/2025 (day and evening shift), 01/05/2025 (day shift), 01/06/2025 (day, evening, and night shift), 01/07/2025 (day, evening, and night shift), 01/08/2025 (day, evening, and night shift), 01/09/2025 (day, evening, and night shift), and 01/10/2025 (day shift)In Wound Assessment forms dated 01/10/2025, Wound Care/Registered Nurse #1 documented Resident #8 had facility acquired wounds, to include a stage three (3) full thickness wound to their left buttock measuring 2.5 centimeters in length, 2.0 centimeters in width, 0.2 centimeters in depth and a stage two (2) partial thickness wound to their right buttock measuring 1.0 centimeter in length, 0.3 centimeters in width, and 0.1 cm in depth. Wound Care Registered Nurse #1 documented the wounds resulted from pressure after being transferred to another unit without their specialty mattress. In a Provider Acute Visit note dated 01/14/2025, Physician Assistant #1 documented Resident #8 was seen for pressure related skin breakdown to their bilateral buttocks. The resident was transferred to another unit without their specialty mattress and developed the pressure injuries as they were without the mattress for a period of time. During a telephone interview on 08/27/2025 at 10:00 AM, Licensed Practical Nurse Supervisor #1 stated during an off shift (evening or night), nursing staff would be the ones responsible for transferring a resident's bed to their new room. If it was a specialty bed/mattress, then it should go the same night as the resident. Licensed Practical Nurse Supervisor #1 stated if the specialty bed/mattress could not be transferred, they would pass it on to the next shift. Licensed Practical Nurse Supervisor #1 stated they recalled a resident needed to be transferred to another unit, the resident was out of bed and transported without their specialty mattress. Licensed Practical Nurse Supervisor #1 stated they became aware the resident did not have their bed with specialty mattress at approximately 2:00 AM or 3:00 AM and passed it on to the day shift supervisor to avoid disturbing the resident at that late hour. During a telephone interview on 08/28/2025 at 11:12 AM, Wound Care/Registered Nurse #1 stated Resident #8 was transferred to another room without their specialty mattress which led to the development of pressure injuries. The specialty mattress was ordered to prevent skin breakdown. Wound Care/Registered Nurse #1 stated when they assessed Resident #8 on 01/10/2025, the resident was on a standard foam mattress instead of the ROHO mattress. Wound Care/Registered Nurse #1 stated Resident #8 had a history of pressure ulcers, and they would recommend ROHO mattresses remain in place for six (6) months while the wounds healed. At the time the new wounds were identified, Resident #8 would have been within the six (6) month timeframe for continued use of the specialty mattress. During an interview on 08/28/2025 at 2:21 PM, the Director of Nursing stated when a resident is transferred to another unit, any equipment would go with them. The nursing supervisors would be responsible for ensuring resident belongings, beds, and mattresses went with the resident on evening and night shifts, weekends and holidays. The Director of Nursing stated if a specialty mattress could not be moved with the resident, either the nurse manager or the nursing supervisor should put alternate interventions in place, make the appropriate notifications, and make plans on how to get the mattress to the room. The Director of Nursing stated if there was an order for a specialty mattress, they would expect nursing staff to follow the order, ensure the mattress is checked and functioning, and appropriately document on the treatment administration record. Upon review of the facility's investigation at that time, the Director of Nursing stated Licensed Practical Nurse #2 included in their statement that Resident #8 did not have the ROHO mattress in place when they worked. During a telephone interview on 09/03/2025 at 1:05 PM, Licensed Practical Nurse #2 stated Resident #8 did not have their ROHO mattress when they arrived on the new unit and could not recall if the specialty mattress was in place when they worked on 01/06/2025, 01/08/2025, and 01/09/2025. Licensed Practical Nurse #2 had documented on the January 2025 Treatment Administration Record that the ROHO mattress was 'administered' on 01/06/2025 (evening shift), 01/08/2025 (evening shift) and 01/09/2025 (night shift).During a telephone interview on 09/02/2025 at 10:16 AM, Physician Assistant #1 stated in January 2025, there was a respiratory illness outbreak that required Resident #8 to be moved to another unit. Resident #8 was transferred to another unit temporarily, the mattress was not taken with the resident, and they developed new wounds. Physician Assistant #1 stated not having the specialty mattress put Resident #8 at an increased risk for skin breakdown and the resident's lack of motivation to get out of bed may have also contributed. Physician Assistant #1 stated if an ordered specialty mattress was not available, they would expect nursing staff to notify a medical provider and/or Administration. During a telephone interview on 09/02/2025 at 2:23 PM, Medical Director #1 stated they had examined Resident #8 prior to their temporary transfer to another unit and the resident was at their baseline (usual state of health) with no clinical changes at that time. Medical Director #1 stated Physician Assistant #1 saw Resident #8 shortly after the wounds were identified and attributed the pressure ulcers to the absence of the specialty mattress. Medical Director #1 stated Resident #8 had previously healed pressure injuries in the same areas, was identified as high risk for pressure ulcers, and the specialty mattress was used to reduce the risk of future skin breakdown. Once breakdown happens to an area, the skin never goes back to the same degree of health it had before. Medical Director #1 stated the skin breakdown was largely due to Resident #8's immobility and difficulty moving without assistance, and use of the specialty mattress had been successful in preventing skin breakdown for several months. Medical Director #1 stated there was nothing to indicate Resident #8 was ill or less mobile than their baseline. During a follow-up telephone interview on 09/03/2025 at 1:01 PM, Medical Director #1 stated they believed the pressure ulcers Resident #8 developed in January 2025 were avoidable because there was no change in the resident's condition and there was a good period of time the resident had no skin breakdown, likely due to the interventions, including the specialty mattress, that were in place. Medical Director #1 stated it was unfortunate the specialty mattress was not continued during that timeframe. During a telephone interview on 09/09/2025 at 4:52 PM, Registered Nurse Supervisor #1 stated they were working an evening shift when they were informed Resident #8 needed to move to another room. When they went to transfer the resident, Resident #8 was sitting up in a wheelchair. Registered Nurse Supervisor #1 stated they could not move the specialty mattress on their own. They were unable to find available staff to assist with transferring the resident back to bed prior to the move or to assist with moving the specialty mattress following the resident's transfer. Registered Nurse Supervisor #1 stated during shift change report they informed Licensed Practical Nurse Supervisor #1 they were not able to move the resident's specialty mattress to the new room, and Licensed Practical Nurse Supervisor #1 said they would try to move it when the resident woke up.10 NYCRR 415.12(c)(1)

Based on interviews and record review conducted during the Recertification Survey from 12/16/2024 to 12/20/2024, for 11 (Residents #24, #35, #136, #158, #246, #257, #357, #374, #375, # 378, #380) of 11 residents reviewed, the facility did not ensure that the baseline care plan (care plan developed within 48 hours of admission that includes the minimum healthcare information necessary to properly care of the immediate needs of the resident) was completed within the required time frame and that a summary of the baseline care plan was provided to the resident and/or their representative. Specifically, for Residents #35, #136, and #257, the facility could not provide evidence that a baseline care plan was developed within 48 hours of the residents' admission. For Resident #246, the baseline care plan was not completed within 48 hours of the resident's admission and the facility could not provide evidence that a summary of the baseline care plan, that included the minimum healthcare information such as physician's orders, was provided to the resident and/or resident representative. For Residents #24, #158, #357, #374, #375, #378, and #380, the facility could not provide evidence that a summary of the baseline care plan, that included the minimum healthcare information such as physician's orders, was provided to the resident and/or resident representative. This is evidenced by, but not limited to the following:
Review of the facility policy admission Policy & Procedure, revised August 2023, included the baseline care plan would be developed within 48 hours of admission, and the resident or health care proxy would be provided a copy of the baseline care plan.
Review of the facility's electronic baseline care plan form included a statement of acknowledgement that a copy of the baseline care plan would be provided to the resident and/or their representative but did not include confirmation of receipt or reviewed date of the baseline care plan by the resident and/or their representative.
1. Resident #35 had diagnoses that included quadriplegia (a condition where both arms and both legs are paralyzed), dependence on a respirator, and dysphagia (difficulty swallowing). The Minimum Data Set Resident Assessment, dated 09/13/2024, documented the resident was cognitively intact.
Review of Resident #35's electronic health record revealed no documented evidence that a baseline care plan had been developed within the required timeframe following admission and the facility was unable to provide evidence of its completion.
During an interview on 12/20/2024 at 3:00 PM, Registered Nurse Manager #1 stated Resident #35 should have had a baseline care plan initiated when admitted from the hospital.
2. Resident #257 had diagnoses that included multiple sclerosis (a chronic disease that affects the central nervous system), anxiety, depression, and chronic pain. The Minimum Data Set Resident Assessment, dated 12/02/2024, documented the resident was cognitively intact.
Review of Resident #257's electronic health record revealed no documented evidence that a baseline care plan had been developed following the resident's admission within the required timeframe and the facility was unable to provide evidence of its completion.
3. Resident #246 had diagnoses that included Alzheimer's disease, chronic kidney disease, and adult failure to thrive. The Minimum Data Set Resident Assessment, dated 10/09/2024, documented the resident had severely impaired cognition.
Review of Resident #246's electronic health record included a baseline care plan, signed by facility staff on 07/25/2023 (greater than 48 hours after the resident's admission). The facility was unable to provide any documented evidence that a summary of Resident #246's baseline care plan, including physician's orders, had been provided to or reviewed with the resident's representative.
4. Resident #24 had diagnoses that included high blood pressure, sarcopenia (gradual loss of muscle strength), and major depressive disorder. The Minimum Data Set Resident Assessment, dated 10/17/2024, documented that the resident was cognitively intact.
Review of Resident #24's electronic health record revealed no documented evidence that a summary of the baseline care plan, including physician's orders, had been provided to the resident and/or their representative.
During an interview on 12/20/2024 at 9:21 AM, Registered Nurse Manager #3 stated the facility's baseline care plan form was completed by the nurse manager and saved in the computer for reference, but no further documentation was completed.
During an interview on 12/20/2024 at 1:25 PM, Registered Nurse Manager #5 stated the baseline care plan was initiated on day two of the resident's admission and focused primarily on nursing care the resident should receive on the unit. Registered Nurse Manager #5 stated the baseline care plan did not include physician's orders or medication orders which were generally reviewed during the initial comprehensive care plan meeting (that could be as late as 21 days after admission) or sooner if the resident/representative had specific medication-related questions or concerns.
During an interview on 12/20/2024 at 2:00 PM, the Director of Nursing stated they were aware that the facility's electronic baseline care plan form implied but did not confirm review or receipt of the baseline care plan.
10 NYCRR 415.11

Based on observations, record review, and interviews conducted during the Recertification Survey from 12/16/2024 to 12/20/2024, the facility did not ensure that the medical team was notified when there was a significant change in the resident's condition for one (Resident #186) of one resident reviewed. Specifically, Resident #186 had a potential serious complication with their tracheostomy (a surgical procedure that creates an opening in the neck to provide an airway to assist with breathing) tube. This is evidenced by the following:
The facility policy Notification of Change, revised April 2021, documented the appropriate department will immediately consult with the resident's physician when there is a significant change in the resident's physical status.
Resident #186 had diagnoses including anoxic brain damage (a condition when the brain has a lack of oxygen), dysphagia (difficulty swallowing), gastrostomy (a surgical procedure to create an external opening into the stomach to receive nutrition), and a tracheostomy tube. The Minimum Data Set Resident Assessment, dated 11/18/2024, documented the resident had severely impaired cognition, was dependent for all activities of daily living and tracheostomy care, including suctioning of the tracheostomy tube, and the resident had a feeding tube.
Review of Resident #186's current physician's orders revealed tracheostomy suctioning every four hours and as needed and tube feeding (via the feeding tube) four times a day. The orders also included that the resident was on aspiration precautions (interventions in place to prevent substances from entering the airway or lungs).
During observations on 12/18/2024 at 9:27 AM and again on 12/19/2024 at 11:35 AM, Resident #186's tracheostomy cannister (container to collect secretions suctioned from the tracheostomy tube) had greater than 450 milliliters of tan colored secretions.
During an observation on 12/20/2024 at 9:36 AM, Resident #186 had thick tan/yellow secretions in their oxygen tubing that was attached to Resident #186's tracheostomy.
In a medical progress note, dated 11/14/2024, Nurse Practitioner #1 documented Resident #186 had clear sputum (mucous) and to continue to monitor the resident and report changes in condition.
In an interdisciplinary progress note, dated 12/13/2024 at 10:46 AM, Respiratory Therapist #1 documented Resident #186 was suctioned for thin, tan secretions.
In an interdisciplinary progress note, dated 12/13/2024 at 8:48 PM, Licensed Practical Nurse #3 documented that Resident #186 was suctioned for tan secretions with tube feeding chunks in it.
In an interdisciplinary progress note, dated 12/15/2024 at 4:20 PM, Respiratory Therapist #2 documented that Resident #186 was suctioned five times for large amounts of thick secretions possibly mixed with tube feeding liquid (also tan in color) and Resident #186 appeared to continue to aspirate (inhalation of food/liquids into the airway).
In an interdisciplinary progress note, dated 12/17/2024 at 9:59 AM, Respiratory Therapist #3 documented that Resident #186 was suctioned for large amounts of tan secretions.
During an interview on 12/19/2024 at 9:19 AM, Licensed Practical Nurse #3 stated the medical provider should be notified if anything was not at baseline for the resident or the possibility of aspiration (inhalation of tube feeding into the resident's airway).
During an interview on 12/19/2024 at 12:10 PM, Licensed Practical Nurse Manager #1 stated that a physician should be notified if a resident had excessive sputum, more than usual, as the resident is at risk for aspiration more than other residents. If the medical team had been notified, it should be documented in the communication log (a log to communicate information to the medical team).
During a follow-up interview on 12/20/2024 at 9:23 AM, Licensed Practical Nurse Manager #1 stated they were unable to find any documentation that the physician has been notified about Resident #186's excessive secretions or potential aspiration.
During an interview on 12/19/2024 at 11:08 AM, Physician #1 stated they were not aware that Resident #186 may have tube feeding liquid in their tracheostomy tubing which is a serious complication, and they should have been notified if this was a possibility.
During an interview on 12/20/2024 at 11:07 AM, the Respiratory Therapy Manager stated that if a resident had secretions that looked like tube feeding, the respiratory therapists should have notified the nurse manager, and the nurse manager should have notified the medical provider.
10 NYCRR 415.3(f)(2)(ii)(b)

Based on observations, interviews, and record review conducted during the Recertification Survey and complaint investigation (NY00356480) from 12/16/2024 to 12/20/2024, for two (Residents #27 and #640) of five residents reviewed for dignity, the facility did not ensure that the residents were treated in a dignified manner. Specifically, Resident #27 could be heard moaning from the hallway with their call light on. Multiple staff members were observed walking by the resident's room without answering the call light or turned the call light off without addressing the resident's concerns or requests. Resident #640 had their call light on for an extended period of time and multiple staff went in the resident's room and turned the call light off without addressing the resident's concerns. This was evidence by the following:
1. Resident #640 had diagnoses including quadriplegia (unable to move all four limbs), neurogenic bladder (a urinary condition causing a lack of bladder control), and diabetes. The Minimum Data Set Resident Assessment, dated 09/25/2024, documented the resident was cognitively intact and incontinent of bowels.
During continuous observations on 12/19/2024 starting at 9:40 AM, Resident #640's call light went on and Certified Nursing Assistant #2 walked into the resident's room, turned off the call light without addressing the resident's concerns, and walked back to nurses' station and sat down. At 9:50 AM, Resident #640 put their call light on again and Certified Nursing Assistant #2 went into the resident's room, turned off the call light, and told Resident #640 they would let their assigned nurse know they needed assist. At 9:59 AM, Resident #640 put their call light back on, Certified Nursing Assistant #2 walked in and out of room in less than a minute. At 10:09 AM, Resident #640 put their call light back on. Unit Administrator #1 entered Resident #640's room, exited, and returned with a cup of water. During an immediate interview at 10:14 AM, Resident #640 stated they have been asking staff if they could get cleaned up and that they do not feel good and have a headache. A foul odor (stool) was present in the room at the time. The resident stated that staff often turn off their light, leave the room without assisting them, and do not come back. Observations continued, at 10:28 AM, Resident #640 put their call light on and a staff member entered the room stating they would find a nurse. At 11:00 AM, a nursing staff exited Resident #640 room. Resident #640 remained not washed up. During an immediate interview at 11:01 AM, Resident #640 stated they were still not changed, that their blood pressure was high, and it was upsetting them and pissing me off. At 11:06 AM, Resident #640 put their call light on and several different nursing staff walked into the resident's room and turned the call light off without providing assist. At 11:37 AM, Certified Nursing Assistant #4 returned to Resident #640's room with bathing supplies to assist the resident with morning care (approximately two hours after Resident #640 first put their call light on).
During an interview on 12/19/24 at 12:02 PM, Certified Nursing Assistant #4 stated they floated to this unit today and have nine residents on their assignment with six residents going out for appointments. Certified Nursing Assistant #4 stated they were made aware that Resident #640 needed assistance around 9:00 AM, but it was difficult to find staff to assist when staffing is so short.
During an interview on 12/20/24 at 9:25 AM, Certified Nursing Assistant #5 stated everyone is responsible for answering call lights and meeting the resident's needs.
During an interview on 12/20/2024 at 10:33 AM, Licensed Practical Nurse Manager #1 stated Resident #640 can advocate for themself. They also stated the unit has a higher acuity as everyone is a two person assist, and they have recently lost multiple Certified Nurse Assistants, but all staff should answer call lights.
During an interview on 12/20/24 at 11:19 AM, Unit Administrator #1 stated their primary role is a liaison between administration and the units for family and resident concerns to mitigate and provide service so that it does not happen again. They also stated they knew Resident #640 needed care in a timely manner and were told that it had been completed, but then found out later that it was not done. If a call bell goes off it should not be ignored and staff should address it promptly.
2. Resident #27 had diagnoses including dementia, diabetes, and high blood pressure. The Minimum Data Set Resident Assessment, dated 10/15/2024, documented the resident had moderately impaired cognition.
During continuous observations on 12/16/2024 starting at 10:01 AM, Resident #27 could be heard moaning from the hallway and their call light was on. At 10:04 AM, Unit Administrator #1 went into room answered the call light and told Resident #27 they would find an aide for them. At 10:08 AM, a Certified Nursing Assistant entered the room and told the resident they would be back (call light still on). At 10:12 AM, Resident #27 could be heard moaning and a staff member walked by the room without seeing what the resident needed. At 10:23 AM, the unit's nurse manager entered Resident #27's room, turned off the call light, and walked out of room. At 10:50 AM, staff were assisting Resident #27 with care. During an immediate interview, Resident #27 stated they had just been changed.
During an interview on 12/20/2024 at 12:46 PM, the Director of Nursing stated call lights should be answered when they go off. If a resident is asking to get cleaned up and changed, we do our best to do the assignments and to get to the person that is asking for help. The Director of Nursing stated if a staff member is available, they should help the resident at that time.
10 NYCRR 415.3

Based on interviews and record review conducted during an Abbreviated Survey (#NY00321703), the facility did not ensure the resident's right to be free from physical abuse for one (Resident #1) of three residents reviewed. Specifically, Resident #1 was slapped on the hand by a staff member that was observed by other staff and on video. The is evidenced by the following:
The facility policy, Abuse Prohibition Program, dated revised on 9/15/22, included that under no circumstances would the facility tolerate resident abuse, neglect, mistreatment, misappropriation of resident property, or resident exploitation. Physical abuse would include hitting, slapping, pinching, and kicking, or controlling behavior through the use of corporal punishment.
Resident #1 had diagnoses that included Alzheimer's disease, dementia, and lack of coordination. The Minimum Data Set Assessment, dated 7/7/23, included that the resident had severe impairment of cognitive function. The MDS did not include that the resident had any behaviors (such as physical behaviors towards others).
The current Comprehensive Care Plan (CCP) included Resident #1's history of trauma, for which staff are to ensure that the resident is provided with a safe and supportive environment that protects against physical harm and re-traumatization. The CCP included that Resident #1 had a history of resisting care and physical aggression towards staff. Interventions included but not limited to that if resident is resistive, staff are to provide a calm environment, and maintain a personable, respectful, kind, and honest manner.
The facility Resident Incident Reporting Form dated 8/8/23 and signed by Registered Nurse #1 documented that on 8/8/23 at 2:45 PM Resident #1 appeared to have been struck on the left hand by a staff member after Resident #1 touched the staff member's face. The resident appeared to be unharmed by the encounter and no frank injury was noted however the resident did appear to recall the incident.
Review of the facility's Investigation Report dated 8/8/23 revealed that Material Service Worker (MSW) #1, while picking up Resident #1 for their medical appointment, observed LPN #1 placing footrests on the resident's wheelchair. Resident #1 reached out and touched LPN #1's face and LPN #1 slapped Resident #1's hand. The report documented that the resident repeated twice to MSW #1 that (they) slapped my hand so hard. Resident #1 was promptly assessed by Assistant Director of Nursing (ADON) #1 following the incident and no injuries were noted. Once the incident was reported to facility leadership, LPN #1 was escorted out of the facility and placed on administrative leave. The facility's investigation concluded that the allegation of resident abuse by a staff member was verified through security video footage and eyewitness testimony.
In an unsigned transcript from an investigatory hearing by the facility held on 8/11/23 and attended by several staff members and the accused, Licensed Practical Nurse #1 had stated that they were putting a footrest on (the resident's wheelchair) when Resident #1 smacked them in the face. LPN #1 stated that they went to restrain the resident's hand (by placing their hand down on the resident's hand) and told the resident never to hit them again. LPN #1 stated that Resident #1 said, Oh, (they) hit me on my hand.
Review of video surveillance of the incident revealed LPN #1 bent over at the waist, facing Resident #1, while Resident #1 was sitting in a wheelchair looking in a forward direction. While pending over, LPN #1 raised their head quickly, looked at the resident, and moved their head and neck away from the resident. At the time, Resident #1 remained looking in a forward direction. LPN #1's right hand appeared raised, then came down in a quick slapping motion towards where the resident's raised hand was and then stood in front of Resident #1 for approximately 11 seconds (unable to visualize what LPN #1 said).
During an interview on 8/17/23 at 9:25 AM, MSW #1 stated that on 8/8/23, they went to the unit to pick up Resident #1 (to transport to an appointment). MSW #1 stated that LPN #1 was putting footrests on the resident's wheelchair when Resident #1 touched LPN #1's face. MSW #1 stated that it was not a hitting or slapping motion and demonstrated by placing the palm on their hand on their cheek and resting it there. MSW #1 stated that LPN #1 then grabbed Resident #1's fingers and slapped the back of the resident's hand. MSW #1 stated that they could hear the slap and that Resident #1 said to them twice, (They) hit me so hard. MSW #1 stated that they took Resident #1 to their appointment and then immediately reported the incident to their supervisor.
During an interview on 8/17/23 at 2:30 PM Environmental Service Worker #1 stated that they were doing rounds and holding the elevator for a transporter (Material Service Worker #1) who was waiting for foot pedals for a resident (Resident #1) when they saw a nurse tap the resident's hand and pointed their finger at the resident and said don't do that again while applying the foot pedals.
During an interview on 8/18/23 at 12:54 PM with the Director of Nursing (DON) and the Acting Administrator, the DON stated that they would never expect a staff member to strike, slap or hit a resident. The DON stated that once aware of the incident, LPN #1 was immediately exited out of the building, the incident was investigated, an investigatory hearing was held, and the staff member was terminated. The Acting Administrator stated that at no time under any circumstances is it acceptable for a staff member to strike a resident.
During an interview on 9/18/23 at 12:56 PM, LPN #1 stated they were putting the left foot pedal on Resident #1's wheelchair when the resident became combative and back handed LPN#1's face. LPN #1 stated that they smacked Resident #1's hand and said to never do that again. LPN #1 stated that Resident #1 was always combative, not directable, and that staff would usually just walk away. LPN #1 stated that they had never done something like that (smack a resident's hand), and that it was just a reflex.
The last documented evidence of abuse training for LPN #1 provided by the facility was 8/12/21.
10 NYCRR 415.4 (b)(1)(i)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews conducted during the Recertification Survey 4/24/23 to 5/1/23, it was determined that for 1 (Resident #328) of 35 residents reviewed for care plans, the facility did not ensure that a resident's care plan was revised to reflect the resident's current condition. Specifically, the residents comprehensive care plan (CCP) was not revised related to the resident's smoking habits, a history of burns to the hands and fingers sustained while smoking, interventions for staff to utilize and any refusals of interventions. This is evidenced by the following:
The facility policy, Smoking Policy, dated as revised 4/4/22, documented that the facility was a smoke free environment where smoking will not be allowed by residents on the facility campus. All new admissions after 4/20/22 shall be informed during the admission process that the facility prohibits smoking on its campus. Those residents who are determined to have a preference to smoke, will be offered a smoking cessation program.
Resident #328 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure, diabetes, and nicotine addiction. The Minimum Data Set Assessment, dated 3/3/23 revealed that the resident was cognitively intact and did not currently use tobacco.
The Certified Nursing Assistant (CNA) Activities of Daily Living Care Card (care plan used by the CNAs to direct daily care) dated 4/14/23, documented that the resident was not a smoker.
The CCP, dated 5/1/23, included that Resident #328 went outside to smoke and had a specialized glove and cigarette holder. The CCP did not include multiple burns sustained while smoking, the resident's person-centered goals related to smoking, storage of smoking materials or refusals of any interventions until after surveyor intervention.
Review of a Nursing Progress Note, dated 1/27/23, revealed the resident had a new open area, full thickness loss of tissue measuring 0.5 centimeters (cm) by 0.4 cm on the left index finger and was being treated by the wound nurse. The resident said they burned themselves while smoking.
During observation and interview on 4/26/23 at 9:25 a.m., Resident #328 had a pack of cigarettes and a lighter in their coat pocket. The resident stated at the time that this was where they always kept their cigarettes and lighter and their vape materials and never in their locked box in their room. The resident stated that they smoke on the sidewalk outside of the building with other facility residents. Resident #328 stated they are supposed to sign out, but they forget.
In an observation on 4/27/23 at approximately 10:00-11:00 a.m. Resident #328 was outside smoking cigarettes. The resident appeared to be wearing a 'glove' but no cigarette holder was present.
During an interview on 4/26/23 at 11:22 a.m., Certified Nursing Assistant (CNA) #2 said Resident #328 spends a lot of time outside smoking but did not know where they keep their cigarettes and lighter.
During an interview on 4/26/23 at 11:43 a.m., Licensed Practical Nurse (LPN) #1 said they often see the resident in front of the building smoking with other residents smoking and that Resident #328 has often burned their hands with cigarettes.
During an interview on 5/1/23 at 9:55 a.m., the Social Worker (SW) stated that they were aware Resident #328 smoked and that they had informed them that the facility had a no smoking policy. The SW stated that they were working with Behavioral Health to help the resident stop smoking. The SW stated that when Resident #328 was burned from smoking, there was no change to their care plan and was aware that the current care plan was not resident-centered nor specific to their needs. The SW stated the cigarettes and lighter should be locked in a safe place.
During an interview on 5/1/23 at 9:55 a.m., Registered Nurse Manger (RNM) #1 said Resident #328 had reported their cigarette burns and that the resident has diabetic neuropathy causing poor feeling in their hands creating an increased risk for burns. RNM#1 said they are responsible for updating the resident's care plan.
During an interview on 5/1/23 at 10:24 a.m., the Assistant Director of Nursing (ADON) stated they, in conjunction with the RNMs revise resident's care plans. The ADON stated that following actual burns from cigarettes, the care plan should be updated to include reinforcement of wearing the special glove, any skin issues related to burns and resident education.
10 NYCRR 415.11(c)(2)(i-iii)

Based on observation, interviews and record review conducted during the Recertification Survey 4/21/23 to 5/1/23, it was determined that the facility did not ensure that the environment remained as free of accident hazards as possible for one (Resident #202) of 10 residents reviewed for accidents. Specifically, Resident #202 who had a history of keeping vaping materials in their room, and was suspected of vaping in their room, had 6 vape pens with cartridges in their room. Additionally, during a room search on 4/27/23, a security officer recovered several containers of marijuana, 2 boxes of vape liquid, 2 lighters, 1 torch lighter, and 1 marijuana pipe.
The finding is:
The facility Smoking Policy, revision dated 4/4/22, documented the facility designated itself a smoke-free campus as of 5/1/22. The use of cigars, pipes, marijuana, e-cigarettes and/or vaping devices is strictly prohibited within the facility, in the outdoor smoking area or on facility grounds.
Resident #202 had diagnoses including quadriplegia (paralysis of all four limbs), polyneuropathy (a disease process involving a number of nerves), and neuralgia (severe pain due to damaged nerves)/neuritis (inflammation of peripheral nerves causing pain and loss of function). The Minimum Data Set (MDS, a resident assessment tool) dated 3/7/23 documented the resident was cognitively intact, exhibited no mood/behaviors, no current tobacco use, and required extensive assistance of one staff member for personal hygiene.
In a nursing progress note, dated 2/2/23, Registered Nurse (RN) #2 documented Resident #202 was using their vape pen in their room and the resident released the vape pen to security. Additionally, Resident #202 stated they understood the rules, regulations and policies set forth by the facility and that they would continue to use vape pen at the facility when they had the opportunity.
The Care Plan Report dated 4/28/23 included the following:
- Problem area: smoking - not an approved smoker, uses vape pen; Resident chooses
to use THC (compound that is the main active ingredient of cannabis) in vape pen.
- Goals: Resident has been made aware that vape pens are not permitted at facility.
Resident has been suspected of vaping in their room, with fire alarm going off.
- Interventions: If staff note vape pens in the room, alert nursing supervisor or nurse
manager and/or security; Vape pens are to be kept with security or with family; Visitor
education on 4/2/23 that facility is a smoke free facility; Remind resident that
marijuana (cannabis) use on site is not acceptable practice.
During observations on 4/24/23 at 11:32 AM, 4/25/23 at 9:00 AM, 4/25/23 at 10:08 AM, 4/26/23 at 7:08 AM, and 4/27/23 at 9:33 AM there was a strong skunk like odor noted at the doorway of, and inside Resident #202s' room.
During an interview on 4/25/23 at 9:00 AM, Resident #202 stated they vaped marijuana outside of the facility, and that security holds all their vaping materials.
During an interview on 4/26/23 at 9:45 AM Certified Nurse Aide (CNA) #1 (assigned CNA) stated they have never witnessed Resident #202 vaping in room but have observed vape pens on the residents over the bed table. Additionally, CNA #1 stated they have reported the vape pens to the Unit Manager (UM).
During an interview on 4/26/23 at 9:49 AM, the RN Assistant Director of Nursing (ADON) stated Resident #202 has been suspected of using vape pens in their room and has had vape pens removed from their room in the past. Additionally, Resident #202 was not an approved smoker, and their vaping materials were to be locked with the security department.
During an interview on 4/26/23 at 10:07 AM, The ADON stated they had just removed 6 vape pens with cartridges from Resident #202's room.
During an interview on 4/26/23 at 11:07 AM, RN/UM (Unit Manager) for Hope 4 resident unit, stated they were aware Resident #202 vaped, had a history of keeping vape materials in their room, and the resident was supposed to keep vaping materials with security. Additionally, the RN/UM stated there had been no recent reports of vaping materials in Resident 202's room.
During an interview on 4/28/23 at 7:30 AM, the Security Director stated a room search of Resident #202's room was conducted on 4/27/23 after surveyor intervention with vaping and smoking materials recovered by security. Additionally, the Security Director stated vaping and marijuana were prohibited within the facility and on facility grounds.
The Room Search Incident dated 4/27/23 at 9:45 AM documented the following items were recovered from Resident 202's room:
- Three (3) sandwich bags containing marijuana
- Two (2) (face cream size) containers filled with marijuana
- One (1) cigarette cigar filled with marijuana
- One (1) cigarette cigar filled with tobacco
- Two (2) boxes liquid for vapes
- Two (2) disposable lighters
- One (1) torch lighter
- One (1) marijuana pipe
10NYCRR 415.12(h)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during a Recertification Survey and complaint investigation (NY00276844), completed on 7/15/21, the facility failed to ensure the environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents for one of two residents reviewed. Specifically, Resident #243 was assessed for safe smoking on 11/30/20, 3/8/21 and again 5/28/21 and determined to be unsafe to smoke unattended. On 4/23/21 Resident #243 went outside unsupervised, obtained cigarettes from another resident, asked another resident to help light the cigarette and Resident #243's hair caught on fire. The fire was put out by another resident and Resident #243 sustained a partial thickness burn to the forehead. There was no Comprehensive Care Plan (CCP) related to smoking or burns due to smoking. There were no documented interventions following the 4/23/21 incident. On 7/13/21 survey staff observed Resident #243 smoking outside unsupervised at approximately 10:30 a.m. Both hands had significant hand tremors while holding the cigarette. There was no staff present. During interview the unit Certified Nursing Assistant (CNA) said the resident is allowed to smoke. The Licensed Practical Nurse (LPN) said the resident can leave the unit unsupervised but is not allowed to smoke and they check on the resident as frequently as they can. This resulted in Immediate Jeopardy and Substandard Quality of Care with the potential for serious harm to Resident #243's health and safety. Findings include:
The facility policy Smoking, dated 3/3/20, revealed all new admissions shall have a Smoking Safety Assessment completed on admission, annually and as the interdisciplinary team (IDT) feels necessary. The use of cigars, e-cigarettes, pipes and or vaping devices are strictly prohibited in the outdoor smoking enclosure or on facility grounds.
Resident #243 was admitted to the facility 10/7/20 with diagnosis that included progressive multiple sclerosis, epilepsy, and bipolar disorder. The Minimum Data Set Assessment, dated 3/9/21, revealed the resident was cognitively intact, required supervision for locomotion on and off the unit and was a current tobacco user.
The CCP, dated effective 5/24/21 to present, included to provide a safe environment and constantly assess possible intent to harm. Goals for behavioral health and trauma included that Resident #243 had a history of smoking cigarettes and opioid dependence. Interventions included to provide direction as needed for inappropriate behavior, to refer to counseling and/or psychotherapy as needed and to provide assistance as needed.
The CCP did not include any interventions related to the resident's wishes to smoke or plans to provide safe smoking or smoking cessation.
The current Resident Care Summary (care plan used by the Certified Nursing Assistants to direct daily care) documented that the resident required staff assist for locomotion off the unit using a manual wheelchair and under smoking, it documented 'no'.
An Occupational Therapy (OT) evaluation, dated 11/30/20, documented that Resident #243 was not safe to go outside independently and did not demonstrate safety or independence with aspects required to have smoking privileges.
A Physical Therapy (PT) evaluation, dated 3/2/21, documented the resident was unable to safely propel outside or over any thresholds independently.
An Incident/Accident (I/A) report, dated 3/3/21, documented that Resident #243 was found outside near the smoking [NAME], alone and on the ground. The resident fell out of their wheelchair. The I/A report summary included that the Resident #243 struggled with uneven surfaces, was unable to safely propel outside and was not following safety recommendations.
An OT evaluation, dated 3/8/21, documented that Resident #243 was found outside by therapy, requiring assistance to re-enter the building. The resident had been smoking. Resident #243 reported to the therapist that they had received assistance by other residents to light, smoke and ash their cigarettes. This was confirmed by other residents.
A Smoking Safety Assessment, dated 3/9/21 and signed by the Registered Nurse (RN), documented that Resident #243 stated they were smoking. The Assessment included that the resident could not safely simulate smoking, including but not limited to, accessing smoking materials, lighting a cigarette, disposal of ashes or the cigarette in an appropriate receptacle. The Assessment did not include any interventions or plans to assist the resident with safe smoking.
An I/A report, dated 4/23/21 at 10:19 p.m., documented the CNA #1 saw Resident #243 in the smoking [NAME] falling asleep. Multiple cigarette burns were observed on the resident's clothing with holes in their pants and jacket and a red area noted on the resident's forehead. The report included that Resident #243's hair caught on fire when they requested a 2nd resident to assist in lighting their cigarette. The fire was put out by the 2nd resident. The red area noted on the resident's forehead was not reported to medical until 4/26/21.
A Medical provider note, dated 4/26/21 and signed by the Nurse Practitioner (NP) documented that Resident #243 had sustained a superficial partial thickness burn to the forehead while smoking outside in the smoke [NAME]. The NP documented the resident's hair was noted to be singed and that the resident had been deemed an unsafe candidate for smoking without staff assistance and had been preciously educated on this.
A physician note, dated 5/27/21, documented that Resident #243 had progressive multiple sclerosis with associated muscle spasm and was being seen for an evaluation of capacity after setting off the smoke alarm in their room due to vaping. Resident #243 was evaluated by physical therapy who again deemed the resident to be unsafe to navigate to the smoking [NAME]. Two physicians determined the resident continued to hold adequate decision-making capacity and was able to understand the risk of smoking to their health and the potential safety to the facility. Resident #243 declined a nicotine patch and was informed of the New York State Smoker's Quit Hotline.
In a nursing progress note, dated 5/27/21, the RN#1 documented that Resident #243 was informed that their smoking privileges were denied (cigarettes outside and vaping in their room).
The Investigation Summary, dated 6/2/21, related to the 4/23/21 incident included that Resident #243 had a history of unsafe smoking behaviors at other facilities and that a behavioral plan would be initiated and the facility would monitor the resident's smoking habits and behaviors through the medical record. The conclusion included that the Interdisciplinary Team met on 5/27/21 and determined that Resident #243 was no longer safe to smoke and smoking privileges were denied.
A Wellness Plan document, dated 6/3/21, included a statement signed by Resident #243 that they acknowledged they had been evaluated by therapies to be unsafe to go outside and smoke, and was not allowed to smoke or vape in their room or anywhere on the facility campus.
A nursing progress note dated, 6/4/21, documented the resident was found vaping in their room.
There was no documented evidence that an investigation was completed or that the CCP was changed or updated following this incident.
A nursing progress note, dated 6/13/21, documented the resident was found outside the building unsupervised.
There was no documentation that the CCP was updated following this incident.
During an observation on 7/9/21 at 10:56 a.m., Resident #243 was observed by surveyor outside the building, propelling their wheelchair towards the smoking [NAME] with a lit cigarette in their hand.
During an observation on 7/13/21 at 10:35 a.m., Resident #243 was sitting in a wheelchair in front of the smoking [NAME] holding a cigarette in their hand smoking. Significant tremors were visible to both of the resident's hands. A 2nd resident wheeled up next to Resident #243 and handed Resident #243 a cigarette. Resident #243 proceeded to smoke the second cigarette. There were no staff in sight.
During an interview on 7/13/21 at 11:12 a.m. the Unit Clerk stated that the residents do not need to sign out when leaving the unit. The Unit Clerk stated they thought that Resident #243 was allowed to smoke.
During an interview on 7/13/21 at 12:02 p.m., Resident #243 stated that they like to go outside and that they do smoke occasionally. Resident #243 stated, in order to go out, they would just wait by the outside door for another resident to go in and out of the building. Resident #243 added they had not burned themselves smoking.
During as interview on 7/13/21 at 2:09 p.m. the Unit Aide stated they did not know who was able to smoke or who was able to leave the unit independently.
During an interview on 7/13/21 at 2:12 p.m. CNA#2 stated that Resident #243 was able to smoke. CNA#2 stated that they did not know which residents were able to leave the unit independently. CNA #2 stated that Resident #243 did not let staff know when the resident was leaving the unit.
During an interview on 7/13/21 at 2:16 p.m. LPN#1 stated after therapy evaluated a resident for smoking it would be documented in the resident's care plan. LPN#1 said if a resident was not able to leave the facility unassisted, they would have a wander guard bracelet on and if they were approved to smoke, they would wear a lanyard indicating that. LPN#1 stated Resident #243 was not allowed to smoke but the resident does leave the unit unassisted and staff try to check on the residents as often as they can.
During an interview on 7/13/21 at 5:30 p.m. LPN #2 stated there were three residents on the unit who smoked including Resident #243. LPN #2 stated those residents should have lanyards or passes to access in and out of the building.
During an interview on 7/13/21 at 5:48 p.m., CNA #3 stated that they were unaware of the residents who smoked and that there was no list of smokers that CNA#3 was aware of.
During an interview on 7/13/21 06:14 p.m., the Administrator stated that Resident #243's care plan should have been revised following the burn if indicated.
During an interview on 7/13/21 at 6:27 p.m. the Assistant Director of Nursing (ADON) stated Resident #243 was aware that they were not allowed to go outside and smoke. The ADON stated the resident vaped. The ADON stated the resident was not allowed to go out of the building by themself as they need assistance.
On 7/13/21 at 8:49 p.m., the survey team declared that the IJ was removed based on the following corrective actions taken by the facility.
On 7/13/21 the facility provided 1:1 supervision to Resident #243 to prevent the resident from leaving the unit unattended and smoking unsupervised. The facility's security department was provided an updated list of residents who had been assessed and approved for smoking independently. Security will monitor the designated smoking location effective immediately for all residents who have access to the smoking area to verify that they are on the approved smoking list. All unit staff were educated on the updated smoking list and the procedures to follow for each resident.
On 7/14/21 Resident #243 agreed to wear a wander guard bracelet on their wheelchair. Resident #243 was provided re-education on the unit sign in and sign out procedures and agreed to this.
10 NYCRR 415.12(h)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during a Recertification Survey and complaint investigation (NY00276844), completed on 7/15/21, it was determined that for one resident (Resident #243) of three residents, the facility did not ensure that alleged violations of abuse, neglect, or mistreatment, including injuries of unknow origin were reported to the Administrator and the State Agency in a timely manner. Specifically, the facility did not report to the New York State Department of Health (NYSDOH) that Resident #243 sustained an injury while smoking unsupervised until 5 weeks after it occurred. This was evidenced by the following:
The facility policy, Accident and Incident Review and Prevention- Residents included all reportable events would be electronically reported per regulatory requirements.
Resident #243 had diagnoses that included progressive multiple sclerosis, epilepsy, and bipolar disorder.
The Minimum Data Set (MDS) Assessment, dated 3/9/21, revealed the resident was cognitively intact and required supervision of staff for locomotion on and off the unit. The MDS documented the resident was a current tobacco user.
A Smoking Safety Assessment, dated 3/9/21 and signed by the Registered Nurse, documented that Resident #243 stated they were smoking. The Assessment included that the resident could not safely simulate smoking, including but not limited to, accessing smoking materials, lighting a cigarette, disposal of ashes or the cigarette in an appropriate receptacle.
An Incident/Accident report, dated 4/23/21 at 10:19 p.m., documented that a Certified Nursing Assistant saw Resident #243 in the smoking [NAME] falling asleep. Multiple cigarette burns were observed on the resident's clothing with holes in their pants and jacket and a red area noted on the resident's forehead. The report included that Resident #243's hair caught on fire when they requested a 2nd resident to assist them in lighting their cigarette. The fire was put out by the 2nd resident. The red area noted on the resident's forehead was not reported to medical until 4/26/21.
A Medical provider note, dated 4/26/21 and signed by the Nurse Practitioner (NP) documented that Resident #243 had sustained a superficial partial thickness burn to the forehead while smoking outside in the smoke [NAME]. The NP documented the resident's hair was noted to be singed and that the resident had been deemed an unsafe candidate for use of the smoke [NAME] and had been preciously educated on this.
The Health Electronic Response Data System - a reporting system where health facilities report incidents to the state revealed that the incident was not submitted until 5/27/21.
During an interview with the Administrator, the Director of Nursing, the Quality Assurance Manager, and the Assistant Administrator on 7/15/21 at 10:33 a.m., the Administrator stated that administration had not been made aware of the incident as it had not been brought to morning report and was not included on the 24 hour-report. It was stated that the incident report was found on the unit on 5/27/21 and brought to the attention of administration who reported it at that time.
[10NYCRR 415.4(b)(2)]