**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 1/9/24, the facility did not ensure that each resident who was unable to carry out Activities of Daily Living received the necessary services to maintain good nutrition for one (Resident #118) of four residents reviewed. Specifically, Resident #118 was not provided with continuous supervision or touching assistance (limited assist) with eating in the alcove as planned. The finding is: The policy and procedure titled Feeding Assistance/Tray Labeling revised 7/2020, documented staff members designated the duties of feeding residents are aware of the assistance level needed by referencing the tray ticket placed on each resident's meal tray and the care guide for each resident. The policy and procedure documented that a limited assist is guided maneuvering any hands-on assistance needed to bring utensils or food/drink to mouth. Picking up cups and bringing to lips, hand over hand assist, intermittently assisting with food to mouth. The QRP Pocket Guide (quality reporting program- quick reference guide) provided by the Assistant Director of Nursing documented that supervision or touching assistance, the helper was to provide verbal cues and/or touching/steadying and/or contact guard assistance as the resident completed the activity. Assistance may be provided throughout the activity or intermittently. Resident #118 had diagnoses including dementia, diabetes mellitus type II, and hypertension (high blood pressure). The Minimum Data Set (a resident assessment tool) dated 11/3/23 documented Resident #118 had severe cognitive impairment, was sometimes understood, rarely/never understands, and required supervision/touching assistance for eating. The comprehensive care plan revised 11/20/23 documented Resident #118 had the potential for variable meal acceptance. Interventions included the resident was to eat in the alcove with a continuous supervision or touching assist (limited assist) and encourage adequate intake. The untitled [NAME] (a guide used by staff to provide care) dated 1/9/24, documented Resident #118 required continuous supervision or touching assist (limited assist) in the alcove for eating. Review of Resident #118's progress notes dated 10/31/23 through 1/8/24 revealed on 1/8/24 at 2:10 PM, Dietary Technician #1 documented Resident #118 had less well consumed meals in the past few days with recent average of 26-50 percent (%) of meal. There was no documented evidence that Resident #118 had refused supervision or touching assist (limited assist) for meals or refusal to eat in the alcove. During an observation of the lunch meal on 1/3/24 at 11:49 AM, Resident #118 was sitting in their wheelchair in their room attempting to eat their lunch independently. There were no staff member providing continuous supervision. During an observation of the breakfast meal on 1/5/24 at 8:38 AM, Resident #118 had poor positioning and was sitting diagonal in their bed in a half lying/half sitting position. The residents breakfast tray was on the bedside tray table in front of them and they were attempting to independently drink orange juice from a plastic container. The straw was removed from the container and the resident was attempting to replace the straw back into the container independently without success. There were no staff members in the room providing continuous supervision or touching assistance (limited assist). During a continuous observation of the lunch meal on 1/5/24 from 11:40 AM through 11:55 AM, Resident #118 was sitting in their wheelchair in their room by them self with their lunch tray on the bed side table in front of them. Resident #118 was coughing and dropped their fork on the floor. At 11:44 AM an unknown staff member sat in a chair outside of the resident's room to assist another resident eating in the alcove for three minutes and then left the alcove area. At 11:48 AM Certified Nursing Assistant #10 entered Resident #118 room and exited the room without offering assistance to the resident. At 11:50 AM Resident #118 was noted to be coughing again. At 11:55 AM Certified Nursing Assist #11 entered room and removed lunch tray from Resident #118. No staff member provided continuous supervision or touching assist (limited assist) during the meal. During an observation of the breakfast meal on 1/8/24 at 8:33 AM, Resident #118 was in their room, lying in bed with their breakfast meal covered on the bedside table and was not within reach to the resident. At 8:55 AM the resident was still in their room, lying in bed with their breakfast tray in front of them. Resident was independently eating their cereal with a spoon. Milk and cereal had spilled on the tray. There was no staff member in the room to provide continuous supervision or touching assist (limited assist). During an interview on 1/8/24 at 12:32 PM, Certified Nursing Assist #10 stated they were assigned to Resident #118 on 1/5/24 and 1/8/24. Certified Nursing Assist #10 stated that Resident #118 was a continuous supervision or touching assistance for meals in the alcove. Certified Nursing Assist #10 stated that Resident #118 should have been eating in the alcove with a staff member always keeping an eye on them to help the resident when needed. During an interview on 1/8/24 at 12:38 PM, Licensed Practical Nurse #8 stated the importance of Resident #118 eating in the alcove was to be supervised for their safety. During an interview on 1/8/24 at 3:36 PM, Occupational Therapist #2 stated Resident #118 was discharge from occupational therapy program on 12/29/22 at a limited assist for eating. They stated in October 2023 assistance level verbiage changed and Resident #118 was changed to a continuous supervision or touching assist. Occupational Therapist #2 stated that both a limited level of assistance and a supervision or touching assist meant that Resident #118 could feed themselves, but staff needed to supervision and assist. Occupation Therapist #2 stated that Resident #118 had difficulty reaching items, scooping their foods, and would become fatigued at times. During an interview on 1/9/24 at 10:12 AM, Register Nurse #2 (Nurse Manger of the 3 East unit) stated the Resident #118 needed continuous supervision because they often fall asleep during a meal and need to be woken up and assisted. During an interview on 1/9/24 at 11:27 AM, Diet Technician #1 stated Resident #118 had variable intake and needed encouragement and assistance during meals due to their cognitive impairment. During an interview on 1/9/24 at 11:59 AM, the Director of Nursing stated that if a resident was care planned for continuous supervision or touching assist during meals their expectation was for a staff member to observe the resident and assist them when needed. Resident #118 should have been in the alcove for meals as planned unless the resident refused; then a staff member should have remained in the room. 10NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 1/9/24, the facility did not ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote wound healing, and prevent new ulcers from developing for one (Resident #142) of three residents reviewed. Specifically, the resident developed an unstageable (full thickness skin or tissue loss-depth unknown) pressure ulcer; wound assessments were incomplete. The wound consultants recommendations dated 12/28/23 were not implemented, and the comprehensive care plan was not fully developed to promote wound healing. The finding is: The policy and procedure titled Initial Skin Disruption and Assessment Documentation revised 6/24/19 documented an Initial Skin Disruption and Assessment Record (Non-Pressure Injury) will be initiated at first recognition of a significant skin disruption. Moisture associated skin damage documentation will be initiated upon recognition. Weekly notes will be written in the electronic record wound and skin component thereafter, until the disruption is healed/closed/resolved. The purpose of this directive is to reflect presence and stats of a skin disruption (non-pressure injury), response to nursing care and continuity of care. The policy and procedure titled Initial Pressure Injury Identification and Assessment Documentation revised 6/18/2020 documented to determine the presence of a pressure injury and stage according to the following scale: unstageable/unclassified: full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description: until slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III (3) or IV (4). Preventative measures: include under intervention on the Interdisciplinary Care Plan. This may include but not limited to repositioning, protective devices, cushions, bed mattress, overlays, lubrication of the skin hygiene, hydration, nutritional support, non-compliance, and close observation of pressure areas. The policy and procedure titled Care Planning, Closet Care Plans, Care Guides-Nursing revised 6/2019 documented Closet Care Plans-Skilled Nursing: included on the closet care plan will be any information known to be needed to meet the resident's needs. The resident's formal turning and positioning needs are also listed on the [NAME] (guide used by staff to provide care). Resident #142 had diagnoses that included Alzheimer's disease, unspecified protein-calorie malnutrition, and generalized osteoarthritis. The Minimum Data Set (a resident assessment tool) dated 12/15/23 documented Resident #142 was moderately cognitively impaired. Resident #142 was at risk for developing pressure ulcers, had pressure ulcers, and were incontinent of bladder and bowel. Additionally, the Minimum Data Set, dated [DATE] documented Resident #142 had moisture associated skin damage present. The untitled comprehensive care plan last revised 11/8/23 documented Resident #142 had the potential impairment to skin integrity related to fragile skin. Documented approaches included to cleanse bilateral buttocks with normal saline, pat dry, apply antifungal powder, Medi honey (use to promote wound healing and cover with dry clean dressing every shift until healed dated 10/12/23. Additionally, revised on 2/23/23 Resident #142 had the potential for pressure ulcer development related to decreased mobility with approaches last revised on 7/17/23. There were no new approaches initiated until 1/9/24 which were to turn and position every two hours while in bed. The [NAME] as of 1/9/24 did not document formal turning and positioning needs for Resident #142. Review of the Order Recap Report dated 2/1/23-1/31/24 for Resident #142 revealed: - 11/22/23, discontinue cleanse bilateral buttocks with normal saline, pat dry, apply antifungal powder, Medi honey and dry clean dressing to moisture associated skin damage every shift. - 11/22/23-11/30/23, cleanse unstageable pressure ulcer to left buttock with normal saline, pat dry, apply Medi-honey and antifungal powder and cover with dry clean dressing every evening shift and as needed for wound healing, discontinued on 11/30/23 per wound consultant services recommendation. -11/30/23-12/14/23, apply Santyl External Ointment (enzymatic debridement agent) to left sacrum/buttock unstageable pressure ulcer topically every evening shift for wound healing. -12/14/23-12/21/23, cleanse left sacrum/buttock unstageable pressure ulcer with normal saline, pat dry, apply Nystatin powder, Santyl and Flagyl powder and cover with dry clean dressing. -12/21/23-12/28/23, Gentamicin Sulfate (antibiotic) external cream 0.1 percent apply twice a day for wound healing. Cleanse unstageable pressure ulcer to left buttock with normal saline, pat dry, apply Medi-honey, antifungal powder and Gentamicin cream and cover with dry clean dressing twice a day. -12/28/23-1/8/24, apply Santyl external ointment to left buttock/sacrum unstageable pressure ulcer topically once a day for wound healing, cleanse with normal saline, pat dry, cover with dry clean dressing. There were no documented orders for a plain x-ray of sacrum to rule out osteomyelitis (infection of the bone) or for wound culture as recommended on 12/28/23 by Wound Consultant Medical Doctor #2. -1/4/24, order to give 120 milliliters mighty shake twice a day for wound healing/nutrition. Review of Medical Visit notes dated 10/10/23 through 12/12/23 revealed there was no documented evidence of the presence of wound/skin concerns and pressure ulcers. The Skin and Wound Evaluation dated 11/22/23 documented Resident #142 had a new in-house acquired unstageable pressure ulcer, the location was not documented. The wound measured 5.0 centimeter squared area, 2.9 centimeters length by 2.3 centimeters wide. The evaluation documented the resident was to be seen by Wound Consultant Medical this Thursday. Review of the Progress Notes dated 11/22/23 at 2:33 PM by Registered Nurse #5, Nurse Manager revealed the resident was to be put on wound care services for recommendations of treatment. A positioning wedge in place and air overlay to be added to bed for protection. Turn and position as ordered while in bed. Review of the Skin and Evaluation dated 11/30/23 revealed Resident #142 had a new unstageable pressure ulcer to left gluteus with wound measurements of 7.0 centimeters squared area, 3.3 centimeters length by 2.9 centimeters wide. Notes documented Wound Consultant Medical Doctor #2, evaluated Resident #142's unstageable pressure ulcer to left buttock/sacrum and debrided wound on 11/30/23. Additionally, new treatment orders given. Review of the untitled initial wound review note completed by the Wound Consultant Medical Doctor #2 dated 11/30 revealed Resident #142 had a stage 3/unstageable pressure ulcer to their left butt/sacrum, wound size 3.34 centimeters by 2.91 centimeters with sharp wound debridement procedure was performed. Review of the Skin and Evaluation dated 12/28/23 revealed Resident #142 had a new unstageable pressure ulcer to left gluteus and there were no wound measurements documented. Treatment documented sharp debridement. Review of the untitled wound review note completed by Wound Consultant Medical Doctor #2 dated 12/28/23 revealed Resident #142 had an unstageable pressure ulcer to their left butt/sacrum, wound size 4.10 centimeters by 2.67 centimeters. Wound status noted to be worse and sharp debridement procedure was performed. Recommendations included a plain x-ray of sacrum to rule out osteomyelitis, a wound culture, and a treatment daily to the pressure ulcer. Review of the Skin and Evaluation dated 1/4/24 revealed Resident #142 had a new unstageable pressure ulcer to left gluteus and measured 7.9-centimeter squared area, 3.8 centimeters length by 2.9 centimeters wide. Depth, undermining tunneling not applicable. Review of the untitled wound review note completed by Wound Consultant Medical Doctor #2 dated 1/4/23 revealed Resident #142 had an unstageable pressure ulcer to their left butt/sacrum, wound size 3.77 centimeters by 2.88 centimeters. There was no wound status documented. During an observation on 1/5/24 at 8:43 AM, Resident #142 was lying on their back in bed, with head of bed elevated, on a standard pressure relieving mattress. There was no air overlay or positioning wedge observed to be utilized on bed. During an observation on 1/8/24 at 7:48 AM and 9:20 AM, Resident #142 was lying on their back on a standard pressure relieving mattress in bed. There was a positioning wedge observed at foot end of bed. During an observation on 1/8/24 at 9:25 AM, morning care was completed on Resident #142 by Certified Nurse Aide #3 and #4. The dressing covering the sacrum/left buttock pressure ulcer was bunched up, loose and the pressure ulcer was uncovered and exposed. The dressing fell off during care and was noted to be saturated with serosanguinous drainage (yellow/blood-tinged fluid). Certified Nurse Aide #4 exited room, and stated they were going to inform the nurse about the dressing. After care was provided, Certified Nurse Aide's #3 and #4 boosted Resident #142 in bed, positioned on their back. The positioning wedge remained at foot of bed. During an interview on 1/8/24 at 10:04 AM, Licensed Practical Nurse #3 stated Resident #142's treatment was completed every day on the evening shift. Licensed Practical Nurse #3 stated an aide reported to them that Resident #142's dressing came off, but they did not have an as needed treatment order to complete treatment at that time. During an observation and interview on 1/8/24 at 10:54 AM, Licensed Practical Nurses #3, #5, and Registered Nurse/Inservice Instructor #2 were all present to complete treatment to the pressure ulcer on the left buttock/sacrum. Resident #142 was rolled onto their left side in bed by Licensed Practical Nurse #5. Resident #142's pressure ulcer was exposed, and small amount of serosanguinous drainage was observed on incontinent brief. Licensed Practical Nurse #5 stated they could smell an odor from the pressure wound. Licensed Practical Nurse #3 stated it was documented as an unstageable pressure ulcer. Licensed Practical Nurse #3 stated the pressure ulcer had depth, looks like it is tunneled and was about 1.5 inches wide. Wound bed was deep maroon/red in color with some granulation tissue and raised areas noted in wound bed. Light yellow slough noted at distal edge of pressure ulcer. Licensed Practical Nurse #3 completed Resident #142's treatment as ordered and placed Resident #142 after care on their back in bed. The positioning wedge remained at the foot of bed. During an interview on 1/8/24 at 3:55 PM, Certified Nurse Aide #6 stated that if a resident needed turning and positioning or had an air mattress/air overlay it would be on the residents' care plan. During an interview on 1/9/24 at 9:53 AM, Unit Manager Registered Nurse #5 Registered Nurse #5 stated turning and positioning should have been implemented for Resident #142 to promote pressure ulcer healing and prevent pressure ulcer from getting worse. Registered Nurse #5 stated they just added turning and positioning to the care plan on 1/9/24. Additionally, Registered Nurse #5 stated Registered Nurse assessments were not done on moisture associated skin damage and pressure ulcer measurements were only done when a resident was seen by the Wound Consultant. During an interview on 1/9/24 at 10:44 AM, Licensed Practical Nurse #5 stated prior to 1/8/24 the last time they saw Resident #142 buttocks was 2 to 3 months ago before Resident #142 was moved downstairs to another unit. Licensed Practical Nurse #5 stated that the area to Resident #142's left buttock/sacrum was opened, and they spoke to Registered Nurse #4 Unit Manager regarding the treatment at that time. During an interview on 1/9/24 at 10:53 AM, Unit Manager Registered Nurse #4 stated they do not complete Skin and Wound evaluations for moisture associated skin damage. Registered Nurse #4 stated they did not take measurements or track Resident #142's moisture associated skin damage because they have time frame to clear it up and was hoping to heal it. Registered Nurse #4 stated that after a couple of weeks of the wound deteriorating and not showing signs of improvement with treatment, they should have tracked it and placed Resident #142 on the Wound Consultant, Medical Doctor #2 list to be seen. During an interview on 1/9/24 at 11:04 AM, Registered Nurse Inservice Instructor #1 stated turning and positioning should be on the residents [NAME], so staff know individualized needs on how to take care of any resident. During an interview on 1/9/24 at 11:47 AM, Unit Manager Registered Nurse #5 stated they were responsible for reviewing Wound Consultant Medical Doctor #2 recommendations and getting orders. Upon review of the 12/28/23 Wound Consultant Medical Doctor #2 recommendations, Registered Nurse #5 stated they did not see those recommendations at that time and should have. During an interview on 1/9/24 at 12:18 PM, Medical Doctor/Director #1 and Nurse Practitioner #1, stated they would expect to be made aware of all Wound Consultant Medical Doctor #2's recommendations within 12 hours to make sure the recommendations were ordered. Medical Doctor/Director #1 and Nurse Practitioner #1 stated the Wound Consultants recommendations from 12/28/23 should have been reviewed with them so that osteomyelitis, infection, and worsening of wound could be ruled out. Additionally, Nurse Practitioner #1 viewed Resident #142's most recent pressure ulcer picture in the electronic medical record and stated they would stage Resident #142's pressure ulcer as a Stage IV based on the depth and wound bed. During an interview on 1/9/24 at 12:53 PM-1:05 PM, Director of Nursing stated while viewing Resident #142's comprehensive care plan in the electronic record there should be a care plan for their unstageable pressure ulcer, as it is part of their care and treatment. The Director of Nursing stated turning and positioning, use of a positioning wedge should have been on Resident #142's care plan; and an overlay or air mattress should have been being used to promote wound healing of an unstageable pressure ulcer. The Director of Nursing stated the Unit Managers were responsible for reviewing Wound Consultant Medical Doctor #2 recommendations and should be followed up on them within the week of getting the recommendations. The Unit Managers should be reviewing recommendations with the medical provider within a week, so the medical provider knows exactly what was going on with the resident. Director of Nursing stated anytime a skin issue has been identified they should be seen by the wound team and if any open areas develop resident's get added to the Wound Consultants list to be seen the following week. During a telephone interview on 1/9/24 at 12:56 PM, Wound Consultant Medical Doctor #2 stated an unstageable pressure ulcer should be restaged after they debrided the unstageable pressure ulcer and if the wound base could be seen it would be a Stage 3 pressure ulcer and if muscle can be seen it would be restaged as a Stage 4. Additionally, Wound Consultant Medical Doctor #2 stated they expected their wound recommendations to be reviewed with the primary care physician and done within a few days. 10 NYCRR 415.12 (c)(1)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Standard survey completed on 1/9/24, the facility did not ensure each resident receives adequate supervision and assistance devices to prevent accidents for one (Resident #8) of 5 residents reviewed. Specifically, the facility did not implement effective interventions to prevent falls for Resident #8, who had over 60 falls since their admission to the facility in August of 2023. The finding is: The policy and procedure titled Fall Prevention Plan revised 5/19 documented the facility will implement a fall prevention plan on every resident to maximize resident safety and identify those at risk for falls. The Certified Nurse Aide will ensure all equipment, including alarms is present and functioning. All departments are required to note which residents had a fall and share this information with their staff so all staff can work together to prevent falls, this includes therapy, environmental services, volunteers, activities, spiritual care, dietary, and social workers. Resident #8 had diagnoses including cerebral infarction (stroke), aphasia (absence or difficulty with speech), and dementia. The Minimum Data Set (a resident assessment tool) dated 11/15/23 documented the resident had severe cognitive impairment and had two or more falls since admission. During an observation on 1/3/24 at 12:23 PM, Resident #8 was seated in their wheelchair in the alcove area. The resident had a dark bruise on the left side of their face and forehead. Review of the comprehensive care plan dated 10/4/23 documented the resident was at risk for falls related to confusion, psychoactive medication use, and self-transfers. The [NAME] Report (guide used by staff to provide care) dated 1/9/24 documented safety interventions included do not leave unattended on the toilet, encourage a body pillow on both sides of the bed, encourage nonskid socks to both feet when in bed, a floor mat to both sides of bed, falling star program, Velcro seatbelt in wheelchair, and a wide low boy bed. Wheelchair equipment included a wedged hemi wheelchair, pummel gel cushion, dycem (non-slip, self-adhesive mat) for all layers, anti-rollback brakes, and rear anti-tippers. Review of the Risk Management historical incidents report dated from 8/17/23 at 12:40 PM to 1/6/24 at 10:40 PM documented the resident had 100 falls. Review of the Therapy Screen dated 1/4/24 documented Resident #8 was found on the floor out of their wheelchair in the alcove area on 1/4/23. The resident had a history of 66 falls in 2023. The nurse Progress Note dated 10/30/23 at 5:30 PM, written by Registered Nurse Manager #2, documented the Accident/Incident Committee met on 10/25/23 and reviewed Resident #8's fall history. All current care plan interventions were reviewed. A recommendation was made to try melatonin (sleep aid) medication, however upon further review, it was noted the resident had an allergy to this medication. There were no further interventions documented as being discussed. During an interview on 1/5/24 at 8:58 AM, Registered Nurse Manager #2 stated Resident #8 had probably fallen daily since they were admitted to the facility. The resident had bruising on their face from falls on Christmas Eve when they sustained a hematoma on their left forehead. The Registered Nurse Manager #2 stated based on the number of falls the resident has had, their interventions were not doing the best they'd like them to. During an interview on 1/8/24 at 11:57 AM, Resident #8's healthcare proxy stated what the facility was doing for the resident's falls wasn't working because there have been multiple falls and it was sad that they were damaging themselves this way at this point in their life. During an interview on 1/8/24 at 10:42 AM, Certified Nurse Aide #1 stated the resident has had falls, and couldn't express how they felt, so maybe that was the reason. Certified Nurse Aide #1 stated they'd never seen Resident #8 have combative behaviors and falling was their main behavior. Certified Nurse Aide #1 stated the resident wanted staff to pay attention to them, but that was hard to do while taking care of other residents. During an interview on 1/8/24 at 10:59 AM, Registered Nurse #1 stated the resident has had many falls and they can't figure it out. They try to meet the resident's needs, but it seems like there's no contentment. The resident's family said the resident was a busy person and very active. Registered Nurse #1 stated the resident couldn't communicate their needs as they were mostly nonverbal and maybe they were bored. The Registered Nurse #1 stated they didn't trust the resident to be alone and that somebody usually sits with the resident. During an interview on 1/8/24 at 4:18 PM, Registered Nurse Supervisor #3 stated Resident #8 has had many falls, sometimes multiple times per shift. Registered Nurse #3 stated they felt the resident just wanted a friend and didn't like to be left alone. Registered Nurse Supervisor #3 stated their goal was to keep the resident from falling and to do this, someone needed to be with them or keep an eye on them. This was an everyday occurrence for this resident. During an interview on 1/9/24 at 9:34 AM, Registered Nurse Manager #2 stated the fall committee meeting reviewed the resident in October. They were not sure if they discussed any additional interventions other than the melatonin (which the resident was allergic to), they might have discussed using a different medication. During an interview on 1/9/24 at 9:59 AM, Occupational Therapist Registered #1 stated they participated in the fall committee meetings, and they meet quarterly. Occupational Therapist Registered #1 stated this resident was a challenge, and thought the resident deliberately slides themselves from their chair. To keep the resident safe, they monitor to ensure all the equipment in place is the ideal equipment for them and the resident gets a lot of attention from the staff. During an interview on 1/9/24 at 12:12 PM, the Director of Nursing stated the interdisciplinary team knew about Resident #8's falls and that they have exceeded 50 since they were admitted to the facility. The Director of Nursing stated it was almost impossible to prevent the resident's falls and they felt they were keeping the resident as safe as they possibly could. The Director of Nursing stated they have not been able to pinpoint any type of pattern with the falls. The Director of Nursing stated obviously not that their interventions weren't working to prevent falls. NYCRR 10 415.12 (h)(2)

Based on observation, interview, and record review conducted during a Standard survey completed on 1/9/2024, the facility did not provide separately locked, permanently affixed compartments for the storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse for one (Unit 4 East) of three resident units observed for medication storage. Specifically, there were three bottles of liquid Lorazepam (Ativan, Schedule IV controlled substance - sedative/antianxiety medication) in a locked box that was not permanently affixed in small refrigerator located in the medication room. Residents #14 and #478 were involved. The finding is: The facility policy and procedure titled, Controlled Substances Administration and Storage revised on 2/2017 documented, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility in accordance with Federal and State laws and regulations. Controlled substances are stored under double lock in a fixed cabinet designated for that purpose in the medication room, separate from other medications. During an medication storage observation on 1/8/2024 at 9:39 AM, Licensed Practical Nurse (LPN) #7 unlocked a small refrigerator in the medication room and removed a small locked metal box. The small metal box, contained three bottles of Lorazepam intensol oral concentrate 2 milligrams (mg) per milliliter (ml). Bottle #1 for Resident #14 had 28.25 milliliters (ml) remaining with a pharmacy fill date of 12/1/23; bottle #2 for Resident #14 had 30 milliliters (ml) remaining with a pharmacy fill date of 12/29/23; bottle #3 for Resident #478 had 30 milliliters (ml) remaining with a pharmacy fill date of 12/29/23. During an interview on 1/8/2024 at 9:39 AM, Licensed Practical Nurse (LPN) #7 stated the metal locked box was newer and had not been affixed to the inside of the refrigerator and did not know if it was required. During an interview on 1/8/2024 at 9:47 AM, Unit Manager Registered Nurse (RN) #6 stated the locked box was not affixed to the refrigerator, and that they believed controlled substances needed to be double locked. RN #6 stated they were not sure if the locked box needed to be affixed to the refrigerator. During an interview on 1/8/2024 at 3:09 PM, the Director of Nursing stated the refrigerator on the Four East Unit was only about two to three months old and they could not affix a locked box to the inside of the refrigerator. Therefore, the Lorazepam should not have been stored in that refrigerator. The Director of Nursing stated it was important to ensure that the control substances were stored in a locked control box that was affixed to the refrigerator to ensure that the no one could take the box out of the refrigerator. The Lorazepam (controlled substance) was not securely stored. 10 NYCRR 415.18(e)(2)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review conducted during the Standard survey, completed on 7/15/19, the facility did not ensure that a resident who is fed by enteral means (method of feeding that uses the gastrointestinal (GI) tract to deliver part or all of a person's caloric requirements) receives the appropriate treatment and services to prevent possible complications for one (Resident #145) of one resident reviewed for feeding tubes. Specifically, the facility did not provide tube feed formula as ordered by the physician. In addition, the nursing staff documented the formula was administered as ordered. The finding is: The facility policy titled Enteral Tube Feeding: General Guideline with a revision date of 9/17 documented tube feedings, using gastrostomy tube ( G-tube, a feeding tube that is inserted through the abdomen or mouth into the stomach wall to feed patients who cannot eat normally) as ordered, will be considered based on comprehensive assessment where there is demonstrated medical need to prevent or reverse malnutrition or dehydration. Tube feedings will be provided according to prevailing standards of professional practice and in compliance with Federal and New York State regulations. 1. Resident #145 was admitted [DATE] and has diagnoses that included a gastrostomy tube (GT, tube feed), dysphagia (difficulty swallowing), and disturbance of salivary secretion. The Minimum Data Set (MDS, an assessment tool) dated 5/22/19 documented the resident was cognitively intact, usually understands and was usually understood. Additionally, the MDS documented the resident received 51% (percent) or more of total calories and 501 cc (cubic centimeters) per day or more fluid intake through parenteral or tube feeding. During an observation on 07/12/19 at 12:08 PM with the Assistant Director of Nursing (ADON) Registered Nurse (RN) #1 present; Licensed Practical Nurse (LPN) #1 provided the resident with the bolus feed (a type of feeding method using a syringe to deliver formula through a feeding tube allowing formula to flow down using gravity). LPN #1 checked for g-tube placement and then for residuals (the volume of fluid remaining in the stomach). LPN #1 attached a large syringe (tumi) to the G-tube and placed 150 cc of water into the syringe to flush the G-tube. LPN #1 then placed the 237 cc of Jevity 1.5 (tube feed formula) into the syringe until it all ran through the tube. LPN #1 once again administered 150 cc of water via the syringe to flush the tube. The Physician's Orders dated 6/10/19 documented and order for bolus feeds, Jevity 1.2 @ 237 cc QID (four times a day) via the G-tube. Flush with 175 cc water before and after the bolus feed. On 6/11/19 the water flush before and after bolus feed was changed to 150 cc. Review of the Medication Administration Record (MAR) dated 7/1/19 through 7/31/19 revealed on 7/12/19, LPN#1 signed that Jevity 1.2 was administered as ordered at 8:00 AM and 12:00 PM. Review of the Physician's Orders from 6/10/19 through 7/12/19 revealed there was no documented evidence of a change in formula. Review of untitled Comprehensive Care Plan dated 6/11/19 revealed the problem for potential weight fluctuations due to order for PEG tube feedings, the goal was that the resident will maintain weight no higher than 128 to 136 pounds (lbs.) Review of Medication Incident/Error/Adverse Reaction Report dated 7/12/19 revealed resident received PEG feed of Jevity 1.5 instead of Jevity 1.2 and the Registered Dietitian (RD) #1 notified. Additionally, company sent incorrect feed packaged in box (package slip stated Jevity 1.2). Review of Delivery Ticket dated and signed 7/3/19 revealed the facility received 56 8-ounce (oz.) cartons of Jevity 1.2. During an interview on 7/12/19 at 12:24 PM LPN #1 stated, The bolus feed order reads Jevity 1.2. The one I gave the resident reads Jevity 1.5. I gave the wrong feed. The feed that I gave at 8:00 AM was also the wrong feed as I gave the Jevity 1.5 that is in the box in the medication room. We do not have any Jevity 1.2 on hand. I did not read the label close enough. I say it read Jevity but did not notice the 1.5 on the box. I should be reading the order first and them checking the product I am administering before giving it to the resident. During an interview on 7/12/19 at 12:32 PM, ADON RN #1 stated, the box of feed LPN #1 administered reads Jevity 1.5. I reviewed the orders from the physician and it reads the bolus feed should be Jevity 1.2. There is no order for the feeding to have been changed to Jevity 1.5. The wrong feed was given. When the order comes in the nurse is to check the order and they sign it off. Before administering the feed, the nurse should be checking the order and then the feed product. We only fax new orders to the company, otherwise they continue to send the product that was originally ordered. The company calls once a week to verify the order. During an interview on 7/12/19 at 12:36 PM, RD #1 stated, The resident is to be receiving Jevity 1.2, not Jevity 1.5. The feed she received is the wrong feed. The nurses should be checking the product received when it comes and before administering the feed to the physician's orders. The Jevity 1.5 could potential cause a weight gain. The goal for this resident is to have the weights remain stable. I will be calling the company immediately to get in the correct product, as all that is here is Jevity 1.5. At 1:30 PM RD#1 stated, I spoke to the representative at the company and they stated that sometimes the wrong product is sent, and it happens due to human error. 415.12(g)(2)