**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, the facility did not allow a resident the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident for one (Resident #31) of five residents reviewed for accidents. Specifically, Resident #31's side rails that were used to increase their independence and mobility in bed were removed by the facility as considered being a restraint without an appropriate assessment resulting in a fall out of bed with injury. This resulted in actual harm to Resident #31 that was not Immediate Jeopardy and is evidenced by the following: The facility policy Use of Side Rails, last reviewed January 2024, documented side rails are considered a restraint when they are used to limit the resident's freedom of movement. Side rails are permissible if they are used to treat a resident's medical symptoms or to assist with mobility and transfer of residents. An assessment will be made to determine the resident's medical symptoms or to assist with mobility and transfers of residents. Resident #31 had diagnoses including a stroke with left hemiparesis (weakness on one side of body), chronic pain, and depression. The Minimum Data Set Resident Assessment, dated 06/06/2024, revealed the resident was cognitively intact and required substantial to maximum assistance to roll left and right. Review of the current Comprehensive Care Plan, dated as revised 06/21/2024, and current [NAME] (used by Certified Nursing Assistants to direct daily care) documented Resident #31 required assistance with mobility related to limited mobility, weakness, and left hemiplegia. Interventions included, but not limited to, substantial to maximum assistance to roll left and right with two staff assistance. During an interview on 08/18/2024 at 8:05 PM, Resident #31 stated the facility staff removed their side rails that they had used for a long time to move around in bed because they (the facility) considered them a restraint. Resident #31 stated after the siderails were removed, they fell out of bed, and they continue to be afraid of falling again. In a facility Accident/Incident Report and Incident Summary, dated 06/17/2024, Licensed Practical Nurse #2 documented Resident #31 had an observed fall on 06/16/2024 resulting in a brain bleed. Recommended steps to prevent recurrence was a therapy evaluation. Review of the facility Fall Risk Assessment Evaluation, dated 06/18/2024, revealed that prior to Resident #31's fall from bed on 06/16/2024 the resident had no history of falls in the prior six months. In a medical progress note, dated 06/17/2024, Nurse Practitioner #1 documented Resident #31 rolled out of bed while receiving care and was hospitalized resulting in a subarachnoid hemorrhage (brain bleed). A Rehabilitation Referral, dated 06/18/2022 (identified by the Director of Nursing as misdated and should have been dated 06/18/2024), signed by the Registered Nurse Supervisor included a referral to therapy to assess for adaptive equipment and/or assistive device due to a fall. Review of Resident #31's medical record did not include any evidence a therapy evaluation had been completed following the resident's fall with injury, or that a side rail assessment had been completed to determine the safety of one or the use of one for increased independence in bed mobility. During an interview on 08/23/2024 at 9:26 AM, Certified Nursing Assistant #1 stated Resident #31 had told them they were upset that their siderails were removed as they only had the use of one arm, and they could grab the siderails with that arm and move around and assist the aides with bed mobility as before. During an interview on 08/23/2024 at 9:44 AM, Unit Clerk/Certified Nursing Assistant #1 stated they had been caring for Resident #31 for many years and they used to have side rails which they used to help themselves roll, in addition to assisting the staff with bed mobility and positioning. The Unit Clerk/Certified Nursing Assistant #1 stated Resident #31 had a fear of rolling out of bed and the side rails also gave the resident peace of mind. During an interview on 08/23/2024 at 10:20 AM, Maintenance Staff #1 stated they were told side rails were not allowed and to remove them all (all side rails in the facility), and they guessed it came from the prior Administrator. Maintenance Staff #1 said they remembered Resident #31 saying they were unable to turn in bed without the side rails. During a telephone interview on 08/23/2024 at 10:28 AM, the Director of Maintenance stated they were ordered by the prior Maintenance Director to pull the side rails approximately 6 to 12 months ago, but did not get any information as to why, stating we just followed the work order. During an interview on 08/23/2024 at 10:38 AM, the Director of Nursing stated side rails were removed throughout (the facility) to stay in line for a restraint free facility and they were not aware Resident #31 had side rails prior to them being taken off their bed. The Director of Nursing stated no other type of bar had been considered to their knowledge and did not know if any side rail audit (assessment) had been completed. The Director of Nursing stated the therapy referral was dated as 06/18/2022 but should have been dated 06/18/2024. It should not have prevented therapy from completing a referral as the referrals were discussed in morning report and therapy checks their referrals on a regular basis. During an interview on 08/23/2024 at 11:15 AM, Occupational Therapist #1 stated this facility did not allow any side rails for any reason because they say they are a restraint. Occupational Therapist #1 said that a side rail on Resident #31's bed would not limit their freedom of movement and would not be considered a restraint for this resident. Occupational Therapist #1 said Resident #31 would actually be a very good candidate for a side rail due to their hemiparesis on one side and a strong arm on the other (to pull themselves over and hang on) and increase their participation with self-positioning and bed mobility (rolling to the side). Occupational Therapist #1 stated they did not put this information in their last therapy discharge note because the facility did not allow any side rails for any resident, and they were told by the Director of Nursing that they had to make a recommendation on Resident #31's Discharge Summary for the resident to participate in rolling to the side using strength of whole body (versus a side rail), despite their affected left side that was unable to yank or pull. During an interview on 08/23/2024 at 12:25 PM, the Administrator stated side rails were not a restraint if they were used appropriately. During an interview on 08/23/2024 at 2:09 PM, Physician #1 stated if the therapy department had made the recommendation for a bed mobility device the resident should be able to have one. Physician #1 stated they knew this resident used to have a siderail for self-positioning but was no longer allowed to have one due to the facility not allowing side rails any longer. Physician #1 stated if a resident had a cerebral vascular accident (stroke), had lost use of one side of their body, and had a strong opposite arm, a side rail or another device that could be added to the bed would help prevent them from rolling out of bed and there would be a less chance to fall with a barrier there. 10 NYCRR 415.5(e)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during the Recertification Survey from 08/18/2024 to 08/23/2024, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (Resident #59 and #71) of two residents reviewed. Specifically, Resident #59 was readmitted from the hospital on [DATE] following surgical treatment of an abscess (a painful, swollen lump filled with pus) and did not have a follow up evaluation as ordered in a timely manner. Resident #71, who had a contracture (a shortening of muscles, tendons, skin, and nearby soft tissues that prevent normal joint movement which is often painful) of the left hand did not have a care plan in place that included measurable goals, interventions, or monitoring which resulted in multiple pressure ulcers and a decrease in range of motion. This resulted in actual harm to Resident #71 that was not Immediate Jeopardy and is evidenced by the following: 1. Resident #71 had diagnoses that included a stroke and hemiparesis (weakness or the inability to move on one side of the body). The Minimum Data Set Resident Assessment, dated 05/31/2024, documented the resident was cognitively intact, had a functional limitation in range of motion in one upper extremity and one lower extremity, and did not have any pressure ulcers. The facility policy Contracture Management Program, dated January 2024, documented the facility will engage residents as appropriate in contracture management interventions to improve, maintain, and prevent deterioration of the mobility of joints, flexion, and extension of extremities. Relevant care plans will be initiated that address resident risks and actual impairments and interventions to address. The facility policy Resident Mobility and Range of Motion, dated January 2024, documented residents with limited range of motion will receive treatment, services, and equipment to increase and/or prevent further decrease in range of motion. The resident care plan will be developed by the interdisciplinary team based on the comprehensive assessment, will be revised as needed, and will include specific interventions, exercises, and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion. Interventions may include therapies, the provision of necessary equipment, and/or exercises and will be based on professional standards of practice and be consistent with state laws and practice acts. Review of an Occupational Therapy Discharge summary, dated [DATE], the Director of Therapy documented Resident #71 had a contracture to their left hand and their splint (a device used to treat a contracture that provides support, improves range of motion, prevents pain and impairment to skin integrity) was missing, a new one was ordered, and the resident would continue therapy treatment once the splint arrived. The facility was unable to provide evidence Resident #71 received a splint or any occupational therapy services since 09/28/2023. There was no documented evidence Occupational Therapy readmitted Resident #71 to resume therapy services. Review of the current Comprehensive Care Plan and [NAME] (a care plan used by Certified Nursing Assistants to provide daily care) did not include information related to Resident #71's contracture to their left hand or interventions and monitoring for the contracture to prevent complications. Review of a progress note, dated 08/18/2024 at 8:37 PM, included Registered Nurse Supervisor #1 documented Resident #71 had three new pressure ulcers on their left hand due to the contracture. Two of the wounds were a stage two (partial thickness tissue loss as a shallow open ulcer) pressure ulcers, with the larger wound measuring three centimeters by one centimeter and one wound was considered an unstageable (full thickness tissue loss and wound base covered with dead tissue) pressure ulcer. The medical provider was notified, and verbal orders obtained for wound treatments and a follow-up with the facility wound care doctor. During observations on 08/18/2024 at 8:38 PM and 08/19/2024 10:42 AM, Resident #71's left hand was contracted and had open wounds of the left palm. There was no splint or dressing to the hand. During an interview at that time, Resident #71 stated the contracture had been there for a while, and they were not receiving any interventions or therapy for the contracture despite asking for therapy for two months. Review of a medical progress note, dated 08/18/2024, following a telemedicine visit Nurse Practitioner #2 documented the resident was being seen for multiple wounds to the left-hand contracture. Nurse Practitioner #2 ordered bacitracin (antibiotic ointment to help prevent infection) daily for three days and a wound consultant on 08/19/2024. There was no documented evidence a wound consult was ordered or completed. Review of a progress note, dated 08/19/2024 at 8:15 AM, the Director of Nursing documented Resident #71 had increased resistance to range of motion of their left hand, altered skin integrity, and an occupational therapy evaluation had been requested. Review of a physician's order, dated 08/19/2024, included to cleanse the left palm wound with normal saline, apply a thin layer of bacitracin, and cover with a dry dressing daily until 08/22/2024. The orders did not include orders for therapy services, or a follow-up visit with the wound doctor. During additional observations on 08/20/2024 at 10:18 AM and again at 2:29 PM, Resident #71 did not have a dressing covering the wounds to their left hand or any splint in place. Review of the August 2024 Treatment Administration Record revealed the left-hand wound treatment was signed off as completed on 08/19/2024 and 08/20/2024. During observations on 08/21/2024 at 1:05 PM, Occupational Therapist #1 was assessing Resident #71's left hand in the resident's room. There was no dressing in place to the left hand. During an immediate interview, Occupational Therapist #1 stated the resident had a contracture to their left-hand that required therapy. Review of an Occupational Therapy evaluation and assessment notes, dated 08/21/2024 and 08/22/2024, revealed the resident was being evaluated for increased pain that limited movement, decreased range of motion, decreased strength, and the need for splinting and passive range of motion, and that occupational therapy services were warranted. During an interview on 08/22/2024 at 9:37 AM, Certified Nursing Assistant #3 stated Resident #71 had a left-hand contracture for at least nine months and was unable to move their hand. Certified Nursing Assistant #3 stated Resident #71 had verbalized they wanted therapy to help with their left hand, but had not received any therapy during that time that they knew of. During an interview on 08/22/2024 at 2:04 PM, Occupational Therapist #1 stated Resident #71 was a high risk for contractures due to having a stroke and was surprised that Resident #71 did not have any interventions in place for contractures. The Occupational therapy department should have followed up and obtained a splint for Resident #71 based on the previous discharge summary, and was surprised it had been so long since occupational therapy had seen the resident. Occupational Therapist #1 stated Resident #71's left hand wounds were most likely caused by pressure from the contracture and the lack of interventions in place to keep the contracture from worsening and to protect the skin from breakdown. During an interview on 08/22/2024 at 4:15 PM, Physician #1 stated Resident #71 had contractures on the left side of their body, including the left hand, most likely a result of paralysis after their stroke. Physician #1 stated they would expect Resident #71 to be receiving interventions for the contracture including therapy services, range of motion exercises, and a device in their hand to help prevent skin breakdown. Physician #1 stated not receiving interventions for the contracture or therapy services could have led to the development of the pressure ulcers in Resident #71's hand. During an interview on 8/22/2024 at 5:25 PM, the Director of Nursing stated Resident #71 should have a care plan for the hand contracture that included interventions to prevent worsening of the contracture and prevent the development of a pressure ulcer. The Director of Nursing stated therapy should have been involved with the resident between their discharge on [DATE] and the development of the pressure ulcers on 08/18/2024 and involved in quarterly assessments and care planning, but there was not a process in place for those evaluations. The Director of Nursing stated without a care plan with interventions for the contracture and the lack of involvement from occupational therapy, it most likely is what caused Resident #71 to develop pressure ulcers in the left hand. 2. Resident #59 had diagnoses that included hemiplegia (partial or complete paralysis on one side of the body), protein-calorie malnutrition, and an abscess (a painful, swollen lump filled with pus) of the buttock. The Minimum Data Set Resident Assessment, dated 05/08/2024, documented the resident was cognitively intact. Review of the Comprehensive Care Plan, dated 08/12/2024, revealed Resident #59 had a surgical incision to the right buttock. Interventions included to apply treatment per the physician's order, weekly documentation of the wound, and referral to appropriate medical specialists as needed for evaluation and treatment. Review of a nursing progress note, dated 07/30/2024 at 5:35 AM, Registered Nurse #1 documented Resident #59 had requested to see a nurse and reported having a boil on the back of their right hip. The wound was assessed and found to be inflamed with signs of infection, and the resident was transferred to the hospital. Review of a hospital History and Physical, dated 07/30/2024 at 4:17 PM, revealed Resident #59 had gluteal (buttocks region) abscess and a Computed Tomography (CT) scan noted a fluid collection that was suggestive of an abscess. A hospital Discharge Summary and After Visit Summary, dated 08/6/2024, included Resident #59 was seen by surgical services while hospitalized and underwent an Incision and Debridement (I&D) surgical procedure on 07/31/2024 and wound closure on 08/02/2024, was being discharged on 08/06/2024, and had a post-operative appointment scheduled with General Surgery on 08/13/2024. Review of a readmission Note, dated 08/06/2024 at 3:13 PM, the Assistant Director of Nursing documented Resident #59 was readmitted to the facility. Review of physician's orders, dated 08/08/2024, included to cleanse the right buttock surgical wound with sterile water or normal saline, place a normal saline soaked gauze to the open area, apply skin prep (liquid skin protectant) to the peri-wound (surrounding skin), and cover with a silicone foam bordered dressing daily. An order, dated 08/06/2024, included an appointment scheduled for 08/13/2024 at 10:00 AM with the hospital general surgeon. During observations on 08/22/2024 at 11:47 AM, the wound was approximately three to four inches long. The lower portion of the wound incision closed with three sutures and the upper portion was a circular in shape open area. During an immediate interview, Registered Nurse #2 stated they would have the physician come look at the wound due to a possible dehiscence (the reopening of a surgical incision that had been stitched or stapled closed). Review of interdisciplinary progress notes from 08/06/2024 to 08/23/2024 did not include any documented evidence the Surgeon's office or any medical provider had evaluated the surgical wound following the resident's return to the facility. During an interview on 08/22/2024 at 2:43 PM, Registered Nurse Supervisor #2 stated they had spoken with the Director of Nursing who said Resident #59 was not being followed by a Wound Care Consultant because the resident was scheduled for a surgical follow-up appointment, but the appointment had been cancelled. Registered Nurse Supervisor #2 stated the facility's physician was assessing the resident's wound at that time. During an interview on 08/22/2024 at 4:59 PM, the Director of Nursing stated when Resident #59 returned to the facility from the hospital, a portion of the incision was not sutured closed (left open). The Director of Nursing stated residents were typically seen by the facility's Wound Care Consultant after surgical follow-up appointments. Resident #59's surgical appointment that had been scheduled for 08/13/2024 had to be changed to 09/12/2024 and Unit Clerk #1 (who schedules appointments) would know more about it. During an interview on 8/22/2024 at 5:53 PM, Licensed Practical Nurse Manager #1 stated Resident #59's surgical follow-up appointment had been rescheduled by Unit Clerk #1 but was not sure why. Licensed Practical Nurse Manager #1 stated the appointment should have been left as scheduled. The Wound Care Consultant had not been asked to see Resident #59 since their re-admission and the surgical follow-up appointment was now scheduled for 09/12/2024. During an interview on 08/23/2024 at 9:49 AM, Unit Clerk #1 stated their role involved setting up resident appointments and scheduling transportation. Resident #59 had an appointment scheduled for 08/13/2024 with the surgeon, but they had to reschedule it for transportation reasons. Unit Clerk #1 stated there were three residents scheduled for outside appointments on 08/13/2024, they could not get medical transport for all three residents, and Resident #59's appointment is now scheduled for 09/12/2024. Unit Clerk #1 stated they did send an email to Licensed Practical Nurse Manager #1 about Resident #59's appointment change but they had only been in their role for about two months and had not been told during training that someone (in leadership) should be notified if an appointment needed to be rescheduled or why. During interviews on 08/23/2024 at 02:17 PM and again at 04:41 PM, Physician #1 stated the facility used Wound Care Consultants (physicians) to assess residents with wounds and provide recommendations and as far as they knew, Resident #59 had not been seen by a Wound Care Consultant (following their surgery and readmission). Physician #1 stated follow-up appointments were important because the surgeon would recommend the treatment course, and they (facility staff) should be notified if an appointment was rescheduled or cancelled. Physician #1 stated rescheduling Resident #59's appointment could impact the resident due to a delay in treatment (not getting the surgeon's recommended treatment) and the resident could get an infection. Physician #1 said they observed Resident #59's wound on 08/22/2024 and the wound looked the same compared to their previous observation (no date provided), and they do not believe it had dehisced (the reopening of a surgical incision that had been stitched or stapled closed). During an interview on 08/23/2024 at 4:49 PM, the Director of Nursing stated Unit Clerk #1 was responsible for resident appointments and if an appointment needed to be rescheduled or cancelled, it should be discussed with the unit manager and notify the physician. The Director of Nursing did not know the why Resident #59's 08/13/2024 appointment had been rescheduled, and a special request for a Wound Care Consult had now been made since the surgical follow-up appointment had been rescheduled (for 09/12/2024). 10 NYCRR 415.12