**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during an abbreviated survey (Case # NY00325764), the facility failed to ensure the resident environment remained as free of accident hazards as possible for 7 (Resident #'s 2, 3, 20, 21, 22, 25, and 26) of 7 residents reviewed. Specifically, the facility (A) failed to provide meals to Resident #'s 2, 20, 21, 22, 25 and 26 who required a modified diet (provides foods that have a texture that is easier to eat), with meal items that were consistent with the physician ordered food texture, and (B) did not ensure that kitchen and nursing staff knew how to properly and consistently prepare and identify modified diets that were safe for residents. Subsequently, this put all residents with modified diets at risk for choking. This resulted in Immediate Jeopardy to resident health and safety and Substandard Quality of Care for Resident #'s 2, 20, 21, 22, 25 and 26, and had the likelihood to affect all 36 residents in the facility who required modified diets. Additionally, (C) the facility failed to ensure Resident #3, with a history of aggression towards others and self-harm, did not have sharp objects in their room and that behavioral interventions were followed for safety; and (D) Resident #2's care plan was not updated, or new interventions implemented after the resident had multiple falls with injuries. This is evidenced by: Cross-referenced to: F600: Abuse Prohibition, F610: Investigate/Prevent/Correct Alleged Violations, F725: Sufficient Nursing Staff. The undated Policy and Procedure titled Meal Tray Preparation and Tray Pass documented it was the policy of the facility's Dietary Department to identify the process followed to deliver food in a safe, accurate, effective, and timely manner to resident consistent with physician prescribed diets. It documented a diet order must be received prior to a meal being accepted. All food/beverage requests were entered into the Meal Service Program, meal production sheets were printed, and meals would be prepared accordingly. Menu items were placed on a tray and prior to loading, all items were checked against the meal ticket for accuracy. (A) The facility failed to provide meals to Resident #'s 2, 20, 21, 22, 25 and 26 who required a modified diet, with meal items that were consistent with the physician ordered food texture, and (B) did not ensure that kitchen and nursing staff properly and consistently knew how to prepare and identify modified diets that were safe for residents. Resident #20 Resident #20 was admitted to the facility with diagnoses of, hypoglycemia (low blood sugar), generalized muscle weakness, and dementia of unspecified severity with psychotic disturbance. The Minimum Data Set (an assessment tool) dated 2/10/2024, documented the resident had moderate cognitive impairment, could understand others, and be understood by others. Comprehensive Care Plan for Significant Weight Loss, revised 2/17/2023, related to inadequate nutritional intake relative to needs, as evidenced by significant weight loss and was at risk for malnutrition. Interventions documented staff were to monitor/document/report as needed any signs/symptoms of dysphagia (difficulty swallowing): pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, and appears concerned during meals. Order Summary Report dated as of 4/01/2024, documented an order dated 2/18/2023 for a regular diet; mechanical soft (food) texture. During an observation on 4/09/2024 at 12:12 PM, Resident #20, who was ordered to have a mechanical soft diet, was served a hamburger patty and kernel corn instead of creamed corn, per the meal ticket. Licensed Practical Nurse #6 was observed cutting the hamburger patty into pieces and then walked away from the resident. At 12:26 PM, Resident #20 was observed not eating their lunch and Licensed Practical Nurse #6 verbally encouraged Resident #20 to eat. At 12:31 PM, Resident #20 was observed using their walker to exit the dining area while crying, and the resident did not eat the meal. Resident #20's meal ticket for the lunch tray dated 4/09/2024, documented mechanical soft (diet). It documented ground #8 beef enchilada casserole and creamed corn. During an interview on 4/09/2024 at 12:34 PM, Registered Dietician #1 inspected Resident #20's lunch tray and stated Resident #20's hamburger patty should have been served with a ground texture instead of cut. Registered Dietician #1 stated Resident #20 was served whole kernel corn instead of creamed corn as it was listed on resident's meal ticket. Resident #21 Resident #21 was admitted to the facility with diagnoses of gastro-esophageal reflux disease without esophagitis (acid reflux disease without erosion of the esophagus), muscle wasting and atrophy (decrease in size or wasting away of a body part) and unspecified dementia with unspecified severity with agitation. The Minimum Data Set, dated [DATE], documented Resident #21 had severe cognitive impairment, could understand others, and be understood by others. Comprehensive Care Plan for Underweight for Age, revised 2/19/2024, related to inadequate PO (oral) intake, documented the resident had impaired swallowing function and was to have a mechanically altered diet. Interventions documented staff were to instruct the resident to eat slowly and chew each bite thoroughly. Comprehensive Care Plan for Oral/Dental Health Problems, revised 2/20/2024, related to poor nutrition, poor oral hygiene, and edentulous (no teeth); has upper dentures. Interventions documented diet as ordered. Order Summary Report dated as of 4/01/2024, documented an order dated 8/01/2023 for a regular diet, mechanical soft texture. During an observation on 4/11/2024 at 12:49 PM, Resident #21's plate was observed to have a sliced turkey meat sandwich cut into 4 (four) pieces. Resident #21's meal ticket was on the tray and indicated the resident was ordered a mechanical soft diet. During observation of the lunchtime meal on 4/11/2024 at 1:05 PM, Registered Dietician #1 was observed talking to Resident #21 at their lunch table. Registered Dietician #1 was heard offering to bring Resident #21 an egg salad sandwich if it would be easier to chew. Resident #21 was observed to pull a long segment of partially chewed, yet still intact, turkey deli meat out of their mouth. Registered Dietician #1 asked Resident #21 whether they had teeth or dentures in their mouth. Resident #21 opened their mouth slightly. Resident #21 was observed to be edentulous (without teeth). Registered Dietician #1 indicated they would get Resident #21 an alternative to the turkey sandwich. The facility was not able to print the lunch meal ticket dated 4/11/2024 for Resident #21. An untitled, undated report provided by the facility documented that on 4/11/2024, Resident #21 was to receive a turkey salad sandwich. During observation of the dinner meal on the South unit, on 4/11/2024 at 5:10 PM, Resident #21's meal ticket documented they were to receive a mechanically soft diet and to be served 6 ounces of chicken noodle soup pureed. Resident #21 was observed to have received a bowl of chicken noodle soup of regular consistency, not pureed. The facility was not able to print the dinner meal ticket dated 4/11/2024 for Resident #21. An untitled, undated report provided by the facility documented that on 4/11/2024, Resident #21 was to receive pureed chicken noodle soup. Resident #22 Resident #22 was admitted to the facility with diagnoses of cerebral infarction (stroke), chronic kidney disease (stage 4), and dementia. The Minimum Data Set (an assessment tool) dated 3/01/24 documented Resident #22 had mild impaired cognition, resident could understand others, and could be understood by others. Comprehensive Care Plan for Has a Swallowing Problem, revised 3/26/2023, related to complaints of difficulty or pain with swallowing, coughing, or choking during meals. Interventions documented all staff were to be informed of the resident's special dietary and safety needs, diet was to be followed as prescribed, instruct resident to eat slowly and chew each bite thoroughly, and the resident was to eat only with supervision. Order Summary Report dated as of 4/01/2024, documented an order dated 7/13/2023, for a no-salt added diet, mechanical soft texture. Observations of the lunchtime meal on the South unit on 4/11/2024 were made between 12:41 PM and 1:18 PM. At 12:41 PM, the kitchen staff were observed delivering the lunch cart to the unit. The facility's Minimum Data Set Coordinator #1 was observed checking resident trays against the meal tickets prior to handing them to staff to deliver and serve to the residents. During an interview on 4/11/2024 at 12:58 PM, Minimum Data Set Coordinator #1 stated the broccoli was tough in texture and needed to be cut. Minimum Data Set Coordinator #1 informed staff to cut the broccoli florets which had already been served. On 4/11/2024 at 1:10 PM, Registered Dietician #1 went into Resident #22's room to check on their lunch. Resident #22 was unsupervised and was observed propped up in bed eating lunch from the tray on the over the bed table. Resident #22's lunch included a side of uncut broccoli florets which appeared uneaten. Registered Dietician #1 asked Resident #22 about the broccoli and Resident #22 replied, not eating it. Registered Dietician #1 asked Resident #22 if the broccoli was too tough for them and Resident #22 stated yes. Resident #22's meal ticket was on the tray and indicated they had a physician's order for a chopped diet. The facility was not able to print the lunch meal ticket dated 4/11/2024 for Resident #22. An untitled, undated report provided by the facility documented that on 4/11/2024, Resident #22 was to receive buttered broccoli. The consistency of the broccoli was not documented. Additional Interviews: During a follow-up interview on 4/11/2024 at 1:13 PM, Registered Dietician #1 indicated mechanical soft and chopped diets do not require sides to be chopped or cut before being served to the resident if the items were soft enough in texture. Registered Dietician #1 indicated Resident #22's broccoli florets should have been cut into quarter inch pieces. Registered Dietician #1 indicated mechanical soft and chopped diets required sandwiches to be served quartered (cut into 4 equal parts). During an interview on 4/12/2024 at 4:02 PM, Registered Dietician #1 stated there were 3 components of a diet order: therapeutic (renal, regular, no sugar and/or no salt), liquid (viscosity), and consistency (chopped, mechanical, regular). Registered Dietician #1 indicated the facility would be switching to a different standard of defining food consistencies because the current system was confusing. Registered Dietician #1 indicated they were auditing past records to be sure diets were currently correct. Registered Dietician #1 stated they did an audit in March 2024 focusing on chopped diets and found mistakes that were being made by kitchen staff. Registered Dietician #1 stated they then educated the kitchen supervisor, who was to train kitchen staff. Registered Dietician #1 stated the facility held large classes as part of their orientation for food safety which included information on cutting sandwiches into quarter pieces. During an interview on 4/12/2024 at 5:00 PM, Administrator #1 stated they indicated the first line in ensuring correct resident diets is the education of the kitchen staff. Administrator #1 indicated they are working on facility-wide education of the facility nursing staff and certified nursing assistants. Administrator #1 indicated they are doing meal audits for 7 (seven) days or as long as it takes to reach 100% accuracy of meal trays. Administrator #1 indicated meal accuracy would be added to the reviews done by their quarterly quality assurance committee. Administrator #1 indicated outside vendors for speech and dietary will be consulted to ensure the in-house dietary education is the way it should be to help get a process together that is less confusing. Administrator #1 indicated a kitchen staff supervisor was in the facility every day to ensure accurate resident textures and consistencies and nursing staff should be the second line of defense in catching meal tray mistakes if those mistakes were to make it out of the kitchen. During an interview on 4/14/2024 at 7:30 AM, Administrator #1 indicated the dietary electronic system for generating meal tickets was not integrated with the electronic medical record used by the facility; therefore, any changes, including new admissions, discharges, and/or changes in resident diets made in the electronic medical record must be manually entered into the dietary system used by the kitchen. Administrator #1 indicated they were catching some meal tickets that were incorrect. Administrator #1 also indicated they discovered that when an alternative meal option is requested in the dietary electronic system for residents with a mechanical soft diet, it lists club sandwich - chopped as an allowable alternative option which was not right. Administrator #1 indicated, now, when they catch mistakes on meal tickets, they are marking the tickets for follow-up corrections to be done in the dietary system. Administrator #1 indicated, from a corporate level, they would be changing to a different dietary electronic system. During a subsequent interview on 4/14/2024 at 5:45 PM, Administrator #1 indicated the Food Director was the person responsible for checking the tickets and ensuring they were correct before the food cart with meal trays were delivered to the units. During an interview on 4/15/2024 at 7:18 AM, Regional Director of Nursing #1 was interviewed and indicated the problems of inaccurate meal trays was coming from the kitchen because the facility had a Food Director who they have since replaced. Regional Director of Nursing #1 indicated the facility anticipated a big improvement with the new Food Director. During an interview on 4/15/2024 at 3:48 PM, interim Director of Speech Pathology #1 was interviewed and indicated they had worked in the facility for about 3 (three) weeks and focused on individual diets and treatments. Director of Speech Pathology #1 indicated they were currently asked to look at the menus and make sure they were correct for all the modified diets. Director of Speech Pathology #1 indicated some of the categories of mechanically altered diets used at the facility (mechanically soft, chopped, and pureed) were outdated and often caused confusion for kitchen and unit staff. They indicated the facility would be shifting to a new, internationally accepted standard for dysphagia diets, but this would be done gradually as residents with physician-ordered mechanically altered diets need to be reassessed for tolerance of new diet guidelines for mechanical soft. Director of Speech Pathology #1 indicated the residents who were currently prescribed a mechanically soft diet would be downgraded to a ground diet for their safety until they could be reassessed by a speech therapist, diet orders reviewed by physician, and all staff trained. Director of Speech Pathology #1 gave the facility a list of the new standardized dysphagia diet levels that included items allowed or prohibited in each diet and the various sizes that were described. Director of Speech Pathology #1 indicated they would be checking daily to ensure meals were served correctly. Director of Speech Pathology #1 indicated Registered Dietician #1 was making a new menu with their consultation. During an interview on 4/17/2024 at 11:30 AM, Director of Nursing #1 was interviewed and indicated meals were to arrive on the unit as ordered per diet from the kitchen. Director of Nursing #1 indicated unit nursing staff should be consulted if a diet texture or size did not look accurate to staff. They indicated the unit nurses must judge whether that current food is appropriate, needs to be cut up or should be returned to the kitchen. Director of Nursing #1 indicated it was the Food Director's responsibility to educate the kitchen staff. Director of Nursing #1 indicated 36 residents in the facility out of 113 residents had physician-ordered mechanically altered diets. Director of Nursing #1 indicated that of the 36 residents, 7 (seven) residents had physician-ordered mechanical soft diets and of those residents, 4 (four) residents needed their care plans updated. Director of Nursing #1 indicated that in total, all 36 residents on a mechanically altered diet had their diets and care plans reviewed and 8 residents had diets changed and care plans updated. During an interview at 4/30/2024 at 3:47 PM, Medical Director #1 indicated physician's orders for mechanically altered diet was intended to reduce resident risk for choking or aspiration. Medical Director #1 indicated a resident who receives food of a size or texture contrary to the physician's order would be at an increased risk for choking. Medical Director #1 indicated they were unsure how the kitchen double checked food on meal trays to ensure the appropriate textures for the diet ordered. Medical Director #1 indicated Registered Dietician #1 should know what a mechanically altered diet was. Medical Director #1 indicated the unit nursing staff should check for accurate diets before passing out the meal trays. They stated they did not know if the nurses received training on diet textures and consistencies. Medical Director #1 reiterated that an altered diet would be less of a choking/aspiration risk for a resident with swallowing difficulties or at risk for aspiration and stated a wrong texture contrary to the physician's order would increase the risk for choking. Medical Director #1 indicated, for that reason, they expect nurses to ensure the meals are served as ordered. (C) The facility did not ensure Resident #3, with a history of aggression towards others and self-harm, did not have sharp objects in their room and that behavioral interventions were followed for safety. Resident #3 Resident #3 was admitted to the facility with diagnoses which included severe intellectual disabilities, schizoaffective disorder (a mental health condition with symptoms of both schizophrenia and mood disorders), and cerebral palsy (a condition marked by impaired muscle coordination). The Minimum Data Set, dated [DATE], documented the resident could be understood and could understand others, with a Brief Interview of Mental Status score assessed to be 7/15 indicative of cognitive impairment for decisions of daily living. The Policy and Procedure titled Resident Right-Safe/Clean/Comfortable/ Homelike Environment, last revised 9/2023, read in part that it was the policy of the facility to provide a safe, clean, comfortable, homelike environment in such a manner to acknowledge and respect resident rights. The resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Comprehensive Care Plan for Behavioral Symptoms: History of Self-Harm, initiated on 10/04/2023, documented Resident #3 had a history of self-harm by cutting themselves and was documented to have cut themselves with a razor earlier this year (2023) at a different skilled nursing facility. Regular rooms checks were to be performed to ensure the resident did not have access to sharp objects. During an observation on 2/11/2024 at 6:20 PM, Resident #3's room was observed to have a thick, metal safety-pin shaped object which was approximately eight inches long and was unfastened, open, and had a sharp metal end. Additionally, there was a metal fork in the trash bin in the room. During an interview on 2/11/2024 at 6:37 PM, Assistant Social Worker #1 stated they worked with Resident #3 and the resident was treated with medication for their psychiatric diagnosis and behaviors. They stated staff would observe the resident for behaviors. Assistant Social Worker #1 observed the sharp metal object on the floor of the resident's room and stated that it was used to fasten laundry bags in the resident's closet. They were unaware of interventions implemented in the resident's care plan that staff should monitor the resident's room for sharp objects. During an interview on 2/27/2024 at 3:31 PM, Certified Nursing Aide #1 stated that Resident #3 had regularly exhibited aggressive behaviors directed at staff and other residents. They stated the resident had multiple altercations with other residents and had spit at them and punched another resident in the leg during a recent incident. They stated that the former Director of Nursing had instituted a daily schedule for the resident each day which was signed off to keep their day structured and help with behaviors. They stated the resident's daily schedule was no longer in place, that no safety checks for sharp objects in resident's room had ever been done, and they were unaware of safety interventions having been implemented. They stated each time the resident would get in an altercation with another resident, the facility would send the resident out to the hospital. The hospital would send them back and nothing would change. They stated they asked Assistant Social Worker #1 about the behaviors and expressed concern for safety of the staff and other residents; however, they were told that referrals to group home settings had been made, but the resident had not been accepted and there was nothing that could be done. During an interview on 4/24/2024 at 10:44 AM, Director of Social Work #1 stated Resident #3 was not a typical nursing home resident due to their psychiatric diagnosis, history, and cognitive limitations. They stated they had verbalized on numerous occasions that staff should be trained to deal with the resident's behaviors and emotional needs. They stated the resident could be easily triggered, but it was all about how the resident was approached and that they were aware some staff were more reactive to the resident's behaviors, which would further exasperate the resident. They stated that staff should monitor the resident's environment for hazards such as sharp objects. They stated Resident #3 did not have safety awareness and had behaviors that could be triggered by others. During an interview on 4/30/2024 at 3:16 PM, Director of Nursing #1 stated staff should be monitoring Resident #3's room for any safety concerns due to the resident's diagnosis and history of behaviors. They stated Resident #3 should not have access to items that could potentially be a danger to themselves or others. (D) The facility did not ensure that Resident #2's care plan was updated, and new interventions implemented after the resident had multiple falls with injuries. The Policy and Procedure titled, Resident Right-Safe/Clean/Comfortable/ Homelike Environment, last revised September 2023, read in part that it was the policy of the facility to provide a safe, clean, comfortable homelike environment such a manner to acknowledge and respect resident rights. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The Policy and Procedure titled, Resident Falls, last revised September 2023, read in part that each resident would be evaluated for fall risk upon admission, readmission significant change in status and with occurrence of fall event. Care planning should be individualized for the specific resident and will represent input from multiple disciplines. Each resident fall should be managed in a manner that maximizes well-being and safety including assessment for injury with appropriate follow up. The follow up procedure should determine causative/contributory factors, root cause, interventions to prevent recurrence or, in event that recurrence is highly likely, means to prevent major injury from falls. Anytime a resident had a fall the Nursing Supervisor should be notified immediately. The Nursing Supervisor should complete an assessment immediately. Resident #2 Resident #2 was admitted to the facility with diagnoses of unspecified dementia (condition characterized by progressive or persistent loss of intellectual functioning) with agitation, contusion (bruise) of lower back and pelvis and muscle weakness. The Minimum Data Set (an assessment tool) dated 1/18/2024, documented the resident could be understood and could sometimes understand others with a Brief Interview of Mental Status indicating severe cognitive impairment for decisions of daily living. The Resident Care Plan, initiated 4/21/2023, documented Resident # 2 was at risk for falls related confusion, incontinence, psychoactive drug use and inability of the resident to recognize safety needs. The care plan documented that the resident had a fall on 5/22/2023, a fall 6/1/2023 which resulted in a hematoma and the resident being sent to the emergency room, a fall on 10/21/2023 with injury, a fall on 11/9/2023 which resulted in injury and sent to the hospital, falls on 12/6/2023, 1/25/2024 and on 2/1/2024 was noted with a laceration to the back of their head which was documented to be an unknown injury. On 2/18/2024 the resident was sent to the emergency room after being found in bed with blood on their face and clothing and multiple bruises. Review of the care plan revealed that new interventions were not implemented based on fall/incident investigations to prevent recurrence of falls and injuries. A Health Status Note dated 1/25/2024 at 3:06 PM written by Licensed Practical Nurse #6 documented that at 1:45 PM, a Certified Nurse Aide notified them that they had heard a bang and that Resident #2 was on the floor next to another resident. Resident #2 was documented to be lying on their back with their pants around their ankles and next to another resident. The resident was documented as able to move all extremities without signs or symptoms of pain or discomfort and vital signs were obtained. The resident was documented to have been assisted from the floor, by two nursing staff. The supervisor, physician and resident representative were documented as having been notified. A Health Status Note dated 2/1/2024 at 6:57 AM written by Licensed Practical Nurse #9 documented Resident #2 was noted to have been walking on the unit that morning and a Certified Nurse Aide noted that the back of their head looked pink. The writer was documented to assess the resident and discovered a small laceration. The resident's neuro checks were documented to be within normal limits. Review of the facility record revealed the resident last fell on 1/25/2024, however no injuries were noted. A Health Status Note dated 2/2/2024 at 2:52 PM written by Licensed Practical Nurse #6 documented the resident was on follow up for a fall, on day 2 out of 3, a small laceration to back of head, which cleansed and bacitracin was applied. The resident was documented to have no signs or symptoms of discomfort and indicated that staff would continue to monitor. There was no documentation of the resident having a fall and the investigation into the injury did not determine the cause of the injury No new interventions were not identified/implemented to prevent recurrence. A Health Status Note dated 2/18/2024 documented the resident had been found lying in their bed with blood on the right side of their face, nose and on clothing. The resident was noted to have swelling on their nose. Bruising was noted on the right of the resident's face as well as bilateral upper and lower extremities. A Health Status Note dated 2/18/2024 documented a new order was received to transfer resident to the hospital to evaluate for a fall earlier in the day. Resident #2 was transferred to hospital by emergency medical services. The resident complained of pain on the right side of their face which was documented as not an abnormal complaint of this resident. Multiple hematomas noted on face at different stages of healing that were associated with resident's history of crawling on floor. During an interview on 2/27/2024 at 3:31 PM, Certified Nurse Aide #1 stated that Resident #2 had numerous falls at the facility and had been sent out to the hospital multiple times. They stated the facility did not implement new interventions after the resident would fall. They stated they were told to just try to get the resident to stay seated. They stated the resident was always on the floor and constantly had bruising on their body. They stated that the facility did not have enough staff to properly supervise the residents. They stated the resident was frequently found on the floor and that neurological checks should be completed with each fall, whether the resident was observed to hit their head or when they had an unwitnessed fall where it could not be determined whether they had hit their head. During an interview on 4/24/2024 at 10:44 AM, Director of Social Work #1 stated that incident/fall investigations should be conducted to look at the environment in the room and what might have caused injury or contributed to the incident and implement new interventions to prevent recurrence. They stated that there was not enough 'eyes on' residents who required supervision to prevent falls/accidents due to insufficient staffing levels and that they were very concerned for the residents at the facility. During an interview on 4/30/2024 at 3:16 PM, Director of Nursing #1 stated that each time a resident had a fall, and they were unable to state what happened, the fall should be investigated to determine the root cause of the fall/injury and the care plan should be updated with new interventions to prevent recurrence. They stated that interventions should be implemented based on what occurred and those interventions should be added to the resident's care plan. 10 New York Codes Rules and Regulations 415.12(h)(1)