Based on observations, record review, and interviews during a recertification and abbreviated survey (Case #NY00338924), the facility did not ensure the resident environment remained free of accident hazards for one resident (Resident #25) out of six sampled residents. Specifically, on 4/11/2024 a windowpane on the third floor care unit, which had previously been identified as a potential hazard and in need of repair; fell inward when Resident #25 tried to close the window. Subsequently, Resident #25 sustain a laceration to their scalp which required six stables to close the wound. This resulted in actual harm that was not immediate jeopardy for Resident #25. This is evidenced by: Resident #25 was admitted to the facility with diagnoses of dementia without behavioral disturbance, age-related reticular degeneration of retina (a group of diseases that cause the retina of the eye to deteriorate), and age-related osteoporosis (a skeletal disorder characterized by low bone density). The Minimum Data (an assessment tool) dated 5/16/2024 documented the resident had severe cognitive impairment for decisions of daily living, could sometimes be understood, and could sometimes understand others. The Policy and Procedure titled, Near Miss Reporting Tool, last revised November 2022, documented the facility's goal was to promote a safe care and living environment for residents and work environment for staff by addressing potential concerns before they caused harm or injury. The Policy and Procedure titled Fall Prevention, Fall Risk Assessment, and Registered Nurse Notification, last revised 6/23/2022, documented the purpose of the policy was to provide residents with an environment as free of accident hazards as possible. The procedure included the identification of environmental hazards that could contribute to falls. The Policy and Procedure titled, Maintenance Work Request System effective date 01/2011 documented the maintenance department would carry out a program to effectively maintain all real property, capital, and non-capital equipment, and to identify the types of work orders and procedures for requesting the services. Work orders would be scheduled by the maintenance department according to the following priorities: urgent, routine, and deferred. Urgent repairs or corrective actions to equipment involving patient care were those which required immediate attention and could affect patient services, endanger life, or seriously damage campus equipment. Maintenance personnel were to respond immediately to urgent work orders, assess the situation and render repair or remove equipment/system from service as needed. The Director of Maintenance should be notified immediately of any urgent work orders. The Facility's Incident and Accident Investigation dated 4/11/2024, documented per witness statements, Resident #25 had attempted to shut a common area window on the third floor and as they were pushing down, the window came out of the frame towards the resident which resulted in them losing their balance and fell backwards with the back of their head hitting the floor. Staff were unable to intervene quick enough to prevent the fall. The investigation concluded that Resident #25's fall and injury were the result of the clips on the window being broken which allowed the windowpane to fall and caused Resident #25 to lose their balance. A work order was placed on 4/09/2024 (two days prior to the incident) by the Director of Nursing stating the window was a safety concern and needed to be fixed immediately. The work order was marked as completed on 4/09/2024. Upon further investigation, per the maintenance department, completed meant they locked the window on 4/09/2024. The investigation documented the resident's fall could have been prevented if the window was fixed properly and the injury was the result of a faulty environment. Corrective actions taken were documented to include that the window was immediately secured, education was provided to the maintenance department, a review of the maintenance work order process was completed, and a building wide window audit was conducted immediately following the incident and any window with a similar problem was fixed. A Maintenance Work order dated 4/09/2024, documented a window on the third-floor common area required that the clips that held the window in place needed to be replaced. The window clips were documented to require replacement as soon as possible due to the window being a safety concern. A Nursing Progress Note dated 4/11/2024 at 2:00 PM written by Registered Nurse #2, documented Resident #25 was heard to call out Oh my from the common area and then a thump was heard. The resident was found lying on their left side on the floor in the common area. A small amount of bleeding was noted to the left side of the back of the resident's head with a hematoma (collection of blood outside of the blood vessels due to injury/trauma) developing. The area was cleansed, ice, and pressure were applied. Resident #25 complained of their head and left elbow hurting. A hematoma was also noted to the resident's left elbow. The resident was seen by Physician Assistant #1 and an order was given to send the resident to the emergency room. A Medical-Acute Problem progress notes dated 4/11/2024 written by Physician Assistant #1 documented Resident #25 was evaluated in the third-floor common area following a fall. The resident sustained a 1.5-centimeter laceration and surrounding hematoma to their mid posterior scalp. Resident #25 was transported to the emergency room for imaging of their head and treatment for the laceration that the resident sustained. A Nursing Progress Note dated 4/11/2024 at 5:11 PM written by Registered Nurse #3 documented Resident #25 returned from the emergency room at 5:00 PM. Imaging completed at the emergency room was negative for abnormalities. The laceration to the back of their scalp was approximated (closed) with six staples and a new order to cleanse the wound and apply anti-bacterial ointment for two days and to then clean and dress daily as needed. Staples were to be removed after ten days. Upon request on several attempts, the facility could not produce documentation that a facility-wide audit of all windows was conducted immediately following the incident to prevent recurrence. Environmental rounding of the facility was conducted on 4/17/2024 (six days after the incident) and documented seven resident rooms were observed. Four of the seven rooms observed during the rounding (Room #'s 314, 315, 316, and 321) were documented to have broken window clips. During an interview on 7/25/2024 at 10:50 AM, Director of Maintenance #1 stated maintenance had received a work order for the window on the third-floor common room prior to the incident with the window falling in and causing Resident #25 to fall on 4/11/2024. They stated after the incident occurred; the facility had implemented a new work order system to triage work orders that could present a hazard to residents. They stated maintenance staff received education on the prioritization of environmental hazards and immediately completed an environmental audit to identify any other windows in need of repair. During an interview on 7/25/2024 11:33 AM, Registered Nurse #2 stated they were working on the third-floor care unit on 4/11/2024 when they heard Resident #25 state oh my and then they heard a thump. They stated Resident #25 had attempted to close the window in the common area of the unit, and it fell in on Resident #25. They stated the resident was assessed to have a laceration to their scalp and was sent to the emergency room where they required six staples to close the wound. They stated the window had a sign placed on it for a long time which indicated the window should not be opened due to need of repair. They stated it had previously been identified that the window needed repair and presented a potential hazard to residents. They stated when they had previously inquired about the repair of the window, they were told the facility was waiting on parts to complete the work order. They stated Resident #25 had dementia and due to cognitive limitations, would not be able to comprehend the signage left on the window which indicated that it was a hazard. They stated the incident was preventable and should not have occurred. During an interview on 7/25/2024 at 1:53 PM, Physician Assistant #1 stated they were called to assess Resident #25 following their fall on 4/11/2024, observed that the resident had sustained a laceration and bruising to their head and gave the order for Resident #25 to be sent out to the emergency room. They stated Resident #25 had advanced dementia and would not be able to comprehend signage indicating a window was broken or recognize potential hazards. Physician Assistant #1 stated Resident #25 had attempted to open the window which broke and caused them to fall back. They stated they were aware of the window needing repair and that nursing staff had asked to have the window repaired prior to the incident. During an interview on 7/26/2024 at 9:17 AM, Director of Nursing #1 stated the root cause of Resident #25's fall/injury on 4/11/2024 was due to an unstable window in the common area of the resident's care unit. They stated the window needed repair for a long time approximately a year. They stated Resident #25 was sent to the emergency room following the incident and required staples to treat the laceration to their head. They stated following the incident, the facility changed how work orders were prioritized and environmental rounding was completed to ensure that no other windows could present a risk to the residents and that issues with windows were given high priority due the potential of being hazardous. 10 New York Codes, Rules, and Regulations 415.4(b) Based on observations, record review, and interview during a post-survey revisit completed on 9/30/2024, the facility was determined not to be in compliance with this citation. Specifically, the facility's plan of correction and documented evidence of implementation of this citation did not satisfy what corrective actions would be accomplished for those residents found to have been affected by the deficient practice; how the provider would identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken; what measures would be put in place or what systemic changes you will make to ensure that the deficient practice does not recur; and how the corrective actions would be monitored to ensure the deficient practice would not recur, i.e., what quality assurance program will be put into practice. This is evidenced by: During an onsite post survey review conducted on 9/26/2024, the facility had not addressed the deficient practice concerns for addressing environmental hazards to prevent reoccurrences of accidents. Mainly, education for the new process to report defective equipment and environmental hazards to prevent a recurrence of accidents had not been provided to all staff and the Policy and Procedure on identifying accident hazards was not provided by end of business on 9/30/2024. During an observation on the 2nd floor Unit on 9/26/2024 at 1:18 PM, a window in the lounge area by the nurses station a lock on that window was found to be broken. A Certified Nurse Aide #1 was unable to verbalize what the process was to correct the problem. During an interview on 9/26/2024 at 11:40 AM, Maintenance Director #1 stated a whole house Audit was being conducted on the windows and the ones defective were repaired. A new system to report defective equipment and hazards with the environment had been implemented. The maintenance staff had been in serviced but not all staff in the facility had been in serviced on the new plan to report hazards. A copy of the new work plan process, any education given to staff, and Audits completed were requested from the Director of Maintenance #1. As of 9/30/2024 at 10:45 AM the documents have not been provided. During an interview on 9/26/2024 at 12:48 PM, Director of Nursing #1 stated they couldn't find any Policy and Procedure that documented changes made that addressed the work plan reporting method that demonstrated all the facility staff had been made aware of how to report concerns with equipment and or the environment. The Director of Nursing was asked to provide the documentation of work orders and education related to this deficiency. As of 9/30/2024 at 10:45 AM, the documents had not been provided. During an interview on 9/26/2024 at 2:15 PM, Licensed Practical Nurse #1 stated tehy had not been educated ob how to place a work order into the new computer system. They would just tell the Supervisor if something needed to be fixed. The Licensed Practical Nurse #1 stated this was how things got missed in the past. The facility was cited for the following deficiencies during the initial recertification and complaints survey conducted on 7/26/2024. Based on observations, record review, and interviews during a recertification and abbreviated survey (Case #NY00338924), the facility did not ensure the resident environment remained free of accident hazards for one resident (Resident #25) out of six sampled residents. Specifically, on 4/11/2024 a windowpane on the third-floor care unit, which had previously been identified as a potential hazard and in need of repair; fell inward when Resident #25 tried to close the window. Subsequently, Resident #25 sustain a laceration to their scalp which required six stables to close the wound. This resulted in actual harm that was not immediate jeopardy for Resident #25. This is evidenced by: Resident #25 was admitted to the facility with diagnoses of dementia without behavioral disturbance, age-related reticular degeneration of retina (a group of diseases that cause the retina of the eye to deteriorate), and age-related osteoporosis (a skeletal disorder characterized by low bone density). The Minimum Data (an assessment tool) dated 5/16/2024 documented the resident had severe cognitive impairment for decisions of daily living, could sometimes be understood, and could sometimes understand others. A Revised Policy and Procedure for addressing corrective action on communication and timely repairs needed to address repairs for resident equipment and resident's environment from staff to the Director of Maintenance #1 was not provided. Proof of education to staff on how to communicate environmental concerns to ensure resident safety and notifying maintenance using the new system was not provided. During an interview on 7/25/2024 at 10:50 AM, During an interview on 9/26/2024 at 11:35 AM, Director of Maintenance #1 stated the maintenance department had made all the repairs needed to the windows to ensure the safety of the residents. They had a new system in place for work orders for environmental and equipment repairs to ensure prompt response of needed repairs. They stated maintenance staff received education on the prioritization of environmental hazards and immediately completed an environmental audit to identify any other windows in need of repair. No education to the facility staff had been given to ensure they were aware of how to use the new system for informing the maintenance department of repairs needed. Audits were being done on monitoring the safety and functioning of the windows. During an interview on 9/26/2024 at 1:25 PM, the Licensed Practical Nurse #1 stated they had no way to document the maintenance repairs other than to tell the supervisor. They stated not everyone has access to the work order system on the computer. Frequently the Registered Nurse Supervisor was the only person that could put a new work order in. We can call maintenance but that was how things got missed before. During an interview on 9/26/2024 at 3:06 PM, The Director of Nursing #1 stated the Administrator did not complete all the plans of corrections for the deficient practices found during the recertification survey conducted in July 2024. They were unaware of any education given to the staff to address the new method of placing work orders to ensure repairs were done as needed for the safety of the residents. They had no Policy and Procedure to provide the surveyors that addressed the new system detailed by the Director of Maintenance #1. Work on the building was going slowly because of the financial situation of the facility. The Policy and Procedure titled, Near Miss Reporting Tool, last revised November 2022, documented the facility's goal was to promote a safe care and living environment for residents and work environment for staff by addressing potential concerns before they caused harm or injury. The policy and procedure near miss reporting tool had not been updated or revised by 9/26/2024. The Policy and Procedure titled Fall Prevention, Fall Risk Assessment, and Registered Nurse Notification, last revised 6/23/2022, documented the purpose of the policy was to provide residents with an environment as free of accident hazards as possible. The procedure included the identification of environmental hazards that could contribute to falls. No updating or revision to the policy was provided on 9/26/2024. The Policy and Procedure titled, Maintenance Work Request System effective date 01/2011 documented the maintenance department would carry out a program to effectively maintain all real property, capital, and non-capital equipment, and to identify the types of work orders and procedures for requesting the services. Work orders would be scheduled by the maintenance department according to the following priorities: urgent, routine, and deferred. Urgent repairs or corrective actions to equipment involving patient care were those which required immediate attention and could affect patient services, endanger life, or seriously damage campus equipment. Maintenance personnel were to respond immediately to urgent work orders, assess the situation and render repair or remove equipment/system from service as needed. The Director of Maintenance #1 should be notified immediately of any urgent work orders. No updating or revision to the policy had been provided on 9/26/2024. 10 New York Codes, Rules, and Regulations 415.4(b) F- 689 Original Citation on 7/26/2024 CS Based on observations, record review, and interviews during a recertification and abbreviated survey (Case #NY00338924), the facility did not ensure the resident environment remained free of accident hazards for one resident (Resident #25) out of six sampled residents. Specifically, on 4/11/2024 a windowpane on the third-floor care unit, which had previously been identified as a potential hazard and in need of repair; fell inward when Resident #25 tried to close the window. Subsequently, Resident #25 sustain a laceration to their scalp which required six stables to close the wound. This resulted in actual harm that was not immediate jeopardy for Resident #25. This is evidenced by: Resident #25 was admitted to the facility with diagnoses of dementia without behavioral disturbance, age-related reticular degeneration of retina (a group of diseases that cause the retina of the eye to deteriorate), and age-related osteoporosis (a skeletal disorder characterized by low bone density). The Minimum Data (an assessment tool) dated 5/16/2024 documented the resident had severe cognitive impairment for decisions of daily living, could sometimes be understood, and could sometimes understand others. The Policy and Procedure titled, Near Miss Reporting Tool, last revised November 2022, documented the facility's goal was to promote a safe care and living environment for residents and work environment for staff by addressing potential concerns before they caused harm or injury. The Policy and Procedure titled Fall Prevention, Fall Risk Assessment, and Registered Nurse Notification, last revised 6/23/2022, documented the purpose of the policy was to provide residents with an environment as free of accident hazards as possible. The procedure included the identification of environmental hazards that could contribute to falls. The Policy and Procedure titled, Maintenance Work Request System effective date 01/2011 documented the maintenance department would carry out a program to effectively maintain all real property, capital, and non-capital equipment, and to identify the types of work orders and procedures for requesting the services. Work orders would be scheduled by the maintenance department according to the following priorities: urgent, routine, and deferred. Urgent repairs or corrective actions to equipment involving patient care were those which required immediate attention and could affect patient services, endanger life, or seriously damage campus equipment. Maintenance personnel were to respond immediately to urgent work orders, assess the situation and render repair or remove equipment/system from service as needed. The Director of Maintenance should be notified immediately of any urgent work orders. The Facility's Incident and Accident Investigation dated 4/11/2024, documented per witness statements, Resident #25 had attempted to shut a common area window on the third floor and as they were pushing down, the window came out of the frame towards the resident which resulted in them losing their balance and fell backwards with the back of their head hitting the floor. Staff were unable to intervene quick enough to prevent the fall. The investigation concluded that Resident #25's fall and injury were the result of the clips on the window being broken which allowed the windowpane to fall and caused Resident #25 to lose their balance. A work order was placed on 4/09/2024 (two days prior to the incident) by the Director of Nursing stating the window was a safety concern and needed to be fixed immediately. The work order was marked as completed on 4/09/2024. Upon further investigation, per the maintenance department, completed meant they locked the window on 4/09/2024. The investigation documented the resident's fall could have been prevented if the window was fixed properly and the injury was the result of a faulty environment. Corrective actions taken were documented to include that the window was immediately secured, education was provided to the maintenance department, a review of the maintenance work order process was completed, and a building wide window audit was conducted immediately following the incident and any window with a similar problem was fixed. A Maintenance Work order dated 4/09/2024, documented a window on the third-floor common area required that the clips that held the window in place needed to be replaced. The window clips were documented to require replacement as soon as possible due to the window being a safety concern. A Nursing Progress Note dated 4/11/2024 at 2:00 PM written by Registered Nurse #2, documented Resident #25 was heard to call out Oh my from the common area and then a thump was heard. The resident was found lying on their left side on the floor in the common area. A small amount of bleeding was noted to the left side of the back of the resident's head with a hematoma (collection of blood outside of the blood vessels due to injury/trauma) developing. The area was cleansed, ice, and pressure were applied. Resident #25 complained of their head and left elbow hurting. A hematoma was also noted to the resident's left elbow. The resident was seen by Physician Assistant #1 and an order was given to send the resident to the emergency room. A Medical-Acute Problem progress notes dated 4/11/2024 written by Physician Assistant #1 documented Resident #25 was evaluated in the third-floor common area following a fall. The resident sustained a 1.5-centimeter laceration and surrounding hematoma to their mid posterior scalp. Resident #25 was transported to the emergency room for imaging of their head and treatment for the laceration that the resident sustained. A Nursing Progress Note dated 4/11/2024 at 5:11 PM written by Registered Nurse #3 documented Resident #25 returned from the emergency room at 5:00 PM. Imaging completed at the emergency room was negative for abnormalities. The laceration to the back of their scalp was approximated (closed) with six staples and a new order to cleanse the wound and apply anti-bacterial ointment for two days and to then clean and dress daily as needed. Staples were to be removed after ten days. Upon request on several attempts, the facility could not produce documentation that a facility-wide audit of all windows was conducted immediately following the incident to prevent recurrence. Environmental rounding of the facility was conducted on 4/17/2024 (six days after the incident) and documented seven resident rooms were observed. Four of the seven rooms observed during the rounding (Room #'s 314, 315, 316, and 321) were documented to have broken window clips. During an interview on 7/25/2024 at 10:50 AM, Director of Maintenance #1 stated maintenance had received a work order for the window on the third-floor common room prior to the incident with the window falling in and causing Resident #25 to fall on 4/11/2024. They stated after the incident occurred; the facility had implemented a new work order system to triage work orders that could present a hazard to residents. They stated maintenance staff received education on the prioritization of environmental hazards and immediately completed an environmental audit to identify any other windows in need of repair. During an interview on 7/25/2024 11:33 AM, Registered Nurse #2 stated they were working on the third-floor care unit on 4/11/2024 when they heard Resident #25 state oh my and then they heard a thump. They stated Resident #25 had attempted to close the window in the common area of the unit, and it fell in on Resident #25. They stated the resident was assessed to have a laceration to their scalp and was sent to the emergency room where they required six staples to close the wound. They stated the window had a sign placed on it for a long time which indicated the window should not be opened due to need of repair. They stated it had previously been identified that the window needed repair and presented a potential hazard to residents. They stated when they had previously inquired about the repair of the window, they were told the facility was waiting on parts to complete the work order. They stated Resident #25 had dementia and due to cognitive limitations, would not be able to comprehend the signage left on the window which indicated that it was a hazard. They stated the incident was preventable and should not have occurred. During an interview on 7/25/2024 at 1:53 PM, Physician Assistant #1 stated they were called to assess Resident #25 following their fall on 4/11/2024, observed that the resident had sustained a laceration and bruising to their head and gave the order for Resident #25 to be sent out to the emergency room. They stated Resident #25 had advanced dementia and would not be able to comprehend signage indicating a window was broken or recognize potential hazards. Physician Assistant #1 stated Resident #25 had attempted to open the window which broke and caused them to fall back. They stated they were aware of the window needing repair and that nursing staff had asked to have the window repaired prior to the incident. During an interview on 7/26/2024 at 9:17 AM, Director of Nursing #1 stated the root cause of Resident #25's fall/injury on 4/11/2024 was due to an unstable window in the common area of the resident's care unit. They stated the window needed repair for a long time approximately a year. They stated Resident #25 was sent to the emergency room following the incident and required staples to treat the laceration to their head. They stated following the incident, the facility changed how work orders were prioritized and environmental rounding was completed to ensure that no other windows could present a risk to the residents and that issues with windows were given high priority due the potential of being hazardous. 10 New York Codes, Rules, and Regulations 415.4(b)