**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the abbreviated survey (NY00321800), the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (Resident #3) reviewed. Specifically, Resident #3, who was previously diagnosed with brain cancer, had recommendations for a magnetic resonance imaging scan (specialized x-ray) and follow-up with oncology (cancer specialist) and neurology (doctor who specializes in diseases of the brain/spinal cord), and there was no documented evidence the follow-up appointment or scan was scheduled or occurred. Subsequently, the resident experienced a decline in their neurological function. This resulted in actual harm to Resident #3 that was not immediate jeopardy. Finding include: The revised 1/2024 Consultation Policy documented the facility was responsible to provide consultation services for any resident as needed. The facility assumed responsibility for obtaining services that met professional standards and principles that applied to professionals providing services in such a facility, and the timeliness of the services. The procedure included the attending physician writing and order for a consult and documenting the reason for the consult in the medical record. Designated staff were to schedule the consult, arrange transportation, and notify the resident/designated representative of the appointment. The facility or designated representative would escort the resident to the appointment and supply nursing staff with the consultation report upon return to facility. Nursing staff would notify the physician of any recommendations and the physician would approve any orders they agreed with. The consultation report would be added to the resident's record. Resident #3 had diagnoses including a seizure disorder, malnutrition, and brain cancer. The 7/11/2023 Minimum Data Set assessment documented the resident's cognition was intact and they required extensive assistance with bed mobility and transfers. The 6/1/2023 hospital discharge summary documented the resident had glioma blastoma multiform (brain cancer) and was admitted to the hospital with seizures. The resident was followed by a local cancer center and the family member reported the resident was currently not receiving chemotherapy (cancer treatment) for one month. The resident was to follow-up with their primary care physician in 1 week and the cancer center as scheduled. The 6/1/2023 comprehensive care plan documented the resident required assistance with activities of daily living including total assistance from 2 staff for locomotion and extensive assistance from 2 staff with toileting and transfers. There was no documentation of a plan related to follow-up for the resident's brain cancer diagnosis. The 6/3/2023 attending physician #12's progress note documented the resident was at the facility for recovery and rehabilitation and was recently hospitalized with seizures. The resident had 2 brain surgeries and chemotherapy in the past, and their prognosis was poor with a long-term history of brain cancer. The resident needed close follow-up from neurosurgery. There was no documented evidence a follow-up appointment with neurosurgery was ordered. The 8/9/2023 at 1:39 PM, Director of Nursing's progress note documented the resident's family requested they be sent to the hospital for a decline in condition as the resident now required a mechanical lift to transfer, was unable to stand on their feet, and leaned to the left. The 8/10/23 hospital discharge summary documented the resident was admitted under observation status and discharged back to the facility. The note documented the resident needed close follow-up with their primary care medical provider and close follow-up with oncology and neurology. The 8/10/2023 attending physician #12's order documented to follow-up with oncology and neurology. The 8/11/2023 attending physician #12's progress note documented the resident was recently hospitalized overnight and diagnosed with weakness and returned to the facility. The resident was to follow-up with oncology . There is no documented evidence a follow-up appointment with oncology was scheduled. The 9/15/2023 attending physician #12's progress note documented the resident was seen for family concerns of their overall health status. The resident was progressively weaker and chose not to ambulate anymore. Nursing reported they now needed a mechanical lift for transfers and recently acquired COVID-19. The note documented they would consider a computed tomography (specialized imaging) scan of the head to see if there were any changes related to the resident's brain cancer. The resident should also have neurology/neurosurgery follow-up with the progression of symptoms. There is no documented evidence a follow-up appointment with neurology/neurosurgery was scheduled. The 9/29/2023 nurse practitioner #11's progress note documented the resident was seen to determine healthcare decision making capacity. The resident's cognition was currently moderately impaired, and they were alert with confusion and had memory loss. They had significant cognitive deficits and no longer had capacity to make their own medical decisions. The resident's spouse was documented as the Surrogate Decision Maker. The 9/29/2023 prescription from the resident's neurology/oncology provider, faxed to the facility on 9/29/2023, documented the resident needed an urgent magnetic resonance imaging scan with and without contrast. The 10/5/2023 at 10:48 AM, Registered Nurse Manager #10's progress note documented the resident's spouse asked about the magnetic resonance imaging scan and the nurse reported they were working on it. The 10/6/2023 at 9:19 AM, Registered Nurse Manager #10's progress note documented the resident's family was notified the magnetic resonance imaging scan was scheduled on 10/26/2023. There was no documented evidence the magnetic resonance imaging scan was completed on 10/26/2023. The 11/2/2023 at 1:36 PM, licensed practical nurse #17's progress note documented the resident was leaning towards the left side when out of bed, even with attempts to reposition. The unit Manager was aware. The 12/12/2023 physical therapist #14's progress note documented the resident was given an ankle orthotic (brace) due to noted inversion (bending inward towards the body) contracture (permanent tightening of muscles, tendons, and skin). The 12/12/2023 occupational therapist #15's progress note documented the resident's left hand was noted in contracture compared with the last visit. A resting hand splint was applied. The nurse practitioner (nurse practitioner #11) was consulted about the resident's condition and recent onset of contraction. The 12/12/2023 at 1:29 PM, nurse practitioner #11's progress note documented the resident was seen per nursing for continued decline. The resident had increased confusion the last few weeks and they were told the resident developed contractures to the left upper arm and left lower leg over the last few days that were rapid in presentation. Contractures were noted on exam. The resident was not currently undergoing treatment for metastatic (cancer that spread) brain cancer, the brain cancer was likely progressing and causing the decline, and they asked staff to ensure follow-up with the resident's oncologist as soon as possible. Staff were to notify the medical provider of any acute change in condition. There was no documented evidence the resident followed-up with oncology and no documentation of an order for an oncology follow-up appointment. The 12/26/2023 at 11:36 AM, social worker #18's progress note documented the resident left with their family for the holiday and was taken to the hospital by the family. The 1/3/2024 hospital discharge summary documented the resident was admitted to the hospital on [DATE] with altered mental status and lethargy. From admission, the objective was to see if there was reversible cause for their decline. After several days, it was evident the decline was likely related to underlying brain cancer. A repeat magnetic resonance imaging scan was completed 12/28/2023 which showed a mass in the right temporal lobe (part of the brain) that was considered enlarged since the previous scan. They discussed with the spouse the resident should follow-up with oncology to go over the scan results to make further decisions based on new information. On 1/3/2024, the comprehensive care plan was updated and documented the resident was at risk for neoplastic disorders (condition that causes tumor growth) related to brain cancer. Interventions included facilitate resident treatments (radiation/chemotherapy) per medical provider and to refer to oncology/hematology (doctor that specialized in conditions that affected the blood or bone marrow cells) as needed. The 1/3/2024 nurse practitioner #16's progress note documented they received a call from nursing the resident was returning to the facility from the hospital. At that time, the resident appeared stable, was to continue the current medication regimen, and have blood work and imaging per protocol. There was no documented evidence of a physician's order for an oncology follow-up and no documented evidence the resident followed up with oncology as recommended in the hospital report. The 1/31/2024 at 5:32 PM, registered nurse #13's progress note documented the resident had a change in mental status. The resident typically yelled out continuously, however was now not verbally responding or yelling out. The on-call medical provider was notified with new orders for a chest x-ray, antibiotics, and Duoneb (breathing treatment). The resident's spouse requested the resident be transferred to the hospital. The resident was discharged to the hospital and there was no documentation they returned to the facility. The resident's medical records from the cancer center were reviewed from 6/1/2023 through 1/31/2024 and there were no documented visits for the resident and no documented communication from the facility to the cancer center's medical provider. During a telephone interview on 3/14/2024 at 11:44 AM, Registered Nurse Manager #10 stated they started as Manager in 8/2023 and was still trying to figure out how appointments with outside providers occurred at the facility. They stated follow-up appointments were scheduled based on recommendations noted on the hospital discharge summary and orders were needed to schedule an appointment. They stated when the resident was admitted , they were not the Manager but at some point, they believed they were told that residents of the facility could not receive chemotherapy and they thought that had something to do with billing. They believed they discussed this with the Director of Nursing and Assistant Director of Nursing. They thought the resident went for a magnetic resonance imaging scan on 10/26/2023 and was not sure why they did not have the report. They did not recall nurse practitioner #11's note on 12/11/2023 and typically the medical provider wrote their recommendations in a communication book and then nursing wrote orders. They were not sure if nurse practitioner #11 wrote a note referring the resident to oncology that day. They were not sure why there was no oncology referral after the resident returned to the facility on 1/3/2024. During a telephone interview on 3/19/2024 at 11:53 AM, physical therapist #14 stated on 12/12/2023, they noticed the resident's left ankle was turning inwards at times and that could occur from tightness or from a contracture. They also noticed the resident's left wrist and fingers were flexed inwards and they told occupational therapist #15 who assessed the resident's hand. They stated they discussed the concerns with nursing and issued the resident an ankle orthotic. During a telephone interview on 3/19/2024 at 12:00 PM, occupational therapist #15 stated on 12/12/2023, they assessed the resident and found they had a flexion contracture of the left arm that was turning inwards. They notified nursing staff that day though could not recall who. A flexion contracture could be caused by an issue with the brain, especially since the resident had concerns on one side of the body. During a telephone interview on 3/20/2024 at 7:47 AM, nurse practitioner #11 stated nursing staff became aware of their recommendations for follow-up appointments through written orders or via telephone calls when they were not in the building. When they wrote their note on 12/11/2023, they assumed they spoke with the unit Manager when they recommended the resident follow-up with oncology. They were not sure the resident's new onset contractures were related to brain cancer, but they were a change in condition, and they felt the resident needed to be seen by oncology. They expected the oncologist to have been notified and it was up to the oncologist whether the resident needed to be seen or not. They were not aware there was no documentation the oncologist was called and not aware there was no documentation a follow-up appointment occurred. During a telephone interview on 3/20/2024 at 10 AM, the Director of Nursing stated if a medical provider ordered an outside consult, then they expected the appointment to occur. They recalled when the resident was admitted to the facility, they were to follow up for chemotherapy after they discharged from the facility. They stated if the hospital discharge summary documented to follow-up with oncology and the facility medical provider ordered the follow-up, then they expected it to be completed. They stated they did not recall having conversations with Registered Nurse Manager #10 regarding the resident's chemotherapy. They were not aware nurse practitioner #11 wanted the resident to follow-up with oncology and they expected it to have been done. During a telephone interview on 3/20/2024 at 10:29 AM, attending physician #12 stated when they wanted a resident to have a procedure or follow-up, they went to nursing staff and told them and it required an order whether written or verbal. Follow-up appointments on the hospital discharge summary were usually set up before residents were admitted to the facility. When they wrote in their 6/3/2023 note the resident needed close follow-up from neurosurgery, they were not sure how aggressive the family wanted to be with treatment, and it was unclear to them if the family wanted to follow-up. On 8/11/2023, when they documented the resident continued to follow-up with oncology, the resident persistently refused and stated they did not want anything done. On 9/15/2023, when they documented the resident should have neurology/neurosurgery follow up for progression of symptoms the resident was again reluctant to have follow up. They were not aware the cancer center faxed a prescription for an urgent magnetic resonance imaging scan and stated if the family and resident wanted it then they expected it to be completed. They stated they left the facility in 11/2023 and could not provide any further information regarding the resident's care at the facility. 10 NYCRR 415.12