**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during an Abbreviated Survey (Complaint # NY00314677), the facility failed to ensure that each resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable. This was evident in 1 (Resident #2) of 3 residents reviewed for pressure ulcers (ulcers which occur on the skin surface due to prolonged pressure). Specifically, Resident #2, who was at mild risk for developing a pressure ulcer, was identified with a pressure ulcer on the sacrum (a bone located on the lower back) on 03/28/2023. The resident's pressure ulcer was not promptly assessed, and treatment was not started until 04/07/2023. Subsequently, on 04/10/2023, Resident #2 was assessed by the physician and diagnosed with a decubitus (Damage to a person's skin caused by constant pressure on an area for a long-time) ulcer infection. Additionally, a care plan to prevent pressure ulcer was not developed for Resident #2. This resulted in actual harm to Resident #2 that is not Immediate Jeopardy. The findings are: The undated facility's policy titled Pressure Ulcer Tracking documented it is the policy of the facility to ensure that all residents with potential for or actual pressure ulcer achieves intactness in skin. All residents identified via the Nursing admission Assessment as well as the Braden Scale Assessment and the Minimum Data Set to be at risk for pressure ulcers will have an active nursing care plan addressing this variable. Resident #2 was admitted to the facility with diagnoses of Peripheral Vascular Disease (is a blood circulation disorder that causes the blood vessels outside of your heart and brain to narrow, block, or spasm), schizoaffective disorder (a mental health condition characterized by abnormal thought processes and unstable mood), and Delusional Disorders (a type of psychotic disorder characterized by firmly held false beliefs). The Minimum Data Set (an assessment tool that measures health status in nursing home residents) assessment dated [DATE] documented that Resident #2 was moderately cognitively impaired. Section M (an item in the Minimum Data Set that documents the risk, presence, appearance, and change of pressure ulcers in nursing home residents) of the assessment documented Resident #2 did not have pressure ulcers and was at risk for developing pressure ulcers. The Minimum Data Set assessment documented that Resident #2 required extensive assistance with 1-person physical assist for transfer, toilet use, dressing, and personal hygiene; limited assistance with 1-person physical assist for bed mobility and eating. The Nursing admission assessment dated [DATE] documented that Resident #2 had intact skin. The Braden Scale (an assessment tool to assess and document a resident's risk for developing pressure ulcer) for Resident #2 dated 01/14/2023 documented Resident #2 had mild risk of developing pressure ulcers. The risk factors documented were slightly limited sensory perception, skin was occasionally moist, slightly limited mobility, and potential problem (requires minimum assistance) on friction and shear. Despite the Braden Scale identifying that Resident #2 was at mild risk of developing a pressure ulcer, a review of Resident #2's Comprehensive Care Plans did not reveal documented evidence that a care plan was developed that identified resident as at risk for pressure ulcer development. There was no documented evidence that interventions were in place to prevent the development of pressure ulcers. The Weekly Skin Assessment forms dated 03/14/2023 and 03/21/2023 documented Resident #2 had intact skin. A Weekly Skin Assessment form for Resident #2 dated 03/28/2023 documented skin exam, with the sacral part circled, description was unstageable. The progress notes from 03/28/2023 through 04/06/2023 had no documented evidence that the unstageable pressure ulcer was evaluated. The Certified Nursing Assistant Documentation Record dated 03/21/2023, 03/28/2023, 04/04/2023, and 04/11/2023 documented that skin check was performed but did not document the skin observations or impairment. A review of the physician's orders from 03/28/2023 through 04/06/2023 did not reveal orders for unstageable pressure ulcer on the sacrum. A review of the Treatment Administration Record from 03/28/2023 through 04/06/2023 did not reveal documented evidence that Resident #2 received treatment to the unstageable sacral pressure ulcer. A review of Resident #2's comprehensive care plans revealed that the facility did not develop a care plan that identified the development of a pressure ulcer or skin alteration until 04/14/2023. At this time the wound was identified as a Stage 4 pressure ulcer to the sacrum. The care plan had no documented goals or interventions in place to guide the care of the wound. Physician #2's progress note dated 04/07/2023 at 2:02 pm documented Resident #2 was seen for sacrum wound break down and copious foul-smelling necrotic (medical term for the death of body tissue that can occur when there is lack of blood flow to the tissues) tissue present on exam. Resident will need twice a week debridement until it improves. The note documented sacrum unstageable decubitus with breakdown 7 by 9-centimeter, 63-centimeter, depth 3.5-centimeter, copious foul-smelling tissue, no granulation tissue, minimal exudate; will debride at bedside today. Recommended topical sodium hypochlorite dressing (a strong topical antiseptic used to treat pressure sores) twice a day, consider Collagenase (treatment for skin ulcers that removes dead skin and tissue), offload pressure, pain control, optimize nutrition. Physician #1's order dated 04/07/2023 documented dilute sodium hypochlorite solution 0.25% -(a solution used to treat bedsores), apply by topical route 3 times per day, cleanse with normal saline wet gauze with dilute sodium hypochlorite solution 0.25% apply to affected area and cover with dry abdominal dressing. The order did not specify the site of treatment. The Treatment Administration Record dated 04/07/2023 through 04/30/2023 documented that Resident #3 received treatment of topical sodium hypochlorite dressing, apply by topical route 2 times per day cleanse with normal saline, wet gauze with topical sodium hypochlorite dressing solution, apply to affected area and cover with dry abdominal dressing. The Treatment Administration Record did not specify the site of treatment. Physician #1's progress note dated 04/10/2023 at 7:11 pm documented Resident #2 was seen for follow up on decubitus ulcer infection. Resident was started on intravenous antibiotics for 7 days. Physician #1's progress note dated 04/17/2023 at 4:09 pm documented Resident #2 was seen for follow up on decubitus ulcer infection. Resident #2 completed antibiotic therapy for decubitus infection with no adverse reaction. The note documented that Resident #2 was stable and that the wound improved. Physician #2's progress note dated 04/28/2023 at 12:14 pm documented Resident #2 was seen for follow up of the pressure ulcer on the sacrum. Wound assessment documented sacrum stage 4 pressure ulcer, 7 by 6 centimeter with undermining, depth of 5-centimeter, moderate necrotic tissue, moderate granulation tissue, minimal exudate. The pressure ulcer was debrided down to the depth level and including bone. Resident #2 tolerated the procedure with no complications. Physician #2's progress note dated 05/05/2023 at 12:34 pm documented Resident #2 was seen for follow up of the pressure ulcer on the sacrum, Wound assessment documented sacrum stage 4 pressure ulcer, 8 by 6-centimeter, depth of 5 centimeter, with undermining, with moderate necrotic and granulation tissue, minimal exudate. The pressure ulcer was debrided down to the depth level and including bone. Resident #2 tolerated the procedure with no complications. Physician #1's progress note dated 05/19/2023 at 10:39 am documented that Resident #2's pressure ulcer in the sacrum area presented with foul odor and purulent drainage; recommended to transfer Resident #2 to the hospital for wound debridement and antibiotic therapy. A nurse's progress notes dated 05/20/2023 at 6:45 am documented Resident #2 was admitted in the hospital. During an interview on 03/06/2024 at 12:17 pm, Registered Nurse #1, who was the nursing supervisor in Resident #2 unit, stated they knew about Resident #2's unstageable pressure ulcer in April 2023, could not recall the exact date, after it had been reported by a staff. Registered Nurse #1 stated they were not aware and had not received report about Resident #2's pressure ulcer prior to April 2023. Registered Nurse #1 stated Registered Nurses are responsible for initiating the care plan for at risk to develop pressure ulcer upon admission and must be updated when there is a change in resident's condition. Registered Nurse #1 stated care plans must have long and short-term goals and interventions. During an interview on 04/11/2023 at 9:11 am, Registered Nurse #2 stated they identified the pressure ulcer on the sacrum on 03/28/2023 during weekly skin assessment. Registered Nurse #2 stated they documented the observation on the Weekly Skin Assessment form and verbally notified the Director of Nursing and the Attending Physician of the suspected pressure ulcer. Registered Nurse #2 stated the facility did not have a wound care nurse at that time. Registered Nurse #2 stated they were responsible for initiating a care plan for pressure ulcer. During an interview on 03/06/2024 at 12:17 pm, Physician #1 stated they were not notified that Resident #2 developed pressure ulcer until 04/07/2023. They stated the Wound Care Consultant evaluated Resident #2 and debrided the wound. They stated Resident #2 was started on antibiotic therapy so that wound did not get worse. Physician #1 stated they believe the reason they were not notified immediately was because the facility had a high turnover of nurses and were using travel nurses. They stated the facility did not have a wound care nurse. Physician #1 stated they cannot say that Resident #2's pressure ulcer was avoidable, but it could have been prevented. They stated they could have referred Resident #2 to a wound care specialist had they been immediately notified. During an interview on 03/12/2024 at 11:20 am, Physician #2, who was the Wound Care Consultant, stated it was the primary attending physician who was responsible for managing a resident's wound. They stated their responsibility was to make recommendations on how to manage the wound. Physician #2 stated Resident #2 was very sick and was bed ridden, and that could lead to developing pressure ulcers. They stated that Resident #2's pressure ulcer was preventable, but the facility must have preventive measures in place. During an interview on 04/11/2024 at 12:00 pm, Director of Nursing #1 stated they recently started working at the facility and was not the director when Resident #2 developed the pressure ulcer. The Director of Nursing stated weekly resident skin assessments were performed by the licensed nurses, and if a nurse identifies a pressure ulcer, they must immediately notify the attending physician to evaluate the wound and get treatment orders; a referral must also be made to the wound care consultant. The Director of Nursing stated the Registered Nurse Supervisors were responsible for developing care plans upon admission and it must be updated when there was a change in resident's condition. During an interview on 03/18/2024 at 1:25 pm, the Administrator stated they started working at the facility towards the end of May 2023 and was not the Administrator when Resident #2 developed the pressure ulcer. They stated they do not recall the issues surrounding Resident #1's pressure ulcer development. The Administrator stated it was the nurse manager and the Director of Nursing's responsibility to ensure care plans were developed and updated with each change in a resident's condition. 10 NYCRR 415.12(c)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification and abbreviated survey (NY00309172) the facility did not ensure each resident received adequate supervision to prevent accidents for 1 (Resident #109) of 3 residents reviewed for wandering and elopement. Specifically, Resident #109, a resident with moderately impaired cognition and a wander alert device (a device that alerts staff when the resident is exiting the building), exited the facility without staff knowledge on 1/23/23 between 3:00 PM and 4:15 PM. The resident was found by the police on 1/24/23 at 7:07 AM and admitted to the hospital with Hypothermia (low body temperature), Altered Mental Status (a change in mental function), and a Urinary Tract Infection (UTI). This resulted in actual harm to Resident #109 that is not immediate jeopardy. The findings are: The policy and procedure titled Elopement dated 05/2008, last updated 3/2009, documented all residents should be assessed for elopement risk upon admission and quarterly. Residents identified at risk for elopement should have a comprehensive care plan (CCP) and a wander alert device provided. The Certified Nursing Assistant Accountability Record (CNAAR) should be updated with the use of a wander alert device, and a photograph of the resident should be maintained at the nursing station and reception desk. If there is a missing resident, a code M should be called to alert staff, and a search for the resident should be conducted. Resident #109 was admitted to the facility with diagnoses which include Urinary Tract Infection, Congestive Heart Failure (CHF) (a condition where the heart does not pump blood as well as it should), and Mood Disorder secondary to Medical Condition. The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #109 had moderately impaired cognition and required limited assistance of one person for transfer and locomotion on and off the unit. The MDS documented wandering behavior was not exhibited and no wander/elopement alarm was used. The Nursing Note dated 11/8/22 documented Resident #109 was admitted to the facility. The resident was alert and oriented with confusion at times. The admission wandering and elopement risk assessment dated [DATE] documented Resident #109 was not at risk for elopement. The assessment documented the resident had no risk factors listed, including cognitive impairment with poor decision-making, high risk diagnoses such as Dementia/Alzheimer's/Delusions, the ability to walk independently, a history of elopement at home, expressing the desire to go home, and wandering aimlessly. The Physician's Orders initiated 11/9/22 and last renewed 1/4/22, documented staff should monitor Resident #109's whereabout two times per shift and conduct hourly rounds q (every) shift. A Nursing Note dated 11/14/22 documented Resident #109 was wandering the unit but easily redirected. The note further documented the resident was walking the unit with supervision. The Physician's Order entered by the Medical Doctor (MD), initiated 11/14/22 and last renewed on 1/4/23, documented Resident #109 should be on every 15-minute visual rounds until a wander alert device is applied. The CNAAR Nursing Instructions covering 11/1/22 to 1/25/23 documented the safety instruction to complete 15-minute monitoring until the wander alert device was applied (added 11/14/22). There were no instructions for the CNAs to check the wander alert device for placement and function. The CCP for Unsafe Wandering at Moderate/High Risk, initiated 11/15/22, documented Resident #109 had a wander alert device in use. Interventions included: check wander alert device for placement and functioning every 12 hours, replace the wander alert device per manufacturer's recommendation. Ascertain the resident's whereabouts during each shift, maintain the resident's photo on the unit and at the receptionist's desk, and the alarmed doors on either end of the hallway on the unit. A Nursing Note dated 11/15/22 documented the writer placed a wander alert device on Resident #109's right wrist, and there were no complaints. A Nursing Note dated 11/16/22 at 1:21 AM documented Resident #109 had a wander alert device on the right wrist in place for unsafe wandering-elopement. The resident attempted to get on the elevator and stated, I will go home and was re-directed. The Medication Administration Records (MARs) from November 2022 to January 2023 documented from 11/14/22 to 1/25/23 nurse signatures every shift to acknowledge the CNAs should complete 15-minute monitoring of Resident #109 until the wander alert device was applied. The CNAAR Nursing instructions documented from 11/14/22 to 1/25/23 to complete 15-minute monitoring until the wander alert device was applied to Resident #109. There was no documented evidence that the wander alert device was monitored for placement or function after the wander alert device was applied to Resident #109 on 11/15/2022. The MDS assessment dated [DATE] documented Resident #109 had moderately impaired cognition with a Brief Interview of Mental Status score of 10 out of 15. The resident exhibited no wandering behavior and required limited assistance of one person for walking and transfers. The MDS further documented the resident was not steady but able to stabilize themselves without staff assistance when moving from a seated to standing position, walking, and surface-to-surface transfers. The MDS documented no wander/elopement alarm was used. The Accident/Incident Investigation Report Summary dated 1/23/23 documented Resident #109 was observed on the phone at the nursing station around 2:30 PM, and Resident #109 went to the day room afterwards. The resident was seen walking on the unit around 4:00 PM, by the assigned day shift CNA #1 before they left. At approximately 5:00 PM, staff identified the resident was missing and started a search without success and called 911. A Nursing Note dated 01/23/23 at 5:54 PM documented at the beginning of the 4:00 PM -12:00 AM shift, the CNA noticed Resident #109 was not in their room and checked all rooms and bathrooms on the unit. When the resident was not found, the CNA informed the nurse and Code M was called. A search was initiated on all units, and the resident was not located. The facility contacted 911 to report Resident #109 missing, and a police officer stated the police will begin a search immediately (report confirmation #8533). A Nursing Note dated 1/23/23 at 7:08 PM documented Resident #109 was noted as missing at 5:00 PM. Code M for missing person was announced, and a facility-wide search commenced. Resident #109 was last seen by staff talking to a friend at the nursing station telephone at 2:30 PM. The facility attempted to contact the friend without success. The facility called 911, and two New York Police Department (NYPD) officers arrived at 6:30 PM. The police completed a facility-wide and local vicinity search without success. The Fifteen Minutes Monitoring Form dated 1/23/23 documented the CNA #1 observed the resident every half hour from 8:30 AM to 4:00 PM. The last check was at 4:00 PM. The facility was unable to provide or review camera footage to establish how and when Resident #109 left the facility. A Nursing Note dated 1/24/23 at 7:31 AM documented the facility received a call from the police at 7:07 AM informing them that Resident #109 was found at a bus ramp. The police reported they would be sending Resident #109 to the hospital for evaluation. The Hospital admission Assessment/History & Physical dated 1/24/23 documented Resident #109 was Alert and Oriented to person only (A&O x 1), combative, and agitated. The resident's temperature was 93.3 degrees Fahrenheit, and Resident #109 was placed in a warming blanket. Antibiotics (Vancomycin, Azithromycin, and Ceftriaxone) were administered, and the resident had a history of dementia. The working diagnoses were lactic acidosis (too much lactic acid in the bloodstream) and altered mental status (a change in mental function) caused by a UTI vs worsening dementia. The note further documented Resident #109 had similar symptoms on the last admission and eventually became A&O x 3 (person, place, and time) after antibiotics. An undated letter from a security camera company documented the facility reached out to have the camera system checked on 1/24/23. The system settings were correct, but the hard drive was not working. The cameras started recording again after the system was rebooted. A written statement dated 1/23/23 from the Security Guard #1 documented they did not see Resident #109 leave the building or hear the wander alert device alarm sound. The Summary of Investigation documented the investigation was still ongoing as of 1/26/23. Resident #109 was last seen on the unit around 2:40 PM when they returned to the dayroom after talking on the phone at the nursing station. The police used the K-9 unit to track the resident's path, and they established Resident #109 left the building through the front door. During an interview on 01/24/23 at 12:25 PM, CNA #1, the assigned 8:00 AM - 4:00 PM shift CNA, stated Resident #109 was confused and walked independently without a device. CNA #1 stated they last saw the resident at 3:45 PM before the end of the shift, and they were informed the resident was missing today. CNA #1 stated Resident #109 wandered and always attempted to use the elevator to leave the unit. CNA #1 stated they redirected the resident and informed the charge nurse of the attempts. Resident #109 did not have a wander alert device and was monitored every 30 minutes. During an interview on 01/24/23 at 4:03 PM and 4:13 PM, CNA #2, the assigned 4:00 PM - 12:00 AM CNA, stated Resident #109 was not on the floor at the beginning of the shift at 4:00 PM. The Physical Therapist (PT #1) came to the unit at around 4:00 PM looking for the resident. PT #1 informed the nurse the resident was missing between 4:00 PM and 4:15 PM. CNA #1 informed them Resident #109 was missing so they went to the 2nd and 3rd floors to look for the resident. When they realized the resident was not in the building, the supervisor (Registered Nurse #2) was informed, and a code was called. Resident #109 wanted to leave when they were first admitted , and they used to get in the elevator. Resident #109's picture was in the lobby. CNA #2 stated Resident #109 stopped getting into the elevator and verbalizing a desire to go home. Resident #109 stayed on the unit unless they were going to therapy between 4:00 PM and 5:00 PM. During an interview on 01/26/23 12:13 PM, the Licensed Practical Nurse (LPN #1) stated they placed the wander alert device on Resident #109, as instructed by the RN Supervisor after reporting exit-seeking behavior. Resident #109 always attempted to leave the unit and had to be redirected. The RN is responsible for writing the order and contacting the physician. LPN #1 stated they visually monitored Resident #109's wander alert device, but they had no place to document it on the MAR because there were no orders. LPN #1 stated the resident was monitored every 15 minutes and hourly for safety. During an interview on 1/25/23 at 11:49 AM, PT #1 stated that, between 2:00 PM and 3:00 PM, they went to the unit to bring Resident #109 to a therapy session. The resident was not in their room, and LPN #1 reported the resident may be in recreation on the 1st floor. PT #1 looked for the resident in recreation but could not find them. At, approximately 3:00 PM, they returned to the unit with the Recreation Director to attempt to find the resident but was unsuccessful. Code M was called at 5:00 PM. During an interview on 01/26/23 at 11:40 AM, the RN #2 stated they updated the CCP for wandering and elopement after the wander alert device was placed. RN #2 was informed by staff that Resident #109 attempted to leave the facility several times and always told staff they wanted to go home. RN #2 did not check for the wander alert device orders, assuming they were already in place, and they did not complete an elopement risk assessment since the resident had one upon admission. RN #2 stated they should have completed an updated elopement risk assessment and ensured orders for the wander alert device were in place. During an interview on 01/27/23 at 11:02 AM, the Medical Doctor (MD) stated a physician's order is not required for a wander alert device, and the order for the monitoring to be completed until the wander alert device was applied indicated a wander alert device was needed. The MD stated Resident #109's wander alert device should have been monitored. During an interview on 01/30/23 at 02:59 PM, the Security Guard (SG #1) stated they were on duty from 8:00 AM to 4:00 PM on 1/23/23. The SG #1 stated they monitored the screen at the front desk, and there were pictures of residents at risk for elopement on the wall. Another security guard (SG #2) was assigned to the station at the front door from 8:00 AM to 4:00 PM on 1/23/23. When the wander alert device alarm triggers, it must be disarmed. The SG could not recall if an alarm sounded and did not see Resident #109 exiting the facility. During an interview on 1/26/23 at 3:45 PM, SG #2 stated they worked at the main entrance from 8:00 AM to 4:00 PM on 1/23/23. SG #2 did not observe any resident attempting to exit through the main entrance door or hear any alarm go off on that day. SG #2 stated that they must be aware of the residents at risk for elopement, and the pictures are posted and in the binder at the main entrance station. SG #2 stated any person who triggers the alarm would be stopped right away to prevent them from leaving the facility. During an interview on 1/26/23 at 9:18 AM, the Director of Nursing (DON) stated that on 1/24/23 at 6:00 PM, they went to the hospital to see Resident #109 and saw the wander alert device on the right wrist. The DON stated they cut off the wander alert device and brought it back to the facility. The wander alert device was tested twice and triggered the alarm both times. The device had an activate by date of 12/26/22. The DON stated the CCP should have been revised to reflect the placement of the wander alert device and revised supervision of every 2 hours. There should have been physician's orders to check the wander alert device twice per day at 6:00 AM and 6:00 PM. The LPN charge nurse should complete the checks and document them on the MAR. During an interview on 01/24/23 at 11:23 AM, the Administrator stated that on 1/16/23, they were informed by the Maintenance Director that the camera footage could not be reviewed and only provided live feed. The issue was identified through a daily check. 10 NYCRR 415.12(h)(1)