**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the recertification and abbreviated (NY00330552) surveys conducted 3/4/2025 - 3/14/2025, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (1) of two (2) residents (Resident #136) reviewed. Specifically, Resident #136: - physician's order for gastrostomy (a tube placed in the stomach) tube feeding was not administered as ordered and when administered was the incorrect volume; - had an order to receive nothing by mouth and medications were ordered to be given orally; - was improperly positioned prior to having a tube feeding administered; - had an indwelling catheter collection bag in a permeable pillowcase laying on the floor; - did not receive their weekly shower or hair washing; - was left in their room with the door closed, their call bell on the floor and out of reach, and the resident was unable to use a traditional call bell and no alternative was given - did not have preferred activities provided for sensory stimulation; - was not provided with timely activities of daily living care; - was visible from the hallway wearing only a brief with their gastrostomy tube insertion site in plain view; - was observed in bed for consecutive days without being dressed. This resulted in physical and psychosocial harm to Resident #136 that was not Immediate Jeopardy. Findings include: The facility policy Activities of Daily Living, revised 9/2024, documented care and services would be provided for transfers, ambulation, bathing, dressing, and grooming; residents who were unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, personal and oral hygiene; and a resident's abilities and activities of daily living would not deteriorate unless deterioration was unavoidable. The facility policy Bathing Techniques-Tub Bath or Shower, revised10/2024, documented all residents were bathed as often as necessary to maintain cleanliness, refresh and stimulate circulation, and residents would be assisted with showering hair and rest of body as needed, moving from head to toe. The facility policy Fall Prevention, revised 10/2024, documented general safety precaution and fall prevention measures that applied to all residents that included easy access to call light, increased observation and surveillance, and observation during walking or safety rounds. The facility policy Resident Care Record, last reviewed 2/21/202, documented the Unit Manager initiated the resident care record on all residents by checking which areas applied to the resident; staff were responsible to do all care as indicated by check marks in each category of care; if care was not given as indicated on the resident care record, the certified nurse aide would notify the charge nurse of what care was not given and why; the charge nurse would intervene with the resident and document the outcome; and at the completion of each shift, the certified nurse aide would initial on the back of the resident care record for the appropriate date and shift indicating care was given. The facility policy, Tube Feeding-Gastrostomy, Percutaneous Gastrostomy (PEG) or Jejunostomy Tube Feeding with Use of Pump, revised 5/2024, documented obtain physician order for type and amount of formula, and frequency of administration. Place resident in semi-Fowler's position (sitting at 45-degree angle) to avoid aspiration (inhaling contents into lungs). The facility policy Call Bell Accessibility, reviewed 9/2024, documented the facility would be adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance; each resident would be evaluated for unique needs and preferences to determine any special accommodations that may be needed in order for the resident to utilize the call system; special accommodations would be identified on the resident's person-centered plan of care, and provided accordingly (examples include touch pads, larger buttons, bright colors, etc.); and staff would ensure the call light was within reach of the resident and secured, as needed. The facility policy, Purpose, Goals, and Methods of Programs, revised 3/24/2024, documented the facility would identify each resident's interests and needs and involve the resident in an on-going program of activities that were designed to appeal to their interests and to enhance their highest practicable level of physical, mental and psychosocial well-being. Resident #136 had diagnoses including depression, obstructive uropathy (obstructed urine flow), cerebral infarction (stroke) with left hemiplegia (inability to move the left side of the body), and dysphagia (difficulty swallowing). The 1/30/2025 Minimum Data Set assessment (an assessment tool) documented the resident had intact cognition, had unclear speech, was sometimes able to express ideas and wants, was dependent for most activities of daily living, had an indwelling urinary catheter, was always incontinent of bowel, had a feeding tube, received 51% or more of total calories through a tube feeding, and was at risk for developing pressure ulcers. The 11/7/2024 Annual Minimum Data Set assessment (an assessment tool) documented the resident felt it was very important to choose what clothes to wear, it was somewhat important to choose between a tub bath, shower, bed bath or sponge bath, listen to music they liked, do things with groups of people, do favorite activities, and participate in religious services or practices. Gastrostomy Tube Feedings and Oral Medications: The comprehensive care plan, initiated 11/4/2024 and revised 3/1/2025, documented a nutritional and hydration risk related to dysphagia and nothing by mouth status. Interventions included diet and tube feeding as ordered, head of bed to always be at 45 degrees, and nothing by mouth. The 12/26/2024 speech language pathology discharge summary documented the resident should be in upright position during and after tube feedings to decrease the risk of aspiration. Physician orders documented the following: -on 11/1/2024 aspirin 81 milligrams by mouth once a day; fluoxetine (an anti-depressant) 20 milligrams by mouth once a day; and senna (a stool softener) two 8.6 milligram tablets by mouth at bedtime. -on 12/19/2024 nothing by mouth, bolus tube feeding by gastrostomy tube. -on 1/22/2025 1.2 calorie high fiber tube feeding formula give 280 milliliters bolus (formula delivered by gravity or syringe) every 4 hours to equal 1680 milliliters and give 50 milliliters water before and after each feeding every 4 hours, give 30 milliliters water before and after medications four times a day The December 2024, January 2025, February 2025, and March 2025 Medication Administration Records documented: - aspirin 81 milligrams chewable tablet 1 tablet orally at 6:00 AM. - fluoxetine 20 milligrams 1 tablet orally at 6:00 AM - senna 8.6 milligrams 2 tablets orally at 9:00 PM The medications were signed as administered daily from 12/19/2024 - 3/14/2025. The March 2025 Medication Administration Record documented - on 3/7/2025 the 10:00 PM 1.2 calorie high fiber tube feeding formula, and water flush was not administered - on 3/8/2025 the 2:00 AM and 6:00 AM 1.2 calorie high fiber tube feeding formula, and water flush were not administered. On 3/6/2025 from 8:20 AM through 2:16 PM a continuous observation of Resident #136 was made. No one entered the resident's room from 10:32 AM to 2:16 PM. Licensed Practical Nurse #36 was not observed administering the resident's tube feeding from 8:46 AM-2:16 PM. At 11:36 AM Licensed Practical Nurse #36 signed for 10:00 AM tube feeding and water flush. At 12:24 PM the resident's mouth was very dry, and their lips were dry and flaking. At 2:16 PM, Licensed Practical Nurse #36 entered the resident's room. The resident was in bed with the head of the bed at approximately 20 degrees. Licensed Practical Nurse #36 flushed the feeding tube with 50 milliliters of water, mixed medications with 20 milliliters of water and administered via the tube, instilled one 237 milliliter carton of 1.2 calorie high fiber tube feeding formula into the tube using a syringe (physician order was for 280 milliliters), then flushed with 50 milliliters of water. Licensed Practical Nurse #36 stated the angle of the head of the bed was maybe 20 degrees and they boosted the resident up in bed. On 3/7/2025 from 8:42 AM through 12:55 PM, a continuous observation of Resident #136 was made. No nursing staff entered the resident's room since 8:42 AM. At 11:03 AM Licensed Practical Nurse #36 passed the resident's room and placed the medication cart at the nursing station. At 11:57 AM Licensed Practical Nurse #36 opened the resident's door, peeked in, shut the door and walked away. At 1:35 PM the tube-feeding formula and water were not signed for on the medication administration record. Licensed Practical Nurse #36 was not observed administering the resident's tube feeding from 9:14 AM-1:44 PM. At 1:44 PM Certified Nurse Aide #22 and Licensed Practical Nurse #36 entered the resident's room. Licensed Practical Nurse #36 elevated the resident's head of bed to about 45 degrees, flushed the resident's tube with 50 milliliters of water, mixed medications with 30 milliliters of water, administered medications, poured one 237 milliliters carton of tube-feeding formula 1.2 into the tube using a syringe (physician order was for 280 milliliters), then flushed with 50 milliliters of water. At 1:57 PM both the 10:00 AM and 2:00 PM tube-feeding formula feedings and water flushes were signed as administered by Licensed Practical Nurse #36 on the medication administration record. During an interview on 3/7/2025 at 3:02 PM, Licensed Practical Nurse #36 stated if something was signed for in the medication administration record then it was given. Any missed treatments or medications should be reported to the physician and documented. Resident #136 could not have anything by mouth and relied on tube-feeding formula and water flushes via their gastrostomy tube to sustain them. The tube-feeding formula and water flushes should be signed for right after they were administered. They stated they did not know who was responsible for the 10:00 AM administration. The Registered Nurse Unit Manager #36 took over for the night nurse at 8:45 AM and then they took over for the Registered Nurse Unit Manager #36. After reviewing the medication administration record, they stated they had signed for the tube-feeding formula and water, but they should have checked not given. The resident did not receive that, and they did not call anyone to get an order to make up for that missed dose. They were not sure who administered the tube-feeding formula and water flushes on 3/6/2025 at 10:00 AM, and thought they did. They signed for it and if they did not give it, it was probably because they had two floors, and it was hard to keep track of everything. After reviewing the medication administration record, they stated they documented it was not administered and the water flush was documented as administered late but they should have clicked not administered. They stated they should have reported it because they did not do anything to make up for that lost feeding. They stated the resident should receive one whole bottle of tube-feeding formula for the feedings and that was how they were shown and how other nurses did it. After reviewing the order, they stated a bottle was 8 ounces or 237 milliliters and the resident was supposed to get 280 milliliters. The resident did not receive the ordered amount. It was important the resident received what was ordered because they depended on the feeding and could become malnourished. During an interview on 3/12/2025 at 2:02 PM, Licensed Practical Nurse #22 stated Resident #136 had an order for nothing by mouth and relied entirely on their tube feedings for nutrition. It was important they received the feedings as ordered or they could lose weight. If the tube feeding was not administered within an hour of the scheduled time, they should contact the Unit Manager or the provider for directives. When administering medications, the nurse should check to make sure it was administered by the right route (by mouth, by tube) the right route and if there was any confusion they would clarify before administering. After referring to their orders, they stated the resident had some medications that were ordered to be given by mouth. The orders should have been clarified, as it was possible someone might try to give them by mouth, which could result in aspiration. They stated when they administered the resident's tube feeding, they flushed with 60 milliliters of water, then administered one carton of tube-feeding. After looking at the order and the carton they stated that they had been giving the wrong amount and should have had a carton plus another 40 milliliters. Elevating the head of the bed to 45 degrees was important to prevent reflux and aspiration. During an interview on 3/14/2025 at 9:31 AM, Physician #8 stated they did not recall being informed by nursing that Resident #136 missed any recent tube feedings. During an interview on 3/14/2025 at 11:05 AM, Registered Nurse Manager #12 stated nurses should check the route in which medications were ordered. If a resident had an order to get nothing by mouth and there were orders for medications to be given by mouth, it needed to be addressed. It was possible someone might give those medications orally and cause the resident to choke. Bolus feedings (tube feeding formula is delivered quickly using a syringe) given at should be given as ordered. If a resident did not receive their feeding within the time scheduled, they expected it be reported to them so they could call the doctor and see if the feeding could still be given, or the next feeding could be bumped out. Nurses should not sign for something they did not give. They administered Resident #136's tube feeding in the past and the resident received one carton of tube-feeding formula 1.2. After referring to the order and the registered dietitian's note they stated the resident should receive more than one carton of tube-feeding formula. The resident was being monitored because they had a couple pound weight loss and Registered Nurse Manager #12 thought that giving the wrong amount may have contributed to that. During an interview on 3/14/2025 at 11:30 AM, Registered Dietitian #49 stated Resident #136 received enteral (through a tube) feedings. The resident should receive tube-feeding formula 1.2 280 milliliters 6 times a day for a total of 1680 milliliters. They should be made aware if the feeding or the water flushes were not provided as ordered as the resident was a high nutrition risk. If the resident was not receiving their feeding as ordered it could lead to weight loss. They were not aware the resident's feeding was not provided or not administered as ordered. During an interview on 3/14/2025 at 1:36 PM, the Director of Nursing stated they expected feeding orders were followed, and the physician was notified of any missed feedings. A bolus should not be skipped or signed for if not given. Missed feedings could cause harmful effects such as weight loss, a pressure ulcer and not feeling well. Resident #136's weights were discussed, and they waxed and waned, which made it even more important the resident received the right amount of formula. The resident was to receive nothing by mouth and their medications and tube-feeding formula should not say give orally. They expected contradictory information to be clarified, as it was possible it could have been given by mouth, which could lead to aspiration. Activities of Daily Living/Dignity/Urinary Catheter/Activities The undated resident care instructions documented the resident required assistance with positioning and turning; total assistance for dressing, grooming, and bathing; bathing was scheduled for Thursdays during the 6:00 AM to 2:00 PM shift; mechanical lift for transfers; assist of two for bed mobility; use of a reclining chair and tilt back wheelchair; and call bell-does not use. The Comprehensive Care Plan documented: - initiated 11/1/2024, the resident was at risk for pain related to increased muscle strengthening and mobility during rehabilitation. Interventions included assist in positioning for comfort. - initiated 11/18/2024, the resident was at risk for pressure ulcers due to friction and shear. Interventions included two (2) or more to lift resident while in bed, consider postural alignment, weight distribution, and pressure relief when position in chair or wheelchair. - initiated 11/1/2024, at risk for infection secondary to urinary catheter. Interventions included provide privacy bag for urine collection bag. - initiated 11/1/2024, at risk for falls. Interventions included increased staff supervision with intensity based on resident need; provide individualized incontinence care based on needs/patterns; and encourage daily activity. - initiated 11/1/2024, at risk for constipation related to decreased mobility. Interventions included encourage to get out of bed daily with exercise and activities as tolerated. Restlessness and confusion due to stroke. Interventions included provide and encourage participation in meaningful activities while awake, provide regular periods of exercise and attempt to reduce daytime napping. The Comprehensive Care Plan did not include activities of daily living requirements. The following observations of Resident #136 were made: - on 3/4/2025 at 10:43 AM, lying in bed with only a brief on, their hair was greasy and flaky, and their gastrostomy tube, including the insertion site, was visible from the hall. - on 3/5/2025 at 12:05 PM, the door to the resident's room was closed. The resident was lying in bed wearing only a brief, their hair was unkempt with flakes, their gastrostomy tube was exposed, and their catheter bag was in a permeable pillowcase resting directly on the floor. The resident was awake and making grunting, indiscernible noises. - on 3/5/2025 at 2:00 PM, lying on their back in bed, their catheter bag was in a permeable pillowcase resting directly on the floor The 3/6/2025 Master Assignment Sheet documented Licensed Practical Nurse #36 and Certified Nurse Aide #44 were assigned to the resident, and the resident was scheduled for a shower that day Resident #136 was observed continuously on 3/6/2025 from 8:20 AM - 2:16 PM: - at 8:20 AM, the resident was lying flat on their back in bed with flaky, unkempt hair. - at 8:37 AM, Certified Nurse Aide #44 briefly entered the resident's room then left, shutting the door behind them. The resident was lying on their back wearing only a brief; their catheter bag was in a permeable pillowcase resting directly on the floor. - at 10:32 AM, Certified Nurse Aide #44 and Licensed Practical Nurse #36 entered the resident's room. The resident had a large amount of dried stool on their buttocks; their skin was red and superficially peeling where the stool was. Certified Nurse Aide #44 cleansed the buttocks and applied skin protectant to the resident's buttocks while Licensed Practical Nurse #36 held the resident on their side. The resident was placed on their back, both staff exited the room and shut the door behind them. There was no television or music provided for stimulation. - no additional care or activities were observed from 10:32 AM - 2:16 PM. There was no documented evidence the resident received their weekly shower during the 6:00 AM- 2:00 PM shift as scheduled. During an interview and observation on 3/7/2025 at 8:42 AM, Resident #136 stated yes when asked if they wanted to get out of bed and dressed; yes when asked if they got bored being in their room all the time; and no when asked if anyone from activities came to see them. They also stated they preferred wearing a light shirt and shorts. The resident's dresser and closet had many articles of clean clothing. Resident #136 was observed continuously on 3/7/2025 from 8:42 AM - 12:55 PM: - at 8:42 AM, the door to the resident's room was closed, the resident was lying flat on their back, not dressed, their hair was unkempt with flakes, their catheter bag was in a permeable pillowcase resting directly on the floor - from 11:32 AM - 1:35 PM, the resident's door was cracked open, the resident was lying on their back in bed, and their catheter bag was in a permeable pillowcase resting directly on the floor. No one entered the resident's room to perform care from 8:42 AM - 1:44 PM. - at 1:44 PM, Licensed Practical Nurse #36 and Certified Nurse Aide #44 entered the resident's room and boosted the resident up in bed. No other care or repositioning was provided. During an interview on 3/7/2025 at 2:02 PM, Certified Nurse Aide #44 stated residents should be turned and repositioned every two hours; showers were listed on the assignment sheets and included hair washing; and if the resident care record did not say what kind of bathing to give, they gave a shower. If giving a bed bath, the resident's hair should be washed with the use of a basin and a cup. Resident #136 was dependent for showers and repositioning and should be repositioned every couple of hours if they could get to it. The resident was at risk for skin breakdown and infection. The resident used to get up to a chair, but now laid in bed all day every day and they were unsure why. The resident was scheduled for a shower that day but was given a partial bed bath and they did not wash the resident's hair because they were very busy. They did not report the shower was not given. They did not reposition the resident but did peek in at them to make sure they were safe. They did not dress the resident as they were told the resident did not like to get dressed but recalled the resident used to get up, got dressed, and liked to wear a tee shirt. During an interview on 3/12/2025 at 12:52 PM Certified Nurse Aide #33 stated catheter bags should be in a privacy bag and not on the floor. If it was on the floor, bacteria could contaminate the tubing and enter the resident, causing an infection. Every resident should be dressed in some capacity each day as it was a privacy and dignity issue, especially if parts of their body were exposed. Doors should be shut only if a resident preferred. Residents at risk for falling should not have their door shut, as they could be unknowingly on the floor or up and walking around. A shut door could also make the resident feel trapped. During an interview on 3/7/2025 at 3:02 PM, Licensed Practical Nurse #36 stated turning and repositioning should be done every 2 hours, and weekly showers should be provided. If a certified nurse aide could not complete a shower, they expected it to be reported at that time and not at the end of the shift. Showers and repositioning were important because it was a resident's right. Lack of showers could make them feel undignified, and lack of repositioning could lead to bed sores. Resident #136 was dependent for repositioning, showers, and dressing. The resident did not get dressed but they had never asked why. They stated Certified Nurse Aide #44 told them at 2:00 PM on 3/6/2025 that the resident did not get their shower. They noticed the resident's hair was flaky. During an interview on 3/12/2025 at 2:02 PM, Licensed Practical Nurse #22 stated catheter collection bags should be hung from a chair or bed, not lying on the floor. Catheter bags on the floor was an infection control issue. Doors could be shut if a resident preferred, but if a resident was a fall risk it should be open to better monitor. If a resident was unable to speak, unable to use their call bell, and was a fall risk, their door should not be shut. All residents should be up and dressed each day. Getting out of bed was important for skin integrity, for stimulation provided by activities, and to experience a change of environment. Resident #136 did not really speak; remained in bed the last few times they had worked that unit; their door was shut quite a bit; they were never dressed; and they liked to crawl out of bed. They were not aware of any reason the resident could not get up, get dressed, or have their door open. They thought their door should be open because they tried to crawl out of bed. During an interview on 3/14/2025 at 11:05 AM, Registered Nurse Unit Manager #12 stated they expected residents to be up and dressed in regular clothing unless they refused. Showers should be done and include shampooing on the assigned days. Turning and repositioning should occur every two hours; catheter bags should not be on the floor; and it was unsafe to have doors shut. If a resident missed their shower, they tried to fit them in on another day and/or time, otherwise that resident would go another week without that shower. It was important residents got out of bed to prevent respiratory and skin issues. Catheter bags should not be on the floor as the floors were dirty and could result in an infection. The resident should be turned and repositioned every two (2) hours to prevent skin breakdown. During an interview on 3/14/2025 at 12:52 PM, the Infection Control Nurse stated catheter bags should be hung on the bed, the chair, or the walker, and not on the floor. That was an infection control issue because the floors were dirty and exposed the outlet tube to whatever germ was on the floor. During an interview on 3/14/2025 at 1:04 PM, the Director of Nurses stated they wanted residents up and about and dressed each day. They expected residents were turned and repositioned every 2 - 4 hours; weekly showers be given; and catheter bags in an impermeable dignity bag and hung from the bed or the chair and not lying on the floor. Call Bell: The following observations of Resident #136's call bell were made: - on 3/4/2025 at 10:43 AM and 12:36 PM on the nightstand out of reach. - on 3/6/2025 at 8:37 AM tucked under the pillow their head was resting on, out of reach. - on 3/7/2025 at 8:42 AM and 1:35 PM on the floor out of reach. During an interview on 3/7/2025 at 2:02 PM, Certified Nurse Aide #44 stated all residents should always have their call bell in reach even if they were unable to use it. The facility had hand bells and tap bells for those who could not use push button bells. They stated Resident #136 had a push button call bell, but they did not think the resident could use it. During an interview on 3/12/2025 at 2:02 PM, Licensed Practical Nurse #22 stated the facility had circular touch bells for those who could not use a regular push button bell. They had never seen Resident #136 use their push button call bell and had never seen an alternative bell tried. During an interview on 3/14/2025 at 11:05 AM, Registered Nurse Manager #36 stated everyone should have a call bell. If a resident could not use the regular push button call bell they should be evaluated for an alternative. The facility had flat touch bells and hand bells as alternatives to the push button. Having a call bell was important so that a resident could get the staff's attention, otherwise they could fall. During an interview on 3/14/2025 at 1:36 PM, the Director of Nursing stated if a resident was unable to use a regular call bell, they should have an alternative like a tap or hand bell. If they did have a call bell, it should not be on the floor. It was important residents had a call bell so they could let staff know if they needed assistance. They thought call bell use assessments were completed, but after referencing the electronic medical record they could not see that one was performed for Resident #136. Activities/Psychosocial Stimulation: The Comprehensive Care Plan documented: - initiated 11/1/2024, the resident needed assistance and reminders to participate in activities. The resident enjoyed playing the drums, watching sports and game shows on TV, going outside, gardening, and talking with others. Interventions were to include the resident in one to one activities on unit; provide activities calendar; provide materials as needed for independent leisure pursuits, i.e., books, magazines, newspaper and puzzles. Remind of programs and encourage involvement; - initiated 11/1/2024, was at risk for miscommunication related to dysphasia (difficulty speaking). Interventions included attempt to anticipate needs; use simple phrases and words; and the resident was able to nod yes or no. - revised 1/30/2025, the resident enjoyed game shows, Catholic services, drums, sports, outside, gardening, and talking with others. Interventions included invite to mass, be sure they had a picture board, provide materials for independent pursuits, include in one-to-one activities such as games, exercise and trivia; transport to events; and use pictures to communicate. The March 2025 activities calendar listed the following categories of activities that were documented as being important to the resident: -on 3/4/2025 visits with Pastor [NAME] -on 3/5/2025 mass and distribution of ashes and rosary -on 3/6/2025 bingo -on 3/7/2025 bible study and theater production of Cinderella -on 3/10/2025 communion and musical melodies -on 3/11/2025 visits with Pastor [NAME] -on 3/12/2025 mass and rosary -on 3/13/2025 bingo -on 3/14/2025 bible study, [NAME] orchestra and moving from the music The undated activities attendance report documented the resident attended the following activities from 3/1/2025-3/14/2025: - on 3/3/2025 1:1 sensory visit, calendar delivery, traveling performer, and trivia. - on 3/5/2025 television - on 3/7/2025 1:1 visit to reminisce - on 3/10/2025 traveling performer - on 3/11/2025 a family visit The 1/31/2025 Social Worker #42's progress note documented the resident sometimes felt lonely and isolated. The following observations were made of Resident #136 in their room: - on 3/4/2025 at 10:43 AM and 12:36 PM: staring at the ceiling with no television or music playing. - on 3/5/2025 at 12:05 PM: in their room in bed with the door closed. At 2:00 PM, awake and lying in bed makes grunting and indiscernible noises with no television or music playing. - on 3/6/2025 at 8:37 AM: Certified Nurse Aide #44 entered the resident's room, left the room a moment later shutting the door behind them. The television was off, and no music was playing. At 10:32 AM, Certified Nurse Aide #44 entered the resident's room to empty the catheter bag and shut the door when leaving. The resident was lying in bed with no television or music provided. - on 3/7/2025 at 8:42 AM: in their room with the door closed. At 9:15 AM, an unidentified activities staff stopped in the resident's room, told them the date and the weather, turned on the television, talked about current events, and exited the room two minutes later at 9:17 AM, shutting the door behind them. At 11:12 AM, they were in bed with the door closed. - on 3/7/2025 at 1:35 PM: lying in bed looking at the wall and ceiling. The television was off, and the door was closed. - on 3/12/2025 at 12:49 PM: in bed with their legs partially over the side of the bed, the television was off, and the door was closed. During an interview on 3/7/2025 at 8:42 AM, Resident #136 stated yes when asked if they wanted to get out of bed and dressed; yes when asked if they got bored being in their room all the time; and no when asked if anyone from activities had come to see them. During an interview on 3/7/2025 at 2:02 PM, Certified Nurse Aide # 44 stated they had not seen activities staff spend much time with Resident #136. Their door should not be shut, as it could make the resident feel isolated which could make them depressed. During an interview on 3/12/2025 at 12:49 PM, Resident #136 stated no wh[TRUNCATED]

Based on record review, observations, and interviews during the recertification and abbreviated (NY00332457) surveys conducted 3/4/2025 - 3/14/2025, the facility failed to ensure a resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote wound healing, prevent infection and prevent new ulcers from developing for three (3) of four (4) residents (Residents #60, #67, and #113) reviewed. Specifically, Resident #60 developed a stage 4 (full-thickness skin loss with exposed bone, tendon or muscle) pressure ulcer to their right hip. Care plan interventions were not consistently followed to prevent pressure ulcers from developing and when the pressure ulcer developed it was not adequately treated to prevent infection. Resident #67 developed a stage 4 pressure ulcer to their left heel while in the facility and there was no evidence the pressure ulcer was treated for 11 days after it was discovered. When the pressure ulcer was assessed by the wound physician consultant there was no evidence the facility evaluated and implemented their recommendations to promote healing. Additionally, on multiple days during survey the resident was observed not wearing their pressure relief booties as planned. Resident #113 had a stage 3 (full-thickness skin loss extending into fatty tissue) pressure ulcer to their right heel and was observed without a dressing on their wound. This resulted in actual harm to Residents #60 and #67 that was not immediate jeopardy. Findings include: The facility policy, Standards of Care - Pressure Injury (Ulcers), dated 12/11/2014, documented the registered nurse should regularly inspect skin for changes, such as redness and discoloration and palpate the skin for changes in temperature (warmth), edema (swelling), or hardness. The assessment documentation should be done on admission, quarterly and with a significant change in resident condition. Pressure prevention recommendations included assess skin regularly, protect high-risk areas such as elbows, heels, sacrum, and back of head from friction injury, and reposition schedules individualized based on the resident's condition. The facility policy, Consults, last reviewed 11/2024, did not document how consultant recommendations were followed up and ordered. The facility policy, Wound and Skin Care, revised 2020, documented the treatment plan would be tailored to meet individual needs. For any applicable treatment, a physician's order would be written. The policy did not address outside wound care consultants. 1) Resident #60 had diagnosis including dysphagia (difficulty swallowing), and stroke with left sided weakness and paralysis. The 2/2/2025 Minimum Data Set (an assessment tool) assessment documented the resident had severely impaired cognition, did not reject care, and was dependent on staff for all activities of daily living including toileting and bed mobility. The resident was frequently incontinent of bowel and bladder. The resident had a stage 3 and stage 4 pressure ulcer. Pressure ulcer care included a pressure reducing device for their bed, nutritional and hydration support, nonsurgical dressings, and applications of ointments/medications. The 8/10/2022 Comprehensive Care Plan documented the resident was at risk for skin breakdown related to urinary incontinence and left-sided weakness and paralysis. Interventions included to instruct the resident to reposition self every two (2) to four (4) hours when in bed, keep linens and skin clean and dry, and report any signs of skin breakdown. On 3/4/2025, the care plan was reviewed and updated to include resident's skin to remain intact. No new interventions related to skin break down were documented. The undated Resident Care Record (certified nurse aide care instructions) documented the resident was at risk for skin breakdown and required assistance with turning every two (2) hours. Use one (1) - two (2) person assist for bed mobility and two (2) person assist for transfers. The activity of daily living care documentation revealed there was no documented evidence the resident was turned and repositioned on all shifts for 12/15/2024, 12/26/24, and 12/27/24, during the night shift on 12/28/2024, and on both day and night shifts on 12/29/2024. The handwritten 24-hour report on 1/3/2025 by Licensed Practical Nurse #32 documented the Unit Manager and Assistant Director of Nursing saw the resident for an area on right buttock. There were no progress notes, assessments, or treatment orders associated with the area on the right buttock. On 1/6/2025 at 3:12 PM, Nurse Practitioner #45 documented the resident was seen for increased pain. The resident had a wound on their right hip measuring 4.4 x 2.6 centimeters. There was no further description of the wound documented or a treatment plan. On 1/7/2025 Physician Wound Consultant #30 documented the resident was seen for a seven (7) day old pressure ulcer on the right hip. The pressure ulcer measured 3.5 x 2.5 x 0.2 centimeters, and the wound bed contained 100% of necrotic (dead) tissue. The wound was debrided (removal of dead tissue). The treatment plan was to apply alginate honey (wound dressing containing honey and calcium alginate) to the pressure ulcer, cover with gauze and island border dressing daily, off-load the wound, reposition, and use an alternating pressure mattress. On 1/8/2025 at 2:34 PM, the Assistant Director of Nursing documented the resident was seen on 1/7/2025 for weekly wound rounds. The resident had an unstageable wound on the right hip. The wound physician recommendations were to apply alginate honey , off load the wound, reposition the resident as able and add an alternate pressure mattress. There was no documented evidence the wound physician's recommendations were discussed or ordered by a provider. There was no documented evidence of any treatment being done to the resident's pressure ulcer. The 24-hour report on 01/12/2025 documented the wound was foul smelling with a large amount of drainage, and pain medication was given. On 1/13/2025 at 4:20 PM, Nurse Practitioner #45 documented the resident was seen for a wound to the buttocks. It was extremely foul smelling with drainage and the Wound Physician Consultant was following the resident. The resident complained of pain regardless of positioning. The resident's right hip wound measured 4.4 x 2.6 centimeters. The Nurse Practitioner did not document any further description of the wound or what the treatment plan was, other than the resident was being followed by the Wound Physician. On 1/14/2025 Physician Wound Consultant #30 documented the right hip pressure ulcer measured 3 x 3 x 0.2 centimeters, and the wound bed contained 100% necrotic tissue. The physician recommended to cleanse the pressure ulcer with wound cleanser at time of dressing change; off-load and reposition and utilize an alternate pressure mattress. This plan was discussed with nursing staff. There was no documented evidence the wound physician's recommendations were discussed or ordered by a facility provider. There was no documented evidence of any treatment being done to the resident's pressure ulcer. On 1/21/2025 Physician Wound Consultant #30 documented the wound to the resident's right hip was a stage 4 pressure ulcer. The wound measured 3 x 2.5 x 0.7 centimeters, and the wound bed contained 60% thick adherent devitalized necrotic tissue with 40% slough. The physician surgically excised 3.75 centimeters of devitalized tissue that extended into the muscle. The plan of care was discussed with nursing staff. There was no documented evidence the wound physician's recommendations were discussed or ordered by a facility provider. There was no documented evidence of any treatment being done to the resident's pressure ulcer. On 1/22/2025 at 11:48 AM, Registered Nurse Unit Manager #31 documented they received a call from the resident's family, who were with the resident at a doctor's appointment. The family asked Registered Nurse Unit Manager #31 questions related to the wound on the resident's right hip. They told the family the resident was seen on 1/7/2025 and wound care was done by the wound physician. At 3:45 PM, the resident's family called back to report the resident was being admitted to the hospital for further work-up and possible infection. The progress note did not document what the further work-up or infection was in relation to. The 1/22/2025-1/27/2025 hospital records documented Resident #60 was admitted to the hospital. The resident was found to have a necrotic (dead tissue) pressure ulcer on the right hip, with exposed bone and foul-smelling drainage. Wound cultures were positive for infectious bacteria requiring treatment with intravenous antibiotics. The hospital social worker documented a discussion with the family regarding their concerns for resident neglect at the nursing facility. During observations on 3/6/2025 at 9:16 AM and 12:45 PM Resident #60 was observed lying in bed on their back. During interviews on 3/6/2025 at 9:20 AM and 03/07/2025 at 10:38 AM, Certified Nurse Aide #52 stated the resident would only get up for a short time and then was put back to bed. The resident was always incontinent, and they should have been repositioned frequently. They tried to reposition the resident every two hours, but the resident did not stay in the position off their wound. The resident was paralyzed on the left side and would lean to their right side. The resident had contractures (shortening of muscle/tendon), so it was difficulty to reposition them. They were not sure how long the resident had a wound, but stated they went to an appointment and was admitted to the hospital because of the wound. During an observation and interview on 3/7/2025 at 1:43 PM, with Licensed Practical Nurse #32 and Resident #60, the Licensed Practical Nurse gathered the supplies for the resident's wound care to the right hip. They stated the wound was on the right hip and was a stage 4 pressure ulcer. The resident was laying on their right side. The current treatment was enzymatic debriding ointment and dry dressing. Once the resident was positioned on their left side to change the dressing, there was no old dressing in place to remove. The pressure ulcer on the right hip was round surrounded by pink intact skin. The Licensed Practical Nurse packed the gauze in the undermining and tunnelling of the wound. They stated the resident sometimes pulled the dressing off and would put their fingers and hands on the wound. They thought the pressure ulcer on the hip started sometime in January 2025, when they reported the area to Registered Nurse Unit Manager #31. They did not always have time to follow up with the registered nurse because they were busy with two floors, they would document on the 24-hour report for the staff to review. Licensed Practical Nurse #32 reviewed the electronic medical record and stated there was no treatment order for the pressure ulcer until 1/27/2025, when the resident returned from the hospital. During an interview on 3/11/2025 at 3:39 PM, Registered Nurse Unit Manager #31 stated the resident was high risk for skin breakdown. The skin assessment should have been completed every three (3) months and whenever they returned from hospital admission. They stated they thought the resident had a stage 2 pressure ulcer to the right hip in the beginning of January. When asked if there was a treatment for the stage 2 pressure ulcer on the right hip, they referred to the resident record. They reviewed the electronic record for notes and specifics. They stated there was nothing, no treatment, no nursing note, and they were responsible to document when there was a new wound area and an assessment of the area. The resident currently had a healing stage 4 pressure ulcer. They stated a stage 4 wound was preventable, but they did not have a turning and positioning schedule documented. They really do not know when the resident was repositioned, or if they refused. They had all the nutrition interventions in place, it was just turning and positioning and getting them out of bed that was missing. The resident was care planned for potential skin break down related to their hemiplegia. During a telephone interview on 3/12/2025 at 2:16 PM, Licensed Practical Nurse #6 stated the resident had a pressure ulcer to the right hip and had been there for a couple of months. Prevention for pressure ulcers was important for this resident because they were contracted, and unable to reposition themselves. They were supposed to reposition and change the resident every two (2) hours and repositioning and protein were important interventions to prevent wounds. During an interview on 3/13/2025 at 12:56 PM, the Assistant Director of Nursing stated they completed wound rounds on Tuesday with the wound consultant. The registered nurse Unit Manager should be seeing their residents weekly for their skin assessment and making notes about change in condition of their skin. Resident #60 was at risk for skin break down and pressure ulcer because they were thin and not eating well. The resident currently had a facility acquired Stage 4 pressure ulcer which was originally unstageable on 1/7/2025. They were informed about the wound on 1/3/2025 and at that time the wound was on the right hip and was 4.4 x 2.6 centimeters and the resident was not seen until 1/7/2025 by the wound doctor. They stated prior to 1/7/2025 there were no recommendations or interventions in place to prevent pressure ulcers. The Assistant Director of Nursing stated, the wound had grown large fast and felt the hospital was dramatic with their documentation and reaction. The licensed practical nurses were responsible for completing the dressing changes. The Assistant Director of Nursing reviewed the record and stated they did not see a treatment order for the pressure ulcer prior to the hospitalization, and staff had not been repositioning the resident. During a telephone interview on 3/13/2025 at 1:54 PM, Physician Wound Consultant #30 stated the resident had a Stage 4 pressure ulcer on the right hip. The resident was at risk for pressure ulcers because they were contracted, and thin. Prior to the wound the resident was on every two (2) hours reposition and using a standard mattress. After their evaluation they added the alternating pressure mattress. The resident was at risk for pressure due to contractures, challenges with nutrition and the need to be assisted with turning and position. They stated an unstageable pressure ulcer could have developed very quickly. They were unaware the facility was not implementing their wound care treatments as recommended. During a telephone interview on 3/14/2025 at 10:20 AM, Registered Dietitian #49 stated they were made aware of skin issues on the 24-hour report and during weekly wound reports from the doctor. They stated they were seeing the resident in October 2024 because they had impaired skin to the left buttock and the resident was at risk for skin breakdown. The resident was receiving additional nutritional supplement and then with the right hip wound they added the prescribed protein supplement with the medication administration. It was important to supplement the protein for the wound healing. 2) Resident #67 was admitted with diagnoses including stage 4 pressure ulcer to their left heel, osteoarthritis, and physical debility. The 12/22/2024 Minimum Data Set assessment documented the resident had severely impaired cognition; did not reject care; had impairments to both sides of their lower extremities; required maximum assist with dressing and personal hygiene; was at risk for developing pressure ulcers, had one or more unhealed pressure ulcers/injuries, and had a stage 4 pressure ulcer. The 8/20/2024 physician orders documented to apply skin prep (protective barrier) to the right heel 3 times daily. The revised 11/21/2024 Comprehensive Care Plan documented the resident exhibited signs and symptoms of a pressure ulcer on the left heel. Interventions included to apply treatment per provider order. No further interventions regarding the left heel were documented. On 2/8/2025 at 11:06 AM, the Assistant Director of Nursing documented the resident was seen on wound rounds on 2/4/2025. They had a stage 4 wound to the left heel. Progress was exacerbated due to generalized decline in the resident, and resident noncompliance with offloading wound. The ordered treatment for skin prep would continue. Recommendations included reposition as often as resident allowed, offload wound, and use of pressure off-loading boot. Nursing would continue to monitor resident's skin integrity. On 2/11/2025 Physician Wound Consultant #30 documented the resident had a stage 4 pressure ulcer to their left heel that measured 2 x 2.5 x 0.1 centimeters. There was moderate serous exudate (wound drainage), and the wound had improved by evidence in decreased surface size. Recommendations included to apply calcium alginate (a soft wound dressing) once daily and apply gauze once daily. Recommendations also included reposition the resident per facility protocol, off-load wound, turn side to side in bed every 1-2 hours if able, and pressure off-loading boot. There was no documented evidence the wound physician's recommendations were discussed or ordered by a provider until 2/21/2025. On 2/21/2025, the Assistant Director of Nursing documented a late progress note for 2/11/2025. The resident was seen on 2/11/2025 for weekly wound rounds. Resident #67 had a stage 4 pressure ulcer to their left heel. There was moderate drainage and had 100% devitalized necrotic (dead) tissue. The treatment plan included to apply calcium alginate covering with dressing, wrap with gauze. On 02/21/2025, a physician order was placed for calcium alginate to left heel, cover with dressing, date, initial, and wrap dressing/ankle with gauze, secure with tape and change daily. On 2/25/2025, Physician Wound Consultant #30 documented the stage 4 pressure ulcer on the left heel measured 3 x 2 x 0.1 centimeters, moderate drainage and 100% necrotic (dead) tissue. The wound was debrided of devitalized and necrotic tissue. The treatment plan was to apply calcium alginate and leptospermum honey, apply sterile gauze and skin prep daily. Additional recommendations included to reposition per facility protocol, off-load wound, turn side to side in bed every 1 to 2 hours if able, pressure off-loading boot. There was no documented evidence the wound physician's recommendations were discussed or ordered by a provider. On 3/1/2025, The Assistant Director of Nursing documented the resident was seen on 2/25/2025 for weekly wound rounds for their stage 4 pressure ulcer to the left heel. The wound had moderate drainage with 100% necrotic tissue. The treatment plan had changed to apply calcium alginate with honey (an absorbent dressing used to remove dead tissue and promote a moist wound environment), cover with gauze sponge and wrapping with gauze daily. The undated resident care record documented the resident needed assistance with turning every 2- 4 hours, was at risk for skin breakdown, and had an off-loading pressure boot for left foot. On 3/5/2025 at 1:48 PM, the resident was observed in the common area in their recliner chair. Their left heel was directly against the footrest. The resident did not have an off-loading pressure boot on. On 3/7/2025 at 9:10 AM, 9:44 AM, and 3:17 PM, the resident was observed without an off-loading pressure boot while seated in their recliner chair. On 3/13/2025 at 12:15 PM, the resident was observed lying in bed with no off-loading pressure boot on. During a wound care observation on 3/13/2025 at 12:25 PM, Licensed Practical Nurse #36 brought the wound care supplies into the resident's room and left the room to get a towel. When they entered the resident's room they did not sanitize or wash their hands prior to putting on their gloves. After removing the resident's old dressing and placing their heel on the towel they went to the bathroom and washed their hands. When they came back to the resident, they raised the head of the bed with the bed remote, touched the resident's bedside table, and did not sanitize or wash their hands prior to putting on new gloves to apply the resident's dressing. During an interview on 3/14/2025 at 9:10 AM with Registered Nurse Unit Manager #17, they stated the Wound Care Consultant Physician's treatment recommendations were entered by their themselves or the Assistant Director of Nursing. Generally, the Assistant Director of Nursing obtained the order from the medical providers. They stated the resident was seen on 2/11/2025 by the Wound Care Consultant Physician and it appeared no wound care treatments were entered to be completed until 2/21/2025, but they were certain staff were completing wound treatments during that time. It also appeared the Wound Care Consultant Physician treatment recommendations made on 2/25/2025 were not entered to be completed as well. The resident had behavior issues and would take off their off-loading boot. If staff observed the resident without their off-loading boot on, they should attempt to apply the boot or let a nurse know about the resident's refusals. During a telephone interview with Consultant Wound Physician #30 on 3/13/2025 at 1:53 PM, they stated they were at the facility weekly and as far as they were aware their treatment recommendations were put into place. They stated the resident's wound had a decline and they changed their treatment. They were unaware the facility was not implementing their wound care treatments as recommended. 3) Resident #113 was admitted with diagnosis including stage 3 pressure ulcer (full-thickness skin loss extending into fatty tissue) to their right heel and protein-calorie malnutrition. The 2/18/2025 Minimum Data Set assessment documented the resident had severely impaired cognition; did not reject care; required partial/maximal assistance with most of their activities of daily living including putting on/taking off their footwear; and the resident used a manual wheelchair. They were at risk for pressure ulcers, had one (1) stage 4 pressure ulcer that was not present on admission and one (1) unstageable pressure ulcer that was not present on admission. They received nutrition/hydration interventions to manage skin problems and received applications of ointments/medication. The 8/15/2024 physician orders documented to attempt to keep blue booties on to off-load heels while in bed. The revised 2/27/2025 Comprehensive Care Plan documented the resident was at risk for pressure ulcers. Interventions included to encourage resident to remain off right foot and monitor as resident frequently removed dressing and walked barefoot. On 03/04/2025, Physician Wound Consultant #30 documented the resident had a pressure ulcer on right heel and right lateral foot. The right heel was a healing stage 4, measuring 0.7 x 0.6 x 0.2 centimeters, moderate serous drainage, and wound bed covered with 100% slough (moist, dead tissue). Treatment was leptospermum honey and cover with gauze island dressing daily. The right lateral foot was a healing unstageable pressure ulcer, measuring 0.3 x 0.3 centimeters in diameter. Treatment was to apply skin prep daily. The undated resident care record (certified nurse aide care instructions) documented the resident was at risk for skin breakdown and used anti-slip socks/shoes. There was no documentation related to the resident removing dressing and walking barefoot. The following 3/6/2025 observations of Resident #113 were made: -At 12:36 PM, the resident was observed in the television lounge on the unit. They did not have their nonslip socks on, there was no bandage on their right foot, and their bare foot was on the carpet. -At 1:02 PM, Certified Nurse Aide #37 walked past the resident down the hallway and did not acknowledge the resident's foot was bare and on the carpet. -At 1:04 PM, Registered Nurse Unit Manager #31 walked past the resident and asked the resident What were you doing with your socks?, but they did not stop and put the resident's socks on. -At 1:18 PM, and 1:33 PM, Certified Nurse Aide #37 walked past the resident down the hallway and did not acknowledge the resident's foot was bare and on the carpet. - At 1:45 PM, Certified Nurse Aide #37 was observed talking to another resident near Resident #113 and did not acknowledge the resident's foot was bare and on the carpet. - At 2:33 PM, the resident was observed with no socks, no bandage on their right foot, and their bare foot was on the carpet in the television lounge area. During an interview on 03/06/2025 at 4:25 PM Certified Nurse Aide #56 stated they put socks on the resident as they noticed they were not wearing any. The resident would frequently take their socks off. The Certified Nurse Aide did not see any dressing on the resident's foot and did not tell anyone that there was no dressing in place. During an interview on 3/7/2025 at 10:23 AM, Licensed Practical Nurse #31 stated if a resident's wound dressing was observed not to be in place, staff should have let the nurse know so the dressing could have been replaced. They had worked the day shift and part of the evening shift on 3/6/2025. They were not aware Resident #113's wound dressing was not on. This was something they would expect staff to tell them as it could lead to the wound worsening or a potential for infection. During a treatment observation with Resident #113 and Licensed Practical Nurse #32, the resident had a small wound on the bottom of the right heel. The wound bed contained dark tissue, and the surrounding skin was white and macerated(wrinkly skin due to prolonged moisture). The Licensed Practical Nurse placed leptospermum honey on the wound and covered with a dry dressing. The wound on the right lateral foot was small with a scabbed area and the surrounding skin was intact. Skin Prep was applied to the wound. During an interview with Registered Nurse Unit Manager #31 on 3/7/2024 at 11:09 AM, they stated if a resident did not have their wound dressing on their foot the resident could develop a possible infection, their wound could worsen or be slow to heal. They stated Resident #113 did take their footwear, socks, and dressings off at times and they observed Resident #113 on 3/6/2025 without socks on, but did not address it or tell anyone. During a telephone interview with Physician Wound Consultant #30 on 3/14/2025 at 2:15 PM, they stated if a resident had an order for a wound dressing it should have been in place and if it came off nursing staff should have replaced it. 10NYCRR 415.12(c)(1)