**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review conducted during a Recertification Survey from 06/02/2025 to 06/09/2025, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for three (3) (Residents #120, #213 and #222) of seven (7) residents reviewed. Specifically, Resident #120 was observed with debris underneath multiple fingernails and eating food items with their hands. Resident #213 was observed over several days with greasy hair and the facility was unable to provide evidence of the resident getting their hair washed for the prior month. Resident #222 was observed with untrimmed overgrown mustache hair going into their mouth which they reported made them feel shameful about themselves and did not want visitors to see them in that state. This resulted in actual psychosocial harm to Resident #222 that was not immediate jeopardy. The findings include: The facility policy Standards of Care dated 01/19/2024, documented for staff to shave men's facial hair and ear hair minimally on shower day or per the residents' choice. Additionally, to clean resident's hands before and after meals, inspect fingernails for cleanliness and need for trimming, and to provide nail care as needed. If a resident declines or refuses any or all portions of care and attempts to re-approach are unsuccessful, the nurse should write a note in the resident's chart. 1. Resident #222 had diagnoses that included repeated falls, congestive heart failure, and weakness. The Minimum Data Set (a resident assessment tool) dated 04/24/2025, documented the resident was cognitively intact, their vision was severely impaired, and they required assistance with personal hygiene. Resident #222's Comprehensive Care Plan dated on 05/22/2025, documented the resident had a self-care deficit related to decreased mobility and loss of vision and preferred to be clean, neat and dressed appropriately. The Key to Care (care plan used by Certified Nursing Assistants) dated 05/30/2025, documented the resident required assistance with dressing and grooming. During an observation and interview on 06/02/2025 at 10:30 AM, Resident #222 had a significant amount of facial hair growing into their mouth. In an immediate interview, the resident stated they had asked for a shave weeks ago and was told by staff that they would get to it soon, but no one ever comes back. The resident said they would like to be shaved weekly, but they were blind and depended on staff. There was an aide that kept on top of it, but they were no longer at the facility and care had decreased due to staff turnover. During an observation and interview on 06/03/2025 at 9:23 AM, Resident #222's mustache remained long with hair hanging over their upper lip and their neck hair more than an inch long. The resident said their mustache hair went into their mouth, and they asked their aide (name unknown) yesterday for a shave and were told they would call downstairs to speak with the barber. The resident said they were told that they were on the schedule to see the in-house barber on 06/21/2025, but they did not want to wait until then because their hair had grown too long. The resident said they were not used to having so much hair on their face and neck. During observations and interviews on 06/04/2025 at 1:00 PM, Resident #222 was eating lunch in their room and remained unshaven. The resident stated they again asked a staff member (name unknown) to shave them but still had not been shaved. The resident said they hated that the hair from their mustache was in their mouth, and they did not want to be seen that way. The resident said they looked like a bum and thought they should get a shave at least every two (2) weeks. When interviewed at 3:18 PM, Resident #222 stated it bothered them when they had to go out because they were used to being clean shaven, and this was not like them. During an observation and interview on 06/05/2025 at 10:30 AM, Resident #222 remained unshaved. The resident stated they did ask their aide, who is new, for a shave today and hope they are better than the others. During an interview on 06/05/2025 at 11:45 AM, Certified Nurse Assistant #4 said Resident #222 required more help due to their visual impairment and that they were not assigned to care for them due to the rotating schedule, but that shaving was usually performed on the unit by staff. Certified Nurse Assistant #4 said the resident's mustache should never grow to the point of going inside the mouth and if a resident requested a shave and they were too busy to complete this, staff should pass the request to the evening shift. If the evening shift could not assist, staff should make sure the request was completed the following day. Certified Nurse Assistant #4 said the resident should never have to wait several days to be shaved and that 06/21/2025 (appointment with the barber) was too long of a wait. During an interview on 06/05/2025 at 12:41 PM, the Director of Nursing said Resident #222 should have received a shave long ago and nursing staff on the unit should have provided it and not waited for them to see the barber. The Director of Nursing said that due to the resident not being able to shave themselves, staff should have offered it that day or the following day. During an interview on 06/09/2025 at 2:46 PM, Nurse Practitioner #2 said they were familiar with Resident #222 and that they did not think it was good that the resident's hair grew so long that they were ashamed. Nurse Practitioner #2 said the resident usually had some facial hair, but not an excessive amount and were unsure why the staff did not assist the resident with shaving since it was an easy fix and could be completed on the unit. 2. Resident #120 had diagnoses including glaucoma (increased pressure in the eyes that damages the eye nerves causing blindness), dysphagia (difficulty swallowing), and heart failure. The Minimum Data Set, dated [DATE] documented Resident #120 was cognitively intact, visually impaired, required setup assistance with eating, and was dependent (on staff) for personal hygiene and bathing. Review of the Key to Care dated 06/03/2025 revealed Resident #120's first choice for bathing was a bed bath which was scheduled weekly on the Friday day shift. The Key to Care documented the resident required one staff assistance with grooming and needed set-up assistance with meals. During an observation and interview on 06/02/2025 at 12:15 PM, Resident #120 was in bed eating lunch. Dark brown debris was observed underneath the fingernails of multiple nails on the resident's left hand. The resident picked up multiple food items off their tray with their left hand placing them in their mouth. Resident #120 stated they were completely blind in one (1) eye, partially blind in the other and wished they had more help (from staff) with eating. During an interview on 06/05/2025 at 10:23 AM, Certified Nursing Assistant #11 said they assist residents with nail care as needed. During an interview on 06/05/2025 at 11:27 AM, Licensed Practical Nurse #7 stated Resident #120 was legally blind and required setup help with meals. Licensed Practical Nurse #7 stated they had never seen Resident #120 use a fork (even for items that required one) and they had seen the resident pick up food with their hands. During an interview on 06/09/2025 at 9:22 AM, Licensed Practical Nurse Manager #1 said nail care should be done on residents' shower (bathing) days and as needed when they are dirty. Licensed Practical Nurse Manager #1 stated they were not aware Resident #120 was using their hands (to eat) and if there was debris underneath their fingernails, nail care should be done. 3. Resident #213 had diagnoses including anxiety, dementia, and macular degeneration (a progressive eye disease causing vision loss). The Minimum Data Set, dated [DATE] revealed Resident #213 had moderately impaired cognitive function and required maximum assistance with bathing and showering. Review of the Key to Care dated 05/01/2025 revealed Resident #213 preferred bed baths and was scheduled for them on Wednesday's day shift. During an observation and interview on 06/02/2025 at 9:33 AM, Resident #213 hair was unwashed and greasy. In an immediate interview, Resident #213 said their hair was last washed a couple months ago when they had it cut. Review of a handwritten document titled Beauty Salon and signed by Beautician #1 revealed that on 05/01/2025 at 1:00 PM, Resident #213 had a shampoo, cut, set and a manicure. In a nursing progress note dated 06/04/2025, Licensed Practical Nurse #8 documented that Resident #213 had received a bed bath, but did not include if the resident's hair had been washed. Review of Resident #213's electronic medical record did not include any documented evidence the resident had gotten their hair washed since 05/01/2025. During an observation and interview on 06/09/2025 at 10:43 AM, Resident #213's hair remained unwashed and greasy. In an immediate interview Resident #213 again stated it had been a while since they had their hair washed. During an interview on 06/09/2025 at 10:46 AM, Licensed Practical Nurse #8 said residents' hair was supposed to be washed on their shower (bath) days and if a resident did not get up for a shower, staff could use a shower cap (to wash hair). Licensed Practical Nurse #8 stated they saw Resident #213 earlier and their hair looked flat and said I guess you can say greasy. During an interview on 06/09/2025 at 11:07 AM, Certified Nursing Assistant #10 said it was hard to wash resident's hair when the residents received bed baths because they did not have basins to put their head (hair) in. Certified Nursing Assistant #10 said they document hair washing in the electronic medical record, under personal hygiene but it does not specifically include hair washing. Certified Nursing Assistant #10 stated they were not sure when Resident #213's hair was last washed because they had never been assigned to the resident on their designated shower (bath) day. During an interview on 06/09/2025 at 11:16 AM, Assistant Director of Nursing #3 said if a resident received a bed bath their hair could be washed via a shower cap or by going to the hairdresser. Assistant Director of Nursing #3 stated documentation of hair washing should be included as part of the resident's shower (bath) day documentation unless the resident went to the hairdresser. 10 NYCRR 415.12(a)(3)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during the Recertification Survey from 06/02/2025 to 06/09/2025, the facility failed to ensure residents with indwelling urinary catheters (a tube inserted into the bladder to drain urine) received the care and services to manage the urinary catheter for two (2) (Resident #112 and #222) of four (4) residents reviewed. Specifically, Resident #112 had a urinary catheter that was not consistently secured to prevent tension resulting in a genital injury. Additionally, Resident #112's Comprehensive Care Plan did not include the presence of a urinary catheter or interventions for appropriate care of the urinary catheter to prevent complications. Resident #222 had a urinary catheter that was observed not secured appropriately to prevent complications. Additionally, the urinary catheter drainage bag (a collection bag attached to the catheter that the urine drains into) was observed on multiple occasions lying on the floor without a barrier. This resulted in actual harm to Resident #112 that is not Immediate Jeopardy. The findings include: The facility policy Insertion and Maintenance of Indwelling and Intermittent Catheters dated 09/18/2024, documented to maintain the closed system and straight gravity drainage by positioning the drainage bag below the level of the bladder, to position the catheter over the top of the leg to prevent occlusion and to secure the tubing (catheter) with a strap to prevent pulling. 1. Resident #112 had diagnoses that included Parkinson's disease (progressive brain disorder that slowly destroys memory and thinking skills), urinary retention (inability to fully or partially empty the bladder), and benign prostatic hyperplasia (enlarged prostate). The Minimum Data Set (a resident assessment tool) dated 05/09/2025 revealed Resident #112 was moderately impaired of cognitive function and had an indwelling urinary catheter. Review of Resident #112's Comprehensive Care Plan dated 04/24/2025 revealed the resident had a focus area of self-care performance deficit related to use of a urinary catheter. The Comprehensive Care Plan did not include any interventions related to the care of the catheter to prevent complications. Physician orders dated 03/11/2025 documented to ensure the urinary catheter was secured to the resident with a securement device (device that secures the catheter tubing to the resident's leg to prevent tension on the catheter and subsequent injury or dislodgement) every shift. In a late entry nursing progress note dated 05/24/2025 at 10:30 PM for 05/23/2025, Licensed Practical Nurse #10 documented that Resident #112 had removed their fully inflated urinary catheter during the prior evening shift and the tip of the resident's penis was observed to be split (an open wound) and a new urinary catheter was inserted. The progress note did not include if the medical team had been notified of the resident's injury at the time. In a nursing progress note dated 05/27/2025 at 7:06 AM, Registered Nurse #1 documented Resident #112 was bleeding from the penis, that the penile split was worse than before, and the on-call (medical provider) was notified. In a medical progress note dated 05/27/2025 at 12:32 PM, Nurse Practitioner #2 documented Resident #112 was evaluated for hematuria (blood in the urine) and an ulceration (a break in the skin) from the catheter through the shaft of the resident's penis. Nurse Practitioner #2 documented that the meatus (the opening in the tip of the penis that the catheter is inserted through) was eroded through into the shaft due to the presence of the urinary catheter and that there is now a securement device in place. Nurse Practitioner #2 documented Resident #112 had a stage three (3) (full thickness skin loss) pressure ulcer to the shaft of their penis from the urinary catheter. Triad cream (medicated paste used to treat pressure ulcers) would be ordered, and to ensure that a securement device was in place and to ensure to position the catheter, so it did not cause further trauma. In a nursing progress note dated 05/29/2025 at 10:25 PM, Licensed Practical Nurse #11 documented Resident #112's penis had split further, there was blood in the resident's brief and the supervisor was notified. In a medical progress note dated 05/30/2025 at 3:13 PM, Nurse Practitioner #1 documented Resident #112 was seen for a pressure area to the penis from the urinary catheter and per nursing, due to the resident's positioning, the urinary catheter had been pressing and pulling on their penis, which created an open area/slit in their urethra (passageway between the bladder and the external part of the body that allows urine to flow out). On exam, Nurse Practitioner #1 documented that Resident #112 did not have a leg securement device on and there was an open slit of the urethra where the urinary catheter tube was. Nurse Practitioner #1 documented they advised nursing to position the catheter carefully to avoid tension to the area with use of a leg securement device and pillows to position the resident's legs. There was no documented evidence the care plan was updated to include Nurse Practitioner #1's recommendations and orders. During an observation and interview on 06/05/2025 at 4:35 PM with Licensed Practical Nurse #11 and Certified Nursing Assistant #10, a securement device was affixed to Resident #112's right inner thigh. Licensed Practical Nurse #11 stated the securement device prevents a urinary catheter from pulling (create tension). The resident had an open wound on the underside of the penis. During an interview on 06/06/2025 at 11:07 AM, Licensed Practical Nurse #8 stated to prevent a catheter from pulling, there were securement devices (straps or adhesive holders) around a resident's leg. Licensed Practical Nurse #8 stated an order was not needed for a securement device and every resident (with a catheter) should have them put on automatically. Licensed Practical Nurse #8 stated prior to the penile injury, Resident #112 did have a securement device, but it was the wrong one and the resident's urinary catheter was incorrectly positioned coming up over the top of their incontinence brief and at times under the securement device (instead of accurately positioned through it). Licensed Practical Nurse #8 said the day the injury was noted, staff said Resident #112 had pulled out the catheter but when they came in, the whole catheter was full of blood, and they felt the issue was due more to a lack of education about the care and of positioning of urinary catheters. During an interview on 06/09/2025 at 10:07 AM, Nurse Practitioner #1 said to prevent skin breakdown from urinary catheters, orders should include checking the resident's skin, looking for leaking or retention, and catheter flushes. Nurse Practitioner #1 stated if there was associated skin breakdown, barrier cream should be used and leg straps (securement devices) in place to assist with catheter positioning. Nurse Practitioner #1 said securement devices were standard interventions unless the resident had a reason for not having it. Medical providers usually order the securement devices, but it is also a nursing intervention that they could put in on their own (without an order). Nurse Practitioner #1 stated Resident #112 had rubbing from the urinary catheter that caused their urethra to split, and when they saw the resident on 05/30/2025, the injury had gotten worse and there was no leg strap (securement device) in place. Nurse Practitioner #1 stated Nurse Practitioner #2 talked to the nursing staff on 05/27/2025 about not having a securement device in place and wrote in their progress note to ensure one was in place. Nurse Practitioner #1 said Resident #112 has had an ongoing order for a securement device since 03/11/2025. Nurse Practitioner #1 stated it was tough to say if the injury could have been prevented, but having a securement device in place could have resolved the injury or prevented the injury from getting worse. During an interview on 06/09/2025 at 11:16 AM, Assistant Director of Nursing #3 stated to prevent skin breakdown from a urinary catheter, a securement device should be used to keep the catheter/tubing from pulling. Assistant Director of Nursing #3 stated they were unaware Resident #112 had a penile injury from their urinary catheter. After review of Resident #112's medical progress notes in the electronic medical record, Assistant Director of Nursing #3 said the resident had an injury to the penis that could have occurred when the resident pulled out their urinary catheter. They were unaware that the resident had not had a securement device in place. Assistant Director of Nursing #3 stated interventions related to care of the urinary catheter were not on Resident #112's care plan and should have been. 2. Resident #222 had diagnoses including urinary retention, acute kidney failure, and chronic kidney disease. The Minimum Data Set, dated [DATE], revealed the resident was cognitively intact and had an indwelling urinary catheter. Resident #222's Comprehensive Care Plan, dated 05/22/2025, documented the resident required an indwelling urinary catheter related to urinary retention and staff were to assist with catheter care and use a leg bag (drainage bag that can be secured to the resident's leg and under clothing) when out of bed. The Comprehensive Care Plan did not include the use of a securement device to prevent complications. Physician orders dated 04/18/2025 documented urinary catheter care per facility policy. In a nursing progress note dated 06/01/2025, Licensed Practical Nurse #14 documented Resident #222's indwelling urinary catheter was replaced after being dislodged, hematuria was noted, and the Registered Nurse Supervisor was notified. During an observation on 06/05/2025 at 10:30 AM, Resident #222 was sitting in their wheelchair in their room. Their urinary catheter drainage bag was lying on the floor without a barrier under it. During an interview on 06/05/2025 at 11:45 AM, Certified Nurse Assistant #4 said the catheter drainage bag should hang from the bed frame and never be on the floor and if it touched the floor, it was considered contaminated and should be changed. During an observation on 06/05/2025 at 12:12 PM, Resident #222's urinary catheter drainage bag remained lying directly on the floor without a barrier under it and a small corner of the drainage bag was underneath the wheel of the resident's wheelchair. The floor was stained with dirt, had scrambled eggs on it and was sticky with an unknown substance. The catheter tubing was coiled around the resident's left ankle and there was no securement device in place at this time. During an interview on 06/05/2025 at 12:41 PM, the Director of Nursing said urinary catheter drainage bags should never be on the floor and should be hung on the bed frame and below the bladder. If found on the floor, the bag should be replaced or disinfected. During an observation and interview on 06/05/2025 at 3:52 PM, Licensed Practical Nurse #3 entered Resident #222 room with the surveyor and stated there was no securement device on the resident's urinary catheter. Licensed Practical Nurse #3 immediately applied one and stated they had received training on properly securing the catheter tubing so the catheter would remain in place and not get dislodged. During an interview on 06/06/2025 at 9:56 AM, Certified Nurse Assistant #5 said when performing care on Resident #222, they ensured the securement device was in place on the resident's leg, because when it is not there, the urinary catheter could come out. Certified Nurse Assistant #5 said a few days prior they noticed the securement device was not in place and the drainage bag was hanging lower than normal, so they reported it to the nurse and shortly after they were notified that the resident's urinary catheter had come out. During an interview on 06/09/2025 at 9:18 AM, with the Director of Nursing and Assistant Director of Nursing #2, the Director of Nursing stated residents with indwelling urinary catheters, especially with a history of catheter dislodgement, should have a securement device in place to stabilize the catheter tubing. The Director of Nursing said nursing orientation covered indwelling urinary catheter care and staff should ensure that securement devices are in place. 10 NYCRR 415.12(d)(1)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review conducted during the Recertification Survey and complaint investigation (#NY00300345) from 12/6/23 to 12/13/23, for three (Residents #90, #108 and #183,) of six residents reviewed for pressure ulcers, the facility failed to ensure the residents received the necessary care, treatment, and services, consistent with professional standards of practice, to promote healing, prevent new pressure ulcers from developing, and/or prevent existing pressure ulcers from worsening. Specifically, the facility did not consistently provide Residents #90, #108 and #183 with physician-ordered treatments for skin impairments and/or care plan interventions. This resulted in actual harm to Resident #90 that is not Immediate Jeopardy. This is evidenced by the following: The facility policy Wounds: Pressure Ulcer Care, dated August 2023, documented that all residents admitted without a pressure ulcer will receive preventative care according to their documented Braden Scale (an assessment that indicates level of risk for skin breakdown). Residents with a pressure injury/ulcer will receive necessary treatment and services to promote healing, prevent infection, and prevent new pressure ulcers from developing. Incontinence care should be provided at least every 4 hours, repositioning should be completed every 2 hours, and treatments should be documented in the Electronic Medical Record with each completion. The facility policy Care: Standards of Care, dated 10/18/18, documented that a significant position change should be done every 2-4 hours, and toileting should be completed according to the Care Plan and Key to Care of Our Elders (care plan used by the Certified Nursing Assistant (CNA) for daily care). 1. Resident #90 had diagnoses of Parkinson's Disease (a progressive disease of the nervous system marked by tremors and muscular rigidity), stroke, and muscle weakness. The Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #90 was cognitively intact, had hemiplegia (paralysis on one side of the body), was occasionally incontinent of bladder, required extensive assist from staff for toileting, and had multiple pressure ulcers at the time of the assessment. Review of the current Comprehensive Care Plan documented that Resident #90 had a pressure ulcer to the natal cleft (where the upper butt cheeks meet) and was incontinent of urine. The Comprehensive Care Plan interventions included to follow the Key to Care of our Elders. Review of the current Key to the Care of our Elders revealed that Resident #90 was to be toileted, checked for incontinence, and turned and positioned every two to three hours. During an observation of incontinence care on 12/08/23 at 3:45 PM, and again on 12/11/23 at 10:02 AM, Resident #90 had no dressing to the natal cleft unstageable pressure ulcer. The wound was macerated (skin was white and fragile from being in contact with moisture for an extended period of time) and covered with yellow slough (non-viable tissue leading to necrotic tissue-dead tissue black or brown in color). Resident #90 was wearing an incontinence brief that was saturated through with urine on both observations. During an interview on 12/8/23 at 3:45 PM, Resident #90 stated they had not received toileting assistance, incontinence care, or re-positioning since 10:00 AM. Review of Resident #90's Interdisciplinary Progress Notes revealed Resident #90 was being followed by the facility's wound care team, comprised of two Registered Nurses. In a wound care team Interdisciplinary Progress Note dated 11/7/23, Registered Nurse #2 documented that Resident #90 had Moisture Associated Skin Damage (MASD-skin damage caused by prolonged exposure to moisture such as urine) to the natal cleft, and a new Physician's order included triamcinolone acetonide paste (a medicated lotion to help promote wound healing) to be applied twice daily. In a wound care team Interdisciplinary Progress Note, dated 11/21/23, Registered Nurse #2 documented the Moisture Associated Skin Damage had worsened to a Stage 3 (full thickness tissue loss involving damage to or necrosis (dead tissue) of subcutaneous tissue) pressure ulcer. Review of Resident #90's medical orders revealed no new orders to address the new pressure ulcer documented on 11/21/23. In a wound care team Interdisciplinary Progress Note dated 12/5/23, RN #2 documented that Resident #90's Stage 3 pressure ulcer was now an unstageable pressure ulcer (wound base is unable to be seen because it is covered by necrotic tissue). The note documented that the wound was macerated, and that there was a new Physician order for the triamcinolone acetonide paste with the application of a border gauze (a dressing with an adhesive border) to be completed twice daily. Review of the Treatment Administration Records, dated 11/7/23 through 12/13/23, revealed 31 of 66 opportunities for treatments to the natal cleft wound were blank. There was no documented evidence between 11/7/23 and 12/12/23 that a medical provider had assessed Resident #90's worsening pressure ulcer. During an interview on 12/11/23 at 9:27 AM, Certified Nursing Assistant #2 (assigned to Resident #90) stated they provided toileting and incontinence care twice a shift, usually in the morning and after lunch. During an interview on 12/11/23 at 10:41 AM Licensed Practical Nurse (LPN) #4/ Clinical Coordinator stated that a blank in the Treatment Administration Record meant that the treatment had not been done. During an interview on 12/11/23 at 2:10 PM Nurse Practitioner #1 stated they do not participate in wound rounds but would go see a wound if needed. Nurse Practitioner #1 stated if medical treatments were not completed it would be considered an error and an incident report filed, which we (medical) would then see and assess. Nurse Practitioner #1 stated they have identified that wound treatments were not being completed as ordered and that staffing has been a struggle. Nurse Practitioner #1 stated that not providing incontinence care, turning, and positioning and/or wound treatments could cause a wound to worsen. During an interview on 12/12/23 at 11:20 AM, with the wound care team nurses Registered Nurse #1 and Registered Nurse #2, both stated that residents with wounds should receive toileting or incontinence care (per their care plan), and that the treatments should be completed as ordered. They both stated a wound could worsen if care plan interventions were not being completed, and Registered Nurse #2 stated a resident with a wound should be turned and positioned at least several times a shift (8 hours). Registered Nurse #1 stated that any wound over a stage 3 should be reported to medical. During an interview on 12/12/23 at 12:15 PM, Resident #90 stated they had not been toileted, had incontinence care, or been re-positioned since getting out of bed at 6:00 AM. During an interview on 12/12/23 at 2:32 PM, the Director of Nursing stated that toileting, incontinence care, and turning and positioning should be completed per the Comprehensive Care Plan and the Key to the Care of Our Elders. 2. Resident #183 had diagnoses that included Alzheimer's disease, muscle weakness, and pressure ulcers. The Minimum Data Set assessment dated [DATE] revealed Resident #183 was severely impaired cognitively and had multiple pressure ulcers requiring the application of dressings and pressure ulcer care. Resident #183's current Comprehensive Care Plan and their Key to Care of Elders included they had a pressure ulcer to the right heel, right hip and coccyx (tailbone), with interventions that included but were not limited to providing treatments as ordered, and a specialized boot (soft boot to offload pressure for the heel) to the right foot at all times. During an observation on 12/12/23 at 2:04 PM, Resident #183 was observed sitting in their wheelchair in a common area. There was no specialized boot on their right foot, which was resting on the floor. Review of Physician orders dated 9/6/23 revealed collagenase (a medicated ointment to promote wound healing by removing dead tissue) and border gauze once daily and as needed to the unstageable pressure ulcer of the upper coccyx. Physician orders dated 10/27/23 included to clean the right heel ulcer with normal saline, pat dry, and apply skin prep twice daily. Review of November 2023 Treatment Administration Records revealed that the wound care to the coccyx was not documented as administered on 11 of 30 opportunities. Wound care to the right heel pressure injury was not documented as administered on 27 of 60 opportunities. Review of December 2023 Treatment Administration Records from 12/1/23 through 12/12/23 revealed that wound care to the coccyx had not been documented as administered on 4 of 12 opportunities. Wound care for the right heel had not been documented as administered on 7 of 24 opportunities. 3. Resident #108 has diagnoses that included paraplegia (paralysis of the lower extremity), osteomyelitis (infection of the bone), and pressure injury. The Minimum Data Set assessment dated [DATE], revealed that Resident #108 was cognitively intact, was always incontinent of bladder and bowel, and had multiple unhealed pressure ulcers. Review of Resident #108's Comprehensive Care Plan included pressure ulcers to the left ischium (upper buttocks) and interventions included, treatments as ordered, and weekly wound assessments by the skin team. Resident #108's current medical orders included the following: a. Stage 4 (full thickness tissue loss with extensive destruction to the tissue that could involve bone and muscle) pressure ulcer of upper left ischium: clean wound with soap and water, pat dry, apply skin-prep to periwound then pack with alginate (absorbs wound drainage) and cover with foam dressing daily and as needed. b. Pressure ulcer to the left distal ischium: apply skin prep twice daily. c. Stage 3 pressure ulcer distal to existing Stage 3 ulcer: apply triamcinolone ointment once daily. During an interview on 12/7/23 at 10:27 AM, Resident #108 stated that they have had their sore forever, and some staff do not change the dressings. Review of the November 2023 Treatment Administration Records revealed that the wound care to the left ischium was not documented as administered as ordered on 6 of 30 days. Review of the December 2023 Treatment Administration Records revealed wound care to the left ischium was not documented as administered as ordered on 4 of 11 days. During an interview on 12/13/23 at 9:46 AM, Licensed Practical Nurse #6/Clinical Coordinator stated there were wound nurses (who do dressing changes when on duty), but if they were not on then the unit nurses are responsible for doing the treatments. Licensed Practical Nurse #6/Clinical Coordinator stated that a blank box on the Treatment Administration Record meant the treatment was not done or that the nurse forgot to document it; if unable to complete the treatment, the nurse should let the next shift or nursing supervisor know. Licensed Practical Nurse #6/Clinical Coordinator said on some weekends, there is only one nurse (on the unit) and the treatments do not always get done. After reviewing Resident #183 and Resident #108's Treatment Administration Records (observing blank boxes for ordered treatments), Licensed Practical Nurse #6/Clinical Coordinator said they were not notified by staff that the wound treatments were not done as ordered. Licensed Practical Nurse #6/Clinical Coordinator said the wound nurses do audits (of ordered treatments) and did mention to them Resident #183 missing treatments. Licensed Practical Nurse #6 stated that Resident #183 had the right heel pressure injury for a while, and it was likely from positioning (lack of). They said that after they had been made aware that Resident #183 had not been wearing their special boot the day before, that it may have been because float aides (aides from other departments) had been assigned to Resident #183 that day. During an interview on 12/13/23 at 10:42 AM, the Director of Nursing (DON) stated wound care treatments should be signed off on the Treatment Administration Record when they are completed, and if not done, an error report should have been generated. The Director of Nursing stated they have recently hired treatment nurses to assist with the dressing changes. During an interview on 12/13/23 at 1:29 PM, the Administrator stated that they had addressed this issue in their Quality Assessment meetings, resulting in hiring a treatment nurse to improve the issue. 10 NYCRR 415.12 (c)(1)