**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and interviews during the extended recertification and abbreviated (NY00335306) surveys conducted 6/4/2024-7/11/2024, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 4 of 7 residents (Residents #222, #265, #271, and #826) reviewed. Specifically, Resident #826 had pressure injuries that were not assessed, and was not provided treatments to promote healing. Subsequently, Resident #826 was admitted to the hospital with a chronic sacral osteomyelitis (inflammation of bone tissue related to infection) with overlying cellulitis (skin infection). The resident underwent surgical debridement (removal of dead tissue), was in a great deal of pain, was unable to sit, which hindered their ability to attend dialysis while in the hospital. Resident #271 developed a deep tissue injury after orders to aid in the prevention of pressure injuries were not followed. Resident #271 had orders for pressure relief boots to be worn while in bed, which were not applied, in addition to other wound care recommendations that were not completed. Resident #265's pressure ulcer treatments were not administered daily as ordered. Resident #222 pressure ulcer treatment and off-loading heel boots were not administered daily as ordered. This resulted in harm and Substandard Quality of Care to Residents #271 and # 826 that was not immediate jeopardy. Findings include: The facility policy, Risk and Skin Assessments, last revised 1/2021, documented prevention of pressure ulcers required early identification of at risk residents and the implementation of prevention strategies. Skin assessments were done by a licensed nurse weekly. The facility policy, Skin and Pressure Injury Prevention, revised 3/2023, documented staff would conduct a comprehensive skin assessment upon admission /re-admission including skin integrity, any evidence of existing or developing pressure injuries, or other skin abnormalities or areas of impaired integrity. The risk assessment should be conducted as soon as possible after admission. Once the assessment was conducted and risk factors identified and characterized, the resident-centered care plan would be created. 1) Resident #826 had diagnoses including prostate cancer, bone cancer, and dependance on renal dialysis (a process that filters blood during kidney failure). The 6/8/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, was at risk for pressure ulcers, and did not have unhealed pressure ulcers. The 6/1/2023 admission evaluation completed by Registered Nurse Unit Manager #23 documented the resident had padded dressings to both heels and no other open areas were noted. The resident had a Braden score of 15, (a scale that determines risk for development of pressure ulcers) and was at low risk. The comprehensive care plan initiated 6/1/2023 documented the resident was at risk for pressure injury development related to immobility. Interventions included apply moisturizer as needed, monitor nutritional status, and monitor and report changes in skin status. The 6/2023 Documentation Survey Report (daily care log) documented to off load heels with pillows or boots as tolerated and turn and reposition every 2 to 4 hours as indicated and as needed. The 6/9/2023 at 9:17 AM Registered Nurse #1 (former Assistant Director of Nursing) progress note documented the resident went to a medical appointment, was sent to the hospital from the appointment due to fatigue. The resident was admitted to the hospital. The 6/16/2023 hospital discharge summary documented the resident had an unstageable pressure injury (full thickness tissue loss in which the base of the ulcer is covered by dead tissue) to the sacral region and a deep tissue injury (discolored skin due to damage of underlying soft tissue from pressure or shear) to the right heel. Discharge instructions included follow up with the wound care center. The 6/16/2023 Nursing admission Evaluation completed by the Assistant Director of Nursing #1 documented the resident had 5 wounds: a bicep fistula, a chest port site, deep tissue injury to both heels, and an unstageable pressure injury to their sacrum. The left heel measured 3 centimeters x 4 centimeters, and the right heel measured 4 centimeters x 2 centimeters and treatments were in place. The heel wounds were noted to have absorbent pads. There was no documentation of wound measurements or a treatment for the unstageable pressure injury on the sacrum. There were no documented treatment orders for the resident's deep tissue injury as referenced in the Assistant Director of Nursing #1's 6/16/2023 admission Evaluation. The comprehensive care plan initiated 6/19/2023 documented the resident was at risk for impaired skin integrity related to fragile skin, impaired mobility, and renal disease. Interventions included apply protective/preventive skin care, minimize extended exposure of skin to moisture with frequent incontinence care and prompt removal of wet clothing/bedding as needed, and report any signs of deterioration or significant change to area of impairment. The care plan did not address the unstageable pressure injury to the sacrum. The 6/19/2023 Nurse Practitioner #6 progress note documented they saw the resident for an admission evaluation. There was no documentation related to the pressure injuries on the resident's sacrum or heels. The 6/20/2023 Nurse Practitioner #6 progress note documented the resident was seen for a follow up visit related to not feeling well. The resident had severe pain in their back. The review of systems included skin impairments of unstageable sacral ulcer and heel ulcers (not specified) to both heels. There were no recommendations or orders for treatments documented. The 6/20/2023 physician order documented weekly skin evaluation every Tuesday on the day shift. The 6/2023 Treatment Administration record did not include treatments for the heel deep tissue injuries or the unstageable sacral ulcer. The record documented the weekly skin evaluation was completed on 6/20/2023 and 6/27/2023. There was no documented evidence of skin impairments to the sacrum or heels from the skin evaluations. There was no documented evidence of wound care or a physician's order for the sacral or heel wounds from 6/16/2023 to 6/28/2023 (when the resident was re-hospitalized ). There was no documented referral to wound care center. A 6/28/2023 at 3:07 PM Licensed Practical Nurse Unit Manager #2 progress note documented the resident went for a cancer care appointment and was sent to the emergency room. The 6/28/2023 hospital History and Physical documented the resident's diagnoses included deep tissue injury to the right heel and an unstageable pressure injury to the sacral region. The comprehensive care plan initiated 7/20/2023 documented the resident had an alteration in skin integrity and had an actual pressure injury to the sacrum, Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle). Interventions included evaluate wound weekly and as needed, document measurements, appearance, drainage, and surrounding tissue, monitor for changes, nutritional and therapy evaluation. (The comprehensive care plan was initiated before the resident returned from a 6/28/2023-7/21/2023 hospital stay). The 7/21/2023 hospital After Visit Summary documented the resident had deep tissue injury to both heels and an unstageable pressure injury on the sacrum. The 7/21/2023 Nursing admission Evaluation completed by Licensed Practical Nurse Manager #2 documented the resident had no skin impairments. There was no documented evidence of an assessment by a qualified professional for the pressure injuries present to the heels or sacrum upon readmission from the hospital. There was no documented evidence of treatments for the pressure injury on the sacrum from 7/21/2023 to 7/25/2023. There was no documented evidence of treatments for the heels through 7/31/2023 (when the resident was re-hospitalized ). Physician orders documented: - consultation for evaluation and treatment for sacrum pressure ulcer that the resident came with, start date 7/25/2023. - Sacrum, cleanse wound with wound cleanser, pat dry with gauze, apply medical grade honey (wound treatment) and calcium alginate (wound treatment that absorbs drainage) combination to wound bed, cover with an island bordered dressing every night shift and as needed, start date 7/25/2023. - Low air loss mattress (specialty mattress for pressure reduction), check setting closest to the resident's current weight and mattress functionality every shift for monitoring and as needed, start date 7/25/2023. There was no documented order for a treatment for the deep tissue injuries on the resident's heels. A 7/25/2023 Wound Consultant Physician #3's progress note documented the resident was referred for an initial evaluation and treatment for a wound on the sacrum. The resident had an unstageable sacral wound, due to pressure, present for greater than 30 days, that measured 2.5 centimeters long, 2.5 centimeters wide, and 0.3 centimeters deep. The treatment included medical grade honey and calcium alginate and recommendations to turn and position every 1 to 2 hours if able, off-load wound, limit sitting to 60 minutes, a pressure-relieving mattress, and vitamin and mineral supplements. There was no documented evidence of referral or evaluation for the wounds on the resident's heels. The 7/31/2023 physician #11 progress note documented the resident was sent to the hospital due to low oxygen and concerns with their ability to attend dialysis. The progress note did not include why the resident had limited ability to attend dialysis. The 8/10/2023 hospital discharge summary documented the resident was admitted with a chronic sacral osteomyelitis (inflammation of bone tissue related to infection) with overlying cellulitis (skin infection). The resident underwent surgical debridement (removal of damaged tissue), was in a great deal of pain, was unable to sit, which hindered their ability to attend dialysis. The 8/10/2023 hospital discharge instructions documented wound care to the sacrum, cleanse with normal saline moistened gauze, apply collagenase (ointment that removes dead tissue) nickel thick to slough (dead tissue) areas of wound, cover entire wound with a single layer of antimicrobial absorbent dressing and apply sacral bordered dressing, change daily and as needed. Wound care to heels, cleanse with foam cleanser and apply protective ointment to help soften heels once daily. The 8/10/2023 Nursing admission Evaluation completed by Licensed Practical Nurse #7 documented the resident had one pressure wound to the coccyx (sacrum). There was no documentation related to the pressure areas to the heels or treatment to the sacral wound. The 8/10/2023 telehealth medical provider readmission note documented the medication was reconciled with the registered nurse, and the resident would need a comprehensive exam and admission by the primary care team. There was no documentation related to the resident's wounds or treatments. The 8/11/2023 physician order documented apply skin prep (protective barrier) to bilateral (both) heels daily, offload heels every day shift, start date 8/12/2023. There was no documented evidence of assessment by a qualified professional or treatment of the wound on the resident's sacrum from 8/10/2023 to 8/15/2023. The 8/16/2023 Wound Consultant Physician #3's progress note documented the resident was seen for wounds on the sacrum, left heel, and right heel. The wound on the sacrum measured 3 centimeters long by 2 centimeters wide, and 0.5 centimeters deep. The wound was improved based on decreased necrotic (dead) tissue and revealed it was now a Stage 4 pressure injury. The treatment included alginate calcium (absorbent wound treatment), gauze island bordered dressing, and recommendations to turn and position every 1 to 2 hours if able, off-load wound, limit sitting to 60 minutes, a pressure-relieving mattress, and vitamin and mineral supplements. The areas on the heels were fully covered with dead tissue. Treatment included daily skin prep to the heels with recommendations for off-loading the wound and floating the heels in bed. The 8/16/2023 physician order documented for the sacrum, cleanse wound with wound cleanser, apply calcium alginate to wound bed, cover with island bordered gauze. During an interview on 6/10/2024 at 11:12 AM the former Assistant Director of Nursing #1 stated skin assessments were completed by a registered nurse when residents were admitted or re-admitted . The assessments should be completed upon admission or within 24 hours. If skin impairments were noted, the physician should be notified for treatment orders. Treatment for Resident #826's unstageable pressure injury on the sacrum and deep tissue injury on the heel should have been initiated immediately with referral to the wound team to be seen on the next rounds. The identified areas should have been assessed weekly on wound rounds and observed with each treatment. They could not recall Resident #826 or the reasons there was no wound treatment documented following their admission on [DATE]. They stated they covered multiple units and completed admission assessments. The Unit Manager was responsible to review the hospital documentation, orders, and make any referrals needed, including wound care. Treatments were not initiated timely from 6/16/2023 until the resident was hospitalized on [DATE]. During an interview on 6/10/2024 at 12:10 PM Licensed Practical Nurse Manager #2 stated licensed practical nurses could complete skin evaluations upon admission. If any skin impairments were noted, a registered nurse should be notified to complete an assessment and initiate a treatment. The Unit Manager was responsible for new admissions, referrals, and reviewing the hospital documentation. Licensed Practical Nurse Manager #2 could not recall if they saw the 6/16/2023 hospital discharge summary that noted wound care follow up. The resident should have had treatment initiated immediately for the sacral wound and heel, in addition to a referral to the wound care team. When Resident #826 was readmitted on [DATE], Licensed Practical Nurse Manager #2 recalled they completed the skin evaluation and documented no skin impairments. They stated it may have been related to not being able to view the resident's back side or heels due to the resident being in pain. They could not recall if they notified a registered nurse to complete the assessment or if the hospital paperwork included information about the pressure injuries. The treatment was initiated on 7/25/2023, and this was not timely, as it should have been done immediately. When the resident was hospitalized again and readmitted on [DATE], the treatment for the sacrum should have resumed immediately and was not. Licensed Practical Nurse Manager #2 was unaware of the reason for the delay in the treatment order for the sacrum. During an interview on 6/10/2024 at 1:02 PM Wound Consultant Physician #3 stated the wound care nurses, Unit Managers, or registered nurses made referrals to the wound physician. They rounded weekly, and a registered nurse would assess the wound and initiate treatment until the wound physician saw the resident. It was their understanding that a registered nurse assessed all newly admitted residents for skin impairments. Any new skin impairments should be assessed and treated immediately. The wound physician first saw Resident #826 on 7/25/2023 and was unaware of their 6/16/2023 admission with the unstageable pressure area and deep tissue injury on the heel. When the resident was referred on 7/25/2023, staff identified the sacrum as the area of focus and the physician was unaware of any issues with the heel. The treatments for the sacrum and heels were not initiated timely. When the resident was readmitted on [DATE], the registered nurse should have assessed the sacral area and implemented the treatment on the hospital discharge instructions. If there were no hospital orders, the registered nurse could have called the wound care physician for a treatment order or revert to the prior treatment. The resident should have had treatment initiated immediately upon return from the hospital. 2) Resident #271 had diagnoses of cerebral infarction (stroke), right sided hemiplegia (paralysis of one side of the body), and diabetes. The 4/19/2024 Minimum Data Set assessment documented the resident had intact cognition, functional limitation on one side of the upper and lower extremities, was dependent for activities of daily living, was frequently incontinent of bowel and bladder, was at risk for pressure ulcers, did not have any unhealed pressure ulcers, and had pressure reducing devices for their chair and bed. The comprehensive care plan dated 4/12/2024 documented the resident was at risk for pressure injury development related to diabetes, impaired mobility, and incontinence. Interventions included minimize extended exposure of skin to moisture by providing frequent incontinence care and prompt removal of wet/damp sheets and clothing, and heel protection-offload with pillows or boots as tolerated. The 6/5/2024 Wound Care Physician #3 evaluation documented the resident had wounds on their right plantar (bottom) first toe, right posterior (back) thigh, and left buttock. The plan of care recommendations for the right toe were cleanse with wound cleanser at time of dressing change; off-load wound; reposition per facility protocol; and float heels in bed. For the left buttock and right posterior thigh moisture associated skin damage recommendations were turn side to side in bed every 1-2 hours if able; upgrade offloading chair cushion: evaluate cushion, was very thin for bariatric size patient, and leave brief open in bed and ensure brief was properly sized. There was no documented evidence the resident's offloading chair cushion was evaluated or the resident's incontinence brief was to be left open while in bed was added to the care planned interventions. The 6/12/2024 Wound Care Physician #3 evaluation documented progress of wound healing for the right plantar first toe healing at goal, right posterior thigh improved, and left buttock exacerbated (worsened) due to increased maceration (exposure to moisture). There was a new unstageable deep tissue injury on the right heel with the etiology (cause) of pressure. The area measured 5 centimeters x 6 centimeters with intact purple, maroon discolored skin. The treatment plan was skin prep (protectant) daily X 30 days, with recommendations for off-loading wound, reposition per facility protocol, and pressure off loading boot. Physician orders dated 6/5/2024 documented zinc oxide (skin protectant) to buttocks every shift. The June 2024 Certified Nurse Aide task documentation included heel(s) protection: offload with pillows or boots as tolerated and was documented as completed 6/1/2024- 6/9/2024 all shifts. The resident was observed and interviewed at the following times: - on 6/4/2024 at 10:44 AM, sitting in their wheelchair. They stated they had sores on their bottom and felt it was from staying in the diaper too long, and in bed too long. They stated the cushion in their wheelchair felt deflated, and they needed an air mattress. - on 6/5/2024 at 9:20 AM, in bed wearing only a brief, with no protective boots on their feet or positioning devices for offloading. - on 6/6/2024 at 9:54 AM, in bed with only a brief on. They stated they had not been changed since before the shift change. They asked for their brief to be left open to dry areas out, but staff closed it anyway. The brief was observed taped tightly on both sides. There were no protective boots on their feet or positioning devices for offloading. - on 6/7/2024 at 9:33 AM, they stated the boots were only worn when they were sleeping. The thin gel cushion remained in the wheelchair seat and continued to be uncomfortable. The resident stated no one had offered them a new wheelchair cushion. - on 6/7/24 at 10:49 AM, Certified Nurse Aide #6 and Licensed Practical Nurse #62 provided peri- care. Zinc oxide was applied by the nurse to the open areas on the back of the right thigh and left buttock. The resident was dark skinned with pink open irritated areas present in the inner gluteal cleft on the left buttock and posterior right thigh. The resident had been incontinent of urine, their brief was changed, and staff stated there was no care plan that included to leave the brief open. The resident refused protective boots and asked to stay in bed due to an upset stomach. - on 6/10/2024 at 11:21 AM, in bed dressed and groomed. Their wheelchair remained with a thin gel cushion in the seat. The resident stated the cushion did not provide enough pressure relief and their bottom hurt when they were in their chair. - on 6/24/2024 at 1:11 PM, sitting in their wheelchair in the therapy gym, with non-skid socks on both feet, there was no padding present on the wheelchair pedals. - on 6/24/24 at 3:20 PM, in their room sitting in their wheelchair wearing non-skid socks on both feet. The wheelchair pedals remained uncovered. - on 6/24/24 at 4:20 PM, in their bed wearing only an incontinence brief and their left foot resting directly on the mattress. There were no pillows used for positioning or a protective boot in place. - on 6/25/24 at 8:39 AM, in bed wearing only an incontinence brief, eating breakfast, wearing a protective boot on the right foot and a non-skid sock on the left foot. There was no pillow used for positioning or to relieve pressure on the heel. During an interview on 6/5/2024 at 9:42 AM, Registered Nurse Unit Manager #23 stated certified nurse aides should let a nurse know of any changes to a residents' skin. They had not been notified that Resident #271 had moisture areas on their buttocks. The current interventions in place included to encourage the resident to get up out of bed, moisture barrier cream with care, and a request for a bed trapeze (to allow the resident to be able to reposition self independently) had been sent. During an interview on 6/7/2024 at 11:33 AM, Certified Nurse Aide # 60 stated resident care information was found in the care instructions including if protective boots were needed. Resident #271 preferred the boots only at night and did not usually wear them daily. They let the nurse know in the past about the resident not wearing boots. The resident often refused to allow staff to place pillows under their heels. The aide stated they should not be charting yes if the resident refused the intervention. Pillows and boots were important to prevent skin breakdown. They noticed the areas on the resident's bottom last week on the 3:00 PM-11:00 PM shift and told the nurse. They were not sure which nurse or which day. The resident had told them the areas were painful, and they thought it may have been from their incontinence brief. The resident received incontinence care when needed and was repositioned to prevent skin breakdown. They had been using barrier cream before the order for zinc oxide. During an interview on 6/7/2024 at 11:50 AM, Licensed Practical Nurse #62 stated certified nurse aides should report any changes in skin to the Nurse Manager. They stated a certified nurse aide told them last week that Resident #271 had some irritation to their buttocks. They told the Unit Manager and asked the wound care team if there were orders for the resident's bottom. The irritated areas could be from moisture. The resident would get up most days for therapy but liked to go back to bed. Prompt treatment was important to keep the areas from getting worse. The areas could turn into pressure or could get infected. Protective boots to protect heels from breakdown should be used when the resident was in bed and staff should notify a nurse if the resident refused. The resident could not move their right leg due to hemiplegia and that was an increased risk for pressure ulcers. During an interview on 6/7/2024 at 12:46 PM, Assistant Director of Nursing #24 stated if a heel protector was documented as yes, in place in the aide tasks of the electronic record, it meant it was on. If they were refused, it should be charted refused and the nurse should be told. Protective boots were important to prevent skin damage or breakdown. If a resident consistently refused, they would look for a different intervention. Resident #271 was at risk for pressure due to obesity, diabetes, and immobility. The resident had right sided hemiplegia and could not move their right side independently. The Assistant Director of Nursing #24 had not been made aware that the resident was refusing protective boots in bed. They were not made aware the resident had skin irritation to posterior thighs and buttocks until 6/5/2024 when they were seen by wound team. Prompt notification of skin issues was important to prevent further skin breakdown or new skin breakdown. In a follow up interview on 6/10/2024 at 4:13 PM, the Assistant Director of Nursing #24 stated recommendations and orders by the wound care team were entered by wound care nurses. The Nurse Manager and wound care team made sure recommendations were carried out. A recommendation for a wheelchair cushion evaluation should be done by physical therapy and should be communicated to physical therapy by the wound care nurse. The recommendation for evaluation of the chair cushion and incontinence briefs left open was not communicated. There was no therapy referral, and no care plan to leave the incontinence briefs open/untaped. The resident was at risk for pressure, and moisture associated skin damage could lead to additional pressure areas if interventions were not implemented. During an interview on 6/10/2024 at 4:28 PM, the Director of Rehabilitation stated wheelchair cushions were decided on by the interdisciplinary team based on resident assessment. A recommendation by wound care for a wheelchair cushion evaluation would need to be communicated to therapy either via email or verbally. They had not received a request for a wheelchair cushion evaluation for Resident #271. Resident #271 could not independently reposition themself due to hemiplegia and this increased their risk for altered skin integrity. If there was a recommendation for an evaluation it should have been communicated on the day it was recommended. During an interview on 6/11/2024 at 9:00 AM, Wound Care Registered Nurse #65 stated there had not been communication to the wound care team about Resident #271's skin irritation. Wound care orders and recommendations were communicated by putting the orders in the electronic health record. This was done by the wound care nurse. A wheelchair cushion evaluation was more of a recommendation and therapy would be notified via email or verbally. If the incontinence brief was to be left open it would be a care plan directive. Resident #271 was seen by wound care team on 6/5/2024, moisture associated skin damage was identified, and orders were placed for zinc oxide three times daily. The wound care nurse did not communicate any other recommendations from that consult. Updated interventions not being implemented could lead to pressure ulcers. They remembered discussing leaving the incontinence brief open but did not realize it was on the consult. They should have made sure all recommendations were communicated. During an interview on 6/11/2024 at 9:17 AM, Wound Care Physician #3 stated they were notified of the resident's need for a consult when impaired skin was noted. The consult was placed, and the resident was seen by the Registered Nurse prior to the consult to assess the need for treatments, actual pressure wounds, skin tears, and moisture associated skin damage present longer than 1 week and not healing. On 6/5/2024, during wound rounds the resident was asked if they had any other concerns and they mentioned their bottom. They stated the resident had moisture associated skin damage and trauma to their skin from the incontinence brief. They recommended treatment of zinc oxide, offloading of the wound, leaving the incontinence brief open, and a wheelchair cushion evaluation. These interventions would provide resolution or prevent worsening. The resident was at risk for pressure due to their immobility and should have offloading boots to prevent pressure on the feet. They were not aware the resident was not wearing the boots. During an interview on 6/27/2024 at 2:44 PM, the Assistant Director of Nursing #24 stated pressure interventions should be monitored by nurses, and offloading boots should be on the Treatment Administration Record. If a resident had a pressure area on their heel, they should have a pressure relieving device on at all times. The resident's wheelchair pedal was not padded, and their non-skid sock was not protective. The certified nurse aide had notified them on the 6/26/2024 that the resident refused the boot and the repositioning of the left heel. The recommendation did not specify a time or frequency, just that the foot should be offloaded as much as possible. The certified nurse aides should not be documenting heel offloading if it was not happening. During an interview on 6/27/2024 at 3:12 PM, Advanced Practice Registered Nurse #90 stated the resident was seen today in their wheelchair. They only had non-skid socks in place and there was no padding to the wheelchair pedals. The protective preventive pressure devices should always be in place because the resident was at risk for pressure due to limited mobility, morbid obesity, hemiplegia, and diabetes. During an interview on 6/28/2024 at 10:01 AM, Wound Care Licensed Practical Nurse #64 stated the resident had a deep tissue injury to their right heel and was seen by Wound Care Physician #3 on 6/12/2024. The physician recommended a pressure off-loading boot, with the heel always protected to promote healing and prevent worsening of wound. The pressure off loading boot should be in the care plan and communicated to staff to make sure interventions were in place. During an interview on 7/03/24 at 8:57 AM, Wound Care Physician #3 stated there should be a boot to the right heel to offload from pressure. It did not have to be a boot, but the heel had to be floated or on multiple pillows. Nurses should be checking and documenting the boots every shift. The pressure to the right heel was avoidable if interventions had been followed. The protective boots should be worn on both feet when the resident was in bed. 3) Resident #222 was admitted to the facility with diagnoses including osteomyelitis (inflammation of the bone caused by infection) of the sacral and sacrococcygeal (buttocks) region, and unstageable pressure ulcer (full thickness tissue loss in which the base of the ulcer is covered by dead tissue) of the left buttocks. The 3/22/2024 Minimum Data Set assessment documented the resident was cognitively intact, was dependent for bed mobility, transfers, and toileting, had a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle pressure ulcer), received daily pressure ulcer care, applications of ointments/treatments other than to feet, had a pressure relieving device for the bed and chair, and did not reject care. The comprehensive care plan initiated 5/7/2023 documented the resident had an alteration in skin integrity and had an actual pressure injury Stage 4 to left ischium (back part of the pelvis) and a Stage 4 to the right heel. Interventions included dressings were monitored daily to ensure they were clean, dry, and intact; wounds were monitored daily for signs and symptoms of infection; weekly wound evaluations were completed; and any changes were documented and reported. The 5/28/2024 physician order documented to cleanse right heel with wound cleanser, pat dry with gauze, apply calcium alginate (absorbent

Based on record review and interviews during the extended recertification survey conducted 6/4/2024-7/11/2024 the facility's Medical Director did not ensure the coordination of medical care with interdisciplinary teams and implement and evaluate resident care policies to assure they reflected current professional standards. Specifically, the Medical Director failed to ensure that policies and procedures were developed and implemented to provide and monitor the delivery of care and services to residents in the areas of Self-administration of Medication (F 554), Pain Management (F 697), Laboratory Services/Notification of Results (F 773), and Provision of Medically Related Social Services (F 745), resulting in actual harm with potential for serious harm that was Immediate Jeopardy. Findings included: The undated facility Medical Director Job Description documented the Medical Director was a physician who served as the leader in the clinical setting or a health care facility. They were responsible for developing and implementing policies and procedures and best medical practices and coordinating care in the facility. They would oversee training and provide continuing education for their staff. The Medical Director would assure the medical facility was in line with all State, Federal and Local laws and should directly report any relevant information to the senior management of the facility. Additionally, the Medical Director would supervise the medical staff, review, and participate in quality assurance activities and directly oversee clinical safety and risk management. Resident Self Administration of Medication Refer to citation text under F554. Residents #21, #64, #72, #207, and #239 were not assessed to determine their ability to safely self-administer medications or had physician orders for self-administration of medication. The facility's failure to ensure residents' medications were safely administered placed all 248 residents at risk for serious harm or serious adverse outcomes. This resulted in Immediate Jeopardy to resident health and safety. Pain Management Refer to the citation text under F697. Residents #28, #37, #64 had unresolved pain that affected their daily functional abilities, psychosocial well-being, and diminished quality of life. This placed all residents with pain, who received pain medication, at risk for harm that was Immediate Jeopardy and Substandard Quality of Care. Provision of Medically Related Social Services Refer to citation text under F745. Residents #41, #126, #153, #235, and #250 were not provided medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. This placed all residents with mental health disorders at risk for physical, mental, and psychosocial harm that was Immediate Jeopardy and Substandard Quality of Care. Lab Services/Physician Order/Notification of Laboratory Results Refer to the citation text under F773. Residents #153, #260, and #529 had critical laboratory results that fell outside of the clinical reference range and the ordering physician was not promptly notified of the results. This resulted in the likelihood of serious injury, serious harm, or death that was Immediate Jeopardy to resident's health and safety. During an interview on 7/9/2024 at 1:23 PM, Nurse Practitioner #22 stated they worked with the Medical Director for 14 years. The corporate administration did not include the providers in their administrative discussions. Prior to the corporate takeover of the facility the provider had some input into the admission and services for incoming residents, the day to day operations of the facility, and the needs of the residents. The providers used to be an integral part of the residents care and now they were not as involved. They had medical staff meetings with administrative staff, pharmacy, and all providers. The Medical Director oversaw the residents on 3 North. The policies were all corporate policies. During a telephone interview on 7/10/2024 at 2:25 PM, the Medical Director stated their responsibility was overseeing of physician services, ensuring the physicians were doing their mandated resident visits, and working closely with the Administration. They were not responsible for overseeing care of every resident in the facility, they were an attending physician with their own case load of residents. They currently did not have any input regarding facility policies. They used to have to sign off on the policies and procedures and was advised of and made aware of policy and procedure changes. They thought the facility was pulling most of the polices from the corporate level. They had gone to the Director of Nursing when they had concerns about policies and procedures and felt they were not being heard. They were unsure who to speak to beyond the Director of Nursing. The facility corporation was a complex system and ran things in layers and was filtered down to the facility. There were many people involved in who the facility would admit and how facility staff provided care to the residents. They stated they had not heard about the facility assessment and had no input into that document. In the past they would review residents and decide if the facility was able to accommodate and appropriately care for the new resident. The policies and procedures were corporate driven policies and they provided insight as requested but the corporation had their own way of doing things. During an interview on 7/11/2024 at 8:52 AM, the Administrator stated the Medical Director participated in the quality assurance meetings, the plan of correction, and rehospitalizations meeting. The policies come from the corporate team and the Medical Director should be aware of all the policies. 10 CRR NY 415.15(a)(1)(2)(3)

Based on observation, record review, and interview during the extended recertification and abbreviated (NY00331669) surveys conducted 6/4/2024-7/11/2024, the facility did not ensure the physician was consulted and the resident's representative was notified when there was a significant change in the resident's physical, mental, or psychosocial status for 4 of 4 residents (Residents #37, #147, #153, and #528) reviewed. Specifically: - Resident #37 did not receive their Lyrica (used to treat nerve pain) on the day shift (7:00 AM-3:00 PM from 6/22/2024-6/24/2024 due to the facility not having the medication and the provider was not notified. Subsequently, the resident had complaints of uncontrolled pain. - Resident #147 refused heparin (a blood thinner), insulin (used to treat diabetes), and labs as ordered for a period of 6 months, the medical provider was not notified and there was not an assessment by the provider to determine the outcome of the refusals. - Resident # 153 had a critically low blood glucose level reported to the facility by the contracted laboratory service on 6/22/2024 and the provider was not notified. - Resident #528 had a change in condition including lethargy, loose stools, medication refusal, and poor food/fluid intakes and was not assessed by a qualified professional when the change was noted, the medical provider was not notified, and the resident's representative was not notified. Subsequently, the resident was hospitalized with severe dehydration. This resulted in harm to Residents #528 and #37 that was not immediate jeopardy. Findings include: The facility policy, Change in Condition Notification, revised 8/2022, documented residents would be monitored for changes in their condition, the facility staff would respond appropriately to those changes, and notify the physician and responsible party/family member of changes. The licensed nurse was to notify the resident's next of kin/responsible party when there was a significant change in the resident's condition, physical, clinical, or psychosocial well-being. In the event of a non-life threatening but significant change in the resident's condition, the facility would notify the physician. The licensed nurse would record in the resident's medical record any significant changes in the resident's condition or medical status. The facility policy, Medication Administration, last revised 1/2021 documented medications shall be administered in a safe and timely manner, and as prescribed. Medications must be administered in accordance with the orders, including any required time frame. 1) Resident #528 had diagnoses including Alzheimer's disease (a type of dementia), post-traumatic stress disorder, and anxiety disorder. The 12/29/2023 Minimum Data Set assessment documented the resident had severe cognitive impairment, did not exhibit behavioral symptoms, was independent with bed mobility, transfers, and walking, required set-up assistance for eating, substantial assistance for dressing, and was dependent for hygiene. The comprehensive care plan initiated 12/26/2023 documented: - the resident required assistance with self-care and mobility related to Alzheimer's Disease. Interventions included supervision and set up assistance for eating and drinking, supervision with walking, and was independent with transfers and bed mobility. - The resident had behavioral symptoms such as wandering/pacing, aggression, and refusal of care. Interventions included check for hunger/thirst, toileting needs, and reapproach. - The resident used psychoactive medications related to anxiety and depression. Interventions included monitor, record, and report to the physician side effects and adverse reactions including unsteady gait, falls, refusal to eat, dry mouth, depression, diarrhea, fatigue, loss of appetite, weight loss, and behavior not usual for the person. The 1/2024 Documentation Survey Report (care log) documented the following fluid intakes (recorded in ranges): - on 1/1/2024, 480 cubic centimeters (same as milliliters) to 600 cubic centimeters; - on 1/2/202, 1320 cubic centimeters (higher intakes noted with one amount versus a range); - on 1/3/2024, 1 cubic centimeter to 160 cubic centimeters; - on 1/4/2024, 303 cubic centimeters to 663 cubic centimeters; - on 1/5/2024, 968 cubic centimeters to 1199 cubic centimeters; - on 1/6/2024, 450 cubic centimeters to 1047 cubic centimeters; - on 1/7/2024, 2 cubic centimeters to 330 cubic centimeters; - on 1/8/2024, 1710 cubic centimeters to 2060 cubic centimeters; - on 1/9/2024, 881 cubic centimeters to 1080 cubic centimeters; and - on 1/10/2024, refused or not recorded due to hospitalization. The 1/2024 Documentation Survey Report documented the following food intakes (recorded in percentage ranges): - on 1/1/2024, breakfast, lunch, dinner, and evening snack refused; - on 1/2/2024, breakfast and lunch not documented, dinner 76-100%, and an evening snack; - on 1/3/2024, breakfast, lunch, dinner refused, and no evening snack (marked not applicable); - on 1/4/2024, breakfast and lunch 0-25%, dinner 51-75%, and an evening snack; - on 1/5/2024, breakfast 0-25%, lunch 26-50%, dinner 51-75%, and an evening snack; - on 1/6/2024, breakfast and lunch 0-25%, dinner 76-100%, and an evening snack; - on 1/7/2024, breakfast 0-25%, lunch 51-75%, dinner, and evening snack refused; - on 1/8/2024, breakfast and lunch 51-75%, dinner 76-100%, and an evening snack; - on 1/9/2024, breakfast not applicable, lunch 26-50%, dinner refused, and an evening snack; - on 1/10/2024, breakfast and lunch refused, dinner resident not available (hospital). The 1/2024 Medication Administration Record documented: - on 1/1/2024, 1/5/2024, and 1/7/2024, Senna (constipation medication) was held; - on 1/5/2024, all the 7:00 PM- 9:00 PM medications were spit out; - on 1/8/2024, all the 7:00 PM to 9:00 PM medications were refused; and - on 1/9/2024, melatonin (hormonal sleep aid) was held. The electronic medication administration notes (documented separately from daily nursing progress notes) documented: - on 1/5/2024 at 8:51 PM, entered by Licensed Practical Nurse #4, the Senna (constipation medication) was held due to loose stools, the registered nurse was aware. Vital signs were stable, the resident was very tired, and fluids were encouraged. - on 1/7/2024 at 9:25 AM, entered by Licensed Practical Nurse #4, Senna was held due to loose stools, vital signs were stable, the resident was very tired, and the registered nurse was aware. - on 1/8/2024 at 7:55 PM, entered by Licensed Practical Nurse #8, the resident refused their medications and was very lethargic. - on 1/9/2024 at 1:05 PM, entered by Licensed Practical Nurse #9, the resident's appetite remained poor, and they were very tired this shift. Staff assisted the resident back to bed; they appeared unsteady on their feet and was not ambulating on the unit this shift. - on 1/9/2024 at 5:36 PM, entered by Licensed Practical Nurse #4, the resident was very tired, appeared depressed, the day shift reported reduced intakes at breakfast and lunch. Their vital signs were stable, they accepted 240 milliliters of chocolate nutritional drink on the 3:00 PM-11:00 PM shift, the Registered Nurse Unit Manager was informed at 3:00 PM. - on 1/9/2024 at 8:19 PM, entered by Licensed Practical Nurse #4, melatonin was held due to the resident being very lethargic on both day and evening shifts. The registered nurse was aware. There was no documented evidence of registered nurse assessments, medical provider notification, or evaluation related to the resident's symptoms of lethargy, loose stools, medication refusal, and loss of appetite/poor intakes from 1/5/2024 to 1/9/2024. There was no documented evidence the resident's representative was notified of the resident's change in status from 1/5/2024 to 1/9/2024. A 1/10/2024 at 1:46 PM Registered Nurse Manager #5 progress note documented the resident was unresponsive to verbal commands, their blood pressure was 121/89, pulse 99, respirations 22, oxygen was placed on the resident at 8 liters per minute, Code Blue (emergency) was called, and a crash cart (emergency supply cart) was placed at the bedside for precautions. The nurse practitioner provided orders to send the resident to the hospital for evaluation. The 1/10/2024 hospital record documented the resident was admitted for severe dehydration. Per emergency medical services, facility staff reported the resident was last seen well at 10:30 AM, and found just after 1:30 PM, minimally responsive with irregular breathing. Emergency medical services reported the resident's Glasgow Coma Scale (scale that describes the extent of impaired consciousness in all types of acute medical and trauma patients) was 5 (scale of 3-15, with 8 or less meaning severe brain injury). During an interview on 6/11/2024 at 9:45 AM, Licensed Practical Nurse #4 stated they noted a change in Resident #528's condition in the days prior to their hospitalization. The resident was normally up and walking about the unit, visiting with the nurse at the medication cart, and wanting to help staff and other residents. It was a change for the resident to be in bed, lethargic, and not eating or drinking much. The resident had reduced voiding as well. The licensed practical nurse notified the registered nurse supervisor each time they documented it on 1/5/2024, 1/7/2024, and 1/9/2024. They could not recall which registered nurse responded and was unaware if they registered nurse assessed the resident at those times. The licensed practical nurse also notified Registered Nurse Manager #5 on 1/9/2024. The licensed practical nurse stated they did not notify the medical provider due to following the chain of command and notifying the registered nurse. During an interview on 6/11/2024 at 11:48 AM, Registered Nurse Manager #5 stated a change in condition included falls, symptoms of illness, behaviors, loose stools, change in baseline functioning, fatigue, or responsiveness. When a change in condition was noted, an assessment should be completed. The licensed practical nurse should call the medical provider or a registered nurse supervisor for assessment. If the licensed practical nurse notified a registered nurse supervisor, the licensed practical nurse could still notify the physician. The registered nurse assessment and/or medical provider contact should be documented in the progress notes. The Registered Nurse Manager stated an assessment should have been completed or the medical provider notified when Resident #528 refused their medications, exhibited fatigue, loss of appetite, and loose stools. The family should have been notified once there was an assessment or a plan from the physician. They were unaware of any registered nurse or medical provider evaluations from 1/5/2024 to 1/9/2024 and was not able to access their 24-hour reports. They could not recall what happened with Resident #528 and they were not made aware of any change in their condition prior to 1/10/2024. They stated following a weekend or off-shift, they would review 24-hour shift report notes and anything the registered nurse supervisors documented. The Registered Nurse Manager could not recall being notified on 1/9/2024 by Licensed Practical Nurse #4 related to the resident's fatigue and loss of appetite. During an interview on 6/11/2024 at 2:08 PM the Director of Nursing stated a change in condition included falls, an event, or a decline in condition. A resident with reported poor intakes and lethargy should be assessed by a registered nurse and the medical provider should be notified. A licensed practical nurse could notify a medical provider, however they typically would have a registered nurse assessment prior to notification to provide the relevant information. If the licensed practical nurse notified a registered nurse for a resident's change in condition, they expected the registered nurse to notify the medical provider, not the licensed practical nurse. The family/resident representative should also be notified when the resident had a change in condition once the provider evaluated them and had a plan. When Resident #528 was noted with loose stools and a medication refusal, they would not expect a medical provider notification at that time. When the resident continued with symptoms of loss of appetite, lethargy, and poor intake, the medical provider should have been notified. Additionally, Resident #528's care plan documented to notify the medical provider of symptoms the resident had been experiencing and should have been notified immediately in accordance with their plan of care. During an interview on 6/20/2024 at 1:02 PM, Certified Nurse Aide #40 (who documented care provided on 1/1/2024, 1/3/2024, 1/6/2024, and 1/7/2024) stated they vaguely recalled Resident #528 and did not know of any concerns related to their change of condition prior to their discharge. During an interview on 6/20/2024 at 2:30 PM, Certified Nurse Aide #91 (who documented meal and care refusals on 1/7/2024 in the evening) stated the resident did not eat well due to frequent walking about the unit. The resident refused meals and needed much encouragement with offers of snacks and sandwiches. The resident could eat as they walked around. They did not recall the resident's change in condition prior to their discharge. During an interview on 6/21/2024 at 7:45 AM Physician #41 stated when the resident continued to exhibit changes such as loss of appetite and lethargy in the days prior to 1/10/2024, they should have been notified. The primary reason would be to evaluate the resident, possibly order laboratory tests, and to discuss treatment options with the family. The resident's behaviors contributed to the resident's overall condition, and further testing and monitoring were required to better understand their needs. The resident's sodium level was high indicating possible dehydration. The physician did not feel the facility contributed to the resident's decline; however, they should have notified the physician before the situation became emergent. During an interview on 6/21/2024 at 1:30 PM Certified Nurse Aide #90 stated they were assigned to Resident #528 on 1/10/2024. The resident remained in bed that morning and was alert when care was provided. The aide stated they heard from another (unidentified) aide that the resident had some changes noted such as not walking around as much per their normal behavior. The nurse (unidentified) advised Certified Nurse Aide #90 to let the resident remain in bed. The resident had been up and walking around during the previous day or two. Before lunch, they went to provide care to the resident and noted the resident was alert and said a few words. When the aide turned the resident, they thought there was a change in their breathing and immediately notified the nurse. The nurse (not identified) brought in oxygen and the machine for vital signs. The resident was sent out to the hospital. 2) Resident #147 had diagnoses including end stage renal disease (kidney disease), Type 1 diabetes (the body does not produce insulin) with polyneuropathy (nerve damage), and adjustment disorder with depressed mood. The 3/30/2024 Minimum Data Set quarterly assessment documented the resident had intact cognition, understood verbal content, did not exhibit behavioral symptoms, did not reject care, required set up assistance or supervision for activities of daily living, received an insulin injection 1 of the last 7 days, and received an anticoagulant (blood thinner) during the last 7 days. A 1/2/2024 physician order documented heparin sodium injection solution 5000 units per milliliter inject 1 milliliter subcutaneously 3 times daily for blood clot prevention (discontinued 6/26/2024) and insulin lispro (fast acting insulin) injected as per sliding scale (the amount of insulin injected is based on blood sugar reading) subcutaneously before meals for diabetes mellitus. The 1/2024- 6/2024 Medication Administration Record documented the resident received heparin on 6/3/2024 at 8:00 PM and on 6/23/2024 at 2:00 PM and 8:00 PM, all other doses during that time were not given due to refusal or resident out of the facility. The resident received blood glucose monitoring and sliding scale insulin zero times in January 2024, twice in February 2024, 5 times in March 2024, twice in April 2024, zero times in May 2024, and 9 times in June beginning 6/22/2024. The comprehensive care plan documented: - on 4/21/2022 the resident had a history of exhibiting behavior symptoms such as verbal aggression, combativeness, and refusing dialysis and care. Interventions included notify physician of new or escalating behavior. The care plan was updated on 6/21/2024 to include reapproach the resident for care/toileting/medication administration/treatments and other needs when resident is more agreeable. The resident refused medications. - on 8/15/2022 the resident had insulin dependent diabetes mellitus with interventions including administer medications per physician orders, and monitor blood glucose finger stick per physician orders. - on 10/3/2022 the resident was at risk for bleeding secondary to non-steroidal anti-inflammatory drugs/anticoagulant use prophylaxis. Interventions were to administer medications as prescribed, and monitor effectiveness of medications given and observe for adverse reactions. Drug regimen reviews completed by Registered Pharmacists #92 and #93 on 1/3/2024, 1/31/2024, 2/28/2024, 3/31/2024, 4/30/2024, 5/31/2024, and 6/30/2024 documented no recommendations. There was no mention of missed or refused medications in the reviews. Progress notes by Physician #10 dated 2/4/2024, 3/13/2024, 4/1/2024, 4/27/2024, and 5/12/2024 did not document any refusal of medications, glucose monitoring, or labs. There was no documentation of risk/benefits or alternate treatment possibilities. During an interview on 6/26/2024 at 11:33 AM Registered Nurse Unit Manager #94 stated resident refusal of medications should be communicated to the registered nurse. When refused, the medication nurse should reapproach the resident. If the resident still refused it should be documented and the registered nurse should be notified and then notify the provider. Verbal notification had been given to the physician regarding the resident's refusals. There was no evidence of documented communication with the provider. Registered Nurse Unit Manager #94 stated it was important that significant medication refusals be addressed by medical, and heparin and insulin were clinically significant medications. During an interview on 6/26/2024 at 11:46 AM Licensed Practical Nurse # 49 stated they offered resident their medications as ordered, they notified the Registered Nurse Unit Manager of refusals. They thought the Unit Manager would then notify the physician. It was important for the physician to know of refused medications. During an interview on 6/26/2024 at 1:41 PM Physician #10 stated Resident #147 was on heparin for deep vein thrombosis (blood clot) prophylaxis, and insulin sliding scale coverage for diabetes mellitus. They were notified at the beginning of June 2024 about the resident's medication refusals and had a conversation with the resident about taking medications. They did not change the orders so the medications would continue to be offered. The resident refused all labs, finger sticks, and refused heparin 90% of the time. If the resident did not receive the heparin it could lead to blood clots, and not receiving the insulin could lead to elevated blood glucose levels. During an interview on 6/27/2024 at 10:38 AM Registered Pharmacist #92 stated during the medication regimen review they looked at all medications and did look at the Medication Administration Record. If a resident refused medications and it was brought to their attention, or if they knew of refusals, they would notify the prescriber and provide options. The most important thing was notification of the provider. They ensured heparin had appropriate diagnosis, dosing per standards of practice, and lab monitoring. Refusal of medications was not included on their recommendations as the nurses should notify the medical providers. The medical provider should be made aware of refusals, and it was the medical provider's responsibility to come up with a plan. A resident who did not receive prescribed heparin could be at increased risk for a blood clots, deep vein thrombosis, pulmonary embolism (blood clot in the lung), or stroke. The physician should have been made aware of the refusal of insulin and blood glucose monitoring due to increased risk of hyperglycemia (elevated blood sugar) or hypoglycemia (low blood sugar). The pharmacist did not feel pharmacy was responsible for notifying the physician of medication refusals and nursing should be making the medical provider aware of medication refusals. During an interview on 6/27/2024 at 3:26 PM Nurse Practitioner #22 stated refusal of medications should be communicated to medical by nursing. Medical should know about refusals because they would need to assess the resident or make changes to medications. If a resident was ordered heparin and not receiving it, it could increase the risk for blood clots. If insulin or finger sticks were not being administered, it was clinically important to prevent hypoglycemia or hyperglycemia. During an interview on 6/28/2024 at 9:42 AM the Medical Director stated the medication regimen review should look at medications for reasonability, clinical indication, and make sure that levels are obtained as needed. They were not sure if the pharmacist looked at the medication administration record. Medications not being received should be reported to the medical provider. They were not aware Resident #147 had not been receiving medications as ordered. Not receiving heparin could lead to stroke, pulmonary embolism, or blood clots. The risk for not receiving insulin as ordered was out of control blood sugars. If medications were ordered, they should be given. 3) Resident #37 had diagnoses including diabetic neuropathy (nerve damage) and chronic venous insufficiency (damaged veins that can cause inflammation). The 5/29/2024 Minimum Data Set assessment documented the resident was cognitively intact, did not reject care, frequently felt down, depressed, or helpless, had frequent trouble falling or staying asleep, felt bad about themself, had trouble concentrating, and had thoughts they would be better off dead, or of hurting themself in some way. The resident received a scheduled pain medication regime, received as needed pain medication, had almost constant pain that made it hard for them to sleep at night. and the pain constantly limited their day-to-day activities. The resident's worst pain was a 10 (0-10 pain scale with 10 being the highest pain level). Pain was triggered as a care area with a care plan. The Comprehensive Care Plan initiated 9/29/2022 documented the resident had an alteration in comfort related to neuropathy, back pain, and intermittent claudication (muscle pain from poor blood flow). Interventions included administer medications as ordered, report to the nurse resident complaints of pain or requests for pain treatment, notify physician if interventions were unsuccessful of if current complaint is a significant change from the resident's experience with pain, monitor for signs and symptoms of pain, if resident appears to be in pain utilize appropriate non-pharmacological interventions. Interventions were revised on 5/30/2024 and included evaluate effectiveness of pain intervention, review for compliance, alleviation of symptoms, dosing schedules and resident satisfaction with results, and observe for new onset or increased agitation, restlessness, confusion, hallucinations, nausea, vomiting, dizziness, and falls, and report occurrences to the physician. Physician orders documented: - on 5/22/2024 pain evaluation every shift, record pain on a 0-10 scale. - on 5/22/2024 Lyrica oral capsule 100 milligrams, give 1 capsule every 12 hours for neuropathy, maximum daily dose 2 capsules. The 6/2024 Medication Administration Record documented Lyrica oral capsule 100 milligrams, give 1 capsule by mouth every 12 hours for neuropathy at 9:00AM and 8:00 PM. - on 6/21/2024 Lyrica was last administered at 9:00 PM by Licensed Practical Nurse #86. - On 6/22/2024 Lyrica was documented as a 9 (other/see nurse notes) at 9:00 AM Licensed Practical Nurse #53, and at 8:00 PM by Licensed Practical Nurse #28 - On 6/23/2024 Lyrica was documented as a 9 at 9:00 AM by Licensed Practical Nurse #87, and at 8:00 PM by Licensed Practical Nurse - On 6/24/2024 Lyrica was documented as a 9 at 9:00 AM by Licensed Practical Nurse #28 and documented as administered at 8:00 PM by Licensed Practical Nurse #28. Nursing notes documented: - on 6/22/2024 at 10:37 AM by Licensed Practical Nurse #53 Supervisor aware that Lyrica needs to be ordered, not available in Pyxis (an automated medication dispensing system). - on 6/22/2024 at 8:58 PM by Licensed Practical Nurse #28 the Lyrica was on order, awaiting pharmacy to deliver. - on 6/23/2024 at 8:18 AM by Licensed Practical Nurse #87 the Lyrica was not on hand. - on 6/23/2024 at 8:44 PM by Licensed Practical Nurse #28 the Lyrica was on order, waiting for the pharmacy to deliver. - on 6/24/2024 at 9:14 AM by Licensed Practical Nurse #28 the Lyrica was on order, waiting for the pharmacy to deliver. The nursing notes did not document the resident's pain level. The 6/2024 Treatment Administration Record documented pain evaluation every shift. The residents pain level was documented: - on 6/22/2024 at an 8 for the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts; and a 0 for the 11:00PM-7:00 AM shift. - on 6/23/2024 at a 0 for the 7:00 AM-3:00 PM shift; an 8 for the 3:00 PM-11:00 PM shift; and a 0 for the 11:00 PM-7:00 AM shift. - on 6/24/2024 at a 7 for the 7:00 AM-3:00 PM and 3:00 PM-11:00 PM shifts. There was no documented evidence the provider was notified Lyrica was not administered to the resident. The 6/24/2024 at 3:49 PM progress note transcribed by Nurse Practitioner #22 and signed by the Medical Director documented the resident's pain was a 7 on 6/24/2024 at 10:46 PM. The resident had chronic lower extremity pain. The resident did not feel their pain was fully compensated on oxycodone (an opioid pain reliever) every 12 hours and the oxycodone was increased to every 8 hours. The resident stated their neuropathic pain in the lower extremities was worse. The resident did not think they received their Lyrica that morning. They spoke with the Nurse Manager who would check on the administration of the resident's Lyrica. During an interview on 6/24/2024 at 4:44 PM, Resident #37 stated they had not received their Lyrica since 6/21/2024. They stated the Lyrica and oxycodone worked well together. They stated facility staff informed them they had ordered Lyrica last Monday 6/17/2024. They stated acetaminophen did not touch their pain. During an interview on 6/25/2024 at 9:32 AM, Licensed Practical Nurse #28 stated Resident #37 had consistent pain. The resident ran out of scheduled Lyrica on 6/21/2024 and they ordered the medication through the pharmacy. On 6/22/2024, they notified the supervisor that the resident did not have medication available. Resident #37 did not receive their Lyrica on 6/22/24, 6/23/24, and 6/24/24 morning dose. During an interview on 6/25/2024 at 9:32 AM, Licensed Practical Nurse #28 stated the resident was in constant pain. The resident's Lyrica ran out on 6/21/2024. The Licensed Practical Nurse Unit Manager #2 called the pharmacy on 6/21/2024. Licensed practical nurses notified the supervisor if medications were not given to a resident. They notified the supervisor on 6/22/2024 that the Lyrica was not there, and they would contact the provider directly. The policy in the facility was for the licensed practical nurse to call the supervisor and then the supervisor would notify the provider. During an interview on 6/25/2024 at 9:54 AM, Licensed Practical Nurse Unit Manager #2 stated the resident constantly had pain in their lower back and legs from diabetic pain, wound pain, and vascular pain. The resident's Lyrica was low on 6/21/2024 so it was ordered. The medication was supposed to be on the 4:00 PM pharmacy run on 6/21/2024. They did not work the weekend and were informed on 6/24/2024 that they medication still had not come in. The medication nurse was responsible for notifying the supervisor if medications were refused or not available and document when a supervisor was notified. They stated all nurses had access to the pyxis system. During an interview on 6/25/2024 at 10:31 AM, Nurse Practitioner #22 stated that any missed dose of medication was unacceptable. They expected to be notified about missed doses but was not. The nursing staff did not inform them about the missed doses of Lyrica. The resident notified them on 6/24/2024 when the resident pulled them aside to tell them they did not feel well. During an interview on 7/8/2024, at 1:47 PM, Licensed Practical Nurse #28 stated the supervisor was notified and informed them the Lyrica was not available. They stated during the 8:00 PM medication pass on both 6/22/2024 and 6/23/2024, they notified the supervisor the medication was unavailable. They were unsure which nursing supervisor they spoke with on 6/23/2024. They stated they spoke with the Licensed Practical Nurse Unit Manager on 6/24/2024 who spoke with the pharmacy. They stated they had never received training on the Pyxis system (automated medication dispenser). During an interview on 7/9/2024 at 10:27 AM, Registered Nurse #94 stated they worked on both 6/22/2024 and 6/23/2024. They stated the first thing to do if a scheduled medication was not available was to check the Pyxis and call the pharmacy to see if an emergency run could be done. They would then call the provider to get directions on how to proceed until the medication was available. It was important for residents to receive medications as ordered. It is important that pain medications were given as pain can be a contributing factor that affects several areas of life, from therapy to sleep. They did not recall being notified that the resident's Lyrica was not available. The registered nurse supervisor or Unit Manager would be responsible for notifying the provider. During an interview on 7/9/2024 at 1:47 PM, the Medical Director stated if a resident did not get their narcotic medication, they would expect to be notified. 10NYCRR 415.3(e)(2)(ii)(b,c )

Based on observation, record review, and interview during the extended recertification and abbreviated (NY00335306, NY00334736, NY00331600, NY00335937, NY00337529, NY00340292, NY00340725, and NY00335379) surveys conducted 6/4/2024-7/11/2024, the facility did not ensure services provided met the professional standards of quality in 5 of 5 areas (pressure ulcers, medication administration, respiratory care, activities of daily living, and laboratory testing notifications). Specifically, medication administration was not completed in accordance with accepted standards of clinical practice (see F 554); provider notification was not completed for residents with significant changes in condition (see F 580); oral care and feeding assistance was not completed as ordered or planned (see F 677); pressure ulcer prevention services were not completed as ordered (see F 686); splints were not applied as ordered (see F 688); recommendations for appetite stimulant were not discussed with the provider for a resident with significant weight loss (see F 692); respiratory equipment was not maintained appropriately (see F 695); residents had unresolved pain that affected their daily functional abilities (see F 697); medically related social services were not provided to residents with significant mental health diagnoses (see F 745); and routine laboratory testing and the results were not reviewed by facility staff in a timely manner, and the medical provider was not notified in a timely manner of the abnormal lab results (see F 773) . Additionally, the inability to meet the professional standards led to the outcome of abuse and neglect (see F 600). Findings include: The New York State Education Law Article 139, Section 6902 documented the practice of the profession of nursing included the executing of medical regimens prescribed by a licensed physician. The facility policy, Charting and Documentation dated 10/2019, documented the following information was to be in the resident's record: objective observations; medication administered; treatments or services performed; changes in resident's condition, events, incidents, or accidents involving the resident; and progress toward or changes in the care plan goals. Self-Administration of Medication (F554): - Resident #21 was observed with ammonium lactate 12% cream, pink liquid stomach relief, and bottle of surgical scrub in their room. - Resident #64 was observed with 3 pills at the bedside on 6/4/2024, and a pill on the floor on 6/7/2024. - Resident #72 was observed with eye drops at bedside. - Resident #207 was observed with 1 pill on the bedside table. - Resident #239 was not observed by nursing staff to ensure medication administration was complete for a controlled substance. - All 5 residents did not have documented evidence they were assessed to determine their ability to safely self-administer their medications or of a physician order for self-administration of medication. The facility's failure to ensure residents' medications were safely administered placed all 248 residents at risk for serious harm or serious adverse outcomes. This resulted in Immediate Jeopardy to resident health and safety. Physician Notification for Change in Condition (F580): - Resident #37 did not receive their Lyrica from the day shift (7:00 AM-3:00 PM) of 6/22/2024 until day shift of 6/24/2024 due to the facility not having the resident's ordered medication and the provider was not notified. This resulted in putting residents who received pain medication, at risk for harm that was Immediate Jeopardy and Substandard Quality of Care. - Resident #147 refused heparin, insulin, and labs as ordered for a period of 6 months, the medical provider was not notified and there was not an assessment by the provider. - Resident #153 had a low blood glucose level that was reported to the facility by the lab on 6/22/2024 and the provider was not notified. This resulted in the likelihood of serious injury, serious harm, or death that was Immediate Jeopardy to resident's health and safety. - Resident #528 had a change in condition and was not assessed by a qualified professional when the change was noted, the medical provider was not notified, and the resident's representative was not notified. Subsequently, the resident was hospitalized with severe dehydration. This resulted in harm to Residents #528 and #37 that was not immediate jeopardy. Activities of Daily Living (F677): - Resident #154 did not receive oral hygiene as ordered. - Resident #226 did not receive assistance with eating as care planned. Pressure Ulcer Services (F686): - Resident #826 was readmitted from the hospital with pressure injuries of the sacrum and heel, the areas were not assessed by a qualified professional, and there were no treatments provided for the areas. The resident was re-hospitalized on two subsequent occasions, had pressure injuries of the sacrum and heels, the areas were not assessed timely by a qualified professional or provided with treatments following readmission. - Resident # 271 had orders for pressure relief boots to be worn while in bed and the boots were not applied. Subsequently, the resident developed a deep tissue injury (localized area of purple/maroon discolored intact skin due to damage of underlying tissue) area to their right heel. Additionally, there were wound care recommendations for a wheelchair cushion evaluation and for the resident's brief to be left open to air that were not implemented. - Resident #222 and #265 both had documented pressure ulcers with orders for daily dressing changes that were not completed as ordered. This resulted in harm and Substandard Quality of Care to Residents #271 and #826 that was not immediate jeopardy. Limited Range of Motion (F688): - Resident #64 did not have bilateral hand splints in place as ordered and care planned. Maintaining Acceptable Parameters of Nutritional Status (F692): - Resident #133 had a significant weight loss and recommendations for an appetite stimulant were not discussed with the medical provider. Respiratory Care (F695): - Resident #64's did not receive the appropriate Bilevel Positive Airway Pressure (mechanical non-invasive ventilator for breathing assistance) mask. Pain Management (F697) -Resident #28's physician ordered pain cream was not administered as ordered and was documented as administered. -Resident #37 did not receive Lyrica (used to treat nerve and muscle pain) as ordered for 3 days; -Resident #64 was not aware of an as needed order for acetaminophen (pain reliever) and was not offered the medication when in pain. Subsequently, Residents #28, #37, #64 had unresolved pain that affected their daily functional abilities, psychosocial well-being, and diminished quality of life. This placed all residents with pain, who received pain medication, at risk for harm that was Immediate Jeopardy and Substandard Quality of Care. Medically Related Social Services (F745): - Resident #41 did not have person-centered mental health interventions, licensed psychologist's recommendations were not implemented into the resident's plan of care. There were no documented social services follow up with the resident following their behaviors. - Resident #126 did not have person-centered mental health interventions for their behaviors or refusals of care and medications. There were no documented social services follow up with the resident following their behaviors. - Resident #153's licensed psychologist's recommendations were not implemented into the resident's plan of care, a recommendation for a traumatic brain injury program was not investigated, and recommendations to continue psychotherapy were not followed. There were no documented social services follow up with the resident following their behaviors. - Resident #235 had behaviors of taking things off the nurses' cart and throwing them leading up to an episode of threatening staff with scissors, requiring police intervention and hospitalization for the resident. There were no documented interventions from social services and the resident did not have person-centered interventions for their history of delusions and taking/throwing things off the nurses' cart. - Resident #250 did not have person-centered mental health interventions for their behavioral symptoms. - This placed all residents with mental health disorders at risk for physical, mental, and psychosocial harm that was Immediate Jeopardy and Substandard Quality of Care. Laboratory Services Notification of Results (F773): - Resident #529 had routine laboratory testing and the results were not reviewed by facility staff in a timely manner, and the medical provider was not notified in a timely manner of the abnormal lab results. Subsequently, the resident was hospitalized 3 days later with pneumonia and dehydration. This resulted in harm to Resident #529 that was not immediate jeopardy. - Resident #153 had a critically low blood glucose (blood sugar) of 49 milligrams/deciliter and the provider was not notified in a timely manner and the resident was not assessed. - Resident #260 had a high international normalized ratio (INR, used to determine blood clotting times for residents on anticoagulant therapy) and the provider was not notified timely, and the resident was not assessed. - This resulted in the likelihood of serious injury, serious harm, or death that was Immediate Jeopardy to resident's health and safety. During a telephone interview on 6/10/2024 at 10:05 AM, Nurse Practitioner #16 stated if they ordered acute labs for a resident, they typically followed up the next day to review the results. If routine scheduled labs were completed, they expected nursing to notify them as soon as possible of any alterations. Lab results such as a high white blood cell count and elevated blood urea nitrogen were labs they wanted to be notified about. They stated they believed they did not work on 2/16/2024 and did not review the resident's labs until after the resident was discharged to the hospital. If they had known the resident's white blood cell count was high, they would have intervened and ordered a chest x-ray and/or urinalysis (often used to check for urinary tract infections). For the elevated blood urea nitrogen, they would have ordered extra hydration (fluids) by mouth or intravenously (through a vein). Earlier intervention could have resulted in a different outcome for the resident. During an interview on 6/10/2024 at 11:50 AM, Licensed Practical Nurse #34 stated Resident #28 had not yet received their 9:00 AM dose of pain relief gel. The nurse stated they signed off for all medications in the morning and did treatments after they finished the oral medications. They made a list for tasks they signed off on and had to come back to complete, including application of cream and dressing changes. They stated they should not sign off on medications they did not give. If the resident refused after they already signed off, they would strike out the entry. During an interview on 6/10/2024 at 12:35 PM, Certified Nurse Aide #40 stated the resident had dementia and required assistance with their meals. They stated the resident was on their assignment and they did not help the resident. They had a lot of residents that needed assistance, and they needed more staff to help. During an interview on 6/10/2024 at 12:54 PM, Licensed Practical Nurse #30 stated they were supposed to complete a dressing change for Resident #222 but did not get to complete it. They made a list of items they signed off for in the electronic medical record to make sure they completed the tasks, and their actions matched what they previously charted. If they were unable to complete a task on their list, they tried to go back into the electronic medical record and edit their entry, but they did not always have time. During an interview on 6/11/2024 at 9:18 AM, Nurse Practitioner #22 stated recommended interventions should have been brought to the provider's attention after the interdisciplinary team meeting in May 2024. The medical provider was not notified in a timely manner of the significant weight loss and recommendations for an appetite stimulant. During an interview on 6/11/2024 at 11:54 AM, Assistant Director of Nursing #24 stated medications should not be left at the bedside. Documentation should not be completed before the treatment was done, as the resident could refuse, leave the unit, or staff could forget or get too busy to come back later. During an interview on 6/12/2024 at 10:00 AM, Licensed Practical Nurse #33 stated they were trained to complete all oral medications and sign off on all the medications. They would write down the medications and tasks that needed to be completed based on what they signed off on as completed. If a resident refused or was not in their room, they would strike out the entry and write a progress note. They stated it was not a good idea to sign off on things they had not yet completed, because the sign off documents it as complete. During an interview on 6/12/2024 at 12:29 PM, the Nurse Educator stated they discussed medication administration at orientation, and nurses should document that medications were administered right after being given. They did not train staff to sign for things that were not done, that was unethical. Signing for something that was not done was falsification of documentation, and the nurse did not do it. The expectation was that all medications were signed for at the point of care. If something was not done, it should not be signed for. They expected to see dressing changes done the day they were dated, and the dates should be done as ordered. Respiratory equipment should be placed properly, if not the resident could have problems with breathing when sleeping. During an interview on 6/12/2024 at 12:29 PM, the Director of Nursing stated it was expected that the staff completed treatments as ordered, they were medically necessary for the resident and the provider deemed them appropriate. Staff should not sign off on tasks ahead of time, but if they had and the resident refused, or they were unable to complete the ordered treatment they should edit their documentation to reflect that. They should also let the supervisor know they were unable to complete the required task. Signing off on tasks before completing them, did not meet the professional standard for care. Medications should not be signed off as completed before the medication was administered to the resident. Signing off on medications before administration did not meet the professional standard. It was expected that splints were placed on residents as ordered. The electronic medical record should not be sign off without the splints being placed on the resident. The signature documented the task was complete when it was not. If the task was signed as completed and the resident refused, the documentation should reflect the actual care of the resident. Signing off on splint placement and not placing the splint did not meet the professional standard. It was expected that residents would have their teeth brushed as ordered and should not be signed for if it was not completed. Signing off the task of oral hygiene without completing it, did not meet the professional standard. During an interview on 6/25/2024 at 9:09 AM Registered Nurse #89 stated on 6/21/2024 at 5:26 PM they received a call from the lab stating Resident #153 had a glucose of 49 milligrams/deciliter. They were completing an admission assessment on another resident at the time of the call, but they called the unit to check on Resident #153. They were told the resident had taken all their medications. They should have called a medical provider to let them know the resident had a critical result of 49 milligrams/deciliter to get further orders. 415.11(c)(3)(i)

Based on observation, record review, and interview during the recertification and abbreviated (NY00324500) surveys conducted 11/27/2023-12/5/2023 the facility failed to ensure residents were free from neglect for 2 of 6 residents (Residents #18 and 31) reviewed. Specifically, Resident #18 had blood glucose levels that were outside of parameters and medical was not notified as ordered. The resident continued to have high blood glucose levels and was sent to the hospital for evaluation (Refer to F 684 Quality of Care). Resident #31 was not assisted with toileting per their care plan and as requested resulting in the resident being incontinent and being told to defecate in a brief (Refer to F 677 Activities of Daily Living Care). This resulted in actual harm of emotional distress from neglect of care to Resident #31 and hospitalization of Resident #18. Findings include: 1) Resident #31 had diagnoses of lumbar radiculopathy (a disease involving a spinal cord nerve root), cervical disc disorder (disorder of the bones in the neck), and depression. The 11/2/2023 Minimum Data Set assessment documented the resident was cognitively intact, did not refuse care, was incontinent of bladder and bowel, and required assistance of 2 for transfers and toileting. The 12/2023 resident care instructions documented assistance of 2 with a mechanical sit to stand for transfers, substantial assistance of 2 for toileting hygiene, provide a bedpan or bedside commode, and check resident every 2 hours and assist with toileting as needed. During an observation and interview on 11/28/2023 at 9:13 AM, Resident #31 was lying in bed putting their makeup on and stated they were waiting to get up due to having a medical appointment. The resident stated they used a mechanical sit to stand to get up. They stated they needed to use the bathroom during the overnight shift and was told by staff they were not getting the resident up at 1:00 AM. Staff told the resident to defecate in their brief. The resident stated they were having trouble with constipation, had received a lot of medication to assist with the problem and they needed to use the bathroom frequently. During an observation on 12/1/2023 at 10:50 AM, Resident #31 was lying in bed wearing a wet incontinence brief and there was a wet stain on their bed sheet. The resident stated they asked to get up and use the bathroom and were waiting for their certified nurse aide to come back but it was too late. The resident stated they had been waiting for 30 minutes and now their brief and sheet were wet. During an interview on 12/4/2023 at 11:31 AM, certified nurse aide #5 stated Resident #31 required assistance of 2 with a sit to stand lift for transfers and toileting needs. They stated the facility also had bed pans to offer the resident if they did not want to get out of bed or if it was late at night. Certified nurse aide #5 stated the resident was alert and oriented, could tell you when they needed to use the bathroom, and they were not offered the bed pan because they were coming back to get the resident up. Certified nurse aide #5 stated it would not be appropriate to tell the resident to defecate in their brief and it was undignified to do so. During an interview on 12/5/2023 at 10:47 AM, licensed practical nurse #13 stated the resident used a mechanical sit to stand for transfers and needed extensive assistance of 2 for toileting and they would expect staff to offer a bed pan to the resident if they did not want to get out of bed. They stated it would not be appropriate or dignified to ask the resident to defecate or urinate in their brief. 2) Resident #18 had diagnoses including diabetes with peripheral angiopathy (narrowing of arteries) and retinopathy (damage to blood vessels in the eye). The 10/16/2023 Minimum Data Set assessment documented the resident had intact cognition, did not reject care, and received insulin injections 7 of 7 days. The comprehensive care plan initiated 8/16/2022 documented the resident had insulin dependent diabetes. Interventions included administer medications per physician orders and monitor blood glucose finger stick per physician orders. A physician order dated 10/26/2023 documented insulin glargine (long-acting insulin) inject 18 units subcutaneously in the morning for diabetes call physician if finger stick blood sugar was less than 70 milligrams/deciliter or greater than 300 milligrams/deciliter. The November 2023 medication administration record documented insulin glargine daily at 5:00 AM, notify physician for blood glucose less than 70 milligrams/deciliter or greater than 300 milligrams/deciliter. The following blood glucose results were documented: - on 11/3/2023 blood glucose 377 milligrams/deciliter - on 11/4/2023 blood glucose 484 milligrams/deciliter - on 11/5/2023 blood glucose 470 milligrams/deciliter - on 11/9/2023 blood glucose 395 milligrams/deciliter - on 11/10/2023 blood glucose 336 milligrams/deciliter - on 11/12/2023 blood glucose 380 milligrams/deciliter - on 11/13/2023 blood glucose 365 milligrams/deciliter Nursing progress notes dated 11/3/2023-11/13/2023 did not include documented evidence the physician was notified of the blood glucose results greater than 300 milligrams/deciliter. Nursing progress notes documented: - on 11/14/2023 at 6:40 AM licensed practical nurse # 83 documented the resident's blood glucose reading was HI, 18 units glargine given as ordered, rechecked blood glucose 30 minutes later, remained HI. Telehealth called and order received for 10 units of Novolog (rapid acting insulin) to be given one time for elevated blood sugar. - on 11/15/2023 at 1:30 PM licensed practical nurse #84 documented the resident's blood glucose was 448, the supervisor was made aware and order for lispro (rapid acting insulin) 10 units one time received. - on 11/18/2023 at 5:54 AM licensed practical nurse #85 documented the resident's blood sugar was HI, the nursing supervisor was notified, and the resident was transferred to the hospital. During an interview on 12/5/2023 at 11:13 AM, licensed practical nurse #86 stated they worked mostly evenings and overnights. Their job duties include passing medications, patient care, and staff would come to them with resident concerns. If a resident's blood sugar was out of the parameters, they would call let the supervisor know. The supervisor would call medical and let them know. They stated Resident #18 had blood sugar levels all over the map. They did not remember if they had to call the supervisor regarding Resident #18's elevated blood sugars. If the resident had an order to notify medical of blood sugars outside of certain parameters, it would be important to the resident to make sure that was done. During an interview on 12/5/23 at 12:37 PM, Assistant Director of Nursing # 48 stated they had previously been a night supervisor. Supervisors provided oversight, managed staffing, medical issues, and called providers if needed. The medication nurse would notify the supervisor of any issue on the floor, and the medical provider would be called by the supervisor, this included blood sugars out of parameters. Any issues would be documented on the 24-hour report. They stated an email shift report went to all Nurse Managers, Supervisors, Assistant Directors of Nursing, and the Director of Nursing. They did not remember receiving a phone call about Resident #18's blood glucose level on the morning of 11/5/2023. It was not documented that they were made aware or called medical. The resident's blood glucose was 470 at 4:21 AM per the electronic health record. The order stated medical should be called for a blood sugar less than 70 or greater than 300. If a resident's blood sugars were out of range, they could need more insulin. Medical should have been notified of those instances to make decisions based on correct information. Hypoglycemia and hyperglycemia both posed risks to the resident. During an interview on 12/5/23 at 12:52 PM Assistant Director of Nursing #3 stated there was a 24-hour report that contained any resident issues needing follow up. There was also a report via email by night supervisors, which contained resident issues such as falls, labs, and blood sugars out of parameters. They did not remember Resident #18's blood glucose levels being reported on the above dates in November. The medication nurse should have contacted the supervisor to call medical for the blood glucose levels above 300 and it should have been documented in progress notes. During an interview on 12/5/23 at 1:07 PM, the Medical Director stated medical should always be notified of blood sugars that were out of parameters. The resident goals were trying to maintain blood sugar stability. Changes to monitoring of blood work and changes in insulin would have been important to the resident. During an interview on 12/5/23 at 1:35 PM, nurse practitioner #21 stated that a medical provider should be notified of blood sugars outside of parameters. If the results were off hours telehealth should be called. Nurse practitioner #21 stated that they were aware of Resident #18s elevated blood sugars around 11/14/2023. They had been notified and ordered a urinalysis for symptoms of a urinary tract infection, which could also raise blood sugar levels. They had not been notified of the elevated blood glucose levels on the previous dates. 10NYCRR 415.4(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification and abbreviated surveys (NY00325947) conducted 11/27/2023-12/5/2023, the facility failed to ensure the development of an effective transfer or discharge planning process including documentation in the resident's medical record and appropriate communication with the receiving health care institution for 1 of 1 (Resident #265) resident reviewed. Specifically, Resident #265 was admitted to the facility and did not receive medications timely and was sent to a local acute care hospital emergency department the same day without a physician's order, and without comprehensive information for the acute care hospital to provide adequate care for the resident. The resident was denied admission back to the facility, after being discharged from the acute care hospital emergency department. This resulted in psychosocial harm to Resident #265 that was not immediate jeopardy. Findings include: The facility policy titled Discharge-Transfer/Discharge Process revised on 12/2019 documented that the facility will ensure a safe and proper transfer for all residents leaving the facility. Details of the transfer will be documented in the medical record and appropriate information will be communicated to the receiving health care facility. A resident's physician will determine if a transfer to the hospital was required for an urgent medical need or because the resident's behaviors pose a threat to their or others safety or well-being. A resident and/or their representative will receive written notice of the facility's intent for transfer and their appeal rights prior to the time of the discharge. A resident being transferred to a hospital for an urgent medical or psychiatric need will be provided the written notice at the time of transfer to the hospital, and the resident's representative will be provided the written notice as soon as practicable thereafter. A hospital was not considered an appropriate discharge destination and the resident has a right to return to the facility upon completion of the hospital stay. The facility policy titled Pharmacy Services revised on 4/2020 documented that the facility will have a written agreement with a provider pharmacy to provide regular, reliable, accurate and safe pharmacy services to residents. The pharmacy must provide routine services seven days a week and emergency pharmacy service 24 hours per day, seven days per week. The pharmacy must provide and maintain the facility's emergency medication supply. Residents will have a sufficient supply of their prescribed medications (routine or emergency as needed) in a timely manner. Resident #265 was admitted to the facility with diagnoses including seizure disorder, anxiety/depression, and intellectual disability. The Minimum Data Set assessment was not completed. The resident was admitted to the facility on [DATE] from an acute care hospital, there was no admission time documented. The resident was discharged from the facility on 10/6/2023 at 11:42 PM to an acute care hospital. A written request for the resident's nursing, social work, and medical notes and accident/incident reports was submitted to the Director of Nursing. An electronic response from the Director of Nursing confirmed there was no medical, nursing, or social work documentation for the resident or accident/incident reports completed. There was no documented evidence of medical orders in the resident's electronic medical record. On 10/6/2023 at 9:00 PM, registered nurse #38 documented on the Resident Transfer Form the reason for the transfer was the resident was inappropriate for the facility. The resident was swearing and disrespectful and wanted to leave. Pertinent diagnoses included an intellectual disability. A medication list was not provided to the acute care hospital. During a telephone interview on 12/4/2023 at 9:13 AM the resident's emergency contact stated the resident was discharged to the facility from a local acute care hospital. The resident was sent to a different acute care hospital from the facility the same day as facility admission. They stated the resident arrived at the facility around 12:00 PM on 10/6/2023. They visited the resident at the facility around 2:30 PM. The resident was very anxious and requested anxiety medication. They stated the nursing staff told the resident their medications had not arrived from the pharmacy and was expected to arrive at the facility within two hours. The contact stated they told the nursing staff the resident would get increasingly more anxious the longer they did not have the medication. The contact stated they told the nursing staff around 3:00 PM that the resident would need Depakote (medication to control seizures) at 8:00 PM. The resident's contact stated they were assured the medications would be delivered prior to 8:00 PM. The resident called them by phone around 8:30 PM and told them no medications had arrived at the facility. The resident was extremely anxious by that time, and the symptoms were aggravated by lack of available medication for their anxiety and seizures. They spoke with the nursing staff by phone around 8:30 PM and was told the medications were expected to be delivered to the facility in the next 2 hours. The resident called them back around 9:00 PM and reported they were experiencing an anxiety attack and needed medication immediately. The emergency contact stated they called the facility and spoke with a nurse about the medication and was told the medications had not been delivered but was expected within 2 hours. They were told there were no medications available for the resident. They asked the nurse for the resident to be sent to the hospital so the resident could receive their medications. They thought the resident could be sent to the hospital to receive the necessary medications and then return to the facility. When the hospital staff called to transfer the resident back to the facility, they were told the resident could not return to the facility. The resident was now in the care of the emergency contact. During an interview on 12/5/2023 at 10:40 AM, Assistant Director of Nursing #3 stated the facility was responsible to provide all new residents their ordered medications and they were generally delivered from the pharmacy within one shift. If a resident was admitted on the day shift, the medications should be available from the pharmacy by the evening shift. They stated there was a locked pharmacy cabinet on the premises, provided by the pharmacy, with pertinent medications stocked. They stated all nurses had access to the pharmacy cabinet. There was a list of medications available in the pharmacy cabinet for all nurses to reference. They stated Depakote and anxiety medications were located within the pharmacy cabinet on the premises. If a new admission was returned to the acute care hospital, the facility physician must be contacted for a transfer order. The facility must send a face sheet, recent lab results, medical notes, nursing notes, the transfer form and a copy of the medication administration record and treatment administration record. They stated a resident should not be refused re-admission to the facility once the resident had been deemed safe for discharge from the acute care hospital. They stated there were extenuating circumstances when residents should not return to the facility, however those decisions were made by the facility's Director of Nursing and Administrator only. 10NYCRR 415.3(h)(1)(ii)(a)(b)

Based on observation, interview, and record review during the recertification and abbreviated (NY00327344) surveys conducted 11/27/2023-12/5/2023, the facility did not treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of quality of life for 4 of 5 residents (Residents #31, #109, #121, and #522) reviewed. Specifically, Resident #31 did not receive toileting assistance and was observed lying in a urine soaked incontinence brief (refer to F 677 ADL Care for Dependent Residents); Resident #109 did not have appropriate footwear for community visits outside the facility and had bed linens that were in poor condition, resulting in the resident feeling humiliated (refer to F 684 Quality of Care); Resident #121 did not have an outpatient follow up visit with hematology/oncology for a positron emission tomography scan (an imaging test used to detect diseased cells) as ordered after being diagnosed with a pancreatic mass; and Resident #522 was restricted from going out on pass (leaving and returning to the facility) without explanation. This resulted in psychosocial harm to Residents #31, #109, and #522, and harm to resident #121, that was not immediate jeopardy. Findings include: The facility policy, Resident Rights, revised February 2020, documented employees shall treat all residents with kindness, respect, and dignity. All residents were guaranteed basic rights in accordance with Federal and State laws. Residents have the right to self-determination, communication and access to people and services both in and outside the facility, visit or be visited by people outside the facility, participate in decision making regarding their care, and be informed of and participate in care planning and treatment. The resident would be supported by the facility in exercising their rights. The facility policy Out on Pass/Leave of Absence revised December 2021 documented the procedure for residents who were denied out on pass unescorted or out on pass would have the social worker meet with the resident to discuss the decision. 1) Resident #109 was admitted to the facility with diagnoses including spinal cord injury, right side hemiplegia (paralysis of one side of the body), post-traumatic stress disorder, and major depression. The 9/17/2023 Minimum Data Set assessment documented the resident was cognitively intact and required extensive assistance of 2 for most activities of daily living. The comprehensive care plan documented: -on 5/18/2022 the resident displayed or reported feeling down, depressed, hopeless, easily annoyed and/or short tempered, feeling tired or having little energy, and trouble falling asleep or sleeping too much. Interventions included encourage family involvement, participation in activities, refer for psychiatric evaluation and follow-up as indicated, and have biopsychosocial needs met. - on 5/22/2022 the resident used antidepressants related to diagnoses of depression and post-traumatic stress disorder. Interventions included give medications ordered by physician and monitor/document side effects and effectiveness. - on 3/23/2023 the resident had a specific religious/spiritual affiliation. Interventions included honor and respect the resident's religious/spiritual beliefs. The resident's care instructions active as of 12/3/2023 documented the resident required extensive assistance of 1 with personal hygiene and dressing, and substantial assistance of 1 for putting on/taking off footwear. During an observation and interview on 11/28/2023, at 8:30 AM, Resident #109 stated they had no shoes. The resident stated in their culture they should be able to take care of themselves which included wearing appropriate attire when in public. The resident stated they felt embarrassed and ashamed when they attended events in the community dressed in a nightgown, with blankets over them and socks on their feet without shoes. During an observation and interview on 11/30/2023, at 9:57 AM, Resident #109 lifted the facility blanket from the bed. The blanket was very thin fabric and had 2 half dollar sized holes. The resident stated they felt they deserved better quality linen. They stated the poor quality linen made them feel bad, and they deserved better than this, it made them feel like they were nothing but trash. During an interview on 11/30/2023 at 10:23 AM, certified nurse aide #26 stated the resident refused to get out of bed or wear their clothes. The clean linen supply in the facility was sometimes low in stock or unavailable. They stated they should not use linen with holes for a resident. The resident refused to get out of bed or wear their clothes. During an interview on 12/1/2023 at 11:40 AM, licensed practical nurse Unit Manager #18 stated they were aware that the resident did not have clothes and shoes. They stated they spoke with social work recently about the resident's need for clothes and shoes. The resident had been sent out of the building to community events dressed in a facility night gown, with blankets and socks, and no shoes. They stated the resident's dignity was not maintained when the resident was not dressed in clothes and shoes for those appointments, and they understood why the resident felt upset when that happened. During an interview on 12/4/2023 at 2:36 PM, social worker #25 stated they were notified by a certified nurse aide about one week ago that Resident #109 did not have shoes. They stated the resident wore socks on their feet when they were sent out of the building. They stated the resident's pride and dignity was not maintained when they were sent out of the building with a hospital gown and no shoes. They stated the resident was estranged from their family and it was the responsibility of the facility to assist the resident with their clothing needs when there was no family involvement. During an interview on 12/5/2023 at 10:33 AM Assistant Director of Nursing #3 stated they purchased clothes and shoes for Resident #109 within the past year. They were uncertain why the resident did not have the shoes they purchased. It was important to incorporate the resident's cultural beliefs into their care to maintain dignity and if the resident was sent out of the building to community events without shoes, the resident's dignity was not maintained. 2) Resident #121 had multiple diagnoses including urinary tract infection with sepsis (a life threatening infection), heart failure, and lung cancer. The 8/23/2023 Minimum Data Set assessment documented the resident had intact cognition and did not reject care. An 8/16/2023, nursing progress note documented the resident was admitted from the hospital for treatment of a urinary tract infection and sepsis. The 8/21/2023 at 1:14 PM physician #28 progress note documented Resident #121 had severe sepsis secondary to a complicated urinary tract infection. The resident was evaluated by hematology/oncology (blood and cancer specialists) during their hospital stay for a newly diagnosed pancreatic mass. A positron emission tomography scan was requested to be scheduled for the end of 8/2023. Physician orders from 8/16/2023-12/4/2023, did not include a positron emission tomography scan. The 8/25/2023, 8/29/2023, 9/5/2023, and 9/8/2023, physician #69 progress notes and 9/9/2023, physician #28 progress note documented that for the resident's newly diagnosed pancreatic mass they needed to schedule an outpatient follow up visit with hematology/oncology for a positron emission tomography scan. Nursing progress notes dated 8/16/2023-12/4/2023 did not included documentation regarding a pancreatic cancer diagnosis with recommendation for a positron emission tomography scan. There was no documented evidence a positron emission tomography scan was scheduled from August 2023 through November 2023. Social worker #25 progress notes documented: -10/6/2023 at 12:43 PM social worker informed the family they were awaiting a response for appointment date for positron emission tomography scan from provider's office. -11/15/2023 at 2:00 PM there was an order for a positron emission tomography scan, once the appointment was made the resident and family would be notified. -11/16/2023, at 11:15 AM, social worker #25 progress note documented they were unable to schedule a positron emission tomography scan until the resident was discharged from the facility. During a telephone interview on 11/28/2023 at 11:15 AM, the resident's family member stated the resident needed to have a positron emission tomography scan for their new pancreatic mass. They stated the positron emission tomography scan could not be scheduled until the resident was discharged from the facility because Medicare part A would not pay. They stated the resident needed the appointment so they could be treated for cancer. During an interview on 12/4/2023, at 1:45 PM, patient liaison #70 stated they were responsible for scheduling all resident appointments. The order could be placed by a nurse, nurse practitioner, or the physician as a consult. They stated they were unaware of Resident #121 needing a positron emission tomography scan appointment. Patient liaison #70 searched the orders history in the computer, and stated there was no orders placed in the record, so they would not have known that an appointment was needed. During an interview on 12/4/2023, at 2:19 PM, licensed practical nurse Unit Manager #55 stated Resident #121 had a diagnosis of cancer and after the interdisciplinary team meeting on 11/15/2023 they attempted to schedule the positron emission tomography scan but was told that it would have to be after they were discharged from the facility. They did not write a note. Resident appointments were very important otherwise conditions could worsen without treatment. During a telephone interview on 12/5/2023 at 11:27 AM, physician #69 stated licensed practical nurse Unit Manager #55 and patient liaison #70 were responsible for scheduling appointments and an outpatient consult order should have been placed for Resident #121's positron emission tomography scan. The Unit Managers were responsible for placing the orders for the consults. The appointment should not have been ignored as it was mentioned several times and it was not ordered or scheduled. They stated timeliness of appointments was a problem. Resident #121 had a history of cancer with a new pancreatic mass requiring a positron emission tomography scan. They stated that follow up was very important for any illness or disease process. 3) Resident #522 had diagnoses including chronic obstructive pulmonary disease (lung disease) and congestive heart failure (the heart does not pump efficiently). The 11/7/2023 Minimum Data Set assessment documented the resident had intact cognition, did not have behavioral symptoms, was independent or required set up assistance for most activities of daily living, and was actively working on discharge planning. The 11/29/2023, registered nurse Unit Manager #29 progress note documented an aroma of marijuana was noticed in the resident's room by a certified nurse aide and the resident stated they had received the substance from a friend who had visited. The resident refused to consent to a room search. A 11/29/2023, Medical Director #1 progress note documented they and the attending physician were asked to evaluate the resident as staff detected an odor of marijuana in the resident's room. The resident admitted to using marijuana in their bathroom that morning. The resident was spoken to about the facility's smoke free policy. A physician order dated 11/30/2023, documented the resident may go out on pass for medical appointments supervised by staff only and may only have supervised visitation in the front lobby, all visitors must remain in the lobby, in front of staff. No outside passes. The comprehensive care plan initiated 12/1/2023, documented the resident had a history of or current substance abuse related to the admitted use of marijuana in their room on 11/29/2023. Interventions included monitor the resident for signs and symptoms of intoxication and substance abuse with notification to the medical provider if symptoms were identified. The resident was only allowed to have supervised visitation in the front lobby within staff oversight and was not allowed outside passes (to go out on pass). The resident's care instructions documented the resident was to have only supervised visitation in the front lobby in front of staff and they could not have outside passes. There was no documented evidence the resident's visitation and out on pass restrictions were discussed with the resident. During an interview on 12/1/2023 at 10:09 AM, certified nurse aide #63 stated they were assigned to the resident and was not aware of any restrictions on visitors or any special instructions for the resident. They stated the resident's sibling and friend came to visit and the resident sometimes went downstairs with visitors and sometimes they come up to their room. During an interview on 12/1/2023 at 10:18 AM, registered nurse #40 stated that Resident #522 was stopped from going out on pass for now and they must remain on the unit unless the resident was seeing people downstairs supervised or for physical therapy. Registered nurse #40 stated they were informed verbally of the implementation of the change for the resident by the Unit Manager. The certified nurse aides and any new staff to the floor were also informed verbally. During an interview on 12/1/2023 at 11:18 AM, registered nurse Unit Manager #29 stated Resident #522's outside passes had been eliminated except medication appointments with staff supervision. The resident could have visitation in the front lobby supervised by staff. Staff on the floor were notified by orders being placed in the computer under the treatment administration record and by verbal communication to the two nurses on the floor. There was no set time frame for the duration of the restrictions. During an additional interview on 12/4/2023 at 10:08 AM, registered nurse Unit Manager #29 stated the decision for supervised visitation and no outside passes was made by the interdisciplinary team. Registered nurse Unit Manager #29 stated they were unaware if the physician was involved in the conversation regarding the interventions put in place, but they did inform the physician prior to orders being placed in the treatment administration record. Registered nurse Unit Manager #29 stated they spoke to the resident about the restrictions but was unaware if other staff had a conversation with the resident. Registered Nurse Unit Manager #29 was unable to locate where they documented the conversation with the resident. During an interview on 12/4/2023 at 10:49 AM, the Social Services Director stated resident rights were reviewed with residents upon admission and throughout a resident's stay if needed. The Social Services Director stated they were not involved in the incident with Resident #522 but was involved in the interdisciplinary meeting regarding what interventions to be put in place. They stated the social services department was not involved in the conversation with the resident regarding the restrictions put in place and stated they should have been. If a resident had an order for supervision while out on pass, the Social Services Director stated they reviewed the need for accompaniment. They stated if they had concerns regarding resident's rights with the supervision on the pass, they would bring it up to the interdisciplinary team. During an interview on 12/4/2023 at 1:32 PM, Assistant Director of Nursing #48 stated they contacted the social worker and the Administrator to speak with the resident. The resident was educated that the facility was a non-smoking facility, that all their visits would be supervised in the lobby, and they would periodically ask the resident to do room searches. They stated they believed the Unit Manager had the conversation with the resident regarding the restrictions on going out on pass and supervised visitation. There was no current timeline for the restrictions to remain in place but would likely be reviewed in three months. They acknowledged a resident's right to leave the facility but stated that it was up to the provider when safety could be compromised. During an interview on 12/5/2023 at 12:15 PM, Resident #522 stated they were upset they could not go to their family's home for Christmas as they were looking forward to it. 10NYCRR 415.5 (a)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview during the recertification and abbreviated surveys (NY00323973, NY00324500, NY00324681, NY00325947, NY00326310, and NY00327344) conducted 11/27/2023-12/5/2023, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 9 of 11 residents (Residents #4, #18, #21, #55, #85, #121, #239, #265, and #521) reviewed. Specifically, -Resident #18 had blood glucose levels that were outside of parameters and medical was not notified as ordered. (Refer to F 600 Free from Abuse and Neglect) -Resident #21 had an unwitnessed fall, neurological checks (evaluation of nervous system functioning) were not completed, and the medical provider was not notified. -Resident #121 did not have a urology consult and positron emission tomography scan (an imaging test used to diagnose a disease) ordered and scheduled as recommended (Refer to F 550 Resident Rights) - Resident #239 had a wound dressing that was not changed for two days as ordered. - Resident #265 was admitted to the facility and did not receive medications timely and was sent to a local acute care hospital emergency department the same day without a physician's order, and without comprehensive information for the acute care hospital to provide adequate care for the resident. (Refer to F 622 Transfer and Discharge Requirements) - Resident #521 had an order for a vacuum-assisted closure device (wound vac, a device that uses a negative pressure to assist with healing) that was documented as applied and the resident was observed with an alternate wound dressing. - Resident #85 had recommendations from a wound care consult that were not communicated to the attending physician. - Resident #4 did not have insulin administered as ordered. - Resident #55 did not have a palm protector applied as ordered and did not have leg rests in place on their wheelchair. This resulted in harm to Residents #18, #121, and #265 that was not immediate jeopardy. Findings include: 1)Resident #18 had diagnoses including diabetes with peripheral angiopathy (narrowing of arteries) and retinopathy (damage to blood vessels in the eye). The 10/16/2023 Minimum Data Set assessment documented the resident had intact cognition, did not reject care, and received insulin injections 7 of 7 days. The facility policy Insulin Administration last reviewed 1/2020 documented when administering insulin, the type of insulin, dosage required, strength, and method of administration must be verified to assure that it corresponds with the order on the medication sheet and the physicians' order. Check blood glucose per physicians' order or facility protocol. Document the resident's blood sugar and insulin administration in the medication administration record. The comprehensive care plan initiated 8/16/2022 documented the resident had insulin dependent diabetes. Interventions included administer medications per physician orders and monitor blood glucose finger stick per physician orders. A physician order dated 10/26/2023 documented insulin glargine (long-acting insulin) inject 18 units subcutaneously in the morning for diabetes call physician if finger stick blood sugar was less than 70 milligrams/deciliter or greater than 300 milligrams/deciliter. The November 2023 medication administration record documented insulin glargine daily at 5:00 AM, notify physician for blood glucose less than 70 milligrams/deciliter or greater than 300 milligrams/deciliter. The following blood glucose results were documented: - on 11/3/2023 blood glucose 377 milligrams/deciliter - on 11/4/2023 blood glucose 484 milligrams/deciliter - on 11/5/2023 blood glucose 470 milligrams/deciliter - on 11/9/2023 blood glucose 395 milligrams/deciliter - on 11/10/2023 blood glucose 336 milligrams/deciliter - on 11/12/2023 blood glucose 380 milligrams/deciliter - on 11/13/2023 blood glucose 365 milligrams/deciliter Nursing progress notes dated 11/3/2023-11/13/2023 did not include documented evidence the physician was notified of the blood glucose results greater than 300 milligrams/deciliter. Nursing progress notes documented: - on 11/14/2023 at 6:40 AM licensed practical nurse # 83 documented the resident's blood glucose reading was HI, 18 units glargine given as ordered, rechecked blood glucose 30 minutes later, remained HI. Telehealth called and order received for 10 units of Novolog (rapid acting insulin) to be given one time for elevated blood sugar. - on 11/15/2023 at 1:30 PM licensed practical nurse #84 documented the resident's blood glucose was 448, the supervisor was made aware and order for lispro (rapid acting insulin) 10 units one time received. - on 11/18/2023 at 5:54 AM licensed practical nurse #85 documented the resident's blood sugar was HI, the nursing supervisor was notified, and the resident was transferred to the hospital. During an interview on 12/5/2023 at 11:13 AM, licensed practical nurse #86 stated they worked mostly evenings and overnights. Their job duties include passing medications, patient care, and staff would come to them with resident concerns. If a resident's blood sugar was out of the parameters, they would call let the supervisor know. The supervisor would call medical and let them know. They stated Resident #18 had blood sugar levels all over the map. They did not remember if they had to call the supervisor regarding Resident #18's elevated blood sugars. If the resident had an order to notify medical of blood sugars outside of certain parameters, it would be important to the resident to make sure that was done. During an interview on 12/5/23 at 12:37 PM, Assistant Director of Nursing # 48 stated they had previously been a night supervisor. Supervisors provided oversight, managed staffing, medical issues, and called providers if needed. The medication nurse would notify the supervisor of any issue on the floor, and the medical provider would be called by the supervisor, this included blood sugars out of parameters. Any issues would be documented on the 24-hour report. They stated an email shift report went to all Nurse Managers, Supervisors, Assistant Directors of Nursing, and the Director of Nursing. They did not remember receiving a phone call about Resident #18's blood glucose level on the morning of 11/5/2023. It was not documented that they were made aware or called medical. The resident's blood glucose was 470 at 4:21 AM per the electronic health record. The order stated medical should be called for a blood sugar less than 70 or greater than 300. If a resident's blood sugars were out of range, they could need more insulin. Medical should have been notified of those instances to make decisions based on correct information. Hypoglycemia and hyperglycemia both posed risks to the resident. During an interview on 12/5/23 at 12:52 PM Assistant Director of Nursing #3 stated there was a 24-hour report that contained any resident issues needing follow up. There was also a report via email by night supervisors, which contained resident issues such as falls, labs, and blood sugars out of parameters. They did not remember Resident #18's blood glucose levels being reported on the above dates in November. The medication nurse should have contacted the supervisor to call medical for the blood glucose levels above 300 and it should have been documented in progress notes. During an interview on 12/5/23 at 1:07 PM, the Medical Director stated medical should always be notified of blood sugars that were out of parameters. The resident goals were trying to maintain blood sugar stability. Changes to monitoring of blood work and changes in insulin would have been important to the resident. During an interview on 12/5/23 at 1:35 PM, nurse practitioner #21 stated that a medical provider should be notified of blood sugars outside of parameters. If the results were off hours telehealth should be called. Nurse practitioner #21 stated that they were aware of Resident #18s elevated blood sugars around 11/14/2023. They had been notified and ordered a urinalysis for symptoms of a urinary tract infection, which could also raise blood sugar levels. They had not been notified of the elevated blood glucose levels on the previous dates. 2) Resident #55 had diagnoses including vascular dementia, and left-hand contracture (tightening of muscles, tendons, or joints), and muscle weakness. The 8/26/2023 Minimum Data Set assessment documented the resident had severely impaired cognition, did not reject care, and required total assistance with wheelchair locomotion and dressing. The facility policy Splints, Braces, and Slings last revised 4/2019 documented to protect the safety and well-being of residents, and to promote quality care, this facility uses appropriate techniques and devices for appliances, splints, braces, and slings. To assure all splints, braces, slings etc. are used appropriately and cared for properly and upper and lower extremities are maintained in a functional position. Nursing ensures proper schedule for donning and doffing appliance is known by certified nurse aide staff and provides appropriately sign off of task options. The facility policy Resident Seating Recommendations created 10/12/2021 documented a resident with compromised mobility shall receive appropriate services, equipment, and assistance to maintain or improve to their maximum practical independence and preserve their safety. Feet should be supported in chair, not dangling free, especially during transport. Elevating leg rests are optional for comfort and support. Adjusting the entire leg attachment to the correct height is essential to assist the pelvis into a stable position. A physician order dated 8/28/2023 documented left upper extremity palm guard wear daily, remove for hygiene. The comprehensive care plan initiated 10/12/2022 documented the resident had limited physical mobility related to dementia and weakness. Interventions were updated on 8/28/2023 and included left upper extremity palm guard worn daily and remove for hygiene. Monitor/document/report signs /symptoms of immobility: contractures forming or worsening, thrombus formation, skin-breakdown, fall related injury. The resident care instructions as of 12/4/2023 documented the resident required total assistance with locomotion both on and off the unit, a left upper extremity palm guard was to be worn daily and removed for hygiene, and the resident did not use their own strength for any part of wheeling their wheelchair. Resident #55 was observed: - on 11/28/2023 at 9:47 AM receiving assistance with breakfast. There were no leg rests on their wheelchair, their feet were dangling and did not touch the floor. At 11:12 AM in a high back wheelchair with no leg rests. Their feet were dangling and did not touch the floor. - on 11/30/2023 at 9:20 AM in the dining room waiting for breakfast trays, seated in a high back wheelchair. Wheelchair leg rests were in place and the resident's leg were not on the rests. Their legs were dangling between the chair and the leg rests. There was no palm protector present on their left hand. At 10:34 AM in bed with no palm protector present on their left hand. At 1:57 PM in the dining room with no palm protector present on their left hand and no leg rests on their wheelchair. The resident's feet were not touching floor. - on 12/1/2023 at 10:16 AM sitting in a high back wheelchair. The leg rests were in place with the resident's legs positioned behind the leg rests not touching the floor, and they did not have the palm protector on their left hand. During an interview on 12/4/2023 at 10:48 AM, physician # 68 stated not wearing a palm protector on a hand as ordered could lead to altered skin integrity or worsening of a contracture. Resident #55 should have foot pedals in place to prevent foot drop and provide safety when being pushed in their wheelchair. During an interview on 12/4/2023 at 10:53 AM, certified nurse aide #87 stated resident care information was found in the care plan/ [NAME] (care instructions) in the electronic health record. Information such as how much assistance was needed for activities of daily living and need for leg rests, and splints would all be there. Palm protectors helped keep skin dry and intact where fingers curled up in the resident's palms. Leg rests should be used for residents who could not propel themselves. Resident #55 needed total care; leg rests could improve positioning in the wheelchair. During an interview on 12/4/2023 at 2:36 PM, the Rehabilitation Director palm protectors were used to maintain range of motion, prevent worsening of contractures, and to protect skin integrity. Leg rests were to be used when residents needed to be assisted with locomotion. If the resident's feet did not touch the ground in their wheelchair, then leg rests should be used. During an interview on 12/4/2023 at 10:59 AM, certified nurse aide #88 stated Resident #55 was on their assignment on 12/4/2023. They did not apply palm protectors with morning care and dressing. Using a palm protector would help protect from further contracture. Resident #55 was supposed to have leg rests on their wheelchair because their feet dangled. They stated they must have been going too fast this morning and missed it. During an interview on 12/4/2023 at 11:21 AM, licensed practical nurse # 55 stated certified palm protectors were used to prevent further hand contractures and protect skin integrity. Resident #55 was to wear one on their left hand, on in the morning off in the evening. Leg rests should be used for residents who did not self-propel their wheelchair. Resident #55 needed leg rests to help with positioning and it prevented them from dragging their feet. Leg rests also would help keep them from falling forward and could help prevent foot drop. Certified nurse aides were responsible for the leg rests when they assisted residents to their wheelchair. During an interview on 12/4/23 at 11:56 AM, Assistant Director of Nursing #3 stated Resident #55 should wear their palm protector at all times except with hygiene. They were not aware it had not been applied this morning. Leg rests were important for proper positioning in wheelchairs. If not utilized a resident could develop drop foot, or their feet could get in the way and cause an accident while being assisted with locomotion. 3) Resident #521 was admitted to the facility with diagnoses including surgical amputation of left and right toes, acute osteomyelitis (bone infection) of left ankle and foot, and diabetes. The 11/16/2023 Minimum Data Set assessment documented the resident was cognitively intact, was dependent with transfers, required moderate to maximal assistance with most other activities of daily living, and was receiving surgical wound care with application of dressing to feet. The comprehensive care plan dated 11/9/2023, documented the resident had impaired skin integrity related to surgery and osteomyelitis of the left lower extremity amputation site. Interventions included to apply treatment per physician orders, evaluate the wound for infection, document wound healing, and refer to appropriate medical specialist for evaluation and treatment. The comprehensive care plan did not include use of a vacuum-assisted closure device. Physician orders documented: - on 11/9/2023 change the wound vac/negative pressure machine cannister weekly and as needed every shift, every seven days for wound care. - on 11/9/2023 the wound vac/negative pressure machine should be set at 125 millimeters of mercury (unit of pressure) on the left lower extremity amputation site. It should be checked every shift on Monday, Wednesday, and Friday for wound care and as needed for displacement or soilage. - on 11/9/2023 check the wound vac/negative pressure machine for the left lower extremity amputation site placement and proper function every shift; the machine should be set at 125 millimeters of mercury to the left lower extremity amputation site. - on 11/9/2023 cleanse the left lower amputation site with normal saline solution, apply saline soaked gauze, and cover with a dry dressing as needed if unable to maintain a seal or device. - on 11/16/2023 wound care consult for evaluation and treatment for the replacement of the previous wound vac with a facility wound vac for continued treatment to the left lower extremity great toe amputation. The resident's 11/2023 treatment administration record documented: - a start date of 11/9/2023 check wound vac/negative pressure for placement and proper function. Maintain negative pressure at 125 millimeters of mercury; left lower extremity amputation site every shift for verification. - a start date of 11/9/2023 cleanse left lower extremity amputation site with normal saline, apply saline soaked gauze, cover with dry dressing as needed for inability to maintain a seal or for device malfunction. - a start date of 11/9/2023 wound vac/negative pressure at 125 millimeters of mercury to left lower extremity amputation site, change 3 times per week as needed for soilage/displacement. - a start date of 11/10/2023 wound vac negative pressure at 125 milliliters of mercury to left lower extremity amputation site. Change 3 times per week every day shift on Monday, Wednesday, and Friday for wound care. The following observations of Resident #521 were made: - On 11/27/2023 at 12:33 PM, their feet were wrapped in a white dressing and there was an unplugged wound vac on the resident's dresser. The resident stated the nurses were supposed to be changing their dressings every day, but were not, and they were supposed to have a wound vac on. They stated the nursing staff took off the wound vac and left it on the dresser. - On 11/29/2023 at 8:55 AM, the wound vac had been removed from the resident's room and a gray wash bin was on the resident's dresser with wound care supplies. At 11:01 AM, the resident had a dressing on the left foot dated 11/28/2023. The resident stated that someone came and removed the wound vac from their wound yesterday. - On 11/30/2023 at 9:06 AM, sitting on edge of their bed with their left foot wrapped in gauze that was not dated. The resident stated they had an appointment to get their stiches out today and was waiting for their ride. The resident's 11/2023 treatment administration record documented: - a start date of 11/9/2023 check wound vac/negative pressure for placement and proper function. Maintain negative pressure at 125 millimeters of mercury; left lower extremity amputation site every shift for verification. The treatment administration record was signed as completed by registered nurse #40 on 11/27/2023 on the day and evening shift, and was blank on the night shift; signed as completed by registered nurse #40 on 11/29/2023 day and evening shift, and by licensed practical nurse #82 on the night shift; signed as completed by registered nurse #40 on the 11/30/2023 day shift; other see nurse note licensed practical nurse #90 evening shift, and completed by licensed practical nurse #90 on the night shift. - a start date of 11/9/2023 cleanse left lower extremity amputation site with normal saline, apply saline soaked gauze, cover with dry dressing as needed for inability to maintain a seal or for device malfunction. The treatment was not signed (blank) as administered on 11/27/2023, 11/29/2023, and 11/30/2023. - a start date of 11/9/2023 wound vac/negative pressure at 125 millimeters of mercury to left lower extremity amputation site, change 3 times per week as needed for soilage/displacement. The treatment was not signed as completed for the month of November 2023. - a start date of 11/10/2023 wound vac negative pressure at 125 milliliters of mercury to left lower extremity amputation site. Change 3 times per week every day shift on Monday, Wednesday, and Friday for wound care. The treatment was signed as 9 other see nurse note, by registered nurse #40 on 11/27/2023 and 11/29/2023. The physician #69 progress notes dated 11/27/2023 and 11/218/2023 documented to continue wound vac on the left foot until the resident was seen in clinic for a vascular follow up. During an interview on 12/01/2023 at 10:18 AM, registered nurse #40 stated they followed the orders that were in a resident's chart for wound care. They stated all wound care completed was documented in the treatment administration record and if they were not able to perform the wound care, they would inform the Nurse Manager and wound care team. Registered nurse #40 stated Resident #521 had wound care to both feet. They stated the order for the left foot was to wash with normal saline and to rewrap as needed. The resident had a wound vac order but would get up with the wound vac on, so the order was changed. Registered nurse #40 stated they were unsure when the order was changed but the wound vac orders were still active. The treatment nurses should have documented the wound vac was not in place in the treatment administration record since the order was still active. During an interview on 12/01/2023 at 11:18 AM, registered nurse Unit Manager #29 stated Resident #521 had a wet-to-dry dressing on their left foot as they kept unplugging their wound vac, so the wound care provider discontinued the wound vac. They stated they believed the wound vac was discontinued around 11/22/2023. The registered nurse unit manager #29 stated the wound vac orders were listed as active until today when they discontinued them. They expected the nurses on the floor to document that the wound vac was not in place on the treatment administration record for the days after the wound vac was removed and the order remained active as it would be incorrect to document it was in place. They stated nurses should have documented the dressings they did on the left foot under the as needed order. They stated with an as needed order only the nurses could leave the dressing for days and it would not be changed. They stated there was a wound care note with directions on 11/22/2023 for a wet-to-dry dressing but no frequency was noted. During an interview on 12/4/2023 at 1:32 PM, Assistant Director of Nursing #48 stated Resident #521 was seen by wound care when the wound vac was taken off and new orders were put in. The wound vac orders should have been discontinued when the wound vac was removed. If the active order was not discontinued but the wound vac not in place, the nurses should inform the Unit Manager and document it was not in place until the order was discontinued. 10 NYCRR 415.12

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the abbreviated survey (NY00306583), 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 1 of 3 residents (Resident #1) reviewed. Specifically, when Resident #1 developed maroon, blue, black discoloration on their heels, routine monitoring, treatment interventions, and pressure relief were not implemented when recommended to promote healing and the resident's left heel wound progressed to a Stage 4 pressure ulcer (full thickness tissue loss with exposed bone, tendon, or muscle). This resulted in actual harm that was not immediate jeopardy to Resident #1. Findings include: The facility policy Physician-Consultations revised 8/2019 documented a consultant would perform the requested evaluation and provide a consultant's note or report. The attending physician would consider the appropriateness of the consultants' recommendations relative to the resident/patient's current condition, risk factors, existing medication regimen, etc. The attending physician was ultimately responsible for all orders and should remain involved with any aspect of care for which a consultant was involved. As appropriate, the attending physician would approve orders based on consultant recommendations. The facility policy Food and Nutrition Assessment dated 2/2023 documented a nutritional assessment, including current nutritional status and risk factors for malnutrition, should be conducted for each resident. The dietitian, with the nursing staff and healthcare practitioners' input, would conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that placed the resident at risk for impaired nutrition. Resident #1 was admitted to the facility with diagnoses including dementia, morbid obesity, and dysphagia (difficulty swallowing). The 7/3/22 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance of 2 with bed mobility, total dependence for transfers, was at risk of pressure ulcers, had no skin impairments, had pressure reducing devices for their chair/bed, and was on a turning and repositioning program. A progress note dated 9/3/22 at 11:00 PM by registered nurse supervisor (RNS) #24 documented they were notified by a licensed practical nurse (LPN) of a circular discoloration to both the resident's heels, with the left heel larger than the right. The left heel was pink/red and dark blue, and the right heel was dark blue/black. The resident's heels were elevated off the bed and the care plan was updated. The impaired skin integrity comprehensive care plan (CCP) initiated 9/4/22 documented on 9/3/22 the resident had discolorations noted to both heels with the left greater than the right. CCP and [NAME] (care instructions) interventions included apply protective and preventative skin care and elevate heels off the bed by utilizing a pillow. An Incident Report dated 9/3/22 at 11:00 PM by RNS #24 documented the resident had a skin issue and was found with bruises to both heels. The telemedicine service on-call nurse practitioner (NP #35) was notified on 9/4/22 at 1:00 AM. The incident report documented the family was not notified because the area was a skin discoloration and not an alteration. The resident's heels were elevated. A progress note entered on 9/7/22 at 7:10 PM by licensed practical nurse (LPN) #12 documented they were notified the resident had soft, red areas on both heels. The left heel had a large intact blister, and the right outer heel had a small dark scab. Skin prep (protective barrier) was applied, the nurse practitioner (NP #9) was notified, and a wound care consult would be obtained. A wound evaluation summary by wound care physician #22 entered on 9/7/22 at 8:12 PM documented the resident had a deep tissue injury (DTI, purple or maroon area of intact skin or a blood-filled blister due to damage of underlying soft tissue from pressure) to the right heel that measured 0.5 centimeters (cm) x 0.5 cm. The left heel had a DTI measuring 4.2 cm x 4 cm. The plan included apply skin prep, sponge boots to both feet (a boot that floats the heels from resting on a surface, helping to reduce pressure) and to elevate their legs. A late entry progress note dated 9/7/22 at 3:59 PM (the note did not document when the actual late entry was) by LPN #26 (former wound nurse) documented the resident was seen by the wound care physician for new DTIs to both heels. The left heel was intact (not impaired), and the right heel had a small scab. The resident would dig their heels into the bed to push themselves up. A physical therapy (PT) consult would be ordered, and skin prep would be applied. There was no documented evidence a PT consult or sponge boots were ordered or added to the CCP. On 2/2/23 at 9:37 AM, the Director of Nursing (DON) documented in a correspondence email that physical therapy did not have any consults or notes for the resident around the date of 9/7/22. A 9/9/22 physician order (2 days after wound physician recommendations) documented skin prep to both heels daily and off load heels (elevating the heels to relieve pressure). A wound evaluation summary by wound physician #22 entered on 9/14/22 at 10:54 AM documented the left heel unstageable DTI had a fluid filled blister, had deteriorated, and measured 6 cm x 6 cm. Recommendations included to continue skin prep and switch to a sponge boot. The impaired skin integrity CCP updated 9/15/22 documented the resident had an alteration in skin integrity. Interventions included to evaluate the wound weekly, monitor dressing, report changes to the physician, and refer to the wound specialist as needed. There was no documented evidence the resident had sponge boots added to the plan of care. A nutrition progress note by registered dietitian (RD) #24 dated 9/19/22 at 11:46 AM (16 days after the development of skin impairment), documented they were notified of the resident's impaired skin after reviewing the resident's chart. The resident's estimated needs for skin were 2250 Kcals (calories), 94 grams of protein, and 2250 cubic centimeters (cc) of fluid. Supplements were in place for weight and included super cereal (fortified cereal) for breakfast, and fortified pudding/potato for lunch and dinner. The plan was to continue supplements for wound healing. Nursing progress notes documented: -on 9/24/22 at 3:35 PM by LPN #27 they reported to the RNS the resident's heel wound opened and the original order was to apply skin prep. The RNS stated they would assess the heel. -on 9/25/22 at 6:10 AM by LPN #18 the RNS assessed the open areas on the resident's heel. -on 9/25/22 at 10:40 PM by LPN #29 the resident's left heel was open with a moderate amount of bloody drainage. The area was cleansed with normal saline and a dry sterile dressing (DSD) was applied and covered with Kling (elastic) wrap. -on 9/26/22 at 9:08 AM by LPN #26 the resident's left heel DTI had deroofed (the top of the blister rubbed off) and the right DTI remained closed. The resident was scheduled for the wound physician visit on 9/27/22. There was no documented evidence of an RNS assessment of the resident's heel wounds or a physician order for the applied treatment of normal saline, DSD, and Kling wrap. A physician order dated 9/26/22 documented to cleanse the left heel with normal saline, apply a petroleum wound dressing and cover with a dry dressing every day. A wound evaluation summary entered on 9/27/22 at 7:12 PM by wound physician #22 documented the DTI to the right heel was resolved. The left heel was a Stage 3 (full thickness tissue loss) and measured 4.5 cm x 6 cm x 0.1 cm with 100% necrotic (dead) tissue and moderate exudate (drainage). The plan was to begin collagen powder (sprinkled on a wound to form a protective gel), petroleum wound dressing, covered with an abdominal pad (absorbent dressing) and Kerlix daily. There was no documented evidence wound physician #22's recommended treatment of collagen powder, petroleum wound dressing, covered with an abdominal pad (absorbent dressing) and Kerlix daily were ordered for the left heel wound. On 10/12/22, 10/18/22, and 10/25/22 wound evaluation summaries by wound physician #22 documented the resident's had a Stage 3 pressure wound to the left heel, the wound was improved and continue collagen powder, petroleum wound dressing, abdominal pad, and Kerlix daily. There was no documentation the wound physician's recommendation to add collagen powder was ordered. The 10/2022 Treatment Administration Record (TAR) documented the resident's left heel treatment included cleanse with normal saline, apply petroleum wound dressing and cover with a dry dressing and was administered every day from 10/1/22 through 10/31/22. The 10/19/22 risk for pressure ulcer CCP documented the resident had a history of pressure ulcers. Interventions included sponge boots to both feet to offload heels, inform family of any new area of skin breakdown, and monitor/document/report to physician changes in skin status. The 10/27/22 at 1:19 PM diet technician (DT) #30 progress note documented the resident's weight was down to 203.4 pounds (8 pound loss) though intakes remained excellent at 86%. The resident received double entree portions at meals, double scrambled eggs, and fortified cereal at breakfast, fortified mashed potatoes and fortified pudding at lunch and dinner. The resident consumed 51-75% of supplements/nourishments. The plan was to trial a liquid protein supplement 30 cubic centimeters (cc) twice daily for wound healing support. A 11/4/22 wound evaluation summary by wound physician #22 documented the resident's visit was rescheduled. There was no documentation the resident's wound was assessed by a qualified professional from 10/25/22 to 11/9/22. A wound evaluation summary dated 11/9/22 entered by wound physician #22 (13 days after the last assessment) documented the resident had a Stage 3 pressure wound of the left heel which measured 9 cm x 7 cm x 0.1 cm, was 70% necrotic with moderate serous exudate and had deteriorated. The plan was to continue collagen powder, petroleum wound dressing, abdominal pad and rolled bandage daily. There was no documentation the resident's recommended treatment was ordered. The 11/10/22 physician order documented liquid protein supplement 30 cc twice daily (14 days after recommendations by the diet technician). A wound evaluation summary dated 11/15/22 and entered by wound physician #22 documented the resident had a Stage 4 pressure wound of the left heel measuring 5.4 cm x 6 cm x 0.7 cm. The wound had moderate serous drainage with an odor, was 100% necrotic and had deteriorated. The plan was to change the treatment to a debriding ointment (removes dead tissue), calcium alginate dressing (absorbs wound fluid), covered with an abdominal pad and rolled bandage daily. The 11/22 TAR documented the resident's left heel treatment was to cleanse with normal saline, apply petroleum wound dressing, and cover with a dry dressing and was administered every day from 11/1 through 11/16/22. There was no documentation the 11/15/22 recommended treatment by the wound physician of debriding ointment and calcium alginate was ordered. The 11/15/22 progress note by LPN #23 documented the resident was seen by the wound physician and the left heel had deteriorated. Debridement (removal of dead tissue) was limited by pain. The plan was to debriding ointment/calcium alginate dressing and elevate and offload heels. The 11/17/23 physician order (2 days after recommendation) documented debriding ointment, calcium alginate, abdominal pad and Kerlix daily to heel, and offload heels at all times. From 11/17/23 to 1/17/23, the resident was seen by the wound physician weekly and the Stage 4 pressure wound on the left heel had no documented changes. The 1/18/23 wound evaluation summary by wound physician #31 documented the left heel was a Stage 4 pressure wound and measured 5 cm x 6 cm x 0.3 cm, was 40% necrotic and had no change. The plan was to use gauze-soaked dilute bleach solution, debriding ointment, and cover with abdominal pad and Kerlix. The 1/19/23 physician order documented to cleanse the left heel with normal saline, apply debriding ointment and calcium alginate, cover with abdominal pad and Kerlix. The order did not include gauze-soaked dilute bleach solution as recommended by the wound physician. The 2/1/23 wound evaluation summary by wound physician #31 documented the left heel Stage 4 pressure wound measured 4.6 cm x 3.6 cm x 0.3 cm and had 20% slough (moist, dead tissue) and was improved. The plan was to begin gauze-soaked dilute bleach solution, leptospermum honey (wound treatment containing honey), abdominal pad and Kerlix. The 2/1/23 physician order documented to cleanse the left heel with normal saline, apply honey containing wound treatment followed by calcium alginate, abdominal pad and Kerlix. The order did not include gauze-soaked dilute bleach solution as recommended by the wound physician. The resident was observed: - on 2/14/23 at 8:50 AM, sleeping in a low bed with their covered breakfast tray on the bedside table. The resident had a padded boot on their right foot and the left foot was not visible under a blanket. - on 2/15/23 at 11:09 AM, during a wound evaluation with wound physician #31. The resident's padded booties and the dressing on the left heel were removed. There was a 4.6 cm x 4 cm x 0.2 cm pink/red wound on the left heel with a scant (minimal) amount of slough. Wound physician #31 debrided the wound and the nurse applied the honey containing dressing, calcium alginate and covered the wound with an abdominal pad and Kerlix. During a telephone interview on 2/23/23 at 8:50 AM former wound physician #22 stated when they made recommendations for a wound treatment, the medical providers at the facility would review and approve the treatment, and they expected treatments to be implemented within 24 hours. They stated they had rounded weekly with wound nurses LPNs #23 and #26 and would tell them the recommended treatments. The wound physician would document on the consult form which was uploaded into the electronic medical record. A nutritional assessment should be done within a week after the development of a pressure ulcer and recommended interventions should be implemented as soon as possible. Nutritional interventions were important for wound healing, and the goal was for the resident to have adequate protein stores. If a protein supplement was recommended at the time of the assessment, it should have been ordered then, and waiting 2 weeks was not timely. When the resident's DTI opened on 9/24/22 the skin protectant was no longer appropriate as it could irritate an open wound and they expected medical to be notified for a different treatment to be used. The wound physician stated on 9/27/22 they recommended collagen powder for additional wound healing and was not aware it was not ordered. Wounds should be assessed weekly and if they were not available, they expected an RN to assess the wound. On 11/15/22 the resident's wound had deteriorated, and they ordered the debriding ointment to remove dead tissue and the calcium alginate to absorb drainage and was not aware the treatment had not been ordered until 3 days after the recommendation. During a telephone interview on 2/23/23 at 10:50 AM LPN #23 stated as a wound nurse they assisted the wound physician during wound rounds, took recommendations from the wound physician and addressed them with the facility providers who typically had no issue ordering what the wound physician wanted. A sponge boot required a physician order, and a therapy evaluation was usually needed to obtain the boots. Once ordered the boots would be on the TAR and the resident's care plan. The RN or Unit Manager was responsible to update the care plan. The Unit Manager should notify the RD that a resident had a new skin impairment. An RN should assess wounds when the wound physician was not available. There were RNs available in the facility to assess wounds. The LPN stated when the resident developed DTIs on their heels, they did not recall what interventions were initially in place. LPN #23 did not know why wound physician #22's recommendation of collagen powder was not ordered on 9/27/22. The wound physician would verbally tell them what treatment they wanted during rounds however in the past the verbal order and the wound evaluation summary did not always match so they waited for the completed wound evaluation summary. The wound physician did not always get their summary uploaded into the electronic record timely and that was why the order for debriding ointment and calcium alginate was delayed for 2 days after the wound consult on 11/15/22. During a telephone interview on 2/23/23 at 12:41 PM, RNS #24 stated when a resident had a newly identified pressure ulcer, an RN assessment was done, the physician was contacted, the family was updated, the resident was referred for a wound consult, an accident/incident report was completed, and the care plan was updated. On 9/3/23, they would have notified the on-call provider of the resident's DTI because that was a weekend, and no facility provider was on duty. They did not get an order for the resident's heel because the areas were not open. A wound care referral required a physician's order, and they should have gotten one. During a telephone interview on 2/23/23 at 1:07 PM, former wound nurse LPN #26 stated therapy evaluations and sponge boots required a physician's order and needed to be on the care plan. They were not sure why the therapy evaluation was not completed after they wrote in their note on 9/7/22 that it was ordered. During a telephone interview on 2/27/23 at 8:08 AM, RD #24 stated they needed to know when a resident developed a skin impairment so they could assess the resident's nutritional needs for wound healing. The lead RD went to morning report and if a resident had a new skin impairment, they sent a report out to the nutrition team. RD #24 stated when they made nutritional recommendations, they discussed them with the Unit Manager who was responsible for communicating the recommendations to the physician for an order. RD #24 expected the order to be implemented the same day. RD #24 stated when they wrote their progress note on 9/19/22, they found out about the resident's pressure ulcer after reviewing the record and was not notified prior to that therefore, the assessment was not done timely. RD #24 stated the protein supplement was needed to assist with wound healing. The supplement being ordered 14 days after it was recommended was not timely and could impair wound healing. During a telephone interview on 2/27/23 at 11:50 AM, LPN #12 (former Unit Manager) stated the wound nurses would put the orders in the electronic medical record for the wound physician. They were not aware that skin prep recommended by the wound physician on 9/7/22 did not start for 48 hours after the recommendation and that was not timely. When the resident's DTI opened, they expected staff to report it to the RNS who should assess the wound, call the provider, and document in a progress note. They were not aware there was no documented RN assessment on 9/24/22. Any nurse could send a therapy evaluation in the electronic record and a physician's order was not required and the request was automatically sent to therapy once it was entered in the electronic record. They were not aware the therapy evaluation was not ordered, and it should have been. The former wound nurse LPN #26 was responsible for sending the therapy evaluation. If the wound physician recommended a sponge boot, an order was needed, and it would be on the TAR for a nurse to sign for. The LPN said they were not aware the boot was not ordered. Nutrition staff should have been notified within 24 hours after a resident developed pressure and were typically notified during morning report. The LPN stated they were not aware nutrition was not notified for 16 days after the resident developed a pressure ulcer. The RD was responsible for calling the physician for an order when they recommended a nutritional supplement. The LPN stated, it was not timely when it took 16 days to start the protein supplement for the resident. During a telephone interview with NP #9 on 3/2/23 at 10:30 AM, they stated they expected to be called to review treatment orders from the wound physician and would approve the recommendations. The NP stated they should have been notified for a treatment order for the skin prep and booties when RNS #24 found the resident's heels discolored in September 2022. The NP stated recommendations from the wound physician should be implemented the same day and 2 days for the skin protectant to be implemented was not timely. Nutrition should assess a resident immediately after the development of or a change in a pressure ulcer because nutritional interventions were important for wound healing. If a nutritional intervention was recommended, they expected it to be ordered immediately. When nutrition recommended a protein supplement for the resident it was not timely for the supplement to be ordered 2 weeks later. It was the responsibility of nutrition staff to notify the Unit Manager or the provider to implement their recommendations. When the resident's ulcer opened, they expected an RN to assess the wound at that time. The NP stated that skin protectant was not an appropriate treatment for an open wound as it was very irritating to tissue. The collagen powder should have been added when the wound physician recommended it. The resident did not receive the treatment for 6 weeks after the recommendation and that was not appropriate. When debriding ointment and calcium alginate was recommended on 11/15/22, it was not ordered for 2 days and was not timely. The debriding ointment was needed to remove necrotic dead tissue and calcium alginate was needed for drainage. The NP stated when the wound physician was not available to assess a wound, they expected an RN to assess the resident's wound. 10NYCRR 415.12(c)(2)