**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure one of three sampled residents (Resident 1) was provided with the appropriate resident-centered treatment and care when: 1. Multiple skin discoloration on Resident 1's back observed on 6/28/23 did not have a follow-up assessment, evaluation, and appropriate interventions by the Wound Care Team (Clinicians who develops and implements wound prevention, skin management, and wound care). 2. The Weekly Skin Assessments (WSK, supposed to be documented on the Comprehensive Skin Evaluation/Assessment, CSEA) form were not done for the months of May and June 2023. For the month of July 2023, the WSKs were done only on 7/6/23 and on 7/14/23, not on a weekly basis, as per policy. 3. The Braden Scale for Predicting Pressure Sore Risk (BSPPSR, a tool to identify patients at-risk of forming pressure sores, injuries to skin and underlying tissue resulting from prolonged pressure) was not completed on a quarterly basis after 2/28/23 and after Resident 1's re-admission back to the facility on 5/18/23 and 8/11/23, as per facility policy. Failure to perform follow-up assessment and evaluation, and failure to provide appropriate interventions for the multiple skin discoloration in the resident's back resulted to the development of multiple scattered wounds on 8/6/23 (39 days after it was initially detected). In addition, failure to do the weekly skin assessment and failure to complete the BSPPSR as per policy, allowed the scattered wounds in the resident's back to go undetected, deteriorated and progressed to a wound infection. Resident 1 had to be given an intramuscular injection (a technique used to deliver a medication deep into the muscles) of Ceftriaxone (antibiotic medication) for five (5) days for the treatment of cellulitis (a bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin). Findings: 1. During a closed record review, the Face Sheet indicated, Resident 1 was originally admitted to the facility on [DATE]. The History and Physical dated 5/20/23 indicated, Resident 1 had a history of chronic obstructive pulmonary disease (COPD, a breathing problem), venous hypertension of lower extremities (increased pressure inside the veins of both legs), chronic ulcer of the left lower leg (areas on the legs where underlying tissue damage, or a trauma, has caused skin loss which shows no tendency to heal after 3 months of appropriate treatment), and obesity (excessive accumulation of body fat). In a concurrent record review and interview on 11/30/23, at 1:25 PM, with the MDS (Minimum Data Set, an assessment tool) Coordinator 1, the Quarterly MDS dated [DATE], was reviewed. The MDS Coordinator 1 stated, the Residnet 1's Brief Mental Status (BIMS of 15/15 means the resident is awake, alert, and oriented) was 14, resident was cognitively intact, the resident required extensive assistance with mobility, toileting, dressing, and personal hygiene, and was always incontinent with bladder and bowel movement (having no or insufficient voluntary control over urination or defecation). The Section M of the MDS indicated, the resident was at risk for developing pressure injuries (PI, localized damage to the skin as well as underlying soft tissue), no unhealed PI, and the total number of venous ulcer (leg ulcers caused by problems with blood flow (circulation) in the leg veins)was 0. In an interview on 11/7/23, at 11:18 AM, with the Director of Nursing (DON 1), DON 1 stated, Resident 1 was non-compliant with care, refused to be turned, and was incontinent of bowel and bladder. Record review of the Care Plan on xxx (name of Resident 1) is resistive to care . , with the last revised of 2/12/20 indicated, Administer . medications. Allow . to make decisions . challenge resident reality explaining care team would be able to help . if resident complies to care /assessments . encourage as much participation as possible . to activities. During a record review of the Progress Notes (PN), dated 6/28/23 it indicated, Resident 1 had multiple skin discoloration on the body. was seen today by MD (Physician) . MD suspected cellulitis . MD wants to do a care conference for resident-Including SW (Social Worker), nursing and psych (psychiatry consult)., electronically (e)-signed by the License Vocational Nurse (LVN 1). In an interview on 11/9/23, at 3:37 PM, with the LVN 1, LVN 1 stated, the skin discoloration was on the resident's lower back and the butt (buttocks) area was colored purple. LVN 1 stated, she notified the SW to set up a case conference and was not sure if the case conference happened. Record review of the Physician's Progress Notes (PPN), dated 6/28/23 indicated, History of Present Illness: Incontinent, skin breakdown, refusing some care. The Physical Exam section of the PPN indicated, Skin: perineum (region between the thighs): erythema (redness) small ulcerations, weeping areas (a clear to yellow fluid that leaks out of a wound) through to buttocks. and wound nurse to evaluate and treat. In a phone interview on 11/9/23, at 4:10 PM, with the Treatment Nurse (TN 1) in the presence of the DON 1, TN 1 stated, she did not receive a referral to evaluate the skin discoloration observed on Resident 1's back on 6/28/23 and the resident was not on the list for wound rounds (wound care team visits each resident as a group to review the patient's status and care plan). In an interview on 11/9/23, at 3:02 PM, with the Director of Nursing (DON 1), DON 1 stated, way back in 2022, the resident had chronic leg ulceration, she (DON 1) was the TN and there was no skin condition, only leg ulcerations. The DON 1 stated, on 6/28/23, the LVN 1 documented skin discoloration on the resident's body and the Physician requested a care conference, it did not happen because the LVN 1 did not inform the nursing management (the Charge Nurse, the DON, and the Nursing Supervisor) of the skin discoloration in the resident's body as well as the physician's request for a case conference. The DON 1 stated, according to her interview with the TN 1, the TN 1 did not receive report of skin discoloration observed on the resident's back on 6/28/23, the resident was not on the list for the wound rounds. And because of that, the DON 1 stated, there was no follow-up skin assessment, no evaluation of the resident's skin discoloration, no treatment provided, and the request for a case conference with the team did not happen. The DON 1 stated, on 8/6/23 the staff noted the skin discoloration on the resident's back progressed to multiple scattered wounds. Record review of the Progress Notes (PN), dated 8/6/23 indicated, scattered wounds from left upper back, I (means left as per the Registered Nurse/Unit Manager (RN/UM) I lower back, I hip, I buttock and posterior LLE (left lower extremity, means left leg) . Interventions: . ATB (means antibiotic cream as per UM 1) over all wounds . also IM (intramuscular) ceftriaxone (antibiotic medication) . daily x (for) 5 (five days). e-signed by the RN/UM 1. In an interview on 11/30/23 at 2:03 PM, with the RN/UM 1, RN/UM 1 stated, on 8/6/23, the resident had mixed skin discoloration with skin tears, and opened scattered wounds about the size of a dime and a little less than a quarter in the left side of breast, left hip, left leg, left buttocks, with scanty amount of bleeding. The UM 1 stated, the resident had been refusing care, and was bed ridden. Record review of the Medication Admin. Audit Report, dated 8/6/23 to 8/11/23 indicated, Ceftriaxone 1 (one) gram per day was administered intramuscularly for five (5) days, from 8/6/23 to 8/11/23 for wound infection (the presence of replicating microorganisms within a wound). In an interview on 11/30/23, at 11:15 AM with the LVN 3, LVN 3 stated, on 8/6/23, the primary provider was present with him to assess the resident. The LVN 3 stated, the skin on the left upper back, left side of the breast, left hip, left buttocks, and posterior LLE (back of the left leg), was very raw (red color). There were scattered wounds on the left side of the body with irregular borders and had greenish color material on the wound bed. The UM 2 stated, the resident refused care, was bed ridden, refused to turn, and refused diaper changes. In an interview on 11/9/23, at 3:59 AM, with the RN 1, RN 1 stated, she took care of the resident on 8/11/23 and stated, there were redness on both the resident's underarms, redness on the skin of both breasts, and the upper back had plenty of multiple opened skins, and tears. The RN 1 stated, the resident had been refusing care for the last three days, was not eating, did not drink, and used to ask for oxycodone (pain medication), and had been refusing oxycodone for the last three days (8/11/23, 8/10/23, and 8/9/23). In an interview on 11/9/23 at 3:13 PM, with the DON 1, DON 1 stated, if we only did our part in the skin assessment and the staff informed the nursing management then, the facility could have prevented the progression of the wound. Record review of the facility's Policy and Procedure (P&P) titled, Pressure Injuries /Skin Breakdown - Clinical Protocol, with the last revised date of 4/8 indicated, Assessment and Recognition: 1. 5. The Physician . Cause Identification: 1. The Physician . 2. The Physician . Treatment/ Management: 1. The Physician . 2. The Physician . 3. The Physician . Monitoring: 1. During resident visits, the physician should evaluate . 2. The Physician should guide . There was no mention in the policy of the nursing staff involvement in the skin/wound care, monitoring, treatment, and delivery of care. In an interview on 11/30/23 at 2:58 PM, with the Facility Administrator (FA), FA stated, the facility was bought by the new owner on 5/1/23. FA further stated, the nursing staff were employed by the facility, the Physicians were not employed by the facility, they were contracted (individuals who are self-employed and sell their services to employers on a contract basis). When asked, how come the facility's policy did not mention the nursing staff involvement in the skin/wound care prevention, monitoring treatment, and delivery of care, the FA stated, she would looked into the policy and would later later provide additional policy. Record review of the facility's undated P & P provided by the FA indicated, Pressure Injuries. Purpose: . Skin Assessment: Conduct a comprehensive skin assessment . with each risk assessment, . Inspect the skin on a daily basis . identify any signs of developing pressure injuries (i.e., non-blanchable erythema). Monitoring: Evaluate, report and document potential changes in the skin. 2. Record review of the Care Plan Risk for pressure ulcer and non- pressure skin alterations, with the last revised date of 2/11/20 indicated, Goal: Will develop no new avoidable skin alterations, and the Interventions: LN (License Nurse) skin assessment weekly . In a phone interview on 12/13/23, at 3:10 PM with the Director of Nursing (DON 1), DON 1 stated, a weekly skin assessment/ evaluation should be done because of the resident's chronic leg ulceration and were documented on the Comprehensive Skin Evaluation/Assessment (CSEA) form. In an observation in the resident's room and interview on 11/30/23, at 11:28 AM, with the TN 2, TN 2 was observed performing wound treatment to a random sample resident (Resident 2). TN 2 stated, the resident was admitted with Stage 3 pressure injury (PI, breakdown in the skin integrity and underlying tissues due to pressure) in the coccyx area (tail bone), it was granulating (the development of new tissue and blood vessels in a wound during the healing process) on the side and was healing well. In an observation in the resident's room and interview on 11/30/23, at 11:50 AM, with TN 2, TN 2 was observed giving wound care to a random sample (Resident 3). Resident 3 was awake alert, with open wound on the right side of the neck about the size of a dime. The TN 2 stated the wound was granulating (the development of new tissue and blood vessels in a wound during the healing process) with slough (dead tissue) covering the granulation. In a concurrent record review and interview on 12/14/23, at 12:10 PM, with the RN/UM 1, the Comprehensive Skin Evaluation/Assessment (CSEA) for Resident 1, dated June, July and August 2023, were reviewed. The RN/UM 1 stated, the CSEA for Resident 1 was not done in June 2023 and nothing was completed in May 2023 when the facility was bought by the new owner. For the month of July 2023, the CSEA were done on 7/6/23 and 7/14/23 but not for the week of 7/17/23 to 7/23/23 and the week of 7/24/23 to 7/31/23, it was not done weekly. For the month of August 2023 it was done on 8/6/23 and Resident 1 was transferred out on 8/12/23. The RN/UM 1 stated, the CSEA should be done weekly until resolved to make sure it does not get worse. Review of the facility's P & P titled, Nursing Weekly Summaries/Assessment, with the last revised date of 10/22 indicated, Purpose: . to provide: 1. A complete account of the resident's care . Procedure on nursing weekly summaries: 1. 14. Skin - Hair . Be descriptive . Include locations, size, depth, . status of tissue . 3. In an interview 11/9/23, at 4:12 PM, with the DON 1, DON stated, the Braden Scale for Predicting Pressure Score Risk (BSPPSR) assessment should be done on admission and weekly for additional four (4) weeks, and if no pressure wounds exist, then on quarterly basis. For Resident 1, it should be done on a quarterly basis because of the chronic leg ulcer. In a concurrent record review and interview on 11/30/23 at 11:09 AM, with the LVN 3/UM 2, the BSPPSR dated 2/28/23 was reviewed. The BSPPSR indicated, the resident's ability to respond meaningfully to pressure-related discomfort was slightly limited, activity was bedfast, ability to change and control body position was very limited, and for Friction & Shear it was a potential problem. The LVN 3/UM 2 stated, the Braden Score (BS) was 12, it was high risk for pressure injury. The LVN 3/UM 2 searched the Electronic Health Record and verified, the BSPPSR was not done after 2/28/23, it was not triggered (means generated) in the PCC (Point Click Care, name of the facility software). The LVN 3/UM 2 stated, the staff should have done the BSPPSR on a quarterly basis and when the resident returned to the facility on 5/18/23 and 8/11/23 from the acute care hospital, per facility policy. In an interview on 11/30/23, at 2:15 PM, with the RN/UM 1, RN/UM 1 stated, the BSPPSR should be done quarterly, that was how it was set up in the in the system (PCC). Review of the facility's P & P titled, Braden Scale Risk Assessment Tool, with the last revised date of 9/23/22 indicated, Regardless of any resident's total risk score . clinicians are responsible for evaluating . and determining the resident's overall risk. As a Best Practice, the Braden Scale Risk assessment should be completed following the schedule: . Upon return to the facility, . Weekly for additional 4 weeks, then complete Braden Scale Risk Assessment, quarterly.

Based on interview and record review the facility failed to implement an effective plan of correction. 1. The facility failed to follow up on Resident 1, 2, and 3's allegations of neglect according to facility policies. 2. The facility implemented a room round program asking residents to rate call light response time on a scale of 1-5 (1= poor and 5= excellent). Part of the facility's plan of correction was to follow up on responses that were rated 3 or lower. There were 28 responses for call light that were rated 2 or lower and there were no documented evidence of a follow up. 3. The facility failed to implement clear precise metrics to track interventions regarding call lights response. These three failures did not ensure the facility could effectively implement their plan of correction to address issues of abuse/neglect and call light response. Findings: Review of room rounds interviews documents provided by the facility, dated 12/22/2022 to 2/23/2023, indicated three residents reported allegations of neglect to staff. Resident 1 Review of Resident 1's room rounds interview, dated 2/7/2023, indicated staff documented Resident 1 .stated that he wanted his door open nurse closed it he reopened it and nurse came back and slammed his door closed. Resident then phoned his daughter . (with) concerns. During an interview on 2/24/2023 at 11:48 AM, the Assistant Administrator (AA) stated he received a report of this incident and personally investigated the situation and concluded it was a misunderstanding between Resident 1 and the nurse. The AA was asked to provide documented evidence this abuse allegation was handled according to facility policy. The AA was unable to provide the requested documents. Resident 2 Review of Resident 2's room rounds interview, dated 12/22/2022, indicated documentation regarding .Nursing is rude .Nursing called her a baboon . During an interview on 2/24/2023 at 1:45 PM, the Director of Nursing (DON) and the AA was interviewed about this allegation. The DON searched the records of Resident 2 and was unable to find any information regarding this allegation. The facility was asked to provide documented evidenced this abuse allegation was handled according to facility policy. The facility was unable to provide the requested document. Resident 3 Review of Resident 3's room rounds interview, dated 2/9/2023, indicated staff documented .Seen a nurse be verbally aggressive to resident . During an interview on 2/24/2023 at 1:45 PM, the DON and the AA was interviewed about this allegation. The DON stated they were not able to identify the resident as only the room number was documented in the interview round and not the name of the resident. The DON and AA stated staff should have documented the name of the resident instead of the room number. The DON nor the AA were able to recall if this allegation was discussed during their daily stand-up meetings and/or if any staff investigated and/or followed up regarding this allegation. Twenty-eight low call light response ratings Review of room rounds interviews documents provided by the facility, dated 12/22/2022 to 2/23/2023, indicated twenty-eight responses were rated two or lower. The facility implemented a room round interview program asking residents to rate call light response time on a scale of 1-5 (1= poor and 5= excellent). Review of the facility's plan of correction, emailed on 2/22/2023, indicated .A scale of 1-5 is used for resident interview form A response of less than 3 is followed up by the staff assigned to the specific room during stand up meeting. Department Head is also involved in resolving the concern. The facility was asked to provide documented evidence these poor call light response rating were followed up, new interventions implement and/or the issue was resolved. The facility was unable to provide the requested documents. Lack of clear precise metric(s) in tracking call light response During an interview on 2/24/2023 at 1:45 PM, the DON and the AA both stated that call light response time has improved since implementation of their room round interviews. However, the DON and AA were unable to clearly articulate: 1. What metric(s) the facility were using in order to reach this conclusion. 2. How frequently were they reviewing these metric(s). 3. Other than the room rounds and in-servicing staff regarding answering call lights. The DON and AA did not identify any new interventions to address slow call light response. Review of the facility's policy titled Abuse Reporting and Investigation, not dated, indicated .Reports of resident abuse, neglect, . shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. 1. The individual conducting the investigation will, as a minimum: a. Review the completed documentation forms; b. Review the resident's medical record to determine events leading up to the incident; c. Interview the person(s) reporting the incident; d. Interview any witnesses to the incident; e. Interview the resident (as medically appropriate); e. Interview staff members (on any shifts) who have had contact with the resident during the period of the alleged incident; f. Interview the resident's roommate, family members, and visitors as applicable; g. Interview other residents to whom the accused employee provides care or services; and .The following guidelines will be used when conducting interviews: . Witness reports will be obtained in writing. Either the witness will write his/her statement and sign and date it, or the investigator may obtain a statement, read it back to the member and have him/her sign and date it. Upon conclusion of the investigation, the investigator will record the results of the investigation on approved documentation forms and provide the completed documentation to the Administrator.