**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#1) of three residents remained free from accident hazards out of 16 sample residents. The facility failed to ensure a safe environment and prevent major injury for a resident at risk for elopement and falls. Resident #1 was let out of the facility doors by a facility visitor on 11/17/23. The resident was wearing a wander guard device but the device was not functioning properly and the wander guard system door panel did not sound an alarm to alert staff the resident was exiting the facility. The resident rolled out in the parking lot with her wheelchair and hit a parking lot bumper. Resident #1's wheelchair tipped over and the resident landed on the parking lot asphalt. A facility vendor who was outside observed the resident in the parking lot and alerted staff. The resident required hospitalization for treatment and sustained a fracture to her femur and abrasions to her head. Findings include: I. Facility policy The Wanderguard Bracelet policy and procedure, revised October 2019, was provided by the director of nursing (DON) on 1:05 p.m. According to the policy, the facility was to ensure residents at risk for elopement were assessed and remained safe within the facility. The policy read in part: (Residents) who are at risk such as those presenting with history of attempts of elopement, dementia, confusion or increased confusion and/or Alzheimer's disease wore a wander guard bracelet to alert staff of attempts at independent exit from the facility. (Residents) that are at risk for elopement are assessed by the floor nurse for the need for a wander guard bracelet on admission, quarterly and with a change of condition. Once a (resident) has been assessed as needing a wander guard bracelet, one can be placed, the device is obtained from the restorative department and the following must be completed: - The POA (power of attorney) is notified of why a wander guard is needed. - The physician is notified and a request for an order is made. - The care plan is revised to include the bracelet. - The above steps are documented in the record. Each resident who wears a wander guard bracelet will be checked every shift to ensure that the bracelet is in place. This is documented on the MAR (medical administration record). The night shift nurse will check each bracelet every night to ensure that the bracelet is operational and document on the MAR. Anytime a resident is confused, is either attempting to leave the facility and makes his way outside, is to immediately have a wander guard bracelet applied to ensure safety of the resident. Restorative nurses re-assesses for appropriateness of devices quarterly, with change of condition and PRN (as needed). They care plan the use of the device. The Falls and Fall Risk, Managing policy, revised October 2019, was provided by the director of nursing (DON) on 1:05 p.m. The policy read in part: Based on previous elevations and current data, the staff will identify interventions related to the resident specific risks and causes to try to prevent the resident from falling and to try and minimize complications from falling. II. Resident status Resident #1, over the age of 65, was admitted on [DATE] and discharged to the hospital on [DATE]. According to the January 2024 admission record, diagnoses included Alzheimer's disease, unspecified, dementia in other diseases classified elsewhere, unspecified severity, with agitation, depressive episodes, unspecified macular degeneration, acquired absence of the left leg above the knee, unilateral primary osteoarthritis of the right knee, diastolic (congestive) heart failure. The 11/3/23 minimum data set (MDS) assessment identified Resident #1 had severe cognitive impairment cognitively intact with a brief interview for mental status (BIMs) score of three out 15. According to the MDS assessment, the resident's disorganized thinking and inattentive behavior were continuously present. The MDS assessment identified Resident #1 required a wheelchair for mobility. III. Record review The November 2023 comprehensive care plan identified Resident #1 needed assistance with self care and mobility. The resident had a history of falls and exit seeking behaviors. The November 2023 comprehensive care plan for Resident #1 identified: -Had delusional episodes and hallucinations; -Had poor safety skills and safety awareness; -Had behaviors of restlessness, and wandering, -Had agitation with exit seeking episodes; -Was impulsive; and, -Believed she was staying in a hotel and packed her belongings stating I have to be ready to move. Interventions directed staff to: -Monitor behaviors and symptoms; -Provide positive distraction; -Encourage activities; -Validate feelings; -Encourage mobility; -Provide reassurance of safety; and, -Monitor for increased agitation; -The care plan did not include the resident's use of a wander guard or direct staff how to manage the wander guard, including frequency of ensuring Resident #1's wander guard was in proper working condition. The patient summary report read staff were to ensure the resident's wander guard bracelet was on and functioning every shift and staff were to answer the alarm promptly and attempt to redirect. The 6/27/23 computerized physician orders (CPO) read IDT (interdisciplinary team) review deems that it is necessary to apply a wander guard bracelet to the resident for unsafe exit seeking behaviors and poor safety awareness. The assistive device form was provided by the facility on 1/2/23. The form identified Resident #1's wander guard function was checked on 6/14/23, 7/6/23 and 7/29/23. On 8/31/23 the battery was changed and was now working.-The assistive device form did not identify the wander guard function was checked in September 2023. According to the form, the batteries to Resident #1's wander guard had to be changed on 10/4/23 and on 10/17/23. -The assistive form did not identify Resident #1's wander guard checked for function between 10/18/23 and 11/17/23, ensuring the wander guard was operational. The October 2023 treatment administration record (TAR) identified the wander guard was in place daily. -The October 2023 TAR did not identify the wander guard was checked for function, ensuring it was operational. The November 2023 TAR identified the wander guard was in place daily between 11/1/23 and 11/17/23. -The November 2023 TAR did not identify the wander guard was checked for function, ensuring it was operational. The 11/3/23 fall risk evaluation identified Resident #1 was at risk for falls. -Review of Resident #1's record did not identify the resident was assessed for elopement or had a wander risk assessment in place. The 11/6/23 unannounced wander/missing resident drill record form identified the facility conducted a drill simulating a missing resident, actions and time it took the staff to find the missing resident. According to the record, nine staff participated in the drill and the resident was found in six minutes. The 11/17/23 nursing note read a certified nurse aide (CNA) entered the facility at 3:30 p.m. and said a resident was in the parking lot in the front of the facility. According to the note, staff ran out the facility and found Resident #1 in the parking lot on her back. The note identified the resident fell out of her wheelchair. The nursing note read Resident #1's left side of head was bloody and her right leg was twisted. Emergency personnel were called and Resident #1 was taken to the hospital at 4:00 p.m. The 11/17/23 at 3:30 p.m. risk management report was provided by the facility on 1/2/24. The note read the quality assurance manager (QAM) was called to assist staff in the front parking lot of the facility. Resident #1 fell off the sidewalk and onto the parking lot. The resident was seated on her bottom with a CNA holding her head while other staff members took her vitals. Resident #1's right leg was curled inwards and there was a noted protrusion (bulge) to her posterior knee which was visible through her pants. The resident was complaining that her leg was burning and requested to get up off the ground. The resident was encouraged to take deep breaths and relax. The resident was crying and staff continued to encourage her to calm down as they held her hands and talked to her. The QAM called 911 at 3:43 p.m. for emergency transportation to the hospital for an evaluation and treatment. The medical durable power of attorney (MDPOA) was notified of the resident's fall, possible fracture and transportation to the hospital. The paramedics arrived at the facility at 3:55 p.m. and initiated pain relief. The resident was assisted onto the gurney for transportation and left for the hospital at 4:10 p.m. The risk management incident report read there was an obvious protrusion of the femur, just above the resident's right knee. According to the report, the protrusion did not break through the skin. Resident #1 had a large abraded (scraped) area to the left side of her forehead. The risk management incident report identified wandering as a predisposing situation factor that contributed to the 11/17/23 incident. The risk management incident report read the wander guard was cracked and not functioning. The batteries to the wander guard were dead and did not send a low battery signal to the computer system. The 11/17/23 facility investigation included the following staff witness statements: The witness report of the certified nurse aide with medication authority (CNA/MA) read Resident #1 was found face down with her head and shoulders over the bumper. Her left side of her face was bloody. She was rolled out of the (puddle) of water. The resident screamed not to be moved. The resident was pale, her leg looked bad and crooked. The witness report of CNA #5 read the resident was face down on the asphalt and her left side was bloody. The resident was screaming when her leg was moved. The resident was in much pain and her leg did not look right. The witness report of CNA #6 read she was not sure how the resident got outside because the resident did not know how to work the door. The CNA saw the resident a few minutes before the incident. The resident was by the doors and the CNA asked Resident #1 to come with her. The CNA assisted the resident down the hall to a table. Resident #1 flipped out of her wheelchair face down with the wheelchair on top of her. Registered nurse (RN) #2 attempted to straighten the resident's leg which was bent at the knee. The resident's bone could be felt through her pants. RN #2 told the CNA there was someone lying in the parking lot. She observed the resident on her back between two cars. The resident's leg was twisted at an odd angle. The staff proceed to take the resident's vital signs. The witness report of restorative nurse aide (RNA) #2 read after RNA #2 learned of Resident #1's fall, she tested the wander guard of Resident #1 on 11/18/23. The battery to the wander guard was dead which was why there was not an alert when the resident exited the facility on 11/17/23 and why the wander guard did not show up on the wander guard door monitoring system. The restorative department completed regular checks on the wander guards once or twice a month. The battery in Resident #1's wander guard was checked and replaced on 10/4/23 and on 10/17/23. The 11/18/23 communication note read the QAM received a call from Resident #1's MDPOA. The MDPOA informed the facility that Resident #1's femur was severely broken and she was in much pain. The QAM told the MDPOA the facility was investigating the incident and the CNAs were with her shortly before the accident. According to the note, the MDPOA was tearful and said she already ordered the cake for the resident's upcoming birthday. A wander guard check sheet was provided by the facility on 1/2/23. The wander guard check sheet identified weekly checks were conducted between 11/28/23 and 1/2/23 to determine if the wander guards in the facility and assigned to a resident were working properly. The 12/11/23 unannounced wander/missing resident drill record identified a second drill to find a missing resident was conducted on 12/11/23. The drill was conducted after the 11/17/23 incident with Resident #1. The record identified three staff members who participated in the drill and the resident was found after two minutes. The staff participation of the drill was low because the resident used in the drill was not a wandering risk (unlike Resident #1). The drill record read additional education would be provided to staff in January 2024. The 12/22/23 therapy note (over a month after the resident was discharged from the facility) read Resident #1 had an unwitnessed fall on 11/17/23. Staff were educated through a monthly all staff meeting through dial my call to remind staff to be aware of any residents exiting through doors and question and assist the resident to prevent potential injuries. The staff were informed of increased documentation and were educated on the wander guard system (see above). -However, some staff were not educated after the 11/17/23 incident (see staff interviews below). The wander guard system manual documented if a battery was low it would alternate between green and red. If a low battery indicator light was displayed on the wander guard, the batteries must be replaced within a week. Batteries were to be replaced when a low battery message was displayed (on the door panel) or when identified during routine tests with the magnetic wand (fob). The wander guard system manual read a low battery fault would appear when the device (wander guard) reaches a low battery state. The battery should be replaced as soon as possible before the battery was too depleted to power the device. Devices could fail due to moisture, electrical surges or other environmental factors. The wander guard system manual identified batteries were expected to last eight months under normal use. If the resident continually exercised the wander guard, the battery life would be less. The wander guards should not be stored more than 10 feet from the wander guard installation (exit door panels). The wander guards should be routinely checked for low batteries. The wander guard system set up procedure was provided by the facility on 1/2/23. The wander guard system procedure outlined steps on how to set up a new wander guard. IV. Observation The wander guards of Resident #2 and Resident #3 were tested on [DATE] at 10:15 a.m. The wander guards were attached to the bottom of the resident's wheelchairs. RNA #1 scanned both of the wander guard pendants with a fob. The indicator light on the wander guard flashed green identified the wandering guard was functioning properly. V. Staff interview The DON was interviewed on 1/2/23 at 10:40 a.m. The DON said after an incident such as a fall, the facility conducts an investigation. The staff looked at potential contributing factors such as the new medications or environment. She said the nurse or the CNA would look at the scene right after the fall and attempt to identify any environmental causation factors. The incident would then be reviewed in the next morning meeting with the interdisciplinary (IDT) so the whole team was aware of the concerns. The resident would be assessed for any appropriate safety devices and training of use as appropriate. The DON said the facility conducted a weekly risk management meeting to review incidents and find the root causes. She said the facility reviewed the video camera recording Resident #1's fall on the parking lot on 11/17/23. The DON said the video records showed a visitor letting the resident out of the facility from the main entrance. She said the resident was wearing a wander guard when she went out the door. The facility checked and determined the wander guard system was working properly but she was not she if Resident #1's wander guard was working when she went out the door and out to the parking lot. The DON said after the incident, the facility sent out a call to staff through a call system to remind staff to not to just open the doors for residents wanting to go outside. The DON said after the incident, the facility checked and ensured other residents' wander guards were working properly. The QAM was interviewed on 1/2/24 at 11:02 p.m. The nursing home administrator (NHA) entered the interview while in progress. The QAM said RN #2 informed her she was needed outside in the parking lot. The QAM said she went outside and saw Resident #1 lying in the parking lot with her head on the lap of a staff member. The resident had gone off the curb of the sidewalk with her wheelchair and hit the bumper of a parking space. Resident #1 was crying in pain while attempting to get up and said her leg was burning. The QAM said she could see there was a deformity to the resident's upper knee cap. She said they attempted to calm the resident down, took vitals, covered in blankets to help make her comfortable and called 911 informing them of a possible fracture to the resident's leg. The QAM said the ambulance arrived at the facility at 3:55 p.m. and Resident #1 was taken by ambulance to the hospital at 4:10 p.m. The QAM said the resident's MDPOA called her on the evening of 11/17/23 and told her Resident #1 had a fracture to her femur. The QAM said the resident's family member asked her if the resident was outside alone for a length of time. The QAM said she told the family member the facility was reviewing video camera footage but the interviewed CNAs said they were providing ADL care to the resident shortly before she went outside. She said the resident did not return to the facility. She said the resident did not return to the facility after the 11/17/23 accident. The NHA said the facility provided a timeline of the events to the resident's family. The QAM reviewed the facility investigation. Resident #1 had a wander guard attached to the bottom of the wheelchair that did not work when she exited the building on 11/17/23. She said video footage showed Resident #1 was at the front door at 3:10 p.m. CNA #6, entered the facility, spoke to the resident and redirected her down the hall to a location the resident liked to sit at. The QAM said at 3:20 p.m. the video footage showed the resident exited the facility when a visitor opened the front entrance doors. The visitor let the resident out the door and then walked away. She said there was a red stop sign on the entrance door that read to not let residents out of the door but the visitor let the resident out anyway. She said she did not recognize the visitor as someone who routinely was at the facility. The QAM said a facility vendor notified staff that a resident had fallen in the parking lot. The QAM said the CNA/MA was first to get to the resident at 3:30 p.m. The QAM said after the incident, staff were interviewed and the maintenance report was pulled to make sure the wander guard system attached to the doors were routinely checked. The maintenance report identified the wander guard system door panels were checked on 10/24/23 and then again on 11/17/23, after the incident. The QAM said all the wander guards in the facility were working with door panels on 10/24/23. The only concern identified was the wander guard of Resident #1 was not communicating with the door panel on 11/17/23 and did not sound the alarm when the resident exited the facility on 11/17/23. The wander guard did not sound the alarm after it was brought back into the facility after the resident went to the hospital. The QAM said after the incident the resident's wander guard and a crack in the plastic from edge to edge but felt the crack occurred when the resident fell and the wander guard caught the wheel of the wheelchair. The QAM said maintenance requests were reviewed and there was no requests or identified concerns regarding the wander guard of Resident #1. The QAM said Resident #1 wander guard was checked again on 11/18/23 and there was no battery power. The QAM said when there was a low battery the wander guard computer system was notified. The restorative department reviews the wander guard system and tests all the wander guards to ensure the wander guards were working. The restorative aides checked the wander guard one to two times a month and replaced the batteries as needed. The restorative department documented when they checked the wander guards for each resident who used the wander guards. The QAM said Resident #1's wander guard was last checked by the restorative department on 10/4/23 and 10/17/23 when her battery needed to be changed (see above). The QAM and the NHA said there might be a way to pull a report from the wander guard system tracking low batteries and alarm notifications but was not sure how. The NHA said she would follow up. The QAM said on 11/18/23 all staff received a call through the facility's call system to review the wander guard system procedure (see above). The 11/17/23 incident was reviewed in the risk management team meeting and again in the morning meeting with the IDT. The NHA said post incident notes were usually added to the resident's medical record in the progress notes for follow up but the resident was not going to return to the facility so the notes were not added. The QAM said a note was added to the resident chart on 12/22/23 (see above). The QAM said she did know why the therapy note was not added until 12/22/23. The NHA said the restorative department recently made improvements to the wander guard tracking documentation by creating a new spreadsheet format that streamlined and clarified the tracking and documenting process. The QAM said the restorative nursing aides (RNAs) increased the frequency of checking each wander guard after the 11/17/23 incident. She said the wander guards were now checked weekly. The QAM said another change after the 11/17/23 incident was the removal of excess signs at the front entrance to distract the eye. She said the main sign left at the front door as people were exiting was the stop sign with notification not to open the door for residents. The sign was now more centralized and easier to focus on without the other visual clutter. The NHA was interviewed again on 1/2/24 at 1:40 p.m. The NHA said the wander guard system vendor was contacted and an instruction webinar was set up for 1/3/23 to review all the components of the system including retrieving wander guard reports and notifications. The DON was interviewed on 1/2/24 at 3:05 p.m. The DON reviewed the record of Resident #1 and said the resident did not have an assessment for her wander guard but should have. The DON said Resident #1 should have been care planned for her wandering and elopement risk. The resident should have been care planned to direct staff on the resident's use of a wander guard, why the wander guard was in place and interventions to distract her from exit seeking. The DON said she was in process of training staff on the steps to take when a resident was determined to need a wander guard. The physical therapy assistant (PTA) was interviewed on 1/2/24 at 3:22 p.m. The PTA said she was responsible for overseeing the restorative department since November 2024. She said when a resident was at risk for elopement, a wander guard would be placed on the resident on a device the resident would use for mobility such as a wheelchair. When a resident with a wander guard to the exit of the facility, the wander guard would signal to the wander guard system door panel and an alarm would sound to alert all staff to the resident. The PTA said before she took over restorative oversight and before the 11/17/23 incident with Resident #1, the RNAs checked the batteries of the wander guards once a month. She said RNA #1 would document the monthly wander guard battery checks on each resident who used the wander guards. The PTA said after the 11/17/23 incident, she checked the wander guards weekly to ensure the wander guards were in place, functioning properly and to determine if batteries needed replacement. The PTA said the facility currently had four residents that used a wander guard. She said each wander guard would be checked by use of a wander guard fob. The fob would be placed next to the wander guard. If there was a green flashing light, the wander guard was working. If there was no green light, the wander guard batteries would need to be replaced. The PTA said she was taught that if a resident's wander guard battery was low, the resident's name should appear on the door panel. The PTA said the only way she knew to see when a battery was low was to physically check the wander guards or the door panels. She said on 1/3/23 she was scheduled to attend a webinar to learn if there were more ways to use the wander guard system more efficiently. She said until she receives additional training, she would continue to keep physically checking the wander guard system. The PTA said RNA #1 last checked all the wander guards on 12/27/23. RNA #1 was interviewed on 1/3/24 at 10:06 a.m. The RNA said the restorative department was responsible for checking all the wander guards. She said she has been a restorative aide for the past three years. RNA #1 said before the 11/17/23 incident, the wander guards were checked monthly. The RNA said wander guards were now checked weekly. She said she checked each wander guard with the fob but she could also go to all the exit doors and check the door panel. The RNA said the last time Resident #1's wander guard was checked before 11/17/23 was October 2023. She said on 10/4/23 the wander guard fob showed Resident #1's wander guard batteries were low so she replaced them. The RNA said on 10/17/23 a nurse informed her the wander guard was not working. The RNA said the batteries were dead so she changed them on 10/17/23. RNA #1 said the batteries in the wander guards usually lasted a while so she was surprised to have to change the batteries after a couple of weeks. She said she was provided the wander guard manual on 12/27/23 and read batteries could drain quickly if the resident was frequently near the exit and within the wander guard system radius. RNA #1 said if a wander guard indicator light would flash green and red during a fob test, the wander guard was low and the batteries would need to be changed within the week. RNA #1 said she would check the door panels every time she went through the doors to identify if the wander guard system was registering a wander guard low battery. She said she remembered seeing a low battery warning for Resident #1 on the door panel but could not remember if the warning was in October 2023 or the beginning of November 2023. She said the low battery warning on the door panel would remain on the door panel until it was physically cleared from the panel. She said she did not clear the door panel. RNA #1 said she has not received additional wander guard education from the facility after the 11/17/23 incident. She said RNA #2 had printed instructions on how to set up wander guards and handed the procedure to her and the maintenance director. RNA #1 said the instructions were provided to her before the 11/17/23 incident. The RNA said she and RNA #2 took it on themselves to start checking the wander guards more frequently after the 11/17/23 incident. The maintenance service director (MSD) was interviewed on 1/3/24 at 12:37 p.m. The MSD said she checked the wander guard door panels monthly to make sure the system was operating properly. She said she completed a webinar training this morning (1/3/24) and learned more about the wander guard system. She said she learned the wander guard system could be attached to the call light system in the facility and scan all the wander guards in the facility every 60 minutes. Since the systems could link, it allowed the facility to pull a report on how often the residents with the wander guards were near the exit doors. The MSD said the wander guard system could be set up so the facility's computer system so if there was a problem with the wander guard, the nurses and anyone else on the computer would get a notice of the wander guard problem. The MSD said currently the doors did not automatically lock when a resident with a wander guard was too close to the door. She said the facility was in the process of setting up the wander guard system to allow the doors to lock and not just sound an alarm. The MSD said the facility was in process of determining who could clear the door panel notifications of a low wander guard battery so only she and the administration could clear the notifications. The DON was interviewed on 1/3/24 at 12:58 p.m. The DON said verbal education was completed on 11/17/23 with the staff of duty at the time of Resident #1's incident. The DON said the QAM reminded staff to make sure they always knew where all the residents were an elopement risk. The DON said the facility had an elopement drill before 11/17/23 and again after 11/17/23 (see above). The DON said the restorative aides received training on how to properly check the wander guard system and inform the maintenance staff if a problem was identified. Registered nurse (RN) #1 was interviewed on 1/3/24 at 1:20 p.m. She said she did not have any residents with a wander guard in her hall and did not check if the wander guards were working. She said if a resident with a wander guard was too close to the door, she would try to find something for the resident to do in their room or in another part of the facility. She said if a resident continued to try to exit the doors, she would contact the family to see if they had additional ideas or could come into the facility to redirect the resident. Licensed practical nurse (LPN) #1 was interviewed on 1/3/24 at 1:39 p.m. The LPN said she did not have residents on her hall with a wander guard. She said she had not had elopement training but if she saw a resident go to the door she would ask the resident where they were going, walk with them away from the door and periodically check on the resident and the door. LPN #3 was interviewed on 1/3/24 at 1:44 p.m. He said he did not have a resident with a wander guard on his hall but if he did the resident should be monitored. He said if a resident continued to exit seek, the facility would place a wander guard on the resident. CNA #3 was interviewed on 1/3/24 at 2:32 p.m. He said if a resident tried to exit the facility with a wander guard, an alarm would sound. He said if the alarm sounded he would check the doors and redirect the resident. The NHA and the DON were interviewed again on 1/3/24 at 2:41 p.m. The NHA said during the 1/3/24 webinar, the facility learned the wander guard system could be improved by linking it to the call light system. The NHA said they were working on a way to lock the doors when a resident with a wander guard was close. She said the system currently did not lock the door, it only sounded an alarm. The NHA and the DON said if the doors locked when a resident with a wander guard was too close to the doors, then a visitor could not have let the resident out of the facility. The DON said the staff would have ongoing wander guard training to improve the frequency of checking the wander guards. She said all nursing staff should make sure the wander guards were operating properly. The DON said a broader education on the wander guard system would be conducted with the restorative department. She said wander guards were checked monthly before 11/17/23 and then checked weekly after the 11/17/23 incident but felt the wander guards should be checked daily. She said she would instruct staff to check all wander guards daily. The NHA said she wanted the nurses to check wander guards daily. She said the nurses would be provided a wander guard fob so they could make sure e[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure that all residents were free from abuse, neglect, and exploitation, for two residents (#14 and #420) in two allegations of abuse of five allegations reviewed out of 26 sample residents. Specifically, the facility failed to provide adequate supervision and effective interventions to prevent repeated incidents of resident-to-resident verbal altercations between Residents #14 and #420. Resident #420 and Resident #14 were roommates at one point in time while living in the same facility. As time went by the two stopped getting along, and Resident #14 moved to a new room on the opposite side of the facility. Still Resident #420 continued to target Resident #14 when he saw him in common areas. Resident #420, based on documentation in the resident's records, was very angry and specifically targeted Resident #14 and some other female residents who also lived in the facility. Several residents expressed not liking the way Resident #420 treated them and other residents in the facility. For Resident #420 being in the same space with Resident #14 triggered increased anger. The facility documented two significant events of verbal abuse from Resident #420 towards Resident #14 where Resident #420 launched verbal attacks upon Resident #14. Both of these events, one occurring on 9/22/22 and the other on 10/22/22, were seemingly unprovoked per facility documentation. Facility documentation in both resident records and in the facility's incident investigations revealed that in neither of the incidents listed above did Resident #14 provoke Resident #420 in any way to start the verbal altercation. Resident #420's verbal abuse of Resident #14 increased to the point where Resident #14 expressed feeling bullied and unsafe living in the facility while Resident #420 also lived in the facility. On 9/22/22 Resident #14's mother got involved to step between the two residents as Resident #420 wheeled his manual wheelchair in close proximity to Resident #14 while yelling, threatening and waving his arms in a threatening manner, all directed towards Resident #14. On 10/22/22 Resident #420 again chased Resident #14 down and followed Resident #14 outside to yell and verbally threaten Resident #14. Resident #420 tried to hold back Resident #14's power wheelchair to prevent Resident #14 from getting away from him in the altercation. However, Resident #420 did not let go of Resident #14's wheelchair as he pulled away and Resident #420 fell out of his manual wheelchair and fractured his hip, for which he required surgical intervention to repair the fracture. Resident #420 was discharged after this incident. Findings include: I. Facility policy The Abuse Prevention, Investigation, and Reporting policy, dated November 2022, was provided by the nursing home administrator (NHA) on 12/19/22 at 9:02 a.m. It read in pertinent part: The resident has the right to be free from abuse (including verbal, mental, sexual and physical), neglect, misappropriation of resident property and exploitation. Management will take specific steps to reduce the potential for abuse to occur at Larchwood Inns including, but not limited to education, monitoring and investigating thoroughly if abuse, misappropriation, neglect, or exploitation is suspected. Verbal abuse is defined as any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. II. Resident #14 A. Resident status Resident #14, under the age [AGE], was admitted on [DATE]. According to the December 2022 computerized physician's orders (CPO), diagnoses included multiple sclerosis, depression, and quadriplegia (paralysis of all limbs). The 9/28/22 minimum data set (MDS) assessment revealed the resident had intact cognition as evidenced by a brief interview for the mental status (BIMS) score of 13 out of 15; did not present with inattention or disorganized thinking during conversations; and was not verbally or physical aggressive towards others. The resident did not walk and used a power wheelchair to get around the community independently. The resident needed extensive to full assistance from staff to complete activities of daily living (ADLs) including transferring from surface to surface. The resident was on daily antidepressant medication. B. Record review The resident comprehensive care plan, dated 9/22/22, revealed the resident had a care focus for behavior, which documented Resident #14 had a history of paranoia and verbal aggression towards others. The resident often accused others of stealing his belongings. Additionally the resident had the potential for impaired psychosocial well being related to adjusting to lifestyle changes of facility life. This caused the resident to have difficulties getting along with a roommate. Relevant interventions included: Provide education on resident rights; Listen to resident concerns and address timely; Offer opportunities for interaction with other residents with similar interests. -There was no care focus or interventions to help staff work with Resident #14 prevent reoccurrence of verbal alterations initiated by Resident #420 towards Resident #14 (see below). III. Resident #420 A. Resident status Resident #420, age [AGE] years old, was admitted on [DATE] and discharged on 10/22/22 to the hospital for surgery then to another long term care facility. According to the October 2022 CPO, diagnoses included diabetes mellitus, heart failure, and history of stroke. The 9/13/22 minimum data set (MDS) assessment revealed the resident had intact cognition as evidenced by a brief interview for the mental status (BIMS) score of 14 out of 15; did not present with inattention or disorganized thinking during conversations; and was verbally aggressive towards others. The resident did not walk and used a manual wheelchair to get around the community independently. The resident needed extensive to full assistance from staff to complete activities of daily living (ADLs) including transferring from surface to surface. The resident was not on any antipsychotic medications. B. Record review The resident comprehensive care plan, dated 4/5/22, revealed the resident had a care focus for behavior, which documented episodes of cursing and yelling at staff and other residents. Interventions included: Monitor for significant changes in daily participation; Listen to concerns and address them timely; Offer counseling services as needed; Notify physician of unexpected changes in behavior; Offer reassurance; Follow up as needed with roommate; Ensure Resident #420 has preferred staff. If resident #420 becomes verbally/physically aggressive, ensuring he is in a safe position/place; Get another staff member to assist as appropriate and provide one to one observation-staff to be within line of sight of the resident as needed. -There were no patterns of verbal aggression or interventions identified in relation to Resident #420's verbal aggressions towards other residents. Additional care plan focuses included: mood disorder, which documented Resident #420 had verbal aggression, which appeared to be a symptom of depression; and a potential for impaired psychosocial wellbeing and or adjustment to lifestyle changes when moving into the facility, which included problems getting along with a new roommate. Relevant interventions included: Notify physicians in changes in mood; Encourage socialization; reassure resident safety when concerned with others; Listen to concerns and address them in a timely manner; Redirect when requesting personal information about another resident; Review need for psychotropic medication as needed. IV. Resident interviews Resident #420 was no longer in the facility and an interview with the resident was not possible. Resident #14 was interviewed on 12/22/22 at 4:22 p.m. Resident #14 said he did not feel staff acted to protect him the day Resident #420 chased me down. Resident #14 said staff saw Resident #420 yelling and waving his hands around but did not respond until it was too late. Resident #14 said on 10/22/22, Resident #420 was at the end of the hall, he came at me and started yelling and waving fists around like he was going to hit me. Resident #14 said he decided to get out of the situation by putting his electric wheelchair into drive to get away from Resident #420. Resident #14 said Resident #420 thought he could hold me back with one arm but he flipped out of his wheelchair and he broke his leg. I went past him and did not say anything to him because it would have made things worse. Resident #14 said staff did not respond to the incident until Resident #420 was on the floor and had to be sent to the hospital. Resident #14 said after the event was over the staff told him Resident #420 broke his leg when he fell out of his wheelchair. Resident #14 said he did not think he was in the wrong; because he was just trying to get out of the situation when Resident #420 was trying to hold him back. No one can hold back an electric chair with one leg and one arm. Resident #14 said Resident #420 had been making smart remarks to him for the past several months leading up to the 10/22/22 incident. At first they were friends, but when Resident #420 went out for surgery over the summer (mid-June and July 2022) and came back to the facility things changed, and that was when the bullying began. Resident #14 said since Resident #420 moved to a new facility he felt safe living in the facility, and was relieved that no one was going to attack him any longer. V. Resident to resident altercations Review of Resident #14 and Resident #420's incident investigations revealed the following information: A. 9/6/22 altercation Resident #14-a behavior occurrence note dated 9/6/22 at 11:25 p.m. documented, Staff heard yelling from residents' room. Resident and his roommate were yelling at each other about the roommate's television being too loud. Resident was trying to sleep. Both men were yelling obscenities at each other. Resident #14 stopped when asked, but started again when his roommate continued to mutter and yell. Resident #14 did stop after being asked to several times. Neither one is able to physically approach the other due to mobility (when out of their wheelchairs). They agreed to stop and discuss with social services in the morning. Resident #14-a behavior occurrence note dated 9/7/22 at 12:16 p.m. documented, Follow up regarding roommate disagreement.Roommates were arguing and cussing at each other related to television and music choices. Roommate and Resident #14 were offered a different room/roommate, roommate refused but Resident #14 agreed and was showed room options and plans to move were placed. Staff will continue to monitor behaviors and redirect as needed. B. 9/8/22 altercation Resident #420-a behavior occurrence note dated 9/8/22 at 2:23 p.m. documented in part, Resident #420 yelled at his roommate during lunch in the commons area. This writer spoke with Resident #420 regarding inappropriate behavior and anger management dealing with other residents and staff. Resident denies yelling at staff and treating them rudely. Resident #420-a behavior occurrence note dated 9/9/22 at 10:11 a.m., late entry, documented, Spoke with Resident #420 concerning outburst and inappropriate behavior in the common area. Resident #420 was very angry and resisted taking any responsibility calling others liars. Resident #420 complained about other people in the facility. This writer explained that was their home also and they have rights to be comfortable and secure in their home. Resident #420 stated maybe he would just move out. C. 9/14/22 altercation Resident #420 a behavior occurrence noted dated 9/14/22 at 8:30 p.m. documented, Resident #420 observed screaming at another resident today during lunch due to dislike for increase in television (TV) volume. Resident did request politely that she not turn up the TV, but was instigated by the other resident. She was observed turning up the volume to television while looking at him. She then proceeds to return to her table stating, 'I'm sorry but it's just got to be done. These ladies here could not hear.' Situation escalated quickly, as resident shouted, '(Expletive) you, you (expletive)!' 'You don't run this place!' This RN (registered nurse) to immediately intervene and de-escalate the situation. Resident extremely red in the face and agitated as he was moving towards television to turn it down. He continued yelling and now directing at this RN, 'I don't want to talk to you, or anyone! You got that?' D. 9/22/22 altercation A verbal altercation occurred on 9/22/22 from 4:30 p.m. to 4:54 p.m. The facility reported an allegation of verbal abuse between two residents and filed an online police report to the local police revealing Resident #14 as the victim and Resident #420 as the assailant. The facility incident report read Resident #14 (resident name) and his mother were on the back patio visiting. At the conclusion of the visit. Resident #14 escorted his mother to the front door when Resident #420 came around the pillar in the commons area and began to yell at resident #14 and his mother stating 'I'm going to knock you out.' Resident #420 counted to yell and curse at Resident #14. Resident #14's mother was afraid that something was going to happen and stepped in front of her son. Resident #420 continued to curse and make threats towards Resident #14. Facility staff arrived, instructed Resident #420 to stop yelling, and intervened allowing Resident #14 and his mother to leave the area without further incident. Resident #420 continued to make comments that he was going to 'beat the (expletive) out of Resident #14' 'I can inflict damage on him' 'I can hurt him real bad.' The residents were separated by staff members and Resident #420 will be in line of sight by a staff member while out of his room. Resident #14 was interviewed on 9/22/22 at 5:00 p.m., just after the incident. Resident #14 said he felt that Resident #420's words placed him in harm. Staff interviews revealed no staff witnessed what led up to the verbal altercation. Resident interviews revealed several residents were aware that Resident #420 had a temper and was verbally aggressive towards other residents, including Resident #14 and the ladies who were watching television in the common room. Resident #420 was interviewed on 9/22/22 at 5:22 p.m. just after the incident. Resident #420 said Resident #14 made threats two weeks ago and was lucky that he did not beat the (expletive) out of Resident #14 for it. Resident #420 denied threatening Resident #14 but added that he could inflict harm on Resident #14 and hurt him. Resident #45 was interviewed on 9/23/22 at 11:21 p.m. Resident #45 remembered a lot of yelling and name calling during the verbal altercation between Resident #420 and #14; and said she did not like it but was getting used to their verbal aggressions. E. 9/29/22 altercation Resident #420-a behavior occurrence note dated 9/29/22 at 8:14 a.m. documented Resident #420 was yelling for help at the breakfast table. Resident #420 was cussing and asked if another resident could be moved, after the other resident propelling backward in her wheelchair and lightly bumping into Resident #420's wheelchair. Resident #420 was angry. Staff were not able to redirect Resident #420, he just became increasingly more angry, so staff removed the other resident who was the target of Resident #420's anger from the area. Resident #420-a mental health note dated 10/12/22 late note entry documented, Resident angry and frustrated, but unable to articulate why. Asked him about his increased aggression and verbal abuse towards others. He claims to 'not remember', has very little insight into how his behavior affects others. Is able to talk about feelings in the moment, but unable to apply them to real life/next day scenarios. F. 10/22/22 altercation resulting in physical injury A verbal altercation occurred on 10/22/22 at approximately 2:30 p.m. between Resident #420 and #14. The facility reported an allegation of verbal abuse between the two residents revealing Resident #14 as the victim and Resident #420 as the assailant. The facility incident report documented, On 10/22/22 at approximately 2:30 p.m., staff were called out to the back patio. Resident #420 and Resident #14 had been in an altercation and Resident #420 had fallen out of his manual wheelchair. When staff attempted to move Resident #420 he cried out in pain in his left hip. Resident was sent to the emergency room for assessment. An investigation into the events leading up to Resident #420 falling out of his wheelchair revealed Resident #420 started a verbal attack on Resident #14, and in Resident #14's attempts to distance himself from this verbal abuse he engaged his power wheelchair and took off. Before leaving the area Resident #420 grabbed onto Resident #14's power wheelchair and did not let go as Resident #14 pulled away. This caused Resident #420 to fall out of his chair and injure himself. Resident #14 was interviewed on 10/22/22, just after the incident. Resident #14 said Resident #420 started yelling stuff and he tried to get away but Resident #420 followed him and grabbed the back of his power wheelchair. Resident #14 said he told Resident #420 to let go and he moved forward and saw Resident #420 on the ground when he looked back. Resident #14 said he went inside to get staff help. Resident #14 was interviewed a second time on 10/22/22 at 3:10 p.m. Resident #14 said Resident #420 was harassing and threatening him. He attempted to get away from Resident #420 by going outside, but Resident #420 followed him to the patio and would not stop badgering him. Resident #14 said Resident #420 was calling him names and threatened to knuckle him up. Resident #14 said he did not realize Resident #420 had a hold of the back of his wheelchair and when he moved forward Resident #420's wheelchair tipped over and Resident #420 fell on the ground. Resident #14 denied any instances of physical altercation between the two of them. Staff interviews revealed no staff witnessed what led up to the verbal altercation, the verbal altercation, or how Resident #420 ended up on the ground. Resident interviews revealed several residents were aware that Resident #420 had a temper and was verbally aggressive towards other residents, including Resident #14 and the ladies who were watching television in the common room. Resident #420 was interviewed the day after the event at the hospital after undergoing surgery to repair a hip fracture. Resident #420 recalled reaching out to grab Resident #14's wheelchair but did not recall anything that occurred after that. Resident #420 did not comment on the verbal alteration he had with Resident #14. Other resident interviews revealed: -Resident #45 said Resident #420 had a bad temper and was always cursing at other residents including Resident #14. All Resident #14 was doing, at the time, was going outside to enjoy the sunshine. -Resident #40 said Resident #420 had a bad temper. On 10/22/22 Resident #420 was watching Resident #14 as he went from the dining room table to the back patio and he followed. Resident #40 said he tried to stop Resident #420 from going after Resident #14 but by the time he got to the patio, Resident #420 was already on the ground. He did not see what happened. -Resident #27 said Resident #420 was yelling something at Resident #14 and following Resident #14 outside. Resident #27 did not see what happened. Resident #14-a mental health counseling note dated 10/26/22 at 4:41 p.m. documented, Resident #14 needed to process feelings related to an altercation he had with another resident. He felt attacked and bullied and unsafe by this other resident. This person is not currently in the building for a few days. Was able to process feelings around it. Will see him again. He gave writer permission to tell the social services director (SSD) he felt unsafe and threatened. Resident #14-a mental health counseling note dated 11/3/22 at 4:57 p.m. documented, Resident #14 processing feelings from recent altercation. Verbalized feeling relief that he will not be at risk for being bullied again by that resident. Processed feelings and emotions. VI. Staff interviews The SSD was interviewed on 10/22/22 at 3:33 p.m. The SSD said Residents #14 and #420 were roommates, but they started to have disagreements and the facility offered each the opportunity for a room move. Resident #14 took the offer and moved to an entirely different unit to distance himself from Resident #420. The two were also distanced in the dining room but still had verbal altercations. Resident #420 was presented with a behavioral agreement. The behavioral contract asked for Resident #420 to sign an agreement that he would interact with others in a dignified manner, and refrain from verbal altercations including making threatening comments, cursing or yelling at other residents. The contract also asked Resident #420 to refrain from physically aggressive acts, such as raising his arms or hands in a threatening manner towards others, and requesting staff assistance to handle conflicts. This contract was signed by Resident #420 on 9/26/22. The SSD said Resident #420 signed the behavioral agreement without concern because he felt the agreement actions were things he was already doing, and did not need to change his behavior because he was not the one in the wrong. Both residents were offered in-house counseling services and were participating in regular individual counseling sessions. In the interim, staff were instructed to provide Resident #420 with every-15-minute checks, interventions and redirection when observed to present with any aggressive behaviors towards other residents. The interdisciplinary team (IDT) met to discuss interactions between Residents #420 and #14 and felt the established interventions were sufficient to protect the residents from repeated verbal abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and interviews, the facility failed to ensure two (#60 and #47) of four residents reviewed for pressure injuries received care and services, consistent with professional standards of practice, to prevent development and promote healing of pressure injuries, out of 26 sample residents. Resident #60, who was at risk for wound development due to immobility, admitted to the facility on [DATE] with diagnoses of cerebral infarction (stroke), hemiplegia/hemiparesis (paralysis), enteral feeding, dysphagia and excoriation to her coccyx/sacrum. Resident #60 developed and redeveloped wounds to her sacral area (see record review below). On 11/16/22 Resident #60 developed a stage 3 wound to her coccyx/sacrum. The facility failed to complete weekly wound assessments in their entirety to promote wound healing from 11/16/22 to 12/9/22. The registered nurse/wound nurse (RNWN) said she completed wound treatments every Monday, Wednesday and Friday and the facility had a wound protocol which they followed (see interview below). However, review of Resident #60's physician orders revealed the facility failed to implement wound care orders. The facility's wound protocol documented four different treatments that could be utilized if a resident had a stage 3 wound and staff interviews revealed they would review the progress notes and apply whatever dressing the RNWN previously applied (see interview and record review below). Review of Resident #60's treatment administration record (TAR) revealed no documentation of any treatment being provided for the months of October, November or December of 2022. Furthermore, the facility failed to implement preventative measures (air mattress) for Resident #60 in a timely manner until 12/9/22, three weeks after the wound development. Additionally, the facility failed to ensure weekly wound assessments were completed for Resident #47. Findings include: I. Professional references A. Pressure ulcer classification According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, [NAME] Haesler (Ed.), Cambridge Media: [NAME] Park, Western Australia; 2014, retrieved from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf on 12/27/22, pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising. This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Bruising indicates suspected deep tissue injury. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/Stage 4 ulcers can extend into muscle and/or supporting structures (fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as the body's natural (biological) cover and should not be removed. Suspected Deep Tissue Injury: Depth Unknown Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. B. Pressure injury interventions According to the National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline, [NAME] Haesler (Ed.), Cambridge Media: [NAME] Park, Western Australia; 2014, from https://www.ehob.com/media/2018/04/prevention-and-treatment-of-pressure-ulcers-clinical-practice-guidline.pdf (12/9/21), Skin assessment is crucial in pressure ulcer prevention because skin status is identified as a significant risk factor for pressure ulcer development. The skin can serve as an indicator of early pressure damage. Skin and tissue assessment underpins the selection and evaluation of appropriate preventive interventions. Interventions for Prevention and Treatment of Pressure Ulcers: Five sections of the guideline present interventions that are used for both prevention and treatment of pressure ulcers. Nutrition, repositioning and early mobilization, addressing heel pressure, support surfaces and medical device management are all areas of care that are implemented both as a preventive measure, and to promote healing of existing pressure ulcers. Nutrition for Pressure Ulcer Prevention and Treatment Multivariable analyses of epidemiological data indicate that a poor nutritional status, indicated by low body weight or poor dietary intake among other signs, is a factor that impacts upon pressure ulcer risk. All individuals at risk of pressure ulcers should have their nutritional status screened. A comprehensive assessment should be conducted where risk of malnutrition is identified, and in individuals with existing pressure ulcers. Repositioning and Early Mobilization Repositioning involves a change of position in the lying or seated individual, with the purpose of relieving or redistributing pressure and enhancing comfort. Repositioning and its frequency should be considered in all at-risk individuals and must take into consideration the condition of the individual and the support surface in use. Repositioning should maintain the individual's comfort, dignity and functional ability. Repositioning to Prevent and Treat Heel Pressure Ulcers Heel pressure ulcers are a challenge to prevent and manage. The small surface area of the heel is covered by a small volume of subcutaneous tissue that can be exposed to high mechanical load in individuals on bedrest. It is important to conduct regular inspection and correct positioning in order to relieve heel pressure while avoiding potential complications such as Achilles tendon damage, foot drop and deep vein thrombosis (DVT). Support Surfaces Support surfaces are specialized devices for pressure redistribution and management of tissue load and microclimate. The importance of using a high specification pressure redistribution support surface in all individuals at risk of pressure ulcers or with existing pressure ulcers is highlighted. Medical Device Related Pressure Ulcers Individuals with a medical device in situ are at a high risk of pressure ulcers related to the device. These pressure ulcers often conform to the pattern or shape of the device and develop due to prolonged, unrelieved pressure on the skin, often contributed to by associated moisture around the device, impaired sensation or perfusion and/or local edema, as well as systemic factors. Assessment of skin that is placed at risk due to a medical device is highlighted. II. Facility policy and procedures The Wound Care Standards policy and procedure, reviewed in October 2022, was provided by the director of nurses (DON) on 12/21/22 at 9:51 a.m. It revealed, in pertinent part, Residents are assessed as to the current status of their skin. A plan of care is established and updated as needed for prevention of skin breakdown and/or for treatment of existing wounds in order to heal them if possible and prevent infection. The treatment program for a pressure ulcer then entails: assessment and documentation of each pressure ulcer is to be done upon discovery of the ulcer; weekly by the wound team; PRN with any significant change in the wound. Assessment of the pressure ulcer must include the following: a. Stage, b. Location, c. Size: measurement of the length, width and depth (if any) of the ulcer, d. Color of the wound base, exudates color and consistency, and approximate volume of the wound drainage, e. Necrotic tissue (if present): slough or eschar, stated in terms of approximate percentages, f. Tunneling and/or undermining, g. Infection: presence or absence of signs of local wound infection: erythema, induration, purulent drainage, h. Pain: assess presence of pain associated with the wound both with or without dressing change, i. Healing (when present): indicators of healing include the presence of granulation tissue (fragile beefy red healing tissue composed of small blood vessels and connective tissue) or epithelialization tissue (thin silvery epidermal tissue), j. Surrounding skin: color, appearance and integrity of the area. Pressure ulcers must be monitored daily. III. Resident #60 A. Resident status Resident #60, age less than 70, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke) affecting left non-dominant side, hypertensive heart disease with heart failure, type 2 diabetes mellitus with diabetic chronic kidney disease, dysphagia (discomfort or difficulty swallowing), and received enteral feeding. The 9/13/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. It also revealed that she needed extensive assistance with activities of daily living and bed mobility. She was at risk for developing a pressure ulcer, having moisture associated skin damage, no unhealed pressure ulcers were present, no turning/repositioning program in place, and the treatment for her skin was a pressure reducing device for the bed and application of ointments/medications. B. Observation On 12/21/22 at 9:00 a.m., the RNWN was observed providing wound care to Resident #60. The resident was lying in bed. The nurse pushed the call light for assistance with repositioning the resident in bed. Certified nurse aide (CNA) #2 came in to assist. They positioned the resident on her left side. The resident's dressing was removed and scant serous (thin, watery) drainage was observed. The resident's wound bed to the coccyx had 90% slough tissue and 10% granular tissue to the distal edge of the wound. Attached to the proximal edge of the coccyx wound, was a smaller wound to the upper right sacrum (the wound bed was red). There were no signs and symptoms of infection noted. The wound care nurse cleansed the wound with a wound cleanser, then applied a hydrocolloid (autolytic debridement dressing) dressing and then covered it with a foam dressing. The wound nurse did not measure the wound. C. Record review The care plan, initiated 9/20/22, identified the resident had a potential for worsening skin integrity related to immobility/acute decline in activities of daily living secondary to recent hospitalization/illness. It also revealed that the resident had excoriation to her coccyx upon admission. The interventions that were put in place were as follows: use caution when transferring or moving in bed (use lift device/turn sheet); assess/report/record to the physician any skin condition, presence of any new areas; and weekly skin check by nurse. -The care plan did not include frequent repositioning/offloading, treatment, a pressure reducing bed, or when the air mattress was implemented. The clinical notes for Resident #60 revealed a skin assessment on 9/7/22, with a Braden scale score of 16, mild risk for developing pressure injury, and describing the resident's coccyx area as being red but fully blanchable and a skin barrier was applied. No wound orders for the skin barrier were found in the resident's chart, and no measurements of the area were documented as performed. Wound care notes for the coccyx area on 9/14/22 and 9/16/22 revealed the area was improved with mild excoriation. Skin barrier spray and a foam border pad was applied. No wound orders for either the skin barrier spray or the foam border pad were found in the resident's chart. A wound care note on 9/19/22 revealed no open areas to bilateral gluteal area, skin barrier was applied. -There was no note to document a coccyx area wound was found. A wound care note on 10/3/22 revealed a wound to the right gluteal area, measuring 0.3 x 0.3. Skin barrier was applied, then a foam border patch. -Assessment of the wound was lacking units of measurement and staging of the wound. A wound care note on 10/10/22 revealed that the right gluteal wound was closed, skin barrier applied and foam border pad applied. A wound care note on 10/17/22 revealed a deteriorated 1.0 x 1.0 partial thickness wound with distal border blue/red, skin protectant barrier and foam pad applied. -No location of the wound was identified and no units of measurement were identified with assessment of the wound. A wound care note on 10/21/22 revealed the right gluteal area was mildly excoriated over 3.0 x 3.0 area, cleansed and skin barrier swab applied, and foam border dressing applied. -There was no note regarding how the area was being cleansed and no units of measurement were found. A wound care note on 10/28/22 revealed that the right gluteal area was improving, and the wound bed had pink/red granulation and epithelialization. -No measurement of the wound or wound care was found. A wound care note on 11/2/22 revealed a coccyx wound was improving. -No documentation of the right gluteal area was found. A wound care note on 11/4/22 revealed that the coccyx wound was closed and the right gluteal wound was improving with excoriation, 0.1 x 0.3 open mild maceration. -No wound care documentation and units of measurement in assessing the wound were found. A wound care note on 11/7/22 revealed that the bilateral gluteal areas were improving and that a skin barrier and foam border dressing were applied. -No wound care orders were found. A wound care note on 11/9/22 revealed gluteal excoriation was improving and a skin barrier was applied. -No wound care orders or measurement of the wound were found. A wound care note, within the clinical notes, on 11/16/22 revealed that the coccyx wound had reopened. A blue/black spot 0.7 x 0.7 was noted on the coccyx and another the same size on the right sacrum with partial thickness wound surrounding the wound with tissue maceration, cleaned, skin barrier applied to the entire area and covered with foam border dressing. -No units of measurement in assessing the wound, wound care orders, or bilateral gluteal area wound assessment were found. A wound care flow sheet initiated on 11/16/22 revealed an assessment for a right sacrum wound. -Only two entries had been entered: 11/16/22 and 11/18/22. Both entries were incomplete: missing documentation in the wound stage, tunneling, pain, and other information sections. A wound care flow sheet initiated on 11/16/22 revealed an assessment for a coccyx wound. -The wound care flow sheet revealed an assessment of the coccyx wound on: 11/16/22, 11/18/22, 11/25/22, 11/28/22, 12/5/22 and 12/14/22. -All entries were missing documentation in the pain and other information sections of the assessment. -The 11/18/22, 11/25/22, 11/28/22, 12/5/22, and 12/14/22 entries were missing documentation in the tunneling section. -The 11/25 and 11/28/22 entries were missing the wound staging assessment. -The 12/14/22 entry was not completed or signed, only revealing that the wound had deteriorated. No other entries were found. A wound care note, within the clinical notes, on 12/9/22 revealed that there were two wounds: 0.8 x 0.4 stage 3, coccyx wound with yellow slough in the wound bed, and excoriation on the right sacrum. The wound was cleaned, skin barrier applied, and covered with a border foam dressing. -No units of measurement in assessing the wound or wound care orders were found. A wound care note on 12/14/22 revealed that both wounds had deteriorated, the coccyx wound was 0.8 x 0.4 x 0.1 open, no slough but blue discoloration. Right sacrum 0.8 x 0.5 blue/red non-blanching, skin barrier applied with border foam dressing. -No units of measurement in assessing the wounds or wound care orders were found. A nursing note on 12/15/22 revealed a Braden scale score of 14, indicating a moderate risk for developing a pressure ulcer. A wound care note on 12/21/22 revealed that the sacrum and coccyx wounds were both improving slowly. The sacral wound bed had red/pink granulation tissue with scant areas of maceration. The coccyx wound had red/yellow granulation buds apparent and yellow slough in the wound bed. A hydrocolloid with foam border dressing applied. -No wound care orders were found and the wound was not measured. The wound measurements documented in the wound and clinical notes did not include if the measurements were in millimeters, centimeters or inches. The CPO for December 2022 included an order for skin/wound care per facility protocol PRN (as needed). No specific orders were noted for Resident #60's coccyx and sacrum wounds. An order was added on 12/9/22 for an air mattress to the resident's bed for off-loading and comfort. Review of the treatment administration records (TARs) for October, November and December 2022 revealed a skin/wound care per facility protocol, as needed, order starting 9/6/22, and no documentation of staff performing the treatment was noted. The medication administration record (MAR) for December 2022 revealed no administration record of the wound cleanser being used to treat Resident #60's wounds. The Wound Care Standards policy and procedure, revised in October 2019 and last revised in October 2022, was provided by the director of nurses (DON) on 12/21/22 at 9:51 a.m. It revealed, in pertinent part, Ulcer Care. Initial care of the pressure ulcer involves debridement, wound cleansing, the application of dressings. Treatment product categories protocol for stage 3 wounds: hydrocolloid (absorbent) dressing, should not be used with heavy exudate wound or if infection is present, hydrogels (absorbent), foams and alginates. The policy revealed that in the absence of the wound nurse, it is the responsibility of the staff nurse to assess pressure ulcers on a daily basis. If a dressing is in place and it is not due to be changed, evaluate the status of the dressing, the area surrounding the ulcer for possible complications such as infection or maceration of skin. Initial the TAR and document any findings. Complete treatments as ordered on TAR and initial when completed, assess wound and document. There was no further documentation in Resident #60's record to reflect the care the facility was providing to prevent wound development or interventions to prevent wound development. D. Interviews Licensed practical nurse (LPN) #3 was interviewed on 12/21/22 at 5:20 p.m. She said that the wound care orders were found in the resident's chart. She acknowledged there were no orders, she could not locate them. She said that she looked at the last wound care nurse's note, and applied whatever dressing the wound nurse last applied. She said that she was not able to assess the wounds, it was outside her scope of practice, that a registered nurse needed to assess wounds. The registered nurse/wound nurse (RNWN) was interviewed on 12/22/22 at 9:43 a.m. She said Resident #60 admitted with excoriation to her coccyx and staff applied a skin barrier, the excoriation would get worse, then it would get better. She said Resident #60's coccyx wound healed and then reopened on 11/16/22 and it was documented as a stage 3 pressure ulcer. She said that she did 90% of the wound care at the facility (every Monday, Wednesday and Friday), and that the staff nurses should know what wound care to provide because she reported to them when she provided wound care. She said the facility had a wound protocol which she followed (see above). She agreed that residents with wounds should have specific wound care orders for staff to follow. She acknowledged that she was behind on weekly documentation of wound care and that it needed to include measurements, characteristics of the wound, and if the wound was healing or deteriorating. IV. Failure to ensure weekly wound assessments were completed for Resident #47 A. Resident #47 status Resident #47, age [AGE], was admitted on [DATE]. According to the December 2022 computerized physician orders (CPO), diagnoses included fracture of the right ulna (wrist), fracture of the left and right patella (knee), chronic obstructive pulmonary disease, hypertension, and pressure ulcer of the left and right heel. The 12/2/22 MDS assessment revealed Resident #47 was cognitively intact with a BIMS score of 15 out of 15. She required extensive one to two-person assistance with most activities of daily living (ADLs). She did not exhibit behaviors or reject care. Resident #47 was at risk of developing pressure ulcers/injuries. Two unstageable pressure injuries were present upon admission. She had a pressure reducing device for her chair and bed, pressure ulcer/injury care and application of dressings to her feet. B. Observation The registered nurse/wound nurse (RNWN) was observed providing wound care to Resident #47's bilateral heels on 12/21/22 at 8:45 a.m. She said the resident was admitted with deep tissue injury (DTI) to her bilateral heels. She said the resident was non-compliant with care, and often refused treatments, such as heel booties, L'Nard boots and floating of her heels. The resident had a geo mat (foam) on her bed which she used to float her heels in bed. The resident's right heel was calloused with a dark dry center. The resident's left heel was calloused, dry and boggy. The wound nurse applied skin prep to the resident's heels. The wound nurse did not measure the resident's wounds to her heels. C. Record review The care plan, initiated 11/26/22, revealed Resident #47 had a potential for impaired skin integrity related to immobility/acute decline in ADL function secondary to her recent hospitalization/illness. The resident's Braden (a tool used for predicting pressure ulcer development) score was 16 on admission (15-18=mild risk, 13-14=moderate risk, 10-12=high risk and less than 9=severe risk). Interventions included to administer medication/treatments as ordered and note/report any side effects or complications, float heels, and weekly skin checks by the nurse. Review of the December 2022 CPO revealed Resident #47 had orders to apply skin prep to her bilateral heels every shift (twice daily) and to offload pressure to her heels. Review of the weekly wound reports and weekly clinical notes from 11/14/22 to 12/21/22 revealed staff did not document weekly assessments to include wound measurements, wound characteristics, and/or if the wound improved or deteriorated. The documentation for the left heel was completed on 11/14/22 and 11/16/22. The documentation for the right heel was completed on 11/14/22, 11/16/22, and on 11/28/22 which documented the wound was healed. D. Staff interviews The RNWN was interviewed on 12/21/22 at 9:30 a.m. She said at one point Resident #47's right heel DTI/callous healed on 11/28/22 but then redeveloped on 11/30/22 due to her skin condition ichthyosis (a group of skin disorders characterized by dry, scaly, or thickened skin). She acknowledged Resident #47 did not have weekly wound assessments completed for the past few weeks. She said she was behind on her weekly documentation of wounds. She said she was the only wound nurse and occasionally another registered nurse (RN) would fill in for her when she was off. She said residents with pressure ulcers needed to have a weekly assessment completed to include measurements and documentation if the wound was healing or deteriorated. She said if she did not complete one it would fall on the floor nurses to complete. The director of nursing (DON) was interviewed on 12/22/22 at 1:41 p.m. She said the wound nurse usually completed weekly documentation of wound care. She said the weekly wound assessments needed to include measurements, description of the wound, drainage, signs of infection and if the wound was healing or deteriorating.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Physical abuse between Resident #49 and #50 Resident #49 and Resident #50 were a married couple who were residing in the same room on E Hall at the time physical abuse between the two occurred on 7/28/21. A. Resident #49 1. Resident status Resident #49, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), diagnoses included generalized anxiety, major depression, delusional disorder, insomnia, restless leg syndrome, glaucoma and sensorineural hearing (extremely hard of hearing). The 7/1/21 minimum data set (MDS) assessment revealed the short-term memory was not coded and the long-term memory coded the resident had deficits. She was moderately impaired for daily decision making. There was no brief interview for mental status (BIMS) score completed on this MDS. This MDS documented the resident displayed physical behaviors directed towards others, verbal behaviors directed towards others and behaviors not directed towards others during one to three days during the seven-day lookback period. She received seven days of anti-anxiety medications and hypnotics during the seven-day lookback period. The MDS documented the resident required extensive assistance of one for bed mobility, transfers, ambulating in her wheelchair, dressing, eating, toileting, personal hygiene and bathing. 2. Record review The care plan dated 7/7/21 related to mood documented Resident #49 had the potential for mood decline as evidenced by accusatory screaming, calling out and being difficult to redirect. It documented the resident was vision and hearing impaired, which exacerbated the resident's anxiety. Her spouse reported the resident had made negative comments as her health declined. It documented the resident yelled out comments such as Is there arsenic in those pills, there should be, Just shoot me, or You're abusing me when staff was providing proper care, when someone just entered the room or when no one was in her room at all. It documented the resident was physically aggressive, hit staff during care and was difficult to redirect. On 7/19/21, this care plan was updated to reflect the resident had been started on Sertraline (medication) for anxiety and depression. On 8/4/21, this care plan was updated to reflect the resident had been ordered Seroquel for a new diagnosis of delusional disorder. Interventions included investigating allegations of abuse or concerns as appropriate. -The care plan was not updated on 7/28/21 in relation to a physical altercation between Resident #49 and her husband, Resident #50. The care plan dated 7/7/21 related to psychosocial well-being documented Resident #49 continued to have difficulty adjusting from the community to long term care status with increased episodes of anxiety, resulting in verbal outbursts which were disruptive towards other residents and may be impacting the resident's psychosocial well-being. This care plan was updated on 7/28/21 and documented, Due to increased potential for physical and verbal aggression towards spouse, they are no longer rooming together which decreases their time together. Interventions included encouraging participation in activities of interest, introduce Resident #49 to others with similar interests and encourage and provide individualized activities for the resident's room as needed. The care plan dated 7/7/21 related to behavior documented Resident #49 was irritable and had episodes of physical aggression. It documented she reached out, attempting to grab or touch anyone that was near, such as her spouse. It documented Resident #49 and her spouse would argue at times and would push each other's hands away, resulting in staff visibly seeing the residents' irritation with each other. The resident's spouse stated this was Resident #49's baseline anxiety due to her sensory impairments. It documented Resident #49 was verbally aggressive as evidenced by the resident screaming and yelling at staff. It documented she was demanding with unrealistic expectations of staff. She screams ouch and help as an anticipatory response to any ADL (adult daily living) or request for assistance. It documented, on 7/21/21, Resident #49 entered into a behavioral agreement to ensure the safety and dignity of others. She agreed to be respectful towards staff and to no longer spit, throw items at, scream while proper care was being provided, threaten to harm others and to use the call light instead of screaming and yelling. It was updated on 7/28/21 and documented physical aggression towards her spouse, resulting in injury to both Resident #49 and her spouse, Resident #50. It documented visits with her spouse would be monitored for safety as needed. B. Resident #50 1. Resident status Resident #50, age [AGE], was admitted on [DATE]. The August 2021 CPO documented the resident's diagnoses included chronic kidney disease, type II diabetes mellitus and history of transient ischemic attack (stroke). The 7/6/21 MDS assessment revealed the resident had a BIMS score of 14 out of 15 and was cognitively intact for daily decision making. It documented the resident displayed physical behaviors towards others during one to three days during the seven-day lookback period He required limited assistance from one for ambulating with his walker. He required extensive assistance of one for bed mobility, transfers, dressing, toileting and personal hygiene. 2. Record review The care plan dated 7/7/21 related to psychosocial well-being documented Resident #50 had the potential for impaired psychosocial well-being and/or adjustment problems related to recent lifestyle changes, as he was used to caring for his spouse with minimal interaction with others, as the two were rooming together. This care plan was updated on 7/28/21 and documented that due to the increased potential for physical and verbal aggression towards his spouse, they are no longer rooming together, which decreased their time together. The care plan dated 7/7/21 related to behavior documented Resident #50 had episodes of irritation towards others, which could lead to physical aggression such as hitting a staff member's hand away while they were trying to assist him. It documented he also pushed his spouse's hand away while she was trying to reach or grab out towards him. This care plan was updated on 7/28/21 and documented there was physical aggression towards his spouse, resulting in injury to both Resident #50 and Resident #49. It documented Resident #50 was immediately transferred to a different room following the physical abuse altercation between the two. It documented an intervention of visitation with his wife to be observed for safety as needed. C. Initial facility investigation The facility's abuse investigation related to the resident to resident physical abuse between Resident #49 and Resident #50 was provided by the social services director (SSD) the morning of 8/24/21. The investigation documented a physical abuse investigation was filed on the State Agency related to resident to resident abuse between Resident #49 and Resident #50. This incident was reported to the State Agency on 7/28/21 by the social services director (SSD) at 10:00 p.m. Resident #49 and Resident #50 were spouses who resided together on E Hall. This physical abuse occurred in Resident #49's and Resident #50's room on 7/28/21 at 8:40 p.m. The facility's abuse investigation documented a certified nurse aide (CNA) heard Resident #49 calling out, Help me, help me, so the CNA walked into their room and heard both residents yelling at each other. Resident #49 was calling out for the CNA to move the call light clipped on her shirt to her collar of the shirt, which was done. As Resident #49 continued to yell out, the CNA observed Resident #50 reaching out with his right arm and swatting his wife's back, as they were lying next to each other in twin beds that had been pushed together. Resident #49 was lying on her side, turned away from Resident #50 when he hit her. Resident #49 then retaliated and reached back with her left arm and swatted her husband, hitting his right hand/arm. It was documented both residents were yelling, as both were very hard of hearing. It was documented Resident #50 grabbed and squeezed Resident #49's hand, digging his nails into her hand. Resident #49 started screaming, Abuse, abuse, he's hurting my arm. Call a doctor, call a lawyer. At one point during the physical altercation, Resident #50 sustained a skin tear to his hand. It documented both residents made contact with each other during the incident. Both of the residents sustained injuries, as a few hours later, staff noticed some bruising on the back of Resident #49's left wrist. The residents were immediately separated by the CNA who observed the physical abuse between the two residents. The CNA called for a nurse, who moved Resident #50 to another room in E Hall, where he still resides. Nursing staff assessed both residents for injury. The police department and Adult Protective Services were notified of the incident. D. Staffing training The SSD was interviewed on 8/26/21 at 9:52 a.m. She said the facility had conducted an all staff training on abuse on 7/2/21. The staff development coordinator (SDC) provided documentation on 8/26/21 that facility staff completed two separate abuse trainings in 2021. She said a CMS (Center for Medicaid and Medicare) course on abuse had been presented to all staff on 2/5/21. She said another training on abuse and behavior management had been presented to all staff on 7/5/21. She said both trainings lasted approximately 45 to 60 minutes each. E. Staff interviews The SSD was interviewed on 8/26/21 at 9:52 a.m. She essentially re-iterated what occurred between Resident #49 and Resident #50 on 7/28/21. (see above initial facility investigation). She said both residents still reside in separate rooms on E Hall and neither resident currently had a roommate. She said, following the initial investigation she filed the evening of 7/28/21, she was asked by the nursing home administrator (NHA) to begin the official facility investigation, which began 7/28/21 at 11:20 a.m. She said both Resident #49 and Resident #50 had cognitive deficits and she interviewed the residents separately. She said she interviewed Resident #50 first because she was the alleged victim. She said she then interviewed Resident #50, the CNA who witnessed the abuse, the nurse who assessed the residents and the only resident who was awake at the time of the abuse. She said initially, Resident #49 kept murmuring she wanted to die, but once the residents were separated, both appeared to be calmer and their anger seemed to have dissipated. The SSD said the facility did substantiate the allegation of resident to resident abuse, as it was witnessed by a CNA. She said because staff were not involved in the abuse and because there were no prior incidents of abuse between the two residents, the facility did not expand the investigation further. She said Resident #49 and Resident #50 were still able to visit each other, if they chose to do so, with staff monitoring both resident's mood and behavior and would chart on the visits by exception. She said, because Resident #49 had displayed continued anxiety and behaviors, the resident has not focused much on wanting to be with her husband. She said Resident #50 had been coming out of his room more often and was becoming more social since he stopped sharing a room with his wife. She said the facility was allowing the couple to visit, per their initiation, but neither resident were really asking for visits, which are very minimal. She said a few times, Resident #50 would go to the doorway of his wife's room and look into the room to check on her, but does not go into her room and will return to his room or the common dining area on E Hall. She said the couple's daughter has been focusing on stabilizing her mother's level of anxiety and is very involved in her parent's care, but due to the daughter's declining health issues herself, it limits her ability to come into the facility as often as she used to. She said the daughter still kept in frequent contact with staff via telephone. She said the daughter was fine with her parent's current living arrangement, but did ask staff if her parents would ever be able to room together again. She stated the facility answer was they would have to wait and see. The staff development coordinator (SDC) was interviewed on 8/26/21 at 1:56 p.m. She said a CMS course on abuse had been presented to all staff on 2/5/21. She said another training on abuse and behavior management had been presented to all staff on 7/5/21. She said both trainings lasted approximately 45 to 60 minutes each. She said if the facility substantiated any abuse allegation, additional education should have been provided to the staff, if requested of her. She said facility administration had not requested additional training be provided in the area of abuse, so she had not provided any additional staff training into abuse since 7/5/21. The nursing home administrator (NHA), director of nursing (DON) and quality assurance nurse manager (QANM) were interviewed together on 8/26/21 at 8:03 p.m. The NHA said they had developed an action plan to identify and prevent abuse in the facility. The NHA said it was a standard for their quality assurance (QA) program. She said the facility would monitor and discuss any issues with the SSD. All three being interviewed said they had not identified any trends related to abuse that were concerning prior to the start of the recertification survey beginning 8/23/21. The NHA facility reviewed any allegations of abuse during the 24-hour report every weekday and did not wait an entire month for QA to review the occurrences. The NHA said the facility was unaware of any abusive behaviors between Resident #49 and Resident #50 when they lived at home. She said the facility asked Resident #50 several times if he wanted to move into a different room because Resident #49 was so verbally abusive, but he declined. She said they were concerned that Resident #50 was not getting enough rest and he could just shut her off if he were in a different room. The DON said the facility had contacted the local mental health center's crisis line several times due to Resident #49's behaviors, but were denied services due to the resident's diagnosis of dementia and the fact they were unable to care for her physically in an inpatient setting. She said the facility attempted different things with Resident #49, such as different headphones, different music, bringing the daughter in visit with the resident, and one-on-one staff monitoring when needed. The NHA said the facility had looked into alternative placement , but the facility was not accepting new admission due to low staffing. She said many medication adjustments had been made for Resident #49 by the facility's medical director and they saw a bit of a trend of improvement and then further adjustments were needed. She said the facility has looked into geri-psych placements since the abuse altercation between the two residents. She said the facility did not foresee the altercation and felt the husband was just trying to keep his wife quiet when the altercation began. V. Resident #87 A. Resident status Resident #87, age greater than 65, was admitted on [DATE]. According to the August 2021 CPO diagnoses included chronic obstructive pulmonary disease (COPD), depressive episodes, history of falling and intertrochanteric fracture of right femur. According to the 8/10/21 MDS assessment the resident was cognitively intact with a BIMS of 15 out of 15. Moods included trouble falling/staying asleep, feeling tired or having little energy, poor appetite or overeating. She had no behaviors. She required extensive assistance of two persons for bed mobility and transfers and extensive assistance of one person for locomotion and toileting. B.Resident interview Resident #87 was interviewed on 8/23/21 at 9:41 a.m. She said that one night she had a run in with one of the nurses. She said that the nurse was rough with her when transferring her into bed and that she tossed her into bed like a ragdoll. She said the nurse was impatient and rushed. She said she told the nurse that she did not like being treated that way. The resident said the facility was short staffed, however; that did not mean that they had the right to treat people like that. She said she brought it to another nurses ' attention the following day. She said she was not afraid of the nurse and that she was still taking care of her when she was on duty. C.Staff interviews Registered nurse (RN) #5 was interviewed on 8/23/21 at 11:05 a.m. She said that she remembered that Resident #87 did mention something about negative staff treatment during a care conference meeting. She said that from what she could remember the resident reported there was a personality conflict or maybe a verbal abuse by the nurse on duty. She said that she could not remember exactly what the details were. She said she reported this immediately to the quality assurance nurse manager (QANM). The QANM was interviewed on 8/24/21 at 8:57 a.m. She said that RN #5 did report to her (on 8/12/21) that Resident #87 had made an allegation that a night nurse (RN #2) that worked with the resident the night before was rough, grabby and tossed her around like a puppet doll. The QANM said she immediately went to talk to the resident and based on what the resident said (see report below). She said the allegation was unsubstantiated due to it not meeting the elements of abuse and the conclusion of the investigation was that it was a personality issue. She said that the nurse was no longer to provide care or administer medications to the resident and that a certified nurse aide with medication authority would be available and scheduled on the same nights as the nurse. She said RN #2 had been suspended pending the investigation. -However, the RN #2 was not suspended when the resident reported the allegation to RN #5 to ensure her safety while the investigation was being conducted. The allegation was not reported to the State Agency (cross-reference F609) and a thorough investigation was not conducted (cross-reference F610). C. Record review -There was no documentation found in the resident's clinical record from 8/3/21 to 8/24/21 of an allegation of staff mistreatment. A psychosocial well-being care plan initiated 8/4/21, and with a goal date of 11/4/21, documented in part the resident had the potential for impaired psychosocial well-being related to recent lifestyle change resulting from admission. The interventions included in part to educate the resident about the location of resident rights and listen to her concerns and address them timely. An activities of daily living (ADL) care plan initiated 8/4/21, and with a goal date of 11/4/21, documented in part the resident had an acute decline in independence and impaired physical mobility related to a recent hospitalization and illness and she was at fifty percent weight-bearing status (WBS) for two weeks. Interventions included in part that the resident would obtain assistance as needed, nursing to monitor ADL status while continuing to receive therapy, positioning bars to be provided as needed to assist with bed mobility and provide progressive mobilization as directed per therapy. On 8/24/21 the facility provided a one page typed document of an allegation of abuse by Resident #87 that occurred on 8/12/21. The report documented in pertinent part that RN #5 reported to the QANM a concern by Resident #87. In RN #5's statement to the QANM she said that Resident #87 told her that she did not care for RN #2, who took care of her the night before. She said RN #2 was rough, grabby and tossed her around like a puppet doll. The QANM asked the resident what happened and the resident told her that the night before (8/11/21), RN #2 was giving here medications and she asked RN #2 if she would assist her. The resident said the RN did not have any patience. The QANM asked the resident if she had been injured or was afraid of RN #2. The resident said she was not afraid and to keep her away from me, I do not have to put up with that kind of behavior. She (RN #2) moved too fast and does not give you time to adjust or get ready. The QANM asked the resident about her comment she made about being a puppet doll. The resident said she felt that she received as much compassion as a puppet doll; hurried and tossed away. The QANM asked the resident if she felt like she was tossed and the resident said RN #2 was hurried and did not give her time to adjust to the movement and that she felt rushed. Review of progress notes and staffing schedule for 8/21/21 revealed that RN #2 was scheduled on the same unit as Resident #87 on 8/16, 8/17, 8/18, 8/23, 8/24 and 8/25/21 during the overnight shift. D.Additional interviews The QANM was interviewed a second time on 8/24/21 at 11:27 a.m. She said that when they receive an allegation of abuse that they initiate an in-house investigation. She said if the allegation was non-reportable they would complete a summary sheet. She said she did not have any additional supporting documents except some of her chicken-scratch notes. She said she would provide these. The QANM said that what the resident reported to her when she initially interviewed her did not constitute mistreatment because she had heard the information from a third-party; RN #5. The QANM said she had notified the director of nursing (DON) about Resident #87's allegations after she was made aware. She said the DON provided RN #2 with one-to-one education and tools so that there would not be a recurrence. She said she would provide additional follow up. RN #2 was interviewed on 8/24/21 at 5:58 p.m. She said that she had just been notified today before starting her shift that there was an allegation made against her by Resident #87 about something she had done to her last week when she worked. RN #2 said that she had gone into the resident's room and she was sitting on the side of the bed and she said she needed to go to the bathroom. RN #2 said she assisted her to the bathroom and then when she took her back to get her into her wheelchair the resident was not standing well and she was concerned that the resident was going to fall. She said she told the resident that she needed to get her into the chair right away and then guided Resident #87 into the chair quickly. She said the resident was not happy that she had to guide her and asked me why I was being so rough with her. RN #2 said the resident may have perceived that she was being rough with her however she did not feel she was rough. She said she then transferred the resident from the wheelchair into the bed. RN #2 said today was the first she had heard of the concern and that she had not been contacted previously, placed on suspension or told she was not to work with the resident. She said she was the only nurse at night in the rehabilitation unit and she worked Monday, Tuesdays and Wednesdays. She said she had continued working with the resident when she returned to work on 8/23/21. She said she was told today that the resident said it was ok for her to continue taking care of Resident #87. E.Facility follow-up The QANM was interviewed a third time on 8/26/21. She said that she had re-interviewed Resident #87 on 8/24/21 and based on what the resident reported about being thrown into bed, she initiated another investigation and then reported the incident through the State Agency as physical abuse on 8/24/21. She said the investigation was ongoing. She was asked if RN #2 had been suspended pending the new investigation started on 8/24/21 and she said no, she had not. Based on interviews and record review, the facility failed to ensure freedom from abuse and neglect for five (#31, #47, #49, #50, #87) of 27 residents reviewed out of 44 sample residents. Resident #31, who had severe dementia and was dependent for activities of daily living (ADLs), was physically and verbally abused and neglected by certified nurse aide (CNA) #8, who rammed her fingers into a table, refused to take her to the bathroom, and was verbally abusive during care provision. CNA #8's abuse and neglect of Resident #31 was observed and reported by fellow CNAs. Resident #31 was unable to express how those experiences made her feel. Resident #47, who needed extensive assistance with transfers, was neglected and received injuries in the shower room when CNA #1 banged and scraped her shin on the bath bed, then transferred her from her wheelchair to the bath chair without using a gait belt or locking her chair brakes. As a result, Resident #47 fell and injured her hand, ankle and shin. Further, Resident #47 said in an interview that she had recently been left unattended on the toilet for half an hour. She said both incidents hurt. Resident #87 reported that a night nurse was rough and threw her into bed like a rag doll during a transfer. She said she was not hurt and not afraid of the nurse, but she did not like to be treated that way. Residents #49 and #50 suffered resident-to-resident abuse during a physical altercation. Both residents sustained bruising and skin tears to their wrists and hands. Findings include: I. Facility policy and procedures The Abuse Prevention, Investigation and Reporting policy, dated March 2017, was provided by the nursing home administrator (NHA) on the afternoon of 8/23/21. The policy documented in pertinent part that management would take specific steps to reduce the potential for abuse to occur including, but not limited to, education, monitoring and investigating thoroughly if abuse, neglect or exploitation was suspected. In addition, incidents would be reviewed to determine if abuse was suspected, and if suspected, it would be investigated thoroughly. The facility would ensure staff patterns to meet the needs of the resident, and to assure that the staff assigned had knowledge of the individual residents' care needs. New staff were assigned to work with an employee during their orientation period to become accustomed to the residents. The supervision of staff would be ensured to identify inappropriate behaviors such as derogatory language, rough handling, and ignoring residents while giving care. Employees who suspected abuse were to immediately intervene to protect the residents. Any alleged employee suspect would be removed from contact with any resident and put on administrative leave during the investigation. If evidence was found to support abuse or neglect, the employee would be terminated. II. Resident #31 A. Resident status Resident #31, age [AGE], was admitted on [DATE]. According to the 6/17/21 significant change minimum data set (MDS) assessment, diagnoses included dementia, anxiety and depression. The 6/17/21 MDS assessment further documented Resident #31 had severe cognitive impairment with a brief interview for mental status (BIMS) score of eight out of 15. No behavioral symptoms or care rejection were documented. The resident used a wheelchair for ambulation and needed extensive assistance with bed mobility, transfers (by two or more staff), dressing, and toilet use. The resident was frequently incontinent and had a history of urinary tract infection (UTI). B. Resident observations Resident #31 was observed throughout the survey, conducted 8/22/21 from 6:05 to 9:30 p.m., and 8:00 a.m. to 6:00 p.m. on 8/23, 8/24, 8/25 and 8/26/21. She used a wheelchair and was often in the common areas, pleasantly confused, and visiting with others. C. Interviews Certified nurse aide (CNA) #4 was interviewed on 8/26/21 at 10:42 a.m. She said she had reported abuse, but the allegations did not get passed along and nothing gets done. She said some staff were kind of rude to residents with dementia and Alzheimer's. She said she had reported but it was not addressed. She said CNA #8 was refusing to take Resident #31 to the bathroom. When Resident #31 would ask, CNA #8 would say no. She said she had reported to her supervisor and nothing had happened. I've watched (CNA #8) ram her (Resident #31's) fingers into the table and instead of saying 'sorry' she said 'well?' She said that happened last Tuesday. She said every time CNA #8 was in the room with Resident #31 she got angry that she had to provide her cares. Just Tuesday (two days prior) we wheeled her out and (Resident #31) said she needed to go to the bathroom, and CNA #8 said, 'I already took you.' We've reported before and nobody seems to care. It's rude. And you don't want to get backlash for reporting things. I've reported multiple times. I assumed someone reported from the new nursing class. What if she's doing that to other residents? We just don't know. The quality assurance nurse manager (QANM) was interviewed on 8/26/21 at 11:27 a.m. and the above allegations were reported to her. She said she was in the process of investigating, and that one of the CNAs who witnessed it called off and was not working, another CNA who witnessed it was working in the facility that day. She said CNAs #15 and #16 who reported were not working in the facility that day. She said CNA #16 yelled at CNA #8 and CNA #15 was a witness; CNA #5 saw CNA #8 refuse to take a resident to the bathroom. She said she definitely considered it abuse and neglect. She said it was reported to her late Tuesday afternoon, about 6:30 p.m., when CNA #4 came to her and reported and said she had already reported to CNA #3 and the assistant director of nursing (ADON). The ADON said she was already working on it. The first thing we do is make sure the residents are safe, and CNA #8 was suspended pending the investigation. The QANM said she and the SSD were finishing up their investigations and just typing up their notes now. Copies were requested. CNA #5 was interviewed on 8/26/21 at 11:53 a.m. She said Resident #31 constantly asks to go to the bathroom and she told CNA #8 she was capable of going, knew when she needed the bathroom, was really easy to work with, and if she had to go to the bathroom she knew when she had to go, but the CNA #8 said, I just changed her, it's okay. CNA #5 said she told CNA #8 you don't have to be mean to her, she's really nice. I said there's no reason for you to be rude to her. (Resident #31) said something to her like 'you're too pretty to have this attitude,' and CNA #8 said 'this is why I don't like her.' She said it in front of the resident. It was Tuesday around lunch time. She says stuff like that in front of residents, talks a lot about her personal stuff around residents, how her day's going, cussing. It's been going on but about six months. CNA #5 said she talked to CNA #4 about it, and was told CNA #4 had already reported her and I know other people have reported her multiple times but I personally have not. She said she reported to CNA #3, their lead CNA and then CNA #4. She said the facility had talked to CNA #8 and gave her multiple warnings. She did have to take an abuse test online but they had not been monitoring her, which she knew because she worked with her most of the time. I don't see her being rough, it's more like the way she talks to them, like with (Resident #31), she'll just say 'Roll' (as in roll over), so then the residents get confused and upset and she gets upset. It's more like she doesn't know how to talk to the residents. It's verbally abusive but I've never seen her being rough like physical abuse. D. Facility investigation During an interview on the evening of 8/26/21, the QANM provided undated, untimed interviews with CN[TRUNCATED]