**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure four (#1, #8, #7 and #27) of 11 residents reviewed for abuse out of 28 sample residents were kept free from abuse. Resident #2 was admitted to the facility on [DATE] with diagnoses of cerebral palsy (disease that affects movement and muscle tone), acute respiratory failure, dementia with behavioral disturbance, violent behavior, depression, need for assistance with personal care and cognitive communication deficit. Resident #2's care plan documented he had potential to demonstrate physically and verbally aggressive behaviors due to his diagnosis of dementia. The resident had exhibited aggression toward staff and other residents. On 11/3/24, Resident #8 reported to staff that his roommate, Resident #2, had hit him. Resident #8 was assessed and found to have a bruise under his right eye. Resident #2 told staff that he swung at Resident #8. Resident #8 was sent to the emergency department (ED) where he was treated for bruising and swelling to his face and returned to the facility the same day. On 1/19/25, screaming was heard in Resident #2's room. Resident #2 and Resident #1 were found lying on the floor, both on their right side. Resident #1 was behind Resident #2. Resident #1 had a large bruise and swelling to her left eye, bleeding from her mouth and facial redness and discoloration. Resident #2 stated that he beat up Resident #1. Resident #1 was transported to the hospital and admitted with trauma to the head and neck where she was monitored for agitation and tachycardia (high heart rate). Resident #1 was readmitted to the facility on [DATE] with bruising to the face, chest and neck. Additionally, the facility failed to protect Resident #7 and Resident #27 from verbal abuse by Resident #4. Findings include: I. Facility policy and procedure The Abuse Prevention and Reporting-Guideline policy, revised August 2021, was provided by the nursing home administrator (NHA) on 1/27/25 at 11:49 a.m. It read in pertinent part, Residents will be free from verbal abuse, physical abuse, mental abuse, sexual abuse, involuntary seclusion, neglect and exploitation. Residents will not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, or volunteers, staff or other agencies serving the residents family members or legal guardians, friends, or other individuals. All allegations of abuse are investigated. Verbal abuse is any use of oral, written or gestured language that includes knowingly threatening a resident causing fear or imminent, serious bodily injury within hearing distance, to described residents, regardless of their age, ability or disability to comprehend. Physical abuse is the intentional action of inflicting bodily injury including, but not limited to hitting, slapping, pinching or kicking. It also includes unreasonable confinement, restraint, and bruises of unknown origin. The administrator or designee will complete the investigation and will notify the suspected assailant and victim or responsible party of the conclusions and any corrective actions implemented based on investigative findings. II. Incidents of physical abuse of Resident #1 and Resident #8 by Resident #2 A. Facility incident reports of physical abuse of Resident #8 and Resident #1 The NHA provided investigations for the incidents of abuse of Resident #8 and Resident #1 on 1/28/25 at 3:00 p.m. The investigations documented the following: On 11/3/24, Resident #8 reported to staff that his roommate, Resident #2, had hit him. Resident #8 was assessed by facility staff and found to have a bruise under his right eye. Resident #2 told staff that he swung at Resident #8 because Resident #8 did not want to go to sleep. Resident #8 was permanently moved to a different room and Resident #2 was placed on one-on-one facility staff supervision and no longer had a roommate. After an 11/4/24 physician evaluation, it was determined Resident #8 should be sent to the emergency department where he was treated for bruising and swelling to his face and returned to the facility the same day. On 11/9/24 Resident #2 was documented as having been on 15-minute checks after one-on-one facility staff supervision was discontinued. On 1/19/25, screaming was heard in Resident #2's room. Resident #2 and Resident #1 were found lying on the floor, both on their right side and Resident #1 was behind Resident #2. Resident #1 had a large bruise and swelling to her left eye, bleeding from her mouth and facial redness and discoloration. When questioned, Resident #2 stated that he beat up Resident #1 because she wandered into his room. Resident #1 and Resident #2 were immediately separated and Resident #1 was sent to the hospital for further evaluation and treatment. Resident #1 was transported to the hospital and admitted with trauma to the head and neck and was readmitted to the facility on [DATE] with bruising to the face, chest and neck. Resident #2 was placed on one-on-one facility staff monitoring and discharged to the hospital on 1/19/25 with right hand discoloration to his knuckles and fourth and fifth digits. B. Resident #2 (assailant) 1. Resident status Resident #2, age greater than 65, was admitted on [DATE] and discharged to the hospital on 1/19/25. According to the January 2025 computerized physician orders (CPO), diagnoses included cerebral palsy, acute respiratory failure, dementia with behavioral disturbance, violent behavior, depression, need for assistance with personal care and cognitive communication deficit. The 1/24/25 minimum data set (MDS) assessment revealed the resident was moderately impaired regarding tasks of daily life and cues and supervision were required per staff assessment. A review of the residents electronic medical record (EMR) documented, on 10/22/24, the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) of six out of 15. The 1/24/25 assessment documented Resident #2 needed substantial to maximum assistance with oral hygiene, bathing, dressing and bed mobility. He needed set up assistance with eating. The MDS assessment documented the resident had physical and verbal behaviors directed at others. 2. Record review Resident #2's comprehensive care plan, initiated 7/16/24, documented the resident was at risk for impaired cognitive function/dementia or impaired thought processes related to his dementia diagnosis. Pertinent interventions, initiated 7/16/24, included to monitor, document and report to the physician or a nurse any changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing himself, difficulty understanding others, level of consciousness and mental status. Resident #2's focused care plan for verbally aggressive behaviors related to dementia, initiated 9/5/24 and revised 11/9/24, documented Resident #2 acted in a playful way toward other residents which could be misconstrued. Pertinent interventions included to document the resident's behavior and attempted interventions (initiated 9/6/24 and revised 11/9/24), and analyzing key times, places, circumstances, triggers and what de-escalated the resident's behavior and document; the resident responded to verbal interventions from staff, was placed in a private room (with no roommate) and had potential for unprovoked aggression towards others. -The playful behaviors which could be misconstrued however, were not specified or documented. Resident #2's focused care plan for physical behaviors, initiated 11/4/24, documented he had the potential to demonstrate physical behaviors related to dementia, had exhibited aggression toward staff and other residents and was placed in a private room (with no roommate). Pertinent interventions, initiated 11/4/24, included to document observed behavior and attempted interventions, monitor, document and report to the physician if the resident was a danger to himself and others, and analyze key times, places, circumstances, triggers and what de-escalated the behaviors and document the findings. A review of Resident #2's EMR documented the following: On 7/17/24 provider documentation revealed Resident #2 was previously admitted to a hospital in April 2024 after assaulting an individual at a previous facility and being verbally abusive to the staff prior to admission to the current facility on 7/16/24. -However, the facility failed to implement a care plan that addressed Resident #2's behavior history upon his admission to the facility. Cross reference F744 for failure to provide a person centered dementia services. On 7/18/24 a nursing progress note, written at 3:55 p.m., documented Resident #2 approached multiple residents screaming and cursing at them for no reason. The staff directed Resident #2 away from the other residents and offered Resident #2 food and conversation. The assistant director of nursing (ADON) and on-call provider were notified. Cross reference F609 for failure to report abuse to the State Agency. On 7/19/24 a nursing progress note, written at 5:01 a.m,. documented Resident #2 was extremely aggressive and agitated throughout the shift and was calling residents names using explicit language and overall disrupting the normal nightly routines. Other residents were fearful of Resident #2 during this shift. Resident #2 began stalking residents and trying to physically trip other residents with his feet. Multiple interventions were attempted without effectiveness and a non-emergent message was left with the director of nursing (DON). -However, the incidents on 7/17/24, 7/18/24 and 7/19/24 were not reported to the NHA, who was the facility's abuse coordinator. On 7/19/24 a nursing progress note, written at 6:01 p.m., documented Resident #2 was extremely agitated throughout the shift and was using profanity. Resident #2 began following other residents and trying to trip them with his feet but did not make contact and was more than ten feet away from the other residents. -The facility failed to document attempted interventions to redirect the resident or if the physician was notified. On 8/13/24 a nursing progress note, written at 2:27 a.m., documented Resident #2 continued to wander on the secure memory care unit needing one-on-one facility staff care due to increased aggressive behavior and attempting to go in and out of other residents' rooms. After Resident #2 was redirected away from other residents' rooms, the resident held a closed fist up to staff while swinging and yelling profanities. Several residents got up and returned to their room, as they appeared afraid. Reassurance was given to residents redirected by staff back to their rooms. Resident #2 continued on one-on-one facility staff monitoring for resident safety. The facility placed a call to the provider to send the resident to the ED for evaluation and the ADON was notified. On 8/13/24 at 6:31 p.m. the DON documented a clarification note that indicated the DON followed up and Resident #2 was not yelling at any specific residents but residents were redirected into their rooms related to loud noise from Resident #2. On 8/16/24 a nursing progress note, written at 12:42 p.m., documented Resident #2 was observed in his wheelchair propelling in the hallway and yelling profane names at the female residents as they walked by. Resident #2 was then observed kicking and banging on a resident's door, while yelling and cursing at the female resident on the other side of the door. The resident was redirected to a quiet area, and listened to the staff member, appeared disinterested, verbalized understanding then laughed. On 10/9/24 a provider note documented the staff reported ongoing behaviors of Resident #2 attempting to interact with other residents in a playful manner, which could be irritating to other residents, and providing verbal redirection was usually sufficient. On 10/10/24 a nursing progress note, written at 11:47 a.m., documented Resident #2 was screaming at another resident in the hallway. Staff intervened and separated both residents safely. The resident was redirectable and went to participate in activities. -The facility failed to document the interventions used to redirect the resident or if the physician was notified. On 10/11/24 at 5:53 a.m. a nursing progress note documented Resident #2 continued to scream at a resident and staff and needed to be redirected multiple times. The nurse continued to monitor the resident's behaviors. -The facility failed to document attempted interventions to redirect the resident or if the physician was notified. The 11/4/24 physician note, documented at 7:26 a.m., revealed the physician followed up with Resident #2 regarding the resident assaulting and punching his roommate, and the resident had not had this type of behavior before and had intermittent verbal altercations with staff. -However, previous documentation revealed Resident #2 had previously used profane and derogatory language directed at other residents as well as kicking and banging another resident's door and cursing at her while she was in her room. On 12/8/24 a nursing progress note, written at 5:31 p.m., documented Resident #2 had multiple outbursts, yelling obscenities at staff and other residents. Resident #2 was at times able to be redirected, and this was reported to the DON. -The facility failed to document attempted interventions to redirect the resident or if the physician was notified. On 1/19/25 at 5:20 p.m. a certified nurse aide (CNA) heard screaming from resident Resident #2's room and notified a registered nurse (RN). Upon entering the room, Resident #2 was found on his right side on the floor and Resident #1 was lying on her right side behind him. Resident #1 had a large bruise and swelling to her left eye as well as bleeding from her mouth and facial redness/discoloration. Resident #2 said that he beat up Resident #1 because she wandered into his room. C. Resident #8 (victim) 1. Resident status Resident #8, age greater than 65, was admitted on [DATE]. According to the January 2025 CPO, diagnoses included Alzheimer's disease, chronic obstructive pulmonary disease, chronic respiratory failure, emphysema, depressive episodes, cognitive communication deficit and the need for assistance with personal care. The 1/1/25 MDS assessment revealed the resident was cognitively impaired with a BIMS score of two out of 15. Resident #8 required substantial to maximal assistance with toileting hygiene, bathing and lower body dressing, moderate assistance with personal hygiene and transfers, and supervision with eating. The MDS assessment documented Resident #8 had physical and behavioral symptoms directed toward others. 2. Record review Resident #8's behavior care plan, revised 4/3/24, documented the resident had potential to become verbally and physically aggressive toward others related to dementia and Alzheimer's disease. The care plan indicated his triggers were not understanding his surroundings and others approaching him from behind or not in his line of vision. Pertinent interventions, initiated 3/14/24, included if the resident could not be redirected or calmed, and if safe to do so, staff were to attempt to perform cares at a later time after the resident was calm, offering a deck of cards and staff to approach the resident within his line of vision. Interventions added on 11/11/24 included to approach the resident from the front or make it known you were approaching, redirect the resident and/or offering the resident a deck of cards. D. Resident #1 (victim) 1. Resident status Resident #1, age greater than 65, was admitted on [DATE]. According to the January 2025 computerized physician orders (CPO), diagnoses included early onset Alzheimer's disease, severe dementia, bipolar disorder, anxiety disorders, and psychotic disorder with hallucinations. The 1/1/25 MDS assessment revealed the resident had a memory problem and was severely impaired, never or rarely making decisions per staff assessment. Resident #1 was dependent on care or needed substantial to maximal assistance for all activities of daily living (ADL), used a wheelchair, was independent with eating and transferring self and required set up assistance with showering. The MDS assessment documented the resident had behaviors that were not directed at others. 2. Record review Resident #1's behavior care plan, revised 10/15/24, documented she had potential for a behavior problem related to her Alzheimer's diagnosis, schizoaffective disorder, bipolar type, psychotic disorder with hallucinations, and behavioral exacerbations as evidenced by wandering tendencies through the unit and into others' rooms. Resident #1 presented with periods of affection towards others. Pertinent interventions, initiated 3/1/24, included to document the resident's behaviors and resident response to interventions. Additional interventions, initiated 1/24/25, included to offer Resident #1 a safe wandering area and provide a quiet environment. The facility added a personalized shadow box outside her room so she could easily identify her room. Upon return from the hospital (on 1/24/25) Resident #1 was monitored for 72 hours to determine a pattern of behaviors and wandering. E. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 1/28/25 at 11:25 a.m. LPN #3 said when Resident #2 was asleep alone in his room, he would at times wake up screaming, yelling and throw his wheelchair and other belongings around the room. LPN #3 said Resident #2 was easily redirectable and if he said Resident #2's name, the resident would immediately change his behavior. LPN #3 said Resident #2 sometimes wandered and he reported the resident's behaviors to the physician. LPN #3 said Resident #2 verbally lashed out at other residents. LPN #3 said he was able to redirect the resident's behavior by saying his name and asking the resident to be a gentleman. LPN #3 said he never witnessed Resident #2 have physical contact with another resident. LPN #3 said when Resident #2 had behaviors, it usually happened very quickly and nothing specific triggered the resident's behaviors. LPN #3 said the facility conducted abuse education and he knew to contact the NHA to report abuse. LPN #3 said if he was unable to reach the NHA, he would contact the DON and the ADON to report abuse. The DON and the NHA were interviewed together on 1/29/25 at 11:00 a.m. The DON said the 24-hour nursing report was reviewed daily in the morning meeting. The DON said a note in a resident's EMR could be marked, by the writer, to enable the note to be viewed in the 24 hour report. The DON said when an agency staff member worked at the facility, the facility staffing coordinator provided the agency staff member information that included the DON's and the NHA's phone numbers. The DON said the facility was working on assembling an information and orientation packet for agency staff that included what incidents to report and whom to report to. The DON said the facility identified agency staff were working when Resident #2's behaviors were not accurately documented or reported. The NHA said after interviewing staff after the 1/19/25 incident between Resident #2 and Resident #1, the staff reported they heard the residents in Resident #2's room, and the residents (Resident #2 and Resident #1) were both lying on the floor. The NHA said the staff reported Resident #1 was behind Resident #2, holding him. The DON said both Resident #2 and Resident #1's behaviors were not observed to be out of the ordinary on 1/19/25. The DON said the regional clinical resource (RCR) interviewed the staff about the incident on 1/19/25 and staff reported both residents were baseline. The DON said a stop sign was placed on Resident #2's door in November 2024 to discourage other people from going in his room. The DON said Resident #2 did not like other people in his room. The DON said Resident #1 wandered into Resident #2's room but she was unsure if Resident #1 was able to understand the stop sign. The DON said it took time to become familiar with a resident's baseline behavior, which was why Resident #2 did not have a behavior care plan upon admission to the facility. The DON said if a new resident was admitted to the facility, the facility reviewed the resident's referral packet and resident's PASRR (pre admission screening and resident review) documentation and if behaviors were listed the facility put them into the care plan. The DON said the facility tried to establish a baseline for a residents' behavior and then determine if there were specific resident behaviors that needed to be added to a care plan. The NHA said he was the abuse coordinator for the facility and the staff were to call him to report allegations or suspicions of abuse. The NHA said if staff were not able to reach him, the next person to call was the DON, and if staff were unable to call the DON they could call the ADON. The NHA said he expected staff to call him to report abuse and not text him. The RCR and the DON were interviewed together on 1/29/25 at 3:00 p.m. The RCR said the facility's documentation of Resident #2's behaviors could have been more specific when describing if the behaviors were directed to a specific resident or not. The RCR said Resident #2 would be in his room and fine by himself and then could escalate quickly with no warning. The DON said Resident #2 had his medications adjusted in the latter part of 2024 which seemed to be more beneficial to the resident and his behaviors decreased. The DON said Resident #2 was triggered by people wandering into this room. The RCR said after reviewing the documentation in Resident #2's record, the facility recognized the documentation errors in the resident's EMR primarily originated from agency staff. She said after the incident on 1/19/25, the facility implemented a plan to only schedule facility staff in the secured unit (where Resident #1, Resident #2 and Resident #8 resided) instead of agency staff. The RCR said facility staff knew the residents better, could better anticipate a resident's needs and recognize if a resident's behavior began to change and intervene before the behavior escalated. The RCR said part of the plan of correction implemented after 1/19/25 was to create cards for the staff in memory care so staff could access, on the card, immediate and specific interventions for each resident. She said the cards were made for staff to carry on their person. The RCR said the staff found the cards helpful. The RCR said the plan of correction included ongoing monitoring of the memory care unit for at least a three-month period, which would be reviewed monthly in the facility's quality and performance improvement (QAPI) meetings. F. Facility plans of correction and follow up The NHA provided plans of correction (POC) on 1/30/25 at 3:20 p.m. for the incidents on 11/3/24 and 1/19/25. 1. POC for incident between Resident #2 and Resident #8 The POC for the 11/3/24 incident between Resident #2 and Resident #8 included: -A chart review for Resident #2 completed on 11/6/24 by the medical director with medication recommendations; -Resident #1 returned to the facility with bruising that was monitored and resolved with no complications and offered psychosocial support; -Resident #2 was started on immediate one-to-one staff to resident monitoring; -A chart review and identification of residents on the secure unit on 11/11/24 to ensure residents had appropriate care plans with identified triggers; -A chart review for roommate evaluation to ensure all roommate situations were working; -Monitoring initiated 11/13/24 to 1/24/25 that included observation of the secure unit to identify if any resident behaviors were happening and if staff responded appropriately; -Staff interviews three times a week to determine if they knew residents' triggers and interventions; and, -The DON or designees educated all staff who worked on the secured unit regarding resident's specific triggers. (However, the education was not dated). 2. POC for the incident between Resident #2 and Resident #1 The POC for the 1/19/25 incident between Resident #2 and Resident #1 included: -Resident #2 was put on one-to-one staff to resident monitoring until emergency responders transported the resident to the emergency department; -A review of all residents on the secure unit and five residents were identified who wandered and IDT reviewed their care plans; -The DON provided education to staff who provided direct care of potential triggers and interventions for each resident in the secure unit on 1/21/25; -An audit of the secure unit, initiated 1/25/25, that included five residents three times a week, that included review of resident behaviors, interventions and staff observations of appropriate staff response to resident behaviors; -Resident #1 was monitored for 72 hours upon return to the facility; -A consultation with an abuse preventionist coordinator about triggers and interventions; and, -Results of the audit would be presented in QAPI until substantial compliance was met. -However, the POC was complete as the facility had additional allegations of physical and verbal abuse that were not addressed (see below).III. Incident of verbal abuse by Resident #4 toward Resident #27 on 7/24/24 The facility incident report, dated 7/25/24 at 9:05 p.m., was provided by the NHA on 1/28/25 at 3:00 p.m. The report revealed Resident #4 arrived at the 400 unit seeming upset on 7/24/24 at 9:15 p.m. Resident #4 began yelling at staff members who attempted to de-escalate the resident and direct him away from the common area and other residents. During these attempts, Resident #4 said things about Resident #27 and the nurse present was not sure if Resident #27 heard what Resident #4 was saying about her. Resident #4 was eventually able to be redirected to his room. Resident #27 was assessed and interviewed and did not recall hearing anything or that an incident occurred. Resident #4 was placed on cares in pairs and one-to-one supervision until his behaviors improved. Both residents received psychosocial monitoring. Resident #4 was also placed on a success plan. A. Resident #4 (assailant) 1. Resident status Resident #4, age [AGE], was admitted on [DATE], readmitted on [DATE] and discharged on 12/23/24. According to the December 2024 CPO, diagnoses included multiple sclerosis, depressive episodes, muscle weakness, and thyrotoxicosis (a disorder in which the thyroid gland produces too much thyroid hormone). The 12/23/24 MDS assessment revealed the resident was cognitively intact and was independent with making decisions regarding tasks of daily life. The resident was dependent for most activities of daily living. The assessment indicated that the resident exhibited verbal behavioral symptoms directed towards others one to three days out of the assessment period. 2. Record review The trauma care plan, initiated 3/30/24 and resolved 5/23/24, revealed Resident #4 was at risk for retraumatization due to a history of trauma. Pertinent interventions included engaging with mental and behavioral health support and medication management, approaching in a calm manner, administering medications as ordered, discussing behavior and attempting to de-escalate and implement coping strategies and praising any indication of progress/improvement in behavior. The personality disorder care plan, initiated 3/30/24, revealed Resident #4 had a potential for mood problems due to his personality disorder which included anger and emotional outbursts, slamming objects down and using profanity. Pertinent interventions initiated 3/30/24 included administering medications as ordered, behavioral health consults as needed, encouraging the resident to express his feelings, de-escalating the resident, assisting him to a quieter or less stimulating environment, assisting him to an outdoor space for fresh air and medication. Interventions initiated on 5/6/24 included a success plan and encouraging the resident to ask for assistance when unable to perform ADLs independently. Interventions initiated on 7/25/24 included having the resident on one-to-one supervision. The behavior problem care plan, initiated 3/6/24, revealed Resident #4 had the potential for a behavior problem resulting from his personality disorder and depression. Pertinent interventions initiated on 3/7/24 included having caregivers provide an opportunity for positive interaction and attention, encouraging the resident to use his call light, intervening as necessary to protect the rights and safety of others, praising any indication of progress or improvement in behavior and a success plan. The verbal behavior care plan, initiated 3/7/24, revealed Resident #4 had the potential to demonstrate verbally aggressive behaviors due to anger and his personality disorder, which included swearing and using racially-insensitive language. Pertinent interventions initiated on 3/7/24 included a success plan analyzing key times, places, circumstances, triggers, and what de-escalated the behavior and documenting that information, giving the resident choices for care and activities, encouraging the resident to sit outside or watch funny videos online when upset or angry. Interventions initiated on 5/6/24 included a success plan in which the resident would ask for assistance from staff when he was having problems with his peers or removing himself from interactions with peers by going outside or to his room. Interventions initiated on 7/24/24 included a one-to-one companion and success plan. The behavior problem care plan, initiated 3/30/24, revealed Resident #4 had a potential for behavior problems due to his depression and personality disorder. A Level II PASSAR was conducted and found no significant mental illnesses. Pertinent interventions included the following PASRR recommendations: assisting with transitional housing, providing psychiatric case consultation, providing rehabilitation services and providing management. A practitioner note, dated 4/17/24 at 3:13 p.m., revealed Resident #4 was initially admitted from a previous facility where he had been hospitalized for three months due to psychiatric issues involving aggressive behavior. A progress note, dated 7/24/24 at 6:03 p.m., revealed Resident #4 was roaming up and down the hallways screaming about the food at the facility, using profanity, and disrupting other residents. The facility staff tried to redirect Resident #4 but he began targeting the staff with verbal aggression. The staff stopped engaging with Resident #4 except to politely ask him to discontinue his verbal aggression but were ineffective. The DON, the NHA, and the social services director (SSD) were notified of Resident #4's behaviors. A progress note, dated 7/25/24 at 12:29 a.m., revealed Resident #4 continued to use obscene and racially-insensitive language toward staff members. Resident #4 requested to be transferred to the emergency room, but when paramedics arrived, Resident #4 refused to go with them. Resident #4 then called emergency services throughout the night until he fell asleep. The DON, the NHA, and the SSD were notified of his behavior. B. Resident #27 (victim) 1. Resident status Resident #27, age [AGE], was admitted on [DATE]. According to the January 2025 CPO, diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, anxiety disorder, dementia and cognitive communication deficits. The 10/25/24 MDS assessment revealed the resident was significantly cognitively impaired with a BIMS score of three out of 15. The resident was independent for most activities of daily living. 2. Record review The behavior care plan, revised 4/24/24, revealed Resident [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure four (#79, #60, #31, #13) of four residents reviewed for abuse out of 48 sample residents were kept from mental and verbal abuse, contributing to residents experiencing, among other emotions, anxiety, fear, and humiliation. I. Staff to resident mental and verbal abuse A. In interviews with Resident #79, she stated the activities director (AD) was mean to her, spoke to her rudely, raised her voice at her, and made her feel belittled and like a scolded child on 4/3/24. Resident #79 was upset and was tearful as she recalled the incident. Although three staff who witnessed the incident promptly reported it to the nursing home administrator (NHA), the facility failed for several hours to initiate an investigation or implement corrective actions to protect Resident #79 from further abuse. B. In interviews with Resident #60, he said he was in severe pain from being reclined in his wheelchair for a long time. When he asked certified nurse aide (CNA) #2 to get him out of the wheelchair and into bed, the CNA raised his voice and, in a scolding tone, told him other residents had more important needs and that he would just have to wait. Resident #60 said the CNA made him feel that he was not as important as the other residents. II. Resident to Resident Mental and Verbal Abuse In separate interviews with Resident #13 and Resident #60, the residents said that Resident #31 verbally abused them by using racial slurs and offensive language and making derogatory comments about them. Both residents said they avoided common areas of the facility out of fear and worry that they would be subject to Resident #31's verbal attacks when they were in the same space as Resident #31. Resident #13 said he had to stay in his room more than usual to keep from crossing paths with Resident #31. Resident #13 said this treatment caused him distress and triggered feelings of worry. Resident #60 said he tried to avoid passing by Resident #60 as much as possible because the verbal attacks about his person made him feel bad. Record review and interview revealed the facility failed to take corrective action to prevent further verbal abuse of Resident #13 and #60 by Resident #31. Cross-reference F610; failure to initialize a timely investigation of reports of allegations of abuse. Findings include: I. Facility policy and procedure A. The Abuse policy, revised in October 2022, was provided by the nursing home administrator (NHA) on 4/3/24 at 3:13 p.m. It read in pertinent part: It is the policy of this Facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. This policy applies to all Facility staff including, but not limited to, employees, consultants, contractors, volunteers, students, and other caregivers who provide care and services to residents on behalf of the Facility. Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse includes the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their representatives, or within their hearing distance, regardless of their age, ability to comprehend, or disability. B. NHA and the social services director (SSD) were interviewed on 4/9/24 at 6:18 p.m. about the facility's response to allegations of abuse. The NHA said reports of potential abuse should be fully investigated. The NHA said when abuse was alleged, the process was to suspend the staff in question, protect the residents from further harm, make notifications to the power of attorney, and start a report to the State Agency. The NHA said if a resident's safety was in question, he would also notify adult protection services. He said he would start the investigation by interviewing the resident, then he would interview witnesses and find out if anything similar had happened before, and after completion of the investigation, he would perform a post-incident review. The SSD said he would interview the residents to find out what happened, whether or not they had fear, and if they felt safe. The NHA said the SSD took the lead in investigating allegations of abuse and reported findings to the NHA. II. Staff to Resident mental and verbal abuse - Incident involving the activities director (AD) and Resident #79 A. Resident #79 1. Resident status Resident #79, age over 65, was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia, bipolar disorder, post-traumatic stress disorder (PTSD), anxiety, and depression. The 3/2/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. She was independent with hygiene, dressing, and transferring herself and did not exhibit any behavioral symptoms or refusal of care. The resident's comprehensive care plan, revised on 3/24/24, documented Resident #79 had a history of trauma involving an adverse childhood experience and had the potential to demonstrate physical behaviors related to dementia. The interventions included approach in a calm manner, attempt to de-escalate, and implement coping strategies. When agitated, guide away from the source of distress and staff to walk away if the resident becomes aggressive. 2. Resident interview Resident #79 was interviewed on 4/3/24 at 1:35 p.m. Resident #79 was sniffing and wiping tears from her eyes. She grabbed a tissue, sat down on her bed, and apologized for being so upset. Resident #79 then reported she was very upset over a recent interaction with the AD during and after the resident council meeting that morning. Resident #79 explained the library book program meant so much to her and said many of the other residents had been asking her when they could get books again. She said she felt bad for the people who could not get out to do things and especially bad for those who were deaf and really enjoyed reading. She began to tear up again and wiped her eyes with a tissue. She said the library books meant a lot to her because she felt the book program really helped others and she enjoyed helping people. She said she felt the AD did not understand how important the books were to her and other residents. Resident #79 said the AD was very mean to her, raised her voice at her, was very rude, and told her the facility's library book program was not a priority and would not be a priority. Resident #79 said she was so upset by the way the AD spoke to her that she began crying. She said two therapy staff witnessed the interaction and helped to console her. Resident #79 said the AD's tone was snotty and very belittling. She said it made her feel like a scolded child. Resident #79 began to cry again and said she did not understand why the AD was so mean to her. She said she was so upset by the interaction that she just wanted to lie down and sleep. Resident #79 said she did not think she would even be able to do her therapy session that afternoon because she was so upset. 3. Report and response of staff witnesses to the incident a. Speech therapist (ST) #1 ST #1 was interviewed on 4/3/24 at 1:50 p.m. ST #1 said she witnessed an incident/inappropriate interaction between the AD and Resident #79 that occurred around 11:15 a.m. that morning. She said the AD was speaking to the resident in a manner that was not appropriate and was belittling the resident. She said she did not feel it was appropriate to communicate with residents with dementia in that manner. ST #1 said Resident #79 was crying after the encounter so she and occupational therapist (OT) #1 tried to console the resident. ST #1 said that she observed most of the interaction and OT #1 also heard the end of the interaction between the AD and Resident #79. ST #1 said physical therapist (PT) #1 saw the resident crying after the incident and also tried to console the resident. ST #1 said after the resident calmed down, she went with OT #1 and PT #1 to report the incident to the NHA. ST #1 said they felt more comfortable reporting the incident together because they believed their observations would be better received and not ignored if all three of them reported what they observed as a group since the allegation was against a member of the leadership team. ST #1 was interviewed a second time on 4/9/24 at 2:26 p.m. ST #1 said the AD sounded stressed and very busy. ST #1 said the tone of the AD was not appropriate since the resident had dementia. She said she did not feel it was her job to define abuse but it was her responsibility to report any incident that was concerning and she felt this incident fell into that category. b. PT #1 was interviewed on 4/3/24 at 1:53 p.m. PT #1 said he did not witness the incident but he did see Resident #79 crying after it was over. He said he helped to console her and went with ST #1 and OT #1 to report the incident to the NHA. c. OT #1 OT #1 was interviewed on 4/3/24 at 1:55 p.m. OT #1 said she heard the end of the interaction between the AD and Resident #79. The OT said the AD used an inappropriate tone of voice with Resident #79. OT #1 said the resident was very upset and was seen crying by the end of the resident and AD's encounter. OT #1 said she, ST #1, and PT #1 consoled the resident because she was so upset and tearful. OT #1 said the interaction was very concerning and they felt it needed to be reported to the NHA so that is what they did. OT #1 was interviewed again on 4/9/24 at 2:05 p.m. OT #1 said the AD's tone of voice during the incident with Resident #79 was very stern, direct, and inappropriate. OT #1 said the comment made by the AD that stuck out most to her was when the AD told Resident #79 that the library book program was not a priority. OT #1 said she defined verbal abuse as any type of talk that made a person feel bad or upset. d. The activities assistant (AA) #1 AA #1 was interviewed on 4/9/24 at 2:45 p.m. AA #1 said he only observed the end of the incident between Resident #79 and the AD. When he saw them they were standing in the hall in front of the activities room. AA #1 said Resident #79 started to walk away from the AD and then started talking again but could not remember what the resident said. AA #1 said the AD apologized to Resident #79 for losing her cool in her office. B. Facility response - failure to initiate an investigation or implement corrective actions for several hours to protect Resident #79 from further abuse. The NHA was interviewed on 4/3/24 at 2:00 p.m. The NHA said the staff that reported the incident between the AD and Resident #79 did not tell him that they thought the incident was verbal abuse so he did not start an investigation or take any action to suspend the AD. The NHA said he would look into it further and, depending on his findings, the AD might be sent home. An interview with the NHA on 4/3/24 at 4:30 p.m. revealed he had suspended the AD pending investigation. However, the AD continued to work in the facility without restricted access to interact with Resident #79 or other residents in the facility for five hours after the incident that morning and for two hours after he received reports of the incident from staff who witnessed it. C. The AD was interviewed on 4/10/24 at 3:15 p.m. The AD said the incident began after the resident council meeting when Resident #79 came to her office to talk about the library book program. The AD said she told Resident #79 that it would take time to get it set up as other items had to be relocated first. She said she told Resident #79 that she did not have an immediate solution and the resident became very upset and told the AD that the AD did not care about the library book program. The AD said she did not handle the situation very well and ended the conversation with Resident #79 by saying, If you don't like any of my solutions then we have nothing else to talk about. The AD said she tried to apologize to Resident #79 but the resident did not want to hear it. The AD said she had reflected on the interaction with Resident #79 and said she did not do a good job of de-escalating the resident. The AD said she needed more training and should remember that the facility was home for the residents and she had to respect that. She said if she were in that situation again, she would ask the resident for a break to regroup and settle herself down. The AD said Resident #79 kept talking over her and interrupting her so she raised her voice toward the resident because she did not like being interrupted. D. Facility investigation - failures in the facility investigation (Cross-reference F610) 1. The facility investigation was provided by the NHA on 4/10/24 at 2:10 p.m. The investigation, dated 4/3/24, documented Resident #79 reported the AD was snotty and she did not like her tone of voice. Resident #79 reported she had tried to talk to the AD about supplies needed for the library book program. The resident was placed on increased monitoring. Resident #79 was interviewed by the SSD as a part of the investigation. The investigation interview read: There was a Lengthy meeting with Resident #79 this afternoon to discuss resident council and interactions after resident council. The resident was noted to be calmly resting in her room when I knocked and entered her room. She reported to me that the day hadn't gone very well. Residents expressed frustration regarding the library books that she had previously managed and how many of the residents attended Bingo at the same time she used to set up the library. She reported that she has been waiting for space/supplies to continue with the library books but it hadn't happened yet. She also expressed frustration that everything is changing. She stated that the new activities lady was snotty and that she didn't like her tone of voice. I asked her if she was afraid of anyone here and she stated, Absolutely not. Throughout our meeting her mood varied, however frequently throughout our conversation the resident was joking and laughing. The meeting concluded when physical therapy (PT) came to work with her and she reported to PT that she's having a much better day. The investigation documented that Resident #79 was noted by staff who observed the incident to be tearful at the time of the incident. The facility investigation did not document that an allegation of verbal abuse was substantiated. It concluded that the resident raised her voice during the incident and the AD was attempting to diffuse the interaction. A staff witness said the AD's tone was stern and aggravated. Other staff thought the AD was professional. 2. Failures in facility investigation (Cross-reference F610) The corporate social worker (CSW) was interviewed on 4/10/24 at 2:45 p.m. She said she interviewed the AD but did not document the interview, she only took notes in her personal notebook which she did not share. She said she did not interview AA #1 regarding his statement that he overheard the AD apologizing to Resident #79 for losing her cool. A review of the facility's investigation did not explain which staff thought the AD was professional in her response to the resident and if those staff had witnessed the incident or part of the incident, or had only heard about the incident from other staff witnesses. III. Staff to resident mental and verbal abuse - Incident involving CNA #2 and Resident #60 A. Resident #60 1. Resident status Resident #60, under age [AGE], was admitted on [DATE]. According to the April 2024 CPO, diagnoses included schizoaffective disorder, chronic pain, cognitive-communication deficit, and a history of traumatic brain injury. The 2/28/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The resident had functional limitations in both lower extremities (hips, knees, ankles, and feet) and was fully dependent on staff to complete all activities of daily living (ADL), was not able to walk and used a wheelchair. A review of the resident's record revealed a self-care performance care plan, revised on 3/1/24, related to weakness, impaired cognition, hypertension, psychosis, and osteoarthritis. Interventions included Resident #60 required physical assistance from two staff members with any transfers. 2. Resident interview and observations Resident #60 was interviewed on 4/9/24 at 10:42 a.m. Upon entering the room, Resident #60 was observed in a reclined position in his mechanical wheelchair in his room. The resident had been crying and said he was in severe pain from being reclined for a long time and he could not adjust the position of the wheelchair because it was broken. Resident #60 said he needed to get up out of his wheelchair. Resident #60 said he had asked certified nurse aide (CNA) #2 to get him out of the wheelchair and into bed but CNA #2 just yelled at him. During the interview, CNA #2 appeared in the resident's doorway and entered the room. Resident #60 asked CNA #2 again if he could get him into bed. CNA #2 raised his voice and, in a scolding tone, said to Resident #60 that there were other residents who had more important needs who were wet and needed to be taken care of first because it was a priority to take care of wet residents first. CNA #2 told Resident #60 that he would just have to wait until he had time to come back and help him. After CNA #2 left the room, Resident #60 said the way CNA #2 treated him had made him feel as if he was not as important as the other residents. Resident #60 said he was so uncomfortable and in pain from sitting so long that he just wanted to be repositioned for some relief. B. Facility Response The NHA was interviewed on 4/9/24 at 11:00. The NHA said when residents required assistance they should have been cared for, especially residents who had visible discomfort and distress. He said any staff member who was unable to assist residents in a timely manner was to notify the charge nurse and reach out to other staff for assistance. He said CNA #2 was having a difficult time assisting all his assigned residents in a timely manner but should have reached out for help. The NHA suspended CNA #2 pending an investigation. IV. Resident-to-resident mental and verbal abuse - Incidents involving Residents #60, #13, and #31 A. Residents #60, #13, and #31 1. Resident #60 status - see above 2. Resident #13 status Resident #13, age under 65, was admitted on [DATE]. According to the April 2024 CPO, diagnoses included paraplegia related to a gunshot wound, cognitive-communication deficit, and schizoaffective disorder. The 2/19/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. The MDS assessment revealed the resident had not exhibited any behavioral symptoms. A review of the resident's record revealed Resident #13 had a mental health care plan initiated on 3/7/24, revised 4/4/24, which documented that the resident was at risk for re-traumatization related to a history of trauma involving a shooting and losing his brother at a young age. Additionally, the resident was at risk for ineffective coping related to psychiatric diagnosis. Interventions included: Adjust the environment to be more individually preferred and homelike, document behaviors, and response to interventions. The care plan listed two triggers for his post-traumatic stress disorder (PTSD) related to violence, including talking about violence and violent movies. An ineffective coping care plan initiated on 3/23/24, revealed the resident had ineffective coping skills related to schizoaffective disorder, hallucinations, and a history of trauma. Interventions included an adjusted environment to be more individualized and homelike and encouraged contact with a support system. 3. Resident #31 status Resident #31, under the age of 65, was admitted on [DATE] with an initial admission date of 10/15/22. According to the April 2024 CPO, diagnoses included multiple sclerosis, hyperlipidemia, lymphocytopenia, and personality disorder. The 2/28/24 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for a mental status score of 15 out of 15. The behavior section indicated verbal behavioral symptoms directed toward others with a frequency of every one to three days. B. Incidents of mental and verbal abuse by Resident #31 toward Resident #13 and #60 on 3/5/24 and 3/10/24 1. Investigative report of resident-to-resident mental and verbal abuse on 3/5/24 a. Facility investigation The facility investigation of an allegation of verbal/mental abuse occurring on 3/5/24, documented that Resident #31 was observed to be verbally aggressive with Resident #13 and Resident #60. Resident #31 was heard by a staff witness calling Resident #13 racial slurs and telling him to go back to [NAME]. Resident #31 then called Resident #60 offensive names and made negative comments about his weight. Staff responded and separated the residents from each other. The director of nursing (DON) and the SSD tried to de-escalate the situation and calm Resident #31. Resident #31 remained agitated and started throwing his food and plate. The facility called the police to ensure the safety of facility residents. The police arrived and were able to calm Resident #31. Resident #31 went to his room and remained there for the rest of the night. Resident #13 and #60 were offered psychosocial support and Resident #31 was placed on frequent checks and referred for a psychiatric evaluation and behavioral health services. The SSD interviewed the assailant, Resident #31. The SSD described Resident #31's demeanor as agitated and frustrated. Resident #31 said he had been frustrated because his housing transition application was being delayed. Resident #31 told the SSD, I can say what I want, I have First Amendment rights to do whatever I want. The SSD interviewed Resident #13 who said Resident #31 used racial slurs to call him names and told him to go back to [NAME]. Resident #60 told the SSD that Resident #31 used foul language and made negative comments about his weight. The investigator said neither victim was fearful. The investigator concluded that the allegation was substantiated based on staff witness statements. b. Failure of the facility to take corrective action to prevent further mental and verbal abuse of Resident #13 and #60 by Resident #31. -The facility did not make any changes to Resident #13 and #60's care plans related to the potential for repeated incidents of verbal abuse and emotional distress by Resident #31. -The facility investigation did not pursue questioning of Resident #13 or Resident #60, both of whom were at risk for re-traumatization, to identify other emotional responses characteristic of being a victim of mental and verbal abuse and identify any behavioral changes in Resident #13 and Resident #60. -The facility investigation failed to contain any staff witness statements about the details of the incident, what each resident said and did, or how staff responded to de-escalate the incident and protect the residents from further abuse. However, a progress note in Resident #13's electronic medical record (EMR) dated 3/5/24 that was not a part of the investigation packet (see above) read: Incident note. Late entry: Clarification note on 3/11: Nurse (working) on[the] floor (the unit) was standing at nurses' station when Resident #31 said to Resident #13 (explicit language), go back to [NAME] you (derogatory term) the Resident #31 said he would hit him (Resident #13) with his wheelchair if he didn't get the (explicit language) out of the way. This nurse stood in between the residents and asked them to separate. Resident #13 told Resident #31[that] he doesn't need to be talking to anyone like that. Resident #31 was yelling out at the nurses' station (explicit language) and was moving closer with his [m]otorized chair (to Resident #13) Resident #13 was able to get around Resident #31 and return to his room on his unit. Facility leadership and the police were notified of the incident. Psychosocial assessment [was] performed on [Resident #13] and [the] resident denies feeling fearful or afraid. Will continue with the current plan of care. -The note did not document who conducted the psychosocial assessment, when the assessment was completed, or if the assessor explored emotions other than fear of the assailant related to [Resident #13's] emotional status and existing psychiatric conditions that might be an outcome or side effect of the incident. 2. Investigative report of resident-to-resident mental and verbal abuse on 3/10/24 a. The facility investigation, for an allegation of verbal/mental abuse occurring on 3/10/24, documented Resident #31 was observed by nursing staff to be blocking the hallway path and was verbally harassing and cursing at residents that happened to walk by. When Resident #13 attempted to pass, Resident #31 was observed to say I'm not moving for him and then used racial slurs against Resident #13. The nursing staff asked Resident #31 to move several times but he refused and he would not move. A few minutes later Resident #31 turned his aggression against Resident #60, making derogatory comments about his weight. Resident #31 became increasingly angrier and started yelling profanities and cuss words at staff and despite many efforts, staff was not able to calm him down or determine the cause of his behavior. Resident #31's physician gave an order for the resident to be sent to the hospital for a full evaluation but the paramedics and police refused to take the resident to the hospital. The facility placed the resident on one-to-one monitoring to ensure the safety of all residents until the interdisciplinary (IDT) could determine the root cause for the change in the resident's behavior. The investigation determined that the resident's behavior may have been related to a similar change in behavior that was observed on 3/9/24 when Resident #31 was rude to another resident. The SSD interviewed Resident #31. Resident #31 said he did say stuff to Resident #13 and #60 but said he could not remember exactly what he had said. He then expressed frustration about wanting to leave the facility to move to his own apartment. A review of hallway security footage confirmed staff witness and resident accounts of what happened. Follow-up actions included: A plan to consult with the facility's medical director to meet resident's needs and to develop a plan to keep all residents safe. The SSD was to continue psychosocial monitoring to address Resident #31's behaviors. -Resident #13 and Resident #60 were offered counseling to manage their feelings around the incident of verbal abuse. -The IDT met and discussed a possible discharge plan for Resident #31 if his behavior continued but discharge plans were not initiated at that time. b. Failure of the facility to take corrective action to prevent further mental and verbal abuse of Resident #13 and #60 by Resident #31. -No changes were made to Resident #31's care plan following the incident and the facility gave no documentation of their findings. -The facility investigation did not pursue questioning of Resident #13 or Resident #60, both of whom were at risk for re-traumatization, to identify other emotional responses characteristic of being a victim of verbal abuse and identify any behavioral changes in Resident #13 and Resident #60. -The facility investigation failed to contain any staff witness statements about the details of the incident, what each resident said and did, or how staff responded to de-escalate the incident and protect the residents from further abuse. A progress note in resident #31's EMR that was not a part of the investigative packet read: Incident note. Late entry: Clarification note on 3/10/24. At approximately 1:10 p.m. on 3/10/24, Resident #31 was sitting in the hallway near the nurses station. He began verbally harassing and cursing at other residents [who] happened to walk by. Resident #13 attempted to propel himself in his motorized wheelchair past Resident #31 who was blocking the hallway and refused to move. [The] nurse witnessed Resident #31 refusing to move and verbalizing I am not moving for him. And then said to Resident #13, Hey aren't you from Nigeria? Oh wait, that's because you are a (racial slur). [The] nurse calmly asked Resident #31 to move several times to which he refused. Resident #13 sat quietly during Resident #31's episode and did not respond to his (Resident #31's) comments. [The] nurse was able to redirect Resident #31 but a few minutes later he (Resident #31) called Resident #60 fat. Leadership and police were notified. Resident #31's behavior required police intervention. The resident's physician wrote an order to send the resident to the hospital for further evaluation and treatment but the resident refused care [to go]. Paramedics were unable to take [the] resident due to refusal. Police were then called and spoke to the Resident but unable to do anything further. Resident [#31] was then placed on one to one monitoring. C. Resident interviews 1. Resident #60 was interviewed on 4/9/24 at 9:13 p.m. Resident #60 said Resident #31 had called him names and cursed him out and the facility would not do anything about it. He said the things Resident #31 said were hurtful and offensive, such as comments about his weight and disability. He said Resident #31 had done this more than once and Resident #60 just wanted it to stop. Resident #60 said he did not provoke Resident #31 in any way and took extra precautions going out of his way to avoid passing by Resident #31 because he did not want to be verbally attacked again. He said Resident #31's comments affected him negatively and made him feel bad about himself. Resident #60 said he was scared of Resident #31 and was still fearful that the resident would be verbally aggressive to him if they were to be in the same area. He said he knew it would happen again. He said he avoided parts of the facility to stay away from Resident #31. He said the facility had not put any protective measures in place to keep the situation from happening again. 2. Resident #13 was interviewed on 4/4/24 at 3:10 p.m. Resident #13 said Resident #31 made rude and racist remarks to him on several occasions. He said he did not ever provoke Resident #31 and tried every way possible, including staying in his room when possible,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality for one (#15) of one resident reviewed for dignity out of 22 sample residents. Specifically, the facility failed to ensure staff were not using their personal cell phones while providing incontinence care, assisting a resident with eating and while in resident care areas. The use of employee cell phones during care resulted in Resident #15 reporting anxiety, humiliation, embarrassment and frustration. Findings include: I. Facility policy and procedure The Resident Rights policy, revised February 2021, as received from the nursing home administrator (NHA) on 10/9/23 at 9:53 a.m. The policy documented in pertinent part, the resident has the right to a dignified existence, to be treated with respect, kindness and dignity, to voice grievances to the facility, or other agency that hears grievances, without discrimination or reprisal and without fear of discrimination or reprisal, and have the facility respond to his or her grievance. A policy on employee cell phone use while providing resident care was requested from the NHA on 10/9/23 at 3:17 p.m. and not received by the end of the survey 10/9/23. II. Resident #15 A. Resident status Resident #15, under age [AGE], was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO) diagnoses included gastric bypass surgery, morbid obesity, myopathy (disease affects muscles causing muscle weakness, neuralgia (pain due to damaged or irritated nerves, neuritis (inflammation of nerves due to injury or infection) and chronic pain. The 6/20/23 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She was totally dependent on assistance from two staff for bed mobility, transfers, toileting and personal hygiene. She was totally dependent on the assistance of one staff member for eating. B. Resident interview Resident #15 was interviewed on 9/26/23 at 12:27 p.m. She said CNA #8 had been in her room on her cell phone on 8/3/23 while changing the resident and providing incontinence care. The resident said the CNA had her earphones in and was talking. Resident #15 said she was humiliated, frustrated and embarrassed the CNA would be on the phone while providing personal care. The resident said she had no use of her arms or legs and felt helpless. The resident said she reported it to the other CNA on duty. Resident #15 said CNA #8 came back to her room a short time later and got within an inch of the resident's face. The resident said the CNA gritted her teeth and said sarcastically we're gonna be friends. The CNA said she was not on her cellphone and accused the resident of lying. (Cross-reference F600). Resident #15 said she reported it to the nursing staff on duty at the time. She said she reported it again to assistant director of nursing (ADON) #1 on 8/7/23. The resident said the CNA continued to work on the resident's hall until her employment was ended on 9/22/23. Additionally, Resident #15 reported CNA #9 was texting on her phone while assisting the resident to eat on the first week of September 2023 and two days in a row at the end of August 2023. She said the CNA denied it and spoke to the resident as if the resident were confused. Resident #15 said she reported this to ADON #1. Resident #15 stated she continued to have anxiety and frustration over the staff use of cellphones while providing care. Resident #15 said her husband helped her write events that occurred since she could not write due to inability to move her arms. III. Record review The resident council notes were received from the director of nursing (DON) on 9/26/23 at 10:55 a.m. On 7/11/23 (for June 2023), the resident council notes documented in pertinent part, old business, CNAs were on their phones at the nurse's station while call lights were going off. The resident council notes document the NHA and DON were present at the meeting. Resident #15 was not at the resident council meeting and did not report the concern. There was no documentation as to which resident reported the concern. The resident council form documented the staff was educated. All grievance reports related to staff cell phone use were requested from the DON on 9/26/23 at 4:00 p.m. There were no grievance reports for June or July 2023 related to staff cell phone use, despite the concern in resident council. A grievance report dated 8/4/23 for Resident #15 documented the resident complained that CNA #8 was on her cell phone in her room. The DON documented verbal education was provided to the CNA and the resident did not want the CNA in her room again. The grievance form documented the CNA said she was using the flashlight on her phone in the resident's room. -There was no further information as to why the resident did not want the CNA in her room again. It did not address the use of a personal cell phone while providing incontinence care. A grievance report dated 9/10/23 documented Resident #15 complained a staff member was on her phone in her room. The grievance form documented the staff said they were just texting about the schedule. The form documented the DON provided verbal education. The name of the CNA was not documented. The grievance was signed by the NHA on 9/11/23. -There were no grievance forms regarding the staff the cellphone use for the end of August 2023 despite the concern reported by Resident #15. On 9/12/23 the resident council notes documented new business, residents were concerned the CNA's were on their cell phones. The resident council notes documented the NHA and DON were present at the meeting. -It did not document when or where the staff were on their cell phones. A Resident Council Concern Follow Up note dated 9/12/23 documented CNA's on their phones at nurses station. The grievance form documented that signs were posted at nurse stations and bathrooms that phones were not allowed at nurses stations or care areas. -The form was blank under was action sufficient and was action effective. However no signs were posted (see below). The personnel file for CNA #8 was reviewed on 10/3/23 at 10:00 a.m. There was no counseling regarding personal cell phone use while providing incontinence care. The file documented CNA #8 was terminated on 9/22/23 for sleeping on the job as seen on video. She had been previously given a final written warning for sleeping on the job 7/18/23 and racial misconduct having to do with pictures taken. The personnel file for CNA #9 was reviewed on 10/3/23 at 10:00 a.m. The file contained verbal counseling for cell phone use in a resident room on 9/11/23. There was no education or counseling in August 2023 for the concern reported by Resident #15. On 10/3/23 at 4:00 p.m. Resident #15 provided typed notes from the resident's representative regarding the events since the resident admitted . The notes documented in pertinent part on a number of occasions the resident's representative had walked by the nurses' station and the CNA staff were sitting at the nurses' station on their cell phones. It further documented that a number of times, CNA #9 was on her cell phone while assisting the resident with eating. The notes further documented there were a number of incidents of the CNAs taking personal calls while assisting the resident with eating and changing her, violating her confidentiality. The representative documented he felt the resident was beginning to withdraw and shut down due to the concerns above. Education regarding cell phone use with resident care for September 2023 was requested from the DON on 10/3/23. No documentation was received by the end of the survey on 10/9/23 or within 24 hours after the survey. IV. Staff interviews The DON was interviewed on 10/3/23 at 9:30 a.m. She said she was not aware of CNA #8 getting in Resident #15's face after Resident #15 had reported the CNA for being on her cellphone during care. The DON said she was aware of the concerns with staff use of cellphones at the nurses station and while providing care for Resident #15. She said had written a grievance on it. She could not explain why the grievance on 8/4/23 documented Resident #15 no longer wanted CNA #8 in her room. -The DON provided no further information. The NHA was interviewed on 10/9/23 at 3:17 p.m. He said he was not aware of the concern with staff use of cellphones while providing care. -However, the resident council minutes documented the NHA was present, and some of the grievance forms related to staff cell phone use were signed by the NHA (see above). He said if the concern had been brought up at resident council then he would have looked into it. V. Observations On 10/9/23 at 10:08 a.m., the nurse station and staff bathroom on the hall where Resident #15 resided was observed with ADON #1. The ADON confirmed there were no postings regarding staff cellphone use. ADON #1 said he had not seen any postings. At 2:00 p.m. two CNAs were observed at the nurses' station viewing something on a cellphone together.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#10) of three residents reviewed for professional standard out of 22 sample residents. Specifically, the facility failed to ensure Resident #10 received the care and services to treat a surgical wound and prevent the development of severe cellulitis (skin infection). Resident #10 was admitted on [DATE], readmitted on [DATE] and discharged on 4/5/23. Resident #10 had a diagnosis of chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, dementia, need for assistance with personal care and gastro-esophageal reflux disease (GERD). Resident #10 had a dermatological surgical procedure on 3/30/23 to remove a cancer lesion from her left upper arm. The dermatologist prescribed oral antibiotics, topical antibiotics, dressing changes and pain medications. The facility failed to complete all physician ordered dressing changes and accurately assess Resident #10's surgical incision to her left upper arm for infection. According to the follow-up appointment note on 4/5/23 from the dermatologist, the wound was grossly infected and had severe cellulitis. The dermatologist drained 30 cubic centimeters (CC) of drainage, cleaned the wound and sent the resident to the hospital to receive intravenous (IV) antibiotics. Findings include: I. Resident #10 A. Resident status Resident #10, age [AGE], was admitted on [DATE], readmitted on [DATE] and discharged on 4/5/23. According to the April 2023 computerized physician orders (CPO) the diagnoses included type two diabetes mellitus, dementia, dysphagia (swallowing difficulty) and gastro-esophageal reflux disease (GERD). The 1/25/23 minimum data set (MDS) assessment revealed Resident #10 was cognitively intact with a brief interview for mental status (BIMS) with a score of 13 out of 15. She required extensive assistance of one person for bed mobility, locomotion on and off the unit, dressing, toileting and personal hygiene. She required extensive assistance of two people for transfers. She required supervision of one person assistance for walking in her room and in the corridor, eating. B. Record review The pain management care plan, initiated on 1/18/23, revealed Resident #10 needed pain management and monitoring related to limited mobility. The interventions included: administering pain medication as ordered, coordinating with the patient and family to identify patient's favorite items and activities that could serve to distract from pain, evaluating and establishing a level of pain on a numeric scale, evaluating characteristics and frequently of pain, evaluating need to provide medications prior to treatment, implementing the patient's preferred non-pharmacological pain relief strategies, observing for potential medication side effects, repositioning as needed and utilizing a pain monitoring tool to evaluating effectiveness of interventions. The March and April 2023 CPO revealed Resident #10 had the following physician orders for post operative skin care: -Post-surgery instructions left upper arm: light activity, keep dressing on for 72 hours, then remove and apply bacitracin ointment twice a day, do not get incision wet until follow-up, every shift for incision for 14 days, ordered 3/30/23. -Cleanse wound area to left upper arm with wound cleanser and cover with xeroform and dry dressing once a day and as needed, one time a day for wound care, ordered 3/18/23 and discontinued on 4/3/23. -Left upper arm: apply bacitracin ointment twice a day and cover with a bandage every shift for incision site for 14 days, ordered 4/3/23. -According to the April 2023 treatment administration record (TAR), the licensed nurses completed cleansing the wound area to left upper arm with wound cleanser and cover with xeroform and dry dressing on 4/1/23 and 4/2/23. -However, the dermatologist had ordered a new treatment to the wound after the surgery on 3/30/23. The physician's order was to leave the dressing on the surgical incision for 72 hours. The dressing should have remained intact to the surgical site until 4/2/23. -According to the April 2023 TAR, the facility failed to provide treatment as ordered to the residents left upper extremity on the night shift on 4/3/23. The resident refused treatment on 4/4/23 due to pain. The facility did not notify the physician of the increased pain to the area, resulting in the resident refusing treatment. Cross-reference: F697 the facility failed to provide pain medications as ordered by the physician for post operative pain management. The 3/30/23 nursing progress note documented Resident #10 returned to the facility after having a surgery to her left upper arm at 5:26 p.m. The resident's vital signs were within normal limits, she denied pain and had not acute distress. The post-surgery orders were entered. Resident #10 was eating dinner and the licensed nurse documented she would continue to monitor the resident. The 3/30/23 weekly wound assessment documented the resident had a surgical incision to her left arm that was 3.6 centimeters (cm) in length by 3.6 cm in width and 0.1 cm in depth. The wound had 30% epithelial, 45% granulation, 5% sloth and 20% dermis. The wound had scant serous drainage. -The physician ordered the dressing to stay intact for 72 hours after surgery. The dressing should have remained intact from 3/30/23 until 4/2/23. The licensed nurse removed the dressing to assess the wound (see wound assessment above). The licensed nurse did not follow the physician's post operative instructions. The 3/30/23 operative report documented by the dermatologist (DERM) revealed in pertinent part, Resident #10 had surgery to remove a soft tissue mass on her left upper arm. The 3/31/23 nurse practitioner progress note documented in pertinent part, Resident #10 saw the dermatologist yesterday (3/30/23) and had a left arm lesion removed. Resident #10 was placed on as needed Norco for pain management. Resident #10 reported she had pain to her left arm. The 3/31/23 nursing progress note documented Resident #10 had surgery on 3/30/23 to remove a lesion from her left upper arm. A dressing was placed to the surgical area and was not to be removed for 72 hours. The nursing progress note documented the resident had two new orders for medications, which were entered. The family provided the medications from an outside pharmacy and the medications were in the medication cart. The 3/31/23 nursing progress note documented Resident #10 continued on monitoring for antibiotic use related to her recent surgery to her left upper extremity. The resident's vital signs were within normal limits. Resident #10 complained of pain and as needed pain medications were administered. The progress note documented the pain medications were effective. The resident was at her baseline. The 3/31/23 nursing progress note documented the resident was alert and oriented at baseline. The resident ate all of her meals and was taking her medications as ordered. The resident's vital signs were within normal limits. The resident complained of pain and as needed pain medication was administered. The pain medication was effective. The dressing to the residents left upper arm was clean, dry and intact. According to the April 2023 MAR the licensed nurse completed a weekly head to toe skin assessment on 4/3/23. -However, a review of Resident #10's electronic medical record revealed there was no documented head to toe skin assessment on 4/3/23 (see interview below). The 4/2/23 nursing progress note documented the resident's surgical dressing was clean, dry and intact. There were no signs or symptoms of infection. The resident had no allergic reactions to the antibiotic. The licensed nurse documented she would continue to monitor. The 4/2/23 nursing progress note documented the resident remained on antibiotics post surgery. The resident's dressing remained in place per physician orders. The dressing was clean, dry and intact. The resident complained of pain and there were no further concerns. The 4/3/23 nursing progress note documented the resident remained on increased observation due to her recent surgery to remove a cancer legion from her left upper arm. The resident was on an oral and topical antibiotic for infection prevention. The skin was warm and dry to touch. The nursing progress note documented there was trace edema to the resident's left upper arm. The resident denied pain or discomfort. The licensed nursing encouraged fluid. The note documented facility staff would continue to monitor the resident. The 4/4/23 nurse practitioner progress note documented in pertinent part, Resident #10 was seen lying in bed. Resident #10 reported ongoing pain to her left arm and has relief from the prescribed as needed Norco. The 4/4/23 nursing progress note documented at 11:38 p.m. revealed the resident was on an antibiotic after a surgery to her left upper arm. Resident #10 refused to have her dressing changed to her arm due to pain. The progress note documented the nurse administered the scheduled pain medication. The nurse attempted to change the dressing to the resident's arm later that shift and the resident declined the dressing change and said she did not want the dressing touched. The 4/5/23 head to toe skin assessment documented the resident had skin issues. The assessment documented the licensed nurse was unable to assess the resident as she was at the hospital. The 4/5/23 nursing progress note documented the resident remained on an antibiotic after a surgical procedure to remove a mass from her left upper arm. The dressing remained clean, dry and intact. There was no draining or warmth. The resident's upper arm was slightly red and swollen. The resident complained of pain and as needed pain medication was administered. The 4/5/23 dermatology note documented the resident had an excision of a left upper arm lesion on 3/30/23. The dermatologist documented the area was grossly infected, painful and the nursing home was not taking care of the site. The note documented the resident had severe cellulitis and 40 cubic centimeters (CC) of purulence (puss) was drained from the site. Cultures were taken, the wound was irrigated and cleaned and a clean dressing was placed. Resident #10 was transferred to the hospital for intravenous (IV) antibiotics related to the gross cellulitis and infection. The 4/5/23 incident report documented Resident #10's granddaughter alleged the facility did not treat Resident #10's arm and identify infection. Resident #10 was sent to the hospital from the dermatologist appointment. Resident #10 received intravenous (IV) antibiotics when she arrived at the hospital. The incident report documented the facility reviewed resident notes, care plan diagnosis and medications. Through staff interviews the facility concluded that the redness on Resident #10's arm was at baseline and there were no signs or symptoms of infection. The facility determined the 4/5/23 allegation was not substantiated due to staff providing dressing changes consistently. -However, according to the April 2023 MAR and skin assessments, the licensed nurses did not follow the physician orders and removed the dressing prior to the 72 hour order. According to the April 2023 TAR the facility did not provide the physician prescribed topical antibiotic or a dressing change on the night shift of 4/3/23. A review of the 4/5/23 hospitalist note documented the resident had increased pain, erythema (redness), heat, pain and edema. The resident was admitted to the hospital and started on IV Vancomycin (antibiotic) and IV Ceftriaxone (antibiotic) to treat the infection. II. Interviews The dermatologist was interviewed on 9/28/23 at 2:10 p.m. The dermatologist said Resident #10 had a follow-up appointment on 4/5/23. The dermatologist said upon assessing the surgical incision to the resident's left upper arm he knew it was infected. The dermatologist said the surgical incision was dried out, crusted over, extremely swollen, warm to the touch, tender and fluid filled, which were all signs of infection. The dermatologist said he cleaned the wound and drained fluid from the wound. The dermatologist said it was clear the infection had been developing for several days and not just a few hours. The dermatologist said the wound was in very bad shape and needed immediate attention. The dermatologist said he cleaned the wound and packed it. The dermatologist said the best course of action was to send the resident to the hospital to get IV antibiotics. The dermatologist said he had to clean the wound out two or three more times to help with the infection. The dermatologist said he had ordered the licensed nurses at the nursing home to leave the dressing on for 72 hours after the surgery. He said after 72 hours the licensed nurses were supposed to clean the wound, place an antibiotic ointment on the wound and place a clean dry dressing over the wound. The dermatologist said the licensed nurses should have noticed the infection and called him for further orders. The dermatologist said he ordered an oral and topical antibiotic prior to the surgery prophylactically. The dermatologist said the resident was at a high risk for infection related to her comorbidities. Registered nurse (RN) #2 was interviewed on 10/3/23 at 10:29 a.m. RN #2 said signs of infection include red, oozing and painful. The director of nursing (DON) was interviewed 10/9/23 at 11:48 a.m. The DON said Resident #10 had a surgical procedure to remove a cancer lesion from her left upper arm on 3/30/23. The DON said the resident attended a follow-up appointment on 4/5/23 as was sent to the hospital. The DON said the granddaughter alleged the facility did not care for the resident's surgical incision The DON said the facility completed an investigation by interviewing staff members and determined the resident did not have signs of infection. The DON said she did not review the dermatologist notes that indicated the facility was not caring for the resident's surgical incision. The DON said she briefly spoke to the dermatologist assistant on 4/5/23 when they notified the DON that the resident was being transferred to the hospital. The DON said the licensed nurse signed off on the MAR that she completed a head to toe skin assessment, but there was not a skin assessment documented in the resident's medical record. The DON said she would have expected the resident's arm to be a little swollen and red, since the resident recently had surgery. The DON said she was not aware that Resident #10 had not received her dressing change on 4/3/23. The DON said the facility typically notified the resident's primary care physician if the resident was refusing medications or treatments. -However, a review of the resident's medical record revealed the facility had not notified the physician of the resident's dressing change refusal related to pain on 4/3/23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Resident #10 A. Facility policy and procedure The Medications Brought to the Facility by the Resident/Family, revised April 2007, was provided by the DON on 10/9/23 at 12:44 p.m. It revealed in pertinent part, The facility shall ordinarily not permit residents and families to bring medications into the facility. If a medication is not otherwise available and/or it is determined to be essential to the resident's life, health, safety, or well-being to be able to take a medication brought in from outside, the Director of Nursing Services and nursing staff, with support of the Attending Physician and Consultant Pharmacist, shall check to ensure that: state law and regulations allow such use; the medications have been ordered by the resident's Attending Physician, and documented on the physician's ordered sheet; the contents of each container are labeled in accordance with established policies; the contents of each container have been verified by a licensed pharmacist; and signed receipt of medication, listing medication brought in to acknowledge delivery from family or RP (representative) and receiving staff member is completed. B. Resident status Resident #10, age [AGE], was admitted on [DATE], readmitted on [DATE] and discharged on 4/5/23. According to the April 2023 CPO the diagnoses included type two diabetes mellitus, dementia, dysphagia (swallowing difficulty) and gastro-esophageal reflux disease (GERD). The 1/25/23 MDS assessment revealed Resident #10 was cognitively intact with a brief interview for mental status with a score of 13 out of 15. She required extensive assistance of one person for bed mobility, locomotion on and off the unit, dressing, toileting and personal hygiene. She required extensive assistance of two people for transfers. She required supervision of one person assistance for walking in her room and in the corridor, eating. The MDS assessment indicated the resident was on a scheduled pain medication regimen and had not received non-medication interventions for pain during the review period. According to staff assessment, Resident #10 displayed non-verbal sounds of pain and showed evidence of pain daily. C. Record review 1. Comprehensive care plan-pain The pain management care plan, initiated on 1/18/23, revealed Resident #10 needed pain management and monitoring related to limited mobility. The interventions included: administering pain medication as ordered, coordinating with the patient and family to identify patient's favorite items and activities that could serve to distract from pain, evaluating and establishing a level of pain on a numeric scale, evaluating characteristics and frequently of pain, evaluating need to provide medications prior to treatment, implementing the patient's preferred non-pharmacological pain relief strategies, observing for potential medication side effects, repositioning as needed and utilizing a pain monitoring tool to evaluating effectiveness of interventions. 2. Physician orders related to pain The March 2023 CPO revealed Resident #10 had the following physician orders for pain management: -Acetaminophen Tablet 325 MG (milligrams), give two tablets by mouth three times a day for chronic pain syndrome, ordered 10/6/22. -Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen), give one tablet by mouth every four hours as needed for pain, ordered 3/30/23 and discontinued on 4/5/23. According to the March 2023 medication administration record (MAR), Resident #10 received the Norco Oral Tablet 5-325 MG on 3/31/23 at 9:11 a.m. when she reported her pain level as a 5 and on 3/31/23 at 4:35 p.m. when she reported her pain level as a 7. -However, Resident #10 was prescribed Percocet for pain. The April 2023 CPO revealed Resident #10 had the following physician orders for pain management and skin treatments: -Acetaminophen Tablet 325 MG, give two tablets by mouth three times a day for chronic pain syndrome, ordered 10/6/23. -Norco Oral Tablet 5-325 MG (Hydrocodone-Acetaminophen), give one tablet by mouth every four hours as needed for pain, ordered 3/30/23, discontinued on 4/5/23. -Left upper arm: apply bacitracin ointment twice a day and cover with a bandage every shift for incision site for 14 days, ordered on 4/3/23. -Percocet Oral Tablet 5-325 MG (Oxycodone with Acetaminophen), give one tablet by mouth every four hours as needed for pain, ordered 4/5/23 and discontinued on 4/6/23. According to the April 2023 MAR, Resident #10 received the Norco Oral Tablet 5/325 MG on 4/1/23 at 8:18 a.m. when she reported her pain level as a 5, on 4/2/23 at 8:45 a.m. when she reported her pain level as a 4, on 4/3/23 when she reported her pain level as a 5, on 4/5/23 at 5:36 a.m. when she reported her pain level as a 9 and on 4/5/23 at 9:59 a.m. when she reported her pain level as a 5. -However, Resident #10 was prescribed Percocet for pain. 3. Controlled drug records The health information manager (HIM) provided a copy of two controlled drug records on 10/5/23 at 4:30 p.m. The controlled drug record documented Resident #10 received Norco 5/325 MG 1 tablet every 4 to 6 hours as needed for pain on 3/3/23, 3/31/23, 4/1/23, 4/2/23, 4/3/23, 4/4/23 and 4/5/23. The second controlled drug record documented Resident #10 received Hydrocodone/APAP 5 (Norco) on 4/5/23. -According the the April 2023 MAR, Resident #10 did not receive the Norco 5/325 MG on 4/4/23. However, the nurse signed the controlled drug record on 4/4/23 at 10:00 a.m. Norco 5/325 MG was administered. 4. Progress notes The 3/30/23 operative report documented by the dermatologist (DERM) revealed in pertinent part, Resident #10 had surgery to remove a soft tissue mass on her left upper arm. The 3/31/23 nurse practitioner progress note documented in pertinent part, Resident #10 saw the dermatologist yesterday (3/30/23) and had a left arm lesion removed. Resident #10 was placed on as needed Norco for pain management. Resident #10 reported she had pain to her left arm. The 4/4/23 nurse practitioner progress note documented in pertinent part, Resident #10 was seen lying in bed. Resident #10 reported ongoing pain to her left arm and has relief from the prescribed as needed Norco. The 4/4/23 nursing progress note documented at 11:38 p.m. revealed the resident was on an antibiotic after a surgery to her left upper arm. Resident #10 refused to have her dressing changed to her arm due to pain. The progress note documented the nurse administered the scheduled pain medication. The nurse attempted to change the dressing to the resident's arm later that shift and the resident declined the dressing change and said she did not want the dressing touched. -The licensed nurse administered the scheduled Acetaminophen Tablet 325 MG when the resident reported pain to her dressing site. Resident #10 did not receive the as needed Norco Oral Tablet 5-325 MG as needed pain medication when she refused to have her dressing changed related to pain. The 4/5/23 nursing progress note documented by the DON revealed Resident #10 had a dermatology appointment last week. The dermatologist prescribed Percocet for pain. The note documented Resident #10 had been receiving Percocet. The order was incorrect in the MAR. The progress note documented the order was under Norco instead of Percocet. The note documented the resident had been receiving the correct medication. The note documented the facility would continue to monitor. -However, according to the March 2023 and April 2023 MAR and the controlled substance records Resident #10 received Norco on 3/31/23, 4/1/23, 4/2/23, 4/3/23, 4/4/23 and 4/5/23 (see interviews below). The 4/5/23 dermatology note documented the resident had an excision of a left upper arm lesion on 3/30/23. The dermatologist documented the area was grossly infected, painful and the nursing home was not taking care of the site. The note documented the resident had severe cellulitis and 40 cubic centimeters (CC) of purulence (puss) was drained from the site. Cultures were taken, the wound was irrigated and cleaned and a clean dressing was placed. Resident #10 was transferred to the hospital for intravenous (IV) antibiotics related to the gross cellulitis and infection. D. Interviews The dermatologist was interviewed on 9/28/23 at 2:10 p.m. The dermatologist said Resident #10 had surgery to remove a cancer lesion on 3/30/23. The dermatologist said Resident #10 had cognitive impairment and was not able to always accurately voice her pain. The dermatologist said he would have expected Resident #10 to have pain, as the surgery covered a big area. The dermatologist assistant (DA) was interviewed on 9/28/23 at 2:10 p.m. The DA said the dermatologist prescribed Percocet for pain management following the surgical procedure on 3/30/23. The DA said the doctor called the facility and gave the order to the nurse on duty. The DON was interviewed on 10/9/23 at 11:48 a.m. The DON said Resident #10 was prescribed Percocet for pain management following a surgical procedure on 3/30/23. The DON said the dermatologist called the facility and verbally gave the order to the nurse on duty. The DON said Resident #10's granddaughter provided the medication from an outside pharmacy. The DON said the facility relied on the outside pharmacy to verify the medication was correct and accurate. The DON said the physician's order was entered incorrectly into the resident's electronic medical record. The DON said the physician's order read to give the resident Norco instead of Percocet for pain management. The DON said the controlled substance sheets and MAR documented the resident had received Norco. The DON said the resident's physician notified the DON that the order in the electronic medical record was not accurate. The DON said Resident #10 received Percocet. The DON said multiple licensed nurses signed off on the MAR and the controlled substance record sheets that they administered Norco. -However, according to Resident #10's MAR and the controlled substance record sheets, Resident #10 received Norco. Based on observations, interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (#15 and #10) of three residents reviewed out of 18 sample residents. Resident #15 admitted on [DATE] with chronic pain and neuralgia (pain due to damaged or irritated nerves, neuritis (inflammation of nerves due to injury or infection). According to record review and interviews, the facility failed to ensure the Resident #15's Oxycodone pain medication was available on three separate occasions resulting in increased pain. Additionally, the facility failed to administer Resident #10 the correct pain medication per physician order after a surgical procedure. Findings include: I. Facility policy and procedure The Pain Assessment and Management policy, revised October 2022, was received from the director of nursing (DON) on 9/28/23 at 2:00 p.m. The policy documented in pertinent part, Contact the prescriber immediately if the residents pain or medication side effects are not adequately controlled, report the following information to the physician or practitioner, significant changes in the level of residents pain, prolonged unrelieved pain. II. Resident #15 A. Resident status Resident #15, under age [AGE], was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO) diagnoses included gastric bypass surgery, morbid obesity and myopathy (disease affects muscles causing muscle weakness), neuritis (nerve pain) and chronic pain. The 6/20/23 minimum data set (MDS) assessment indicated Resident #15 was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She was totally dependent on assistance from two staff for bed mobility, transfers, toileting and personal hygiene. She was totally dependent on the assistance of one staff member for eating. The assessment documented the resident reported her worst pain level on a 0 to 10 scale (with 10 being the worst pain on the scale) was 8 out of 10. The assessment documented Resident#15 had pain frequently which affected her day -to-day activities. She was on scheduled and PRN (as needed) pain medication and had no non-pharmacological pain interventions. B. Resident interview Resident #15 was interviewed on 9/26/23 at 12:27 p.m. She said the nursing staff did not have her Oxycodone pain medication at least three times since she was admitted in July 2023. Resident #15 said there was no Oxycodone pain medication available for her on admission for the first two days, and then twice in July 2023. She said on admission she only received Tylenol for pain. She said the staff would have it for two weeks and then run out on the weekend. The resident said this happened twice. She said she had chronic nerve pain all over and new pelvic pain. Resident #15 said the pain was tolerable at level 3 out of 10 if she did not move. She said when the nursing staff ran out of Oxycodone she had pain all over from 9 to 10 out of 10. Resident #15 said her pain was usually around a f5, but often could get up to an 8 before she received her pain medication. She said when the facility ran out of the Oxycodone pain medication she experienced anxiety and her mind began racing. She said she worried all the time about the staff running out of her pain medication now. Resident #15 said the lack of pain medication affected her ability to get out of bed and sleep. Resident #15 described the pain as throbbing to her back, knees and arms. Resident #15 said she had new pelvic pain since she had a urinary tract infection in the beginning of September 2023. The resident said the facility was supposed to have scheduled a follow up appointment with a gynecological physician related to the pelvic pain, and a neurologist for her nerve pain but she had not heard from the facility regarding either appointment (cross-reference F745 provision of social services). Resident #15 said her husband helped her write events that occurred since she could not write due to inability to move her arms. C. Record review On Saturday 7/1/23 at 7:03 p.m. the nursing notes documented the resident was out of Oxycodone. The nurse spoke to the pharmacy this morning about it and the pharmacy said they would deliver it. The note documented no oxycodone had been delivered. The nurse attempted to get it from the facility's emergency kit, but there was no second nurse at the facility available with username access to the kit to get the medication. The nurse documented she called the provider, but the provider was unreachable and she left a message. -There was no further documentation. On 7/16/23 at 6:00 p.m. the nurse's notes document the resident was having pain 10 out of 10 and the resident's Oxycodone had not arrived from the pharmacy. The nurses note documented the medication had been ordered on 7/15/23 from the pharmacy. The pharmacy said they were waiting on information from the physician. The progress notes documented the resident requested the nurse call the provider to get a one time order for Oxycodone 10 mg, twice the amount the resident normally took for pain. The nurse obtained a one time order for Oxycodone 10 mg and administered the medication from the emergency kit. On 7/17/23 at 1:21 p.m. the progress notes documented a one time order was received for Oxycodone 5 mg times two. This was twice the amount Resident #15 normally took again. On 7/18/23 at 4:03 p.m. the nursing progress notes documented the resident wanted her Oxycodone at 5:00 p.m. She said she had previously been in pain for a long time. She said it was fine now but it had taken her a long time to recover. On 7/25/23 at 12:53 p.m. the provider documented the resident had chronic pain. She complained the facility had run out of her Oxycodone the weekend before the fourth of July holiday. The note documented the resident was back on her routine dosing. The provider note further documented that the nursing staff had asked to discontinue the nighttime Oxycodone because they have to wake up the resident. The provider documented the resident did not want to discontinue the Oxycodone at that time because that was when she received incontinence care and she did not want to have any decrease in care. On 7/27/23 at 2:00 p.m. the nursing progress notes documented Resident #15 was concerned about her medication and wanted to make sure she had enough Oxycodone for the weekend. The June 2023 medication administration record (MAR) was reviewed. The MAR documented after the resident was admitted on [DATE], the Resident #15 received Acetaminophen (Tylenol) 325mg two tablets via PEG tube (percutaneous endoscopic gastrostomy) twice on 6/15/23 for pain levels of 5 and 6. She received Tylenol at the end of the month for pain levels of 4 to 6. -There were no parameters for what pain level the tylenol was to be given. The June 2023 MAR was blank for Oxycodone 5 mg tablet one tablet via PEG every four hours as needed for pain for the day of admission 6/14/23 and 6/15/23. After 6/15/23 the Oxycodone was given three to four times per day for pain ranging from 4 to 8. -There were no parameters for when to give the Oxycodone The July 2023 MAR was reviewed. The July MAR revealed the resident received Oxycodone on 7/1/23 at 4:30 a.m. for pain level of 4 and then not again until 7/3/21 at 2;17 p.m. for pain level of 8. -The resident did not have any Oxycodone available (see above). After 7/3/21 the July MAR revealed the resident received Oxycodone between two and four times daily for pain levels between 4 and 10. -However, another gap in the MAR indicated the resident had no Oxycodone 5mg after Saturday 7/15/23 at 5:00 p.m. for pain level of 7 until Monday 7/17/23 at 10:00 p.m for pain level of 7. The resident again had ran out of Oxycodone on the weekend again from 7/15/23 until Monday 7/17/23 (see above). The resident continued to receive Oxycodone as needed up to five times per day for pain levels up to 8 after 7/17/23. The resident was administered a one time dose of Oxycodone 10mg on 7/16/23 at 2:47 p.m. and one time on 7/17/23 at 1:26 p.m. (see above). On 10/3/23 at 4:00 p.m. Resident #15 provided typed notes the resident's representative had typed for her regarding the events since the resident admitted . The notes documented in pertinent part that on a number of occasions the facility had run out of the residents pain medication on the weekends. The resident had to go the weekend and most of Monday without her pain medication. D. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 9/28/23 at 9:12 a.m. She said medication reordering was done through a computer program with the pharmacy. She said when medications are reordered or ordered for a new admission the medication was usually delivered the same day or the next day. LPN #2 said there was no formal process for reordering medications. She said the nurses reordered medications when they noticed they were getting low. She said if the nurses ran out of medication they would call the pharmacy or get the medication out of the emergency medication kit. Assistant director of nursing (ADON) #1 was interviewed on 9/28/23 at 2:10 p.m. He said Resident #15's pain was manageable with pain medication. He said the facility had an order for a pain clinic and the facility was going to get her an appointment. ADON #1 said the resident took Oxycodone as needed for pain. He said Resident #15 had new pelvic pain and the facility was going to get the resident an appointment with a specialist. ADON #1 said if the nurse did not have a prescribed pain medication they should call the pharmacy and notify the physician of the missed dose or request new orders for something else for pain. ADON #1 said regarding the missed Oxycocodne medication for Resident #15, he was not in charge of ensuring narcotics were ordered. The DON was interviewed on 10/3/23 at 9:30 a.m. She said when a new resident admitted to the facility, orders were faxed over to the pharmacy. She said medications arrive that night or the next day. The DON said if the resident needed medication on the day of admission the nurse could get the medication from the facility's emergency supply machine. She said Oxycodone was in the machine. She said the nurse would have had to call the pharmacy for a code to open the machine and have a second nurse present. She said barriers to this have been the pharmacy not answering the phone. The DON said the nurse could have called the physician and received an order for a different pain medication. The DON said the nurse could call the on-call nurse for help or the medical director when they did not get a hold of the physician. She said the on call number the nurse called on 7/1/23 was the number for the medical director. She said the number for the medical director did not answer when called. She said the nurses did not have access to any other number for the medical director. The nursing home administrator (NHA) was interviewed on 10/9/23 at 3:17 p.m. The NHA said the unavailability of pain medication was brought up during the facility's clinical meetings in the morning but the facility had no process improvement plan for the concern.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure three (#14, #20 and #22) of three residents reviewed for dementia care of 22 sample residents, received appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Resident #14 was admitted to the facility for long term care on 5/25/23 with diagnoses of Alzheimer's disease, senile degeneration of the brain, anxiety disorder, depressive episodes, and cognitive communication deficit. The resident required supervision with one person physical assistance with walking in the room and corridors. The resident required extensive one person assistance with dressing. Since admission on [DATE] the resident had increasing wandering, agitation and physically aggressive behaviors. Due to the facility failures, Resident #14 wandered into other residents' rooms. The facility failed to determine and prevent triggers that caused agitation and physical aggression toward other residents. The facility failed to maintain the ability for the resident to communicate with staff with the translator machine that required the internet to operate. These failures resulted in Resident #14 was involved in four resident to resident altercations with three other residents, one resident twice over an eight day period. Additionally, the facility failed to implement personalized interventions for Resident #20 and Resident #22, who wandered into other resident rooms. Cross-reference F600 the facility failed to prevent resident to resident altercations by implementing appropriate safety measures for Residents #14 and #20. Findings include I. Census and conditions demographic The 9/26/23 Census and Condition form documented 111 residents resided at the facility. There were 62 residents with dementia or Alzheimer's disease and 28 with behavioral health needs. The facility had one long-term secured memory care unit open with 25 residents in the unit. II. Facility policy and procedures The Dementia - Clinical protocol, revised April 2021, was delivered by the director of nursing (DON) on 9/27/23 at 2:05 p.m. It read in pertinent part, As part of the initial assessment, the physician will help identify individuals who have been diagnosed as having dementia and those with otherwise impaired cognition. The staff and physician will evaluate individuals with new or worsening cognitive impairment and behavior and differentiate dementia from other causes. As needed the physician will help verify or reconsider the diagnosis of dementia and identify other possible causes and coexisting psychiatric conditions. Individuals with dementia can also have personality disorder, mental illness, psychosis, delirium, depression, adverse drug reactions (ADRs), or other conditions causing or contributing to impaired cognition and problematic behavior. As needed, the physician may obtain a psychiatrist or neurologist consultation to assist with diagnosis, treatment selection, monitoring of responses to treatment, and adjustment of medications. The staff and physician will determine any relationship between the resident's level of pain and cognitive loss. For the individual with confirmed dementia, the IDT (interdisciplinary team) will identify a resident-centered care plan to maximize remaining function and quality of life. Nursing assistants will receive initial training in care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. Additionally, performance reviews will be conducted annually and in-service education will be based on the results of the reviews. If a psychiatric consultation is called to help manage behavioral or psychiatric symptoms in the individual with dementia, the IDT team will retain an active role by reviewing and implementing the consultant's recommendations, addressing issues that affect mood, cognition, and function, monitoring for complications related to treatment, and evaluating progress. III. Resident #14 A. Resident status Resident #14, over age [AGE], was admitted to the facility on [DATE] and lived in the secured memory care unit. According to the September 2023 computerized physician orders (CPO), diagnoses included Alzheimer's disease, senile degeneration of the brain, anxiety disorder, depressive episodes and cognitive communication deficit. The 8/17/23 minimum data set (MDS) assessment documented the resident had a severe cognitive deficit with a brief interview for mental status (BIMS) score of three out of 15. The resident required supervision with one person physical assistance with bed mobility, personal hygiene, and toileting, and supervision with set up assistance with transfers between surfaces, walking in the room and corridors, locomotion on and off the unit, and eating. The resident required extensive one person assistance with dressing. -The facility failed to assess the resident's behaviors. B. Record review The care plan for the secured unit, initiated on 5/25/23 and revised on 8/29/23, documented the resident resides on the secured unit related to wandering. Interventions included staff to redirect the resident to safe wandering area as needed. The care plan for communication, no initiation date and revised on 8/29/23, documented the resident had impaired communication due to a diagnosis of Alzheimer's and was Russian speaking. The resident can communicate effectively via a translating machine. Interventions include communicate through identified communication method; staff used a translator to communicate. The care plan for mood, revised on 8/31/23, documented the resident got nervous and anxious at times. Interventions included to approach the resident from the front and address him or her by name, touch/hold his or her hand, avoid things that make the resident more anxious, and if the resident was upset to redirect the conversation or task. The care plan for activities, revised on 9/1/23 documented the resident had a language barrier and the staff was able to use a translator when needed, he enjoyed watching the news, going outside in warm weather, gardening, and listening to Russian music. Interventions included to provide an activity calendar, provide independent leisure as requested and speak to the resident with the translator machine. -The care plan did not have personalized interventions for dementia care. The admission and baseline care plan summary dated 5/25/23 at 7:38 p.m. documented communication and difficulty understanding others due to language barrier, wandering, anxiousness and restlessness concerns. Social services progress note dated 6/22/23 at 1:50 p.m. documented the IDT team met to discuss resident wandering and secure unit placement. The social services director (SSD) and assistant director of nursing (ADON) found a wander guard bracelet in the resident's bedside drawer. -The facility documented moving the resident to the secure memory care unit on 6/22/23, the facility failed to initiate safety measures to prevent the resident from wandering into other residents rooms to prevent physical abuse (cross-reference F600). Administrator progress note dated 6/22/23 at 1:51 p.m. documented the resident was admitted to the secure unit due to wandering and going into other residents rooms. Nursing progress note dated 7/3/23 at 12:15 a.m, documented the resident had increased agitation and intruded into all residents rooms one-by-one, taking their belongings and attempting to hit other residents with wheelchairs, walkers and other items believing the other residents were in his room. The resident attempted to break the windows on the double doors, attempted to crawl over the nurses station half door and attempted to hit staff with a chair. After being redirected to his room he attempted to break the window. Staff called 911. Administrator progress note dated 7/3/23 at 8:52 a.m. documented the resident was sent to the hospital on an M1 (mental health) hold. Nursing progress note dated 7/3/23 at 8:32 p.m. documented the resident returned to the facility from the hospital. The resident displayed aggressive behaviors toward staff by grabbing, pinching, and hitting and taking a CNA's (certified nurse aide) jacket and wallet. Physician progress note dated 7/5/23 at 8:00 a.m. documented a psychiatric consultation was sent but had not been received and were not able to see the resident. Physician progress note dated 7/12/23 at 5:54 a.m. documented the psychiatric consultation was pending. Nursing progress note dated 7/16/23 at 11:09 a.m. documented the resident was digging in the trash and found bread and put it in his pocket. Physician progress note dated 7/31/23 at 1:57 a.m. documented the psychiatric consultation was still pending. Nursing progress note dated 8/14/23 at 3:01 a.m. documented the resident was going in and out of other resident's rooms and was unable to be redirected. The resident was picking up chairs, walker and wet floor signs and attempting to hit staff and other residents. The resident said this is my house, and they all need to leave. He attempted to hit residents who were walking in the hallway. The resident spit at the nurse. Staff called 911, officers calmed the resident but when the officers departed the resident became aggressive again. The staff placed other residents who were ambulating in the halls in the nurses station for their safety while the resident banged on the door with his fists and other objects. IDT follow up progress note dated 8/31/23 at 10:31 a.m. documented a review of resident targeted behaviors. Interventions included offer lower stimulating behavior, utilize translator machine and offer to go outside. IDT follow up progress note dated 9/25/23 at 10:16 a.m. documented the review of the resident to resident altercation interventions included resident to be redirected into a safe wandering area. Nursing progress note dated 10/1/23 at 11:35 p.m. documented the resident continued to wander in and out of other resident's rooms and was difficult to redirect. IDT event review progress noted dated 10/2/23 at 9:45 a.m. documented following the current IDT review no new interventions suggested at this time. Social services progress note dated 10/6/23 at 11:30 a.m. social services director (SSD) reached out to the psychiatric services provider for a female provider, the provider stated they do not have female providers. Nursing progress note dated 10/6/23 at 2:48 p.m. documented the IDT met to review the resident to resident incident. Interventions included for staff to utilize translator for resident to be able to communicate with other residents due to language barrier. C.Altercations Event initial progress note dated 9/25/23 at 9:46 a.m. documented on 9/24/23 at 4:20 p.m. Resident #14 was arguing with Resident #7 and Resident #7 threw a two inch cowbell and hit Resident #14 in the face causing a reddened area to the left cheek. Event initial progress note dated 9/26/23 at 3:15 p.m. documented a resident to resident altercation on 9/26/23 at 3:00 p.m. between Resident #14 and Resident #20. Resident #14 was walking toward Resident #20 with a closed fist and shoved him in the shoulder. Resident #20 then hit Resident #14 in the face causing a small swelling on the left cheek. Nursing progress note dated 9/30/23 at 7:30 p.m. documented a witnessed resident to resident altercation between Resident #14 and Resident #21. Resident #14 was walking in the hallway when Resident #21 came out of his room yelling at Resident #14, #14 responded in a foreign language and Resident #21 punched #14 on the left side of his face. No injury noted at the time. IDT event initial progress note dated 10/1/23 at 2:17 p.m. documented a resident to resident altercation between Resident #14 and Resident #20. The RN heard a plate break in the dining room and found Resident #14 standing over Resident #20, who was seated, hitting him in the face. Resident #20 suffered a cut on the left eyelid. -The facility failed to provide person-centered approaches to Resident #14's dementia care services to address triggered physical aggressive behavior in order to prevent physical altercations (cross-reference F600). D. Observation During a brief tour of the memory care unit on 9/26/23 at approximately 3:00 p.m. it was observed two male residents coming face-to-face and their tempers started to rise. The memory care coordinator (MCC) and two CNAs were present and intervened. The MCC redirected Resident #14 away from the dining area since he was agitated. Many of the resident rooms did not have personal appearing items such as pictures, to make the room homelike. Resident #14's room had bare walls and an empty, stripped second bed. The rooms had shadow boxes outside each door that were empty. Some of the doors had stop signs taped to the door, not fabric/velcro across the entry way to prevent wandering into resident rooms. During a brief tour of the memory care unit on 10/1/23 at approximately 4:30 p.m. it was observed the Activities Director (AD) was in the dining area with activities and speaking with Resident #14 in Russian. The AD said the resident is calm when the staff can communicate with him. IV. Resident #20 A. Resident status Resident #20 who lived in the secured memory care unit, over age [AGE], was admitted to the facility on [DATE]. According to the September 2023 CPO, diagnoses included dementia, muscle weakness, cognitive communication deficit, anxiety disorder, depressive episodes and chronic obstructive pulmonary disease. The 8/10/23 MDS assessment documented the resident had severe cognitive deficit with a BIMS score of zero out of 15. The resident required supervision with one person physical assistance with bed mobility, transfers, walking in the room, walking in corridors, and dressing. He required supervision with set up assistance for eating, and limited one person physical assistance with toileting and personal hygiene. The resident did not exhibit any behavior symptoms. B. Record review The mood care plan, revised on 8/22/23, documented the resident exhibited signs and symptoms of depression related to life circumstances. Interventions included utilizing antidepressant (medication) for depression, encourage resident to participate in activities outside of room, including meal and other social activities, involve resident it IDT and care planning and one-to-one validation of feelings and concerns as needed. The care plan for cognition, revised on 8/22/23, documented the resident had cognitive impairments as evidenced by impaired decision making and orientation. Interventions included encouraging resident to make daily decisions, reassure resident as needed if confused, and reorient resident to situations as needed. The care plan for activities revised on 9/8/23 documented the resident enjoyed listening to music, watching tv, and going outside in warm weather. Interventions included to provide an activity calendar and independent leisure materials as requested. -The care plan did not indicate personalized interventions for dementia care. Nursing progress note dated 9/14/23 at 3:32 a.m. documented the resident continued to pace and be intrusive into other resident's rooms. Physician progress note dated 9/27/23 at 3:43 a.m. documented the resident punched another resident on 9/26/23 and grasped other residents and staff. IDT event review progress note dated 10/2/23 at 9:47 a.m. documented a review of the resident to resident altercation; no new interventions were suggested at that time. C. Altercations Event initial note progress dated 9/26/23 at 3:40 p.m. documented a resident to resident altercation between Resident #20 and Resident #14. Resident #14 was walking toward Resident #20 in the hallway, Resident #14 had a closed fist and shoved Resident #20 in the shoulder, Resident #20 hit Resident #14 in the face. Resident #14 had swelling to the left cheek. Event initial progress note dated 10/1/23 at 2:51 p.m. documented a resident to resident altercation between Resident #14 and Resident #20. The RN heard a plate fall on the floor, she went to investigate and found Resident #14 standing over Resident #20, who was sitting, punching him in the face. -The facility failed to provide person-centered approaches to Resident #20's dementia care services to address his behaviors, to include wandering, in order to prevent physical altercations (cross-reference F600). V. Staff interview Certified nurse aide (CNA) #2 was interviewed on 9/27/23 at 11:44 a.m. The CNA said Resident #14 had a language barrier, the staff used the translator phone to talk to him. The CNA said the resident thought he was security for the building and he did not want these people in it. He is under the impression this was his building and they were trespassing. The MCC was interviewed on 9/27/23 at 11:52 a.m. The MCC said interventions in the memory care unit include stop signs on doors. She said the main intervention that was used by staff to prevent resident altercations was redirection. She said Resident #14 had been having behaviors for the past several days. The DON was interviewed on 10/3/23 at 11:45 a.m. She said Resident #14 was on the secure unit and he had a few resident to resident altercations that involved someone hitting him or him hitting someone else. She said his behaviors include getting agitated. She said he had gotten better. She said he was often non-redirectable. She said Resident #14 had four altercations since 9/24/23 and these were more geared toward other residents rather than the staff. She said when he was not redirectable then the staff put him on a one-to-one observation, mainly when he was agitated and not redirectable. She said the facility tried to send him out on the M1 hold due to behaviors but he was sent back. She said to keep other residents safe the staff directed him to his room. The nursing home administrator (NHA) and the social services director (SSD) were interviewed on 10/3/23 at 12:20 p.m. The NHA said there were two instances where Resident #14 was the aggressor. He said the staff put him on a one-to-one observation. He said one-to-one staff was assigned to him as long as needed or the end of the shift. He said the NHA or the DON could initiate the one-to-one observation if needed. He said the facility did not have documentation for one-to-one observations. The NHA said nurses, CNAs or the staff who saw Resident #14 with behaviors should be monitoring him. The NHA said Resident #14 liked to use the translator machine. Registered nurse (RN) #1 was interviewed on 10/3/23 at 12:45 p.m. The RN said the internet was not working and the translator machine was not working. Licensed practical nurse (LPN) #1 was interviewed on 10/5/23 at 12:00 p.m. The LPN said the facility had not had internet service for a while, it had been down. The LPN said the internet had not worked the previous week, yesterday or today. The LPN said the translator machine did not work if the internet was down so the staff has not been able to use it. -The facility failed to ensure the translator machine, which required internet access, was working. The staff was unable to communicate with the resident which caused agitation to the resident. VI. Resident #22 A. Resident #15's interview and record review about Resident #22's wandering Resident #15 was interviewed on 9/26/23 at 12:27 p.m. She said Resident #22 was confused and wandered into her room and rummaged through things in her room, including the trash. She said the nursing staff said the resident had a history of wandering, rummaging and aggression. Resident #15 said Resident #22 had recently come into her room and taken a blanket. She said she did not say anything to Resident #22 when she came in her room because she was afraid Resident #22 would get upset and physically hurt her. Resident #15 said she had no way to defend herself due to the inability to move her legs and arms. She said she felt helpless, with increased feelings of anxiety and fear of physical harm from Resident #22 if she said anything to her. Resident #15 said she had spoken to the assistant director of nursing (ADON) #1 about her fear and concern with Resident #22 coming into her room, but nothing had changed and the resident continued to come into her room. Additionally, Resident #15 said she was concerned when she had seen Resident #22 in the lobby area, eating out of the trash can. Resident #15 said her husband helped her write events that occurred since she could not write due to inability to move her arms. On 10/3/23 at 4:00 p.m. Resident #15 provided typed notes from the resident's representative regarding the events since the resident admitted . The notes documented in pertinent part that Resident #15 has said she was scared because a resident with known to be violent wheels herself into her room and Resident #15 had no way to defend herself. Additionally, the notes documented that Resident #22 had been observed by the resident representative eating out of the trash can in the lobby on 9/22/23. B. Resident status Resident #22, age [AGE], was admitted on [DATE]. According to the October 2023 CPO diagnoses included dementia and major depression. The 7/14/23 MDS assessment indicated the resident had severe cognitive impairment and could not complete a BIMS evaluation. She had short and long term memory loss and did not recognize faces, names, rooms, seasons, or the facility. She required two persons extensive assistance with transfers, dressing, toileting and personal hygiene. She required extensive one person assistance with personal hygiene and eating. The assessment documented the resident had wandered daily and had no behaviors. The assessment documented the resident was on antipsychotic medication. C. Record review The care plan related to behavior, revised 9/12/23 did not indicate when it was initiated. It documented, Resident #22 was confused and forgetful and took others belongings. She became physically aggressive towards others. She was observed by staff eating non edible items like paper and flowers. The goal was that the resident would be able to be redirected when she became physically and verbally aggressive. Interventions were to offer her a snack if she was seen eating non edible items. If the resident could not be redirected or calmed, staff should attempt to do care at a later time. Staff to explain was to the resident prior to and during the process of cares. Staff to redirect the resident to other activities. Staff to reorient the resident to place and situation as appropriate to their cognitive level. The care plan for wandering, revised 9/16/23 did not indicate when it was initiated. It documented Resident #22 was at risk for injury due to wandering throughout the building and attempting to go toward the front door. The care plan documented the resident had a wanderguard and to redirect her when wandering. Ensure all basic needs are met such as if the resident has gone to the bathroom, is hungry or thirsty. Invite the resident to activities. The progress notes documented in pertinent part, On 2/27/23 at 4:16 p.m. the nursing note document the resident was moved off the secure unit to a room two doors down from Resident #15. On 4/11/23 at 4:38 p.m. the progress notes documented that on 4/10/23 between 7:00 p.m. and 7:30 p.m. Resident #22 had gotten into an argument with her roommate when Resident #22 tried to take her roommate's pillow. The roommate resisted and Resident #22 slapped her roommate in the face. On 6/21/23 at 4:35 p.m. and 6/20/23 at 10:03 p.m. the progress notes documented Resident #22 was on monitoring for wandering and invading others privacy. -The progress notes did not document when or why the resident had been placed on this monitoring. On 7/11/23 at 3:59 p.m. assistant director of nursing (ADON) #1 documented that Resident #22 was in Resident #15's room again and Resident #15's spouse wheeled Resident #22 out of Resident #15's room. On 8/18/23 at 11:31 a.m. the director of nursing (DON) documented an IDT (interdisciplinary team) note. The note documented the resident was impulsive. The resident grabbed and rummaged through things like furniture. On 9/19/23 at 2:10 p.m. the provider documented the resident was on seroquel due to delusions and aggression. The provider documented the resident had been eating paint chips. The provider documented it was unclear how long this behavior had been occurring. D. Staff interviews ADON #1 was interviewed via telephone on 9/28/23 at 2:10 p.m. He said Resident #22 propelled around in her wheelchair and wandered into other resident rooms and rummaged. He said she had dementia and recently stole a blanket from a room. He said she was confused and recently stole a blanket from a room. The ADON said Resident #22 was usually looking for something to eat, and he tried to give her snacks. He said Resident #15 had reported to him that Resident #22 had been in her room. He said the plan to prevent Resident #22 from going into other rooms was to continue to try to give Resident #22 snacks. The DON was interviewed on 10/3/23 at 9:30 a.m. She said she was not aware of Resident #22 wandering into Resident #15's room and rummaging. She said she knew Resident #22 had wandered into other resident's rooms. She said Resident #22 was very confused and had done this since she admitted . The DON said she only heard Resident #22 wandered into other resident rooms, not that she rummaged in other resident rooms. The DON said she felt that someone would have said something if Resident #22 was really going into Resident rooms and rummaging. However, Resident #22's care plan documented she wandered throughout the building and took others belongings.(see above). Additionally, ADON #1 said Resident #15 had reported to him Resident #22 had been in her room. The DON acknowledged that this behavior could cause Resident #15 to be fearful due to her inability to move, or defend herself. She said a plan to prevent this would be to maybe put a stop sign on Resident #15's door. Certified nurse aide (CNA) #12 was interviewed on 10/9/23 at 1:00 p.m. She said Resident #22 wandered into other resident's rooms. She said she was usually looking for food and digging in the trash cans of other resident rooms or the lobby trash can. She said the resident ate inappropriate things such as recently trying to eat a blanket. CNA #10 said Resident #22 was frequently physically and verbally aggressive, at least two to three times per shift. CNA #10 said Resident #22 would scream, pinch, grab and kick the staff when they attempted to redirect her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide medically related social services to two (#12 and #15) of two residents reviewed out of 22 sample residents. Specifically, the facility failed to assist Resident #12 in making a dental extraction appointment timely after she reported pain and the dentist recommended extractions resulting in infection. Resident #12 was seen by the mobile dentist at the facility on 3/2/23. The mobile dentist recommended sending a referral to a dentist in the community for five tooth extractions. At this time the resident was in pain. The facility did not obtain consent from the resident until 4/4/23 to send the referral. The facility failed to schedule an appointment for Resident #12's teeth extractions for four and a half months. On 7/19/23 Resident #12 had her teeth extracted and was put on an antibiotic because she had developed an oral infection. Resident #15, who required assistance from staff, had five medical appointments that still had not been scheduled. Due to the lack of following up with scheduling her appointments, the resident felt anxious and frustrated due to her ongoing pain, unexplained muscle weakness and voice issues. Findings include: I. Facility policy and procedure The Dental Services policy, revised December 2016, was provided by the director of nursing (DON) on 10/3/23 at 10:28 a.m. It read in pertinent part, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Social services representatives/designee will assist residents with appointments, transportation arrangements, and for reimbursement of dental services under the state plan, if eligible. II. Resident #12 A. Resident status Resident #12, age [AGE], admitted on [DATE], readmitted on [DATE] and passed away on 8/30/23. According to the August 2023 computerized physician orders the diagnoses included: neurocognitive disorder with Lewy bodies (dementia), dysphagia (difficulty swallowing), dementia, Parkinson's disease (deterioration of the brain), anxiety and depression. The 8/22/23 minimum data set (MDS) assessment revealed she had severe cognitive impairments with short-term and long-term memory deficits according to staff interview. She required extensive assistance of two people for bed mobility, transfers, personal hygiene, walking in her room and in the corridor, locomotion on and off the unit and dressing. She required extensive assistance of one person for eating. The MDS documented the resident had no mouth problems. The MDS documented the resident was on a scheduled pain medication regimen, received as needed pain medications and did not receive non-medication pain interventions. B. Record review 1. Comprehensive care plan-dental A review of Resident #12's electronic medical record, revealed Resident #12's comprehensive care plan did not address her oral/dental needs. 2. Dental progress notes The 11/10/22 dental examination note documented the resident's mouth tissue was inflamed and red. The dentist recommended having all remaining lower teeth extracted and then get upper and lower dentures. The dentist documented to send a referral to another dentist for full lower extractions. The 1/24/23 dental examination note documented the resident refused to see the mobile dentist. The 3/2/23 dental examination note documented the resident was having pain on her lower right side of her mouth. The resident needed to have teeth extracted. The dentist requested a referral to be sent to another dentist for lower teeth extractions. The 6/2/23 dental examination note documented the resident had not gone to the local dentist for teeth extraction. The note documented the resident wanted the work done and was in pain. The dentist requested a referral to be sent to another dentist. The 7/19/23 dental progress note documented the resident had eight teeth extracted. The dentist ordered an antibiotic as the resident had a dental infection. -The facility failed to send a referral to the dentist to get the resident's teeth extracted till July 2023, although the resident started reporting pain in March 2023. 3. Progress notes The 3/6/23 care conference note documented the social services director (SSD), assistant director of nursing (ADON) #2, the activities director (AD) and the resident met. The power of attorney (POA) was invited and said she would be there, but did not arrive. The SSD called the POA and left a voicemail. -The note did not indicate if an attempt was made to obtain dental consents (see SSD interview below). The 3/27/23 care conference note documented the resident, nursing home administrator (NHA), SSD, speech therapist, activities assistant, DON, ADON #2, the ombudsman and the doctor were present. The daughter was invited to come, but did not attend. -The note did not indicate if an attempt was made to obtain dental consents (see SSD interview below). The 4/4/23 social services progress note documented the dentist made recommendations to follow-up for extractions. The resident gave consent and an appointment request was sent to transportation. -The dentist recommended a referral to be sent on 11/10/22 and 3/2/23. The facility did not obtain consent to send a referral until 4/4/23. The 7/20/23 nursing progress note documented the resident was on an antibiotic for eight teeth extractions. The resident was on a soft diet until her mouth was healed. The licensed nurse documented she would continue to monitor. C. Staff interviews The SSD was interviewed on 9/27/23 at 2:54 p.m. The SSD said the mobile dentist saw Resident #12 in November 2022 and recommended for the resident to be seen by a community dentist for teeth extractions. The SSD said the mobile dentist attempted to see the resident in January 2023 and February 2023 and the resident refused to be seen. The SSD said Resident #12 was seen by the mobile dentist again on 3/2/23 and recommended to have the teeth removed. The SSD said the resident then had her teeth extracted in June 2023. -Resident #12 did not have her teeth extracted until 7/19/23. The SSD was interviewed again on 9/27/23 at 2:54 p.m. The SSD said she did not obtain consent from the resident to send a referral to the community dentist until 4/4/23. The van driver (VD) was interviewed on 9/28/23 at 4:03 p.m. The VD said he was responsible for scheduling appointments for all residents and transporting them to their appointments. The VD said typically dentist referrals were emailed to him from the SSD and he would make the appointment. The VD said sometimes referrals were not communicated to him. The VD said he called the doctor's office within a day or two from receiving a referral to calling the physician offices to make appointments. The VD said he was unsure the exact date he sent a referral for Resident #12 to have her teeth extracted. The VD said he did not document or keep record of when he received or sent referrals to doctors. The VD said he was unsure why it took several months to get Resident #12 an appointment to have her teeth extracted. The VD was interviewed again on 9/28/23 at 4:03 p.m. The VD said he spoke with the DON regarding documenting in resident medical records regarding sending referrals for medical records. The DON was interviewed on 9/28/23 at approximately 3:15 p.m. The DON said the nursing staff were responsible for placing referral orders into the electronic medical record and notifying the VD that an appointment needed to be scheduled The DON said the VD was responsible for calling the doctor's office, making an appointment and transporting the resident to the appointment. The DON said at times it took awhile to get certain appointments related to doctors availability. The SSD was interviewed again on 9/28/23 at 9:40 a.m. The SSD said she attempted to reach out to Resident #12's daughter who was the residents proxy (decision maker) and get consent to send a referral to an outside dentist for Resident #12's teeth extractions. The SSD said the VD was responsible for making appointments and transporting the residents to the appointments. The SSD said she was not involved in scheduling Resident #12's dental extraction appointment. The SSD was interviewed again on 9/28/23 at 9:53 a.m. The SSD provided two care conference notes from March 2023. The SSD said she attempted to reach out to the resident's daughter to obtain consent to send a referral to the community dentist. The SSD said the daughter did not call her back. The SSD said a month after the mobile dentist saw Resident #12 and recommended to have teeth extracted she asked the resident for consent to send the referral. The SSD said Resident #12 was able to make her own choices. The SSD said she was unsure why she did not ask the resident for consent sooner than 4/4/23. The NHA was interviewed on 10/3/23 at 11:35 a.m. The NHA said the VD was responsible for scheduling appointments and transporting residents to their appointments. The NHA said the facility had attempted to get her into the dentist that accepted her insurance. The NHA said pain is very subjective and if the facility felt it was an emergency then they would have had Resident #12 seen immediately. The NHA said the resident was not in that much pain. -However, the mobile dentist documentation revealed Resident #12 was in pain and wanted her teeth extracted. The NHA was interviewed again on 10/3/23 at 1:25 p.m. The NHA said the facility had referred the resident to the dentist, but the 7/19/23 date was the soonest available appointment. The NHA said the SSD tried to confirm the appointment with Resident #12's family, but she did not call her back. -However, the care conference notes do not indicate that the SSD attempted to speak to the daughter or the resident regarding consent to send a referral to a community dentist. The NHA said the VD was unable to document in the resident's medical records when he sent referrals. The NHA said the VD was given permission to document in medical records when he sends referrals and schedules appointments for the residents. III. Resident #15 A. Resident status Resident #15, under age [AGE], was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO) diagnoses included gastric bypass surgery, morbid obesity, myopathy (disease affects muscles causing muscle weakness, neuralgia (pain due to damaged or irritated nerves, neuritis (inflammation of nerves due to injury or infection) and chronic pain. The 6/20/23 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview of mental status (BIMS) score of 15 out of 15. She was totally dependent on assistance from two staff for bed mobility, transfers, toileting and personal hygiene. She was totally dependent on the assistance of one staff member for eating. The assessment documented the Resident#15 had pain frequently which affected her day to day activities. She was on scheduled and PRN (as needed) pain medication and had no non pharmacological pain interventions. B. Resident interview Resident #15 was interviewed on 9/26/23 at 12:27 p.m. She said she was still waiting on five appointments to be scheduled by the facility. She said she was suppose to see an ENT (ear, nose and throat) doctor related to changes in her voice, a gynecologist related to pelvic pain which during a urinary tract infection on 9/8/23, a neurology appointment related to ongoing pain from neuropathy (weakness, numbness, pain due to nerve damage), a sleep study for concerns for sleep apnea (sleep disorder where breathing stops and starts during sleep) and a pain clinic related to her chronic pain. Resident #15 said she had not received any follow up from the nursing staff as to when the appointments were scheduled for. Resident #15 said she was frustrated and anxious regarding the lack of follow up on appointments for her pain, her unexplained muscle weakness and voice issues. C. Record review The September 2023 CPO was reviewed on 9/26/23 at 1:25 p.m. The orders documented the following. 7/27/23, Referral to ENT for voice change, needs vocal cords visualized. 8/11/23, Consult pain management and rehab for chronic pain syndrome. 8/15/23, Referral to neurology to establish care and get EMG (muscle response to electrical activity) done. 8/24/23, Schedule outpatient EMG for generalized weakness and concern for myopathy. 8/24/23, Please schedule sleep study for concern for OSA (obstructive sleep apnea). 9/15/23, Referral to pain management for diagnosis of chronic pain. 9/15/23, Referral to OB-GYN (obstetric gynecologist) for vaginal burning. Twice the provider wrote orders for an EMG and a referral for pain management (see above) and no appointments were scheduled. The provider notes revealed the following: On 7/25/23 at 12:53 p.m. the provider documented in the progress notes the resident had not gotten an EMG as previously discussed. Refer to neurology. The resident would like a referral to ENT. She has had a permanent voice change since intubation. On 7/27/23 at 9:23 a.m. the provider documented in the progress notes confirmed that orders for referrals have been placed to ENT, and neurology for EMG. On 8/3/23 at 12:51 p.m. the provider documented in the progress notes, follow up on neurology referral, if not for some time, plan neuropathy labs, see if EMG can be done elsewhere without neurology appointment. On 8/29/2023 at 1:17 p.m. the provider documented in the progress notes, the resident has still not yet had an EMG. On 9/14/23 at 9:15 a.m. the provider documented in the progress notes, EMG and sleep study pending. On 9/15/23 at 11:11 a.m. the provider documented in the progress notes the referral to gynecology pain management clinic for chronic pain syndrome were still pending. On 9/22/23 at 2:26 p.m. the provider documented in the progress notes the referral to gynecology and pain management clinic were still pending. -However, once the survey began on 9/25/23, appointments began to get scheduled (see below). D. Staff interviews The director of nursing (DON) was interviewed on 9/28/23 at 9:30 a.m. She said if there was a referral in the physician orders the DON or nurse manager sent the referral to the van driver (VD) to schedule the appointment.The DON said the VD schedules and provided transportation to appointments for residents. The assistant director of nursing (ADON) #1 was interviewed on 9/28/23 at 2:10 p.m. He said he was in charge of nursing oversight on the hall Resident #15 resided on. ADON #1 said he did not know if an OB-GYN, neurology, pain, sleep study or ENT appointments had been scheduled. He said he was new at this, being the ADON, and it had been a struggle for him to keep everything straight. He said the VD was responsible for appointments. The nursing home administrator (NHA) was interviewed on 10/3/23 at 11:35 a.m. He said the VD scheduled appointments and transported the residents to the appointments. He said if it was a bariatric resident, the facility would use an outside agency to transport because they would not fit in the facility van. The NHA said he was not sure how the VD was notified of a referral and appointment that needed to be scheduled. The VD was interviewed on 10/5/23 at 10:28 a.m. He said he scheduled appointments, found specialty physicians for referral orders and drove the facility van for appointments. The VD said providers will text him if a resident needs an appointment. He said appointment needs were usually word of mouth. The provider will test him that they put in a referral for a resident and the diagnosis. He said he would then go into the electronic medical record (EMR) and print off the order. The VD said he was just learning how to use the EMR system. He said once he printed the order he would call the physician office to see if they accepted the residents insurance and faxed them the referral order. He said once the appointment was made he gave a copy of the appointment to the resident and the resident's nurse. The VD said he did not go through the medical record to look for new orders for referrals. He said someone had to notify him if there was a new referral order. He said it could take three to seven days to get the appointment once he sent the specialist the fax with resident information and insurance. The VD said he had been working on scheduling appointments for Resident #15. He said she had all her appointments scheduled. -However, this was not completed until after the survey began on 9/25/23 (see below). He said the neurology appointment was scheduled when the referral was made by the provider. The VD said the sleep study had been hard to schedule because the resident needed to fill out a questionnaire for the referral. He said he was not medical so he could not do the questionnaire with the resident. He said the director of nursing (DON) would need to do the phone call and questionnaire together. The VD said he did not keep records of when a specialist office was contacted with a referral or appointment attempts he had made. The VD said he did not want to say why there was a delay. He said there was a delay in getting referrals in the residents chart as orders. E. Facility follow-up On 10/5/23 at 11:00 a.m. the VD provided copies of appointments scheduled for Resident #15. All the appointments were scheduled after the survey began on 9/25/23. The documentation provided by the VD revealed: A pain management clinic referral was dated as ordered 9/28/23, due to chronic pain. There was still no documentation about when this appointment was scheduled for. The original orders for a pain clinic were written on 8/11/23 and 9/15/23 (see above). A neurology referral was dated as ordered 9/28/23 for an EMG. The appointment was scheduled for 12/6/23. The original orders for a neurology referral were written on 8/15/23 and 8/24/23 (see above). An ENT referral was dated as ordered 9/28/23, no diagnosis was listed. The appointment was scheduled for 10/5/23. The original orders for an ENT referral were written on 7/27/23. The VD was interviewed again on 10/9/23 at 11:11 a.m. The VD said the resident did not go to her ENT appointment on 10/5/23 because her wheelchair did not fit in the van from the transport agency. He said the appointment would need to be rescheduled when the transport agency had their larger transport van available. The OB-GYN appointment documented it was ordered on 10/3/23, and was scheduled for 10/24/23 at 1:15 p.m. However, the order for the OB-GYN was written on 9/15/23. -There was no documentation provided regarding an appointment for a sleep study.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to prevent development of pressure ulcers for two (#14 and #101) of four residents reviewed for pressure ulcers of 49 sample residents. Specifically, the facility failed to prevent avoidable pressure ulcers and to provide necessary services to promote healing and prevent new ulcers from developing. The facility failed to obtain physician orders for pressure ulcer prevention, to update the resident's care plan, to implement interventions, and to monitor the effectiveness of interventions for Residents #14 and #101. Due to the facility's failures, Residents #14 developed an unstageable pressure ulcer to her right ischium (the area of skin covering the lower hip bone) that worsened to a Stage 4. Resident #101 developed a deep tissue injury pressure ulcer to his right heel and unstageable pressure ulcer to his coccyx. Findings include: I. Professional reference 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 11/21/22, 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 I 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 (e.g., 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. 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 (retrieved 11/22/22): 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. 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. 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. Individuals with a medical device 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 procedure The facility policy and procedure regarding prevention and care of pressure ulcers was requested on 11/17/22 and was not received. III. Resident #14 A. Resident status Resident #14, age [AGE], was admitted on [DATE], discharged to the hospital on [DATE] and readmitted on [DATE]. According to the November 2022 computerized physician orders (CPO) diagnoses included dementia, major depression, lack of coordination, need for assistance with personal care, and muscle wasting. The 10/21/22 minimum data set (MDS) assessment revealed that the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) of 11 out of 15. The resident was totally dependent on staff to complete activities of daily living including assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was at risk for developing pressure injuries; had one unstageable pressure ulcer; and used a pressure reducing device in her wheelchair and was on a turning/repositioning program. B. Observations On 11/14/22 at 10:45 a.m. Resident #14 was asleep in a semi-reclining position in her bed and her legs were folded slightly to her left side. The resident was lying on an alternating air mattress, had a pillow beneath her head, and was covered with bed linens. Resident #14 was interviewed on 11/16/22 at 9:55 a.m. The resident said repositioning was difficult for her because her pressure ulcer was painful. The resident described the ulcer pain as constant and burning and not having relief. The resident said she expected to have some pain because she had a pressure wound. The resident reported she received narcotic pain medication prior to dressing changes which helps reduce her pain during wound care to a tolerable level. On 11/16/22 a continuous observation was made from 9:55 a.m. through 12:20 p.m. During the observation period the resident was awake in her bed and was served her lunch. At 12:20 p.m. the resident was observed in the same position as she was observed at 9:55 a.m., lying in her bed in a semi-reclining position, on her left side. The resident was not offered any repositioning over the two hour period. On 11/17/22 at 9:30 a.m., Resident #14 was observed during a wound care procedure performed by the resident's wound physician. The resident's right ischium pressure wound was covered by whitish yellow slough and necrotic (both dead tissue). The skin surrounding the wound was a purplish color. The wound physician performed surgical debridement to remove some of the dead tissue from the wound. The wound physician said the wound was starting to spread underneath the top layer and edge of the wound and said the skin surrounding the wound appeared to have a fungal rash. The wound physician recommended changes to the resident's wound care, suggesting the skin surrounding the wound be treated with an antifungal barrier cream. The wound care physician said the wound was improved because there was less slough and the size of the wound was decreasing. Resident #14 was interviewed just after wound care and the dressing change Resident #14 said the staff had talked with her in the past and told her how important repositioning was to help heal her wound; the resident said she understood why the staff encouraged her to accept regular repositioning assistance. The resident said she depended on staff for repositioning due to her paralysis, contractures, and multiple sclerosis; and accepted the assistance whether or not she was in pain. C. Record review Resident #14's comprehensive care plan, revised 9/15/22, revealed the resident had a potential for altered skin integrity related to her decreased mobility, multiple sclerosis, paraplegia, dementia and chronic pain. Interventions included: alternating air mattress on bed; assisting the resident to reposition frequently; document any beginning stages of breakdown; notify wound consultant/nurse and MD (medical doctor); follow skin breakdown protocol and take above measures to prevent further breakdown and promote healing. Perform labs and administer medications,as ordered. Observe and report any changes to skin integrity such as discoloration, blisters, open areas, injuries, provide diet as ordered, provide treatments as ordered, and reinforce the importance of mobility, turning, repositioning of pressure ulcers. The Weekly Head to Toe Skin Check Assessments dated 7/20/22, 8/17/22, and 8/25/22 revealed the resident's skin was clean, dry, and intact. A skin check assessment dated [DATE] revealed the resident had a new skin tear to the right buttock that measured 0.3 cm x 0.2 cm. The assessment gave no other details. A skin check assessment document dated 9/13/22 revealed the resident had a small post surgical wound on the right iliac crest (the upper bone of the pelvic region). -There were no skin assessment notes in the resident's chart until 10/6/22. Wound physician assessment dated [DATE], revealed the resident had developed an unstageable pressure wound on her right ischium (the area of skin covering the lower hip bone) due to necrosis (dead tissue). The pressure injury was facility acquired and had been present for at one day. The wound measured 3.2 centimeters (cm) by 4.0 cm by a non measurable depth. The wound was unstable or due to being covered with 100% slough (whitish yellow stringy dead tissue). The wound was cleansed with normal saline and cleaned by surgical technique. The physician removed a depth of 0.2 cm of dead tissue to reveal healthy bleeding tissue was observed. A weekly skin assessment dated [DATE], documented that the resident had developed a wound on the right bottock; there was no description or measurement of the wound. Wound physician note dated 10/13/22, revealed the resident's right ischium pressure wound remained unstageable due to necrotic dead tissue. The wound present seven days measured 3.2 cm by 4.0 cm and was covered with 80% slough and 20 % granulated tissue inflamed tissue with new capillaries. The skin surrounding the wound was macerated (wrinkly, soft and soggy). The resident was admitted to the hospital 10/14/22-10/17/22 for an medical reason unrelated to the resident pressure wounds. A readmission skin assessment completed on 10/17/22 indicated the resident had a right ischium wound that was unstageable and measured 3.2 by 4.0 cm. A description of the wound was not documented. The resident had a surgical incision present on her back where a nephrostomy tube was placed while she was at the hospital. Wound physician note dated 10/20/22, revealed the resident's right ischium pressure wound had deteriorated. The wound remained unstageable and now measured 5.5 cm by 4.5 cm with an unmeasurable depth due to thick adherent necrotic tissue. The wound was present for more than 13 days. The resident had a new unstageable deep tissue injury to the right sacral area (the coccyx - the skin covering the area between the end of the lumbar spine and the tailbone) measuring 3.2 cm by 2.0 cm. The injury was present for one day. Wound physician note dated 10/27/22, revealed the resident's right ischium pressure wound was improving and measured 5.0 cm by 4.0 cm the depth was unmeasurable. The wound remained unstageable with 80% slough and 20 % dermis viable skin. The wound was present for 19 days. The resident's unstageable deep tissue injury to the right sacral area measured 2.0 cm by 1.0 cm. The injury was present for seven days. A weekly skin assessment, dated 11/2/22 documented the resident's right buttock wound had slough and purulent (foul smelling) drainage. The assessment did not document measurements. Wound physician note dated 11/3/22, revealed the resident's right ischium pressure wound stage 4 pressure wound measured 4.0 cm by 3.5 cm the depth was unmeasurable with 80% slough and 20% dermis viable skin. The resident's unstageable deep tissue pressure injury to the right sacral area measured 1.9 cm by 0.8 cm. The injury was present for 13 days. Wound physician note dated 11/10/22, revealed the resident's right ischium pressure wound stage 4 pressure wound measured 3.5 cm by 3.0 cm the depth was unmeasurable with 70% necrotic tissue, 10% granulation and 20% dermis viable skin. The wound was present for 31 days. The resident's unstageable deep tissue pressure injury to the right sacral area measured 1.0 cm by 1.0 cm. The injury was present for 19 days. Wound physician note dated 11/17/22, revealed the resident's right ischium pressure wound stage 4 pressure wound measured 3.2 cm by 2.8 cm the depth was unmeasurable with 60% necrotic, 10% slough, 10% granulation and 20% dermis viable skin. The wound was present for 37 days. The resident's unstageable deep tissue pressure injury to the right sacral area measured 0.5 cm by 0.5 cm. The injury was present for 25 days. The November 2022 CPO revealed the following orders related to wound care: -Cleanse wound on right buttock with wound cleanser apply skin prep to periwound, cover the wound with medi-honey, apply a silver alginate wound dressing (used to prevent or reduce infection), cover with foam dressing one time a day every other day. -Limit the resident's time in her wheelchair to one hour as the resident will allow, start date 10/7/22. -Turn resident frequently throughout the shifts, when in bed, start date 10/7/22. Review of the resident October and November 2022 treatment administration record (TAR) revealed the staff repositioned the resident 21 of 22 opportunities until 10/6/22. On 10/7/22 the order was changed to reposition the resident frequently during each shift. From 10/7/22 to 10/31/22 the TAR indicated the resident was repositioned each shift 42 of 43 opportunities and 11/1/22 to 11/17/22 the TAR indicated the resident was repositioned 27 of 29 opportunities. D. Staff interview Licensed practical nurse (LPN) #2 was interviewed 11/17/22 at 2:55 p.m. LPN #2 said the resident was dependent on staff for repositioning and preferred to be on her left side due to her contractures. The resident was alert and oriented and would sometimes refuse repositioning. The LPN said the resident had not been repositioned that afternoon because she was sleeping and appeared comfortable. The LPN did not want to disturb the residents. The LPN said when caring for a resident with pressure ulcers staff was expected to provide care assistance to provide repositioning and help the resident offload to relieve pressure on vulnerable areas of the body. III. Resident #101 A. Resident status Resident #101, age [AGE], admitted on [DATE]; discharged to the hospital on [DATE]; readmitted on [DATE]; discharged to the hospital on [DATE]; and readmitted on [DATE]. According to the November 2022 CPO diagnoses included type 2 diabetes mellitus, atrial fibrillation, neuropathy, need for assistance with personal care, and dislocation of lumbar vertebra. The 9/28/22 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of nine out of 15. The resident required limited assistance for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident was at low risk for pressure ulcers. B. Observations On 11/14/22, the resident was observed from 9:00 a.m to 11:30 a.m. The resident was laying in bed with the head of the bed up at 30 degrees propped up with a pillow to the left side. The resident had not been repositioned during the observation. On 11/16/22 a continuous observation was made from 10:00 a.m. to 12:20 p.m. The resident was sleeping, lying on his back. His head was on a pillow and he had one heel protector in place on his right foot. The resident had not been repositioned during this continuous observation. C. Record review The Braden Scale assessment dated [DATE], (a tool used to determine a resident's risk for pressure ulcer development), documented Resident #101 was a low risk for developing pressure ulcers. The Weekly Head to Toe skin check on 10/15/22, 10/29/22 and documented the resident had no skin issues. -There were no weekly skin checks for the other weeks since admission on [DATE] that were present in the resident chart. The 11/11/22 hospital discharge note revealed the resident had a facility acquired pressure injury related to tissue damage on his right heel and sacrum that were present when the resident was admitted to the hospital on [DATE]. On 11/11/22 the readmission nurse documented a pressure wound on the residents coccyx and a deep tissue injury on the residents right heel. There were no descriptions or measurements of either wound. Review of resident #101's November 2022 CPO revealed the following physician order: -Coccyx wound care cleanse with wound cleanser, pat dry, apply medi honey and alginate and cover with foam dressing, one time a day, every other day for wound care. The order started on 11/12/22. The comprehensive care plan updated on 11/15/22 identified the resident had a pressure injury. Interventions included to complete the Braden Scale, preform weekly skin inspection, do not massage over bony prominence, float heels, heel boots, nutritional and hydration support, preventative foot care shoes, inserts, pads, provide pressure reducing wheelchair cushion, provide pressure reduction/relieving mattress, provide thorough skin care after incontinent episodes and apply barrier cream, administer treatments as ordered. Wound physician note dated 11/17/22, revealed the resident was seen for an initial consultation by a wound specialist. The note documented the resident had: -An unstageable deep tissue pressure injury to the right heel. The wound was present for less than two days. The wound measured 4.2 cm by 4.2 cm, the depth was not measurable. -An unstageable pressure injury to the sacrum/coccyx, present for less than two days. The wound measured 11.5 cm by 3.0 cm the depth was not measurable due to the presence of necrotic dead tissue. The skin surrounding the wound was purplish maroon in color. -Recommendations included: wound care and offloading and repositioning for pressure relief. D. Staff interviews The director of nursing (DON) was interviewed on 11/17/22 at 5:30 p.m. The DON said staff were expected to follow facility protocol and physician orders and offload pressure points and assist dependent residents with repositioning in order to promote healing and prevent pressure wounds. The DON stated when a resident refused positioning the nurse should make notes in the record and the physician needs to be notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure supervision and assistive devices to prevent accidents for three (#34, #62 and #4) four residents reviewed for accidents/hazards out of 49 sample residents. Specifically, the facility failed to prevent residents at risk for falls from having repeated falls, falls with injury, and major injury. Resident #34 experienced multiple falls while a resident of the facility. Resident #34 was assessed to have had poor balance, unsteady gait and poor safety awareness. The resident was blind and had severely impaired cognitive impairments, however, the resident's fall prevention care plan lacked any specific person centered interventions which would be appropriate for the blindness and the cognitive impairments. The facility failed to implement effective fall precautions. As a result, the resident had multiple falls causing pain and injuries. On 2/12/22 the resident fell and hit her head on the floor. The fall caused the resident pain and required pain relief medication. On 5/28/22 the resident fell and hit her head on the floor. The physician determined x-rays of her skull were necessary. On 6/14/22 the resident fell to the floor and had hip pain. The resident had pain and x-rays were ordered for evaluation. On 9/6/22 the resident fell to the floor and had severe hip pain. She was transferred to the hospital for evaluation and it was determined she had a fractured right hip that required hip replacement surgery and hospitalization. On 9/21/22 the resident fell and had pain in her wrist and required narcotic pain relief medication. She was transferred and evaluated at the hospital where it was determined she had a non operable wrist fracture that required use of a soft cast for healing. On 9/28/22 the resident fell and hit her head. She required x-rays of her previously fractured wrist and pain relief medication. On 10/22/22 the resident fell to the floor and had pain in her hip. She was transferred to the hospital emergency department for evaluation and it was determined she had a chronic non operable thoracic spine fracture and returned to the facility. In addition, the facility failed to: -To assess risk and maintain safety for Resident #62, who verbalized a desire to go home and then left the facility; and, -To assess Resident #4 for community awareness and ensure adequate supervision to prevent an accident/hazard. Findings include: I. Resident #34 A. Professional reference According to [NAME], P.A., [NAME], A.G. , et.al. Fundamentals of Nursing, ninth ed., 2017, pp. 375: Falls are a major public health problem. Among adults 65 years and older, falls are the leading cause of both fatal and nonfatal injuries. Numerous factors increase the risk of falls, including a history of falling being age [AGE] or over, reduced vision, orthostatic hypotension, lower-extremity weakness, gait and balance problems, urinary incontinence, improper use of walking aids, and the effects of various medications (e.g., anticonvulsants, diuretics, hypnotics, sedatives, certain analgesics). Common physical hazards that lead to falls in the home include inadequate lighting, barriers along normal walking paths and stairways, loose rugs and carpeting, and a lack of safety devices in the home. Falls are also a common problem in health care settings. Hospitals throughout the country carefully monitor the incidence of falls and fall-related injuries as part of their ongoing performance improvement work. Falls are often a combination of individual and transient risk factors, the physical environment (e.g., poor lighting, high bed position, improper equipment), and the riskiness of a person's behavior (unwilling to call for assistance when getting up). Falls often lead to serious injuries such as fractures or internal bleeding. Patients most at risk for injury are those with bleeding tendencies resulting from disease or medical treatments and osteoporosis. B. Facility policy and procedure On 11/17/22, a request was made to the nursing home administrator (NHA) for the facility's fall prevention policy; the policy was not provided during the survey. C. Resident status Resident #34, age [AGE], was admitted on [DATE], discharged to the hospital on 9/5/22 and readmitted on [DATE]. According to the September 2020 computerized physician orders (CPO) diagnoses included fracture of the right femur (hip), dementia, cognitive communication deficit, abnormalities of gait and mobility. On 10/1/22 she was admitted to hospice care. The 10/7/22 minimum data set (MDS) assessment showed the resident had severely impaired cognitive status with a score of four out of 15 on the brief interview for mental status (BIMS). The resident required one person extensive assistance from staff for bed mobility, transfers, locomotion on and off the unit, dressing, eating, toilet use, personal hygiene and limited assistance for walking in her room and in the corridor. D. Observations On 11/14/22 at approximately 10:30 a.m., the resident was observed in her wheelchair near the nurses' station. Facility staff walked in the hallways, entered and exited other resident rooms. The resident was frequently without line of sight supervision. On 11/16/22 at 9:30 a.m., the resident sat in her wheelchair next to the nurses' station. There were no staff members present at the nurses' desk or in the hallways. The staff were observed as they entered and exited other resident rooms. The resident was frequently without line of sight supervision. At 9:50 a.m., the resident was observed sitting in her wheelchair in the middle of her room. The resident's room was near the nurses' station; however, she was not in the line of sight of staff members. The resident did not have her call light pull cord within her reach. C. Record review The progress notes indicated the resident had suffered eleven or more falls since admission on [DATE], and seven of those falls occurred in 2022. The falls were as follows: Fall #1 Nursing progress note dated 2/12/22 at 11:30 a.m., documented the resident stated she was standing and talking to her roommate for a long time, then slipped in her socks, tripped and fell. The nurse assessment revealed the resident hit her head and hip and she had pain requiring pain medication. It was determined that no injury occurred. The resident was educated she should sit in her chair while talking for long periods or use her walker for support. The note stated the resident was legally blind and the trip hazard was moved to the corner of the room. Interdisciplinary team (IDT) post fall review note dated 2/14/22 at 9:41 a.m., read: (Resident) was diagnoses dementia with behavioral disturbance, malnutrition, homicidal ideations. The resident's medications were reviewed, the care plan reviewed and updated. The IDT determined the root cause was the resident tripped over roommate's possessions. Intervention: Therapy to evaluate and treat. Therapy progress note dated 2/14/22 revealed the resident fell in her room, tripping over roommate's possessions. Resident #34 was to be evaluated by physical therapy to facilitate safety and functional mobility. The comprehensive care plan dated 1/18/22 documented the resident was at risk for falls. Pertinent interventions included, offer non-skid footwear, encourage resident to call for assistance with items not immediately in reach, encourage resident to use a wheelchair and monitor for resident impulsivity to decrease fall. -The care plan was updated on 2/25/22 to include therapy evaluation. The physician's assistant (PA) note dated 3/15/22 documented, the resident was observed standing in her room without an assistive device. She had good balance and gait (manner of walking). The PA recommended continue to monitor closely with frequent check-ins by staff for fall prevention. Fall #2 A nurse's progress note dated 5/28/22 at 7:53 a.m., documented the resident was observed as she fell backward and hit her head on the floor. The nurse assessment was completed and skull series x-rays were ordered. The 5/31/22 IDT post fall review note documented, the root cause was she slipped and fell backward. The care plan was updated to ensure she was wearing proper footwear at all times. Fall #3 A nurses's progress note dated 6/15/22 at 10:53 a.m., documented the resident was observed on 6/14/22 lying on the floor on her right side in her room. The resident complained of pain when the nurse touched her right hip. An x-ray film of the right hip was ordered and had no evidence of fracture. TheIDT post fall review note dated 6/16/22, revealed the root cause of the resident's fall was the resident slipped and fell to the floor, she was not wearing socks. The care plan was updated to include, frequent checks by staff to meet resident's needs. Therapy progress note dated 6/16/22 documented the resident fell ambulating in the room while completing her morning routine. Resident #34 was currently receiving therapy services and would continue safety awareness education and training. A physician note dated 6/19/22 at 23:00 p.m., documented the resident requested to be evaluated but the staff had not been responding to her needs and wished to be transferred to the hospital. The physician documented he evaluated the resident in follow up to residents complaints and follow up for dementia, hypertension, and depression. It was noted by the physician the resident had confusion, was angry, agitated, and had a decreased mood. Fall #4 A nurse's progress note dated 9/6/22 at 4:46 p.m., documented the resident was found lying supine between her bed and bedside table. The resident screamed during the nurse assessment when her right hip was touched. The physician was contacted and ordered the resident be transferred to the hospital for evaluation. The resident sustained a right hip fracture and required hip replacement surgery. An IDT post fall review note dated 9/7/22 at 9:53 a.m., indicated: medications were reviewed. Root cause: resident tripped and fell in her room. The care plan was updated. Intervention: educate staff to ensure all articles are off floor room free of clutter. A therapy note 9/9/22 at 3:23 p.m., documented the resident's fall incident was discussed with the IDT. Resident fell in her room, was sent to ED (emergency department) for evaluation, will complete therapy evaluation upon return. The PA note dated 9/13/22 documented the resident had a mechanical fall with injury and the resident should continue with physical and occupational therapy. The PA noted the resident had a history of falling, had diagnoses of dementia and poor vision, and the facility should continue fall precautions per facility protocol. The care plan updated 9/17/22 indicated fall prevention interventions included: encourage resident to call for assistance with items not immediately in reach, frequent checks by staff to meet resident's needs, re-educate staff on use of non skid shoes and socks, resident to be in wheelchair near nurses station within sight while awake, staff to provide textured tennis ball attached to call light so resident can find it due to her low vision, staff to rearrange room for safety, therapy to evaluate and treat as indicated, therapy to evaluate for safety with transfers. Fall #5 A nurse's progress note dated 9/21/22 at 6:53 p.m., documented the resident was heard yelling for help. The resident was found sitting on her buttocks in front of her bed holding her right hand and stated she thought she hurt her right wrist. The nurse assessment indicated the resident required narcotic pain medication after the fall. The resident was transferred to the hospital for evaluation of her painful and swollen wrist. The resident sustained a right wrist fracture from the fall that required wrapping with a soft cast. The IDT post fall review note dated 9/23/22 documented the root cause was self-transferring. Pertinent interventions were to: place a tennis ball on her call light so the resident can find easily secondary to poor eyesight. A nurse practitioner (NP) note dated # 9/22/22 documented the resident had a history of falling, had diagnoses of dementia and poor vision, and the facility should continue fall precautions per facility protocol for fall prevention. Fall #6 A nurse progress note dated 9/28/22 at 8:56 p.m., documented the resident was found lying on her right side on the floor in the hallway. Resident reported that she hit her head. The nurse determined that no injury was sustained. Resident complained of pain that required pain medication. An order was obtained to x-ray the previously fractured wrist. A NP note dated 9/28/22 documented the NP evaluated the resident for a recent fall with wrist fracture and did not indicate a plan for fall prevention. A PA note dated 9/29/22 documented the PA evaluated the resident for a recent fall and recommended the facility continue to follow facility protocol for fall prevention. A social services note dated 9/30/22 at 12:00 p.m., revealed the resident was referred to hospice services. An IDT post fall review note dated 10/3/22 9:20 a.m., indicated: the team reviewed and discussed resident's usual self-care and functional mobility performance as reflected in above evaluation. The note indicated the score was derived from an IDT review and discussion of activities of daily living (ADL) documentation, nursing progress notes, staff observations, nursing assessment/evaluation, and skilled therapy evaluation/notes. The following goals have been identified by the IDT: Resident did not reach her goals. discharged to Hospice services. The Hospice diagnosis: senile degeneration of brain. An IDT post fall review note dated 10/3/22 documented the root cause of the fall was ambulating without assistance and fell. Interventions put into place were to keep the resident in line of sight to prevent falls. Although the IDT note documented the care plan would be updated, it was not. Fall #7 A nurse progress note dated 10/22/22 at 6:30 p.m., documented the nurse responded to a loud noise and resident screaming for help. The resident was found sitting on her floor. Resident complained of excruciating pain to her right hip and tailbone area. The physician ordered to the transfer the resident to the hospital for evaluation. On 10/25/22 at 4:34 p.m., the PA evaluated the resident for a post-fall follow up. It was determined at the emergency department the resident sustained a thoracic spine fracture at the T12 level and it was thought to be chronic because the examination at the emergency department was benign. The IDT post fall review note dated 10/24/22 documented, the resident had a diagnosis of dementia, and was blind. The root cause was self- transferring. -The care plan was not updated after fall #7. A physician noted dated 10/24/22 documented the resident had a fall with injury and the plan was to continue to follow facility protocol. The physician noted the resident was unlikely to rebound from her injuries in sequence and discussed the plan to pursue hospice services. Fall risk assessment A falls assessment was completed following each of the resident's fall's. The assessment evaluated the resident status pertaining to falls within the last six months, medications used, memory and recall ability, vision, continence in the last 14 days, agitation in the last seven days, confinement to a chair, blood pressure, and gait analysis. The post fall assessments revealed the resident was: -On 2/12/22 at moderate risk for falls; -On 5/28/22 at moderate risk for falls; -On 6/15/22 at moderate risk for falls; -On 9/6/22 at moderate risk for falls; -On 9/21/22 at high risk for falls; -On 9/28/22 at high risk for falls; and, -On 10/22/22 at moderate risk for falls. E. Interviews Certified nurse aide (CNA) #13 was interviewed 11/17/22 at 10:50 a.m. The CNA stated the resident had several falls and because of staffing it was not always possible to keep the resident in line of sight due to staffing assignment. The CNA stated the resident would sometimes sit in her wheelchair next to the nurses' desk where the staff could watch the resident. The CNA was not aware of specific interventions for fall prevention except to keep a close watch on the resident so that she did try to stand up without assistance. Licensed practical nurse (LPN) #2 was interviewed 11/17/22 at 12:45 p.m. LPN #2 said that the resident was identified as a fall risk based on her fall history. The LPN said a fall assessment was completed after a fall. When the doctor was notified after a fall the doctor would indicate what action was necessary for the resident. The LPN stated the staff could add what was needed like a fall mat and make sure the call light is in place within residents' reach. The LPN stated that Resident #34 was independent and mobilized throughout the facility when she was admitted to the facility and now she was wheelchair bound. The director of nursing (DON) was interviewed 11/17/22 at 5:30 p.m. The DON said Resident #34 was blind and impulsive, that she was not compliant and had gone downhill in her health. She stated Resident#34 had a right to fall. The facility staff recognized that she was impulsive and relocated the resident to a new room to be close to the nurses' desk where staff could watch her closely by keeping the resident in sight. The DON stated the resident received physical and occupational therapy and the facility staff tried the best they could to prevent the resident falls. II. Resident #62 A. Facility policy and procedure The Elopements policy and procedure, initiated 2018, was provided by the director of nursing (DON) on 11/17/22 at 6:05 p.m. It read in pertinent part, Staff shall investigate and report all cases of missing residents. When the resident returns to the facility, the director of nursing services or charge nurse shall: complete and file an incident report and document relevant information in the resident's medical record. B. Resident status Resident #62, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders, diagnoses included paranoid schizophrenia, dementia, and symptoms and signs of cognitive functions and awareness. The 8/4/22 minimum data set (MDS) assessment indicated the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. It indicated the resident was independent with activities of daily living. It indicated the resident did not have signs of psychosis, no physical or verbal behaviors, and did not wander. C. Record review The 9/8/22 progress note indicated a nurse found the resident attempting to leave the facility through the front entrance. It indicated the resident said I'm going home and was reluctant to come back inside. The 10/31/22 progress note indicated staff found the resident sitting in the parking lot. It indicated the resident asked for a ride home. The resident was agreeable to come into the facility and the nurse was notified to check on the resident frequently. The nursing home administrator (NHA) provided psychiatrist notes for Resident #62 on 11/17/22 at 1:30 p.m. On 11/8/22 the resident was seen by the psychiatrist and the notes indicated the resident was having delusions that she was going home and people were outside waiting for her. The behavior care plan, revised 5/17/22, indicated Resident #62 experienced delusions where they made her vomit and a history of suicidal ideations. Interventions included performing care when resident was calm, explaining care prior to and during the process of care, involving family as necessary in behavior management, redirection, and reorientation. -There was not a care plan related to wandering or elopement behaviors. -There was no wandering or elopement assessment. The treatment administration record indicated behavior tracking for antipsychotic use as evidenced by distressing delusions. No delusions were indicated for September, October and November 2022. D. Interviews Registered nurse (RN) #2 was interviewed on 11/16/22 at 4:02 p.m. She said Resident #62 did not have behaviors and had no history of elopement. Certified nurse assistant (CNA) #6 was interviewed on 11/17/22 at 10:05 a.m. She said she was not sure if Resident #62 had a history of elopement. RN #3 was interviewed on 11/17/22 at 11:49 a.m. She said Resident #62 stayed in her room a lot and was not an elopement risk. The director of nursing (DON) was interviewed on 11/17/22 at 1:38 p.m. She said Resident #62 had a diagnosis of paranoid schizophrenia and had frequent paranoia. She said the resident preferred to stay in her room but would work with physical therapy. She said the resident had been found outside of the facility a few times and she was confused. She said the events appeared to be isolated and the resident had not attempted to elope again. She said any attempt to leave the facility would require an assessment related to wandering. She said she was unsure if the resident had an assessment completed for wandering or elopement and she was unsure if a WanderGuard was an option for the resident. The social services director (SSD) was interviewed on 11/17/22 at 2:56 p.m. She said Resident #62 experienced distressing delusions. She said there were a few times the resident had left the facility but was easily redirected inside by staff. She said the resident was experiencing a delusion when she left the facility and said she wanted to go home. She said the care plan should be updated to include wandering or elopement behaviors. She said the resident enjoyed sitting outside and was allowed to sit outside if she wanted but should notify the nurse first. III. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease, diabetes Mellitus, and cerebral palsy. According to the 9/9/22 minimum data set (MDS) assessment, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out of 15. The resident had verbal and physical behaviors directed toward other symptoms. He required extensive assistance for bed mobility, transfers, grooming and toilet use. B. Record review The care plan, initiated 4/11/22 and revised 9/15/22, identified the resident exhibits and reports mood problems related to life circumstances, verbal outbursts towards staff. The resident makes false allegations against staff members. Residents would delay times of shower times and get out of bed. Interventions include offering grievance forms as needed. Monitor for increase in depression, anxiety, and address accordingly. Encourage residents to participate in activities outside of the room, including meals and other social activities. Validate residents' feelings and concerns, as needed. The care plan, initiated 4/11/22 and revised 9/15/22, identified the resident has a physical functioning deficit related to multiple sclerosis (MS). Resident has a left hand splint that is managed by therapy. Interventions include assistive devices for motorized wheelchairs. Inform the resident of risk of refusal of care. Resident required two person assistance for all ADL and transfers. Log note dated 11/7/22 at 3:02 p.m., revealed in pertinent part: Report received that the resident left the building at 9:30 a.m. this morning and did not give a description of where he was going. Resident is currently still not in the building and his cell phone is not going through. Director of nursing (DON), assistant director of nursing (ADON), and nursing home administrator (NHA) notified. Resident was self-responsible. Lakewood police department notified. Log note dated 11/2/22 at 7:03 p.m., revealed in pertinent part: Resident left the building this morning at 9:30 a.m. Medications were administered per physician's order. Resident stated I would be back by 3:00 p.m., it is currently 7:05 p.m., and he is not back yet. DON, and NHA were notified. NHA stated to tell the night nurse to call him if the resident is not back by 8:00 p.m. Written request for missing person investigation for Resident #4 was given to the nursing home administrator on 11/16/22 at 2:07 p.m., and again on 11/16/22 at 4:26 p.m. In addition, a request for Resident #4 sign out sheet, facility off ground assessment, and education for Resident #4's safety of campus. C. Interviews The social services director (SSD) and nursing home administrator (NHA) were interviewed on 11/16/22 at 10:46 a.m. The NHA said Resident #4 was his own person and he could leave the facility as long as he signed out and gave a description of where he was going and when he would return. The SSD said there was no assessment completed for Resident #4, which identified if Resident #4 was safe to go out into the community. The NHA said there was an assessment which assessed the resident's ability to use his power chair indoors but there was not an assessment for residents community use. The SSD said the facility had not received a report on condition of Resident #4 or if Resident #4 would return to the facility. At time of facility exit facility on 11/17/22, documentation was not provided including the resident's sign out sheet, facility off ground assessment and safety education for Resident #4.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review the facility failed to ensure that a resident who enters the facility without pressure sores does not develop pressure sores unless the individual's clinical condition demonstrates that they were unavoidable; and a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing for three (#218, #99 and #73) of three sample residents. Specifically the facility failed to: -Thoroughly assess, timely consult the physician, obtain orders, develop interventions and render treatments for pressure ulcers developed at the facility for Resident #218. The facility's failure contributed to the resident developing an unstageable pressure ulcer to her and one stage four pressure ulcer. Resident #218 was admitted to the facility without pressure injuries. The resident developed a stage III pressure injury to the coccyx while at the facility. The pressure injury was discovered on 7/16/21. The documentation and interviews showed the resident did not have any other skin issues. However, when she was admitted to the hospital on [DATE] the hospital diagnosed a right heel unstageable pressure injury. The documentation showed, the resident was seen at the hospital by the emergency room physician within six minutes of arrival. -Furthermore the DON confirmed the nursing staff had not had any training on how to identify and report pressure injuries which was consistent with not identifying pressure injuries as evidenced by Resident #218, # 99 and #73 pressure injuries to the heels; and -Identify a pressure injury for Resident #73 stage II pressure injury to the right heel; and -Identify Resident #99's stage II pressure injury to right heel and stage I to left heel. Findings include: I. Professional reference The NPUAP Pressure Injury Stages | The National Pressure Ulcer Advisory Panel - NPUAP. The National Pressure Ulcer Advisory Panel NPUAP. Web. (undated) http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages reads: A pressure injury is localized damage to the skin and/or underlying soft tissue, usually over a bony prominence as a result of pressure, or pressure in combination with shear. The updated staging system includes the following definitions: -Stage 1 Pressure Injury: Intact skin with a localized area of non-blanchable erythema. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. -Stage 3 Pressure Injury: Full-thickness skin loss. Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar was removed, a Stage 3 or Stage 4 pressure injury will be revealed. B. According to the National Pressure Ulcer Advisory Panel (NPUAP), Pressure injury prevention points, updated 2016, revealed in part Consider bedfast and chairfast individuals to be at risk for development of pressure injury; Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for pressure injury as soon as possible (but within eight hours after admission); Use heel offloading devices .on individuals at high risk for heel ulcers. II. Policy The facility policy Skin Assessment Monitoring Guidelines were requested and delivered by the DON on 8/31/21 at 4:36 p.m. The policy states, all residents will be assessed upon admission, quarterly and with a significant change in condition to identify risk factors that may lead to impaired skin integrity. Designated assessment tools will be utilized by the nursing stall to identify residents at risk to ensure consistency and accuracy of collected data. All residents identified at risk will be reviewed by the Interdisciplinary Team to ensure that all efforts to implement preventive measures have been addressed. Purpose: to prevent skin impairment by assessing risk factors in a timely manner; to gather accurate, objective and consistent data for the purpose of implementing an individualized Plan of Care designated to meet the residents needs; to ensure consistency in implementation of prevention measures to assist with maintaining skin integrity; to evaluate outcomes. III. Facility matrix The facility matrix was received on 8/30/21 from the director of nurses (DON). The facility matrix indicated there was no pressure injuries in the building. The DON was interviewed on 9/2/21 at 3:25 p.m. The DON said that to her knowledge there were no other residents in the building that had pressure injuries. IV. Avoidable pressure injury for Resident #218 1. Resident #218 A. Resident Status Resident #218, age [AGE], was admitted on [DATE]. According to the August 2021 computerized physician orders (CPO), the diagnoses included chronic kidney disease stage 3, mild protein calorie malnutrition, anxiety disorder, major depressive disorder. The minimum data set (MDS) assessment dated [DATE] revealed the resident was cognitively intact with moderately cognitive impairment with a brief interview for mental status score of seven out of 15. She required extensive assistance with one to two persons for ADLs. The care plan revised on 4/9/21 identified that the resident had impaired skin integrity and required turning and positioning every two hours to three hours to prevent skin breakdown. Pertinent interventions included an air mattress, weekly skin checks and reminders to the resident to turn and reposition. B. Development of a pressure injury coccyx The 7/5/21 skin assessment documented the resident did not have any wounds or skin issues, heels- no identifiable skin issues noted. The 7/12/21 skin assessment documented that the resident had no skin issues, heels-no identifiable skin issues noted. The 7/16/21 nurse progress note documented, the resident was seen by the wound clinic. The documentation showed, the resident had a stage III coccyx pressure injury and measured at 3.4 x 6.7 x 0.1 with 60% granulation and 40% epithelial; minimal serosanguinous drainage; periwound edema, bruised, red. The new order was for the coccyx to be cleaned with wound cleaner, pat dry, skin prep periwound, apply medihoney to wound bed, cover with foam dressing. Change every day. Power of attorney and primary physician were involved in the plan of care. The 7/16/21 documentation from the wound physician did not identify any other skin issues. The wound nurse was interviewed on 9/3/21 at approximately 12:00 p.m. The wound nurse said Resident #218 was being treated by the wound physician for the coccyx pressure injury stage III. The wound nurse said the resident did not have any wounds on her heels. C. Change of condition The 7/20/21 progress note showed the resident had an increased lethargy and vital signs that had changed slightly from the previous assessment resident was tachycardia. The resident was transferred to the emergency room for evaluation. The facility did not have a skin assessment completed prior to the resident leaving for the hospital. The resident arrived at the hospital on 7/20/21 at 5:33 p.m. The registered nurse triaged her at 5:35 p.m., and the emergency room physician exam was at 5:39 p.m. The hospital record progress note dated 7/20/21 documented the resident was admitted to the intensive care unit. The hospital records showed the diagnoses were as follows: -septic shock from E. coli urinary tract infection; -obstructing ureteral stones, -acute kidney injury, -acute respiratory failure secondary to sepsis; and -multiple decubitus ulcers on the coccyx, and right posterior shoulder. The ICU notes dated 7/20/21 documented she arrived to the ICU at 8:24 p.m., and it showed she had a stage III coccyx pressure injury, and right heel was unstagable pressure injury. The wound care physician at the hospital was consulted on 7/21/21at 6:41 a.m. for the sacral (coccyx) wound which was staged as a state IV pressure injury with measurements 4 x 5 cm with tunneling that required surgical debridement by plastic surgeon. The right heel was an unstageable pressure injury. D. History of Resident #218 Resident#218 was having increased complications related to chronic kidney disease and renal calculi which required surgical placement of nephrostomy tubes on 3/19/21. There was resolution of the renal calculi however more renal calculi developed in April 2021 which required surgery on 4/7/21. Resident#218 returned to the facility and was placed on the interdisciplinary team (IDT) for weekly review for nutritional status tracking due to weight loss. The RD had placed Resident#218 on multiple nutritional supplements for weight loss. Resident#218 had been successfully treated for moisture associated skin damage (MASD) and had a care plan for risk for skin integrity problems and to be turned and positioned every two to three hours. The RD was interviewed on 9/2/21 at 2:20 p.m., stated that the resident demonstrated the ability to recover from the MASD and they were supplementing her nutritional needs to promote wound healing. E. Failure to identify right heel pressure injury The hospital record progress note dated 7/20/21, showed the resident had an unstageable right heel pressure injury. The facilities records failed to identify the right heel pressure injury. The skin assessments showed that on 3/20/21 the resident was readmitted from an overnight hospital stay for surgical procedure. The nurse skin assessment documentation noted that the resident had very dry heels. There was no further mention or documentation of continued care for the dry heels from 3/20/21 through 7/20/21 when the resident was admitted to the emergency room for a change in condition-lethargy. The electronic medical records do show that skin assessments were being conducted and documented however not on a weekly basis until 4/2/21 when the wound nurse practitioner identified a moisture associated skin damage (MASD) to the left buttock but there was no indication of right heel pressure injury. The care plan revised on 4/9/21 identified the resident was at risk for skin integrity problems and to be turned and positioned every two to three hours. F. Skin assessments The electronic records show that weekly skin assessments were being documented with no changes in skin condition to include the right and left heels. The nurse progress notes document that the resident refused to be turned and positioned multiple times however the interview with LPN #4 stated that the resident would not refuse but would become anxious with the turning and repositioning. On 7/16/21 when the facility wound care physician identified the sacral (coccyx) wound there is no documentation of a right heel injury. G. Nutrition interventions The electronic record shows that the resident was on a care plan related to increasing nutritional needs due to weight loss. The RD had added enriched cereal three times a day (TID); Boost pudding twice a day (BID); Breeze nutritional supplement TID; fluids were encouraged in addition to house made shakes (supplemental nutrition) 240 ml TID between meals for hydration. Staff were monitoring the percentage of meal that was eaten by Resident t#218 consumed. H. Staff interviews Licensed practical nurse (LPN) #4 was interviewed on 8/31/21 at 2:09 p.m. LPN #4 said Resident #218 used to reside on the hall he worked. He said she was beginning to have a change in condition and she was not as verbal as prior. He said they would reposition her, and she would moan. He said she did not refuse, however, she was more anxious about it. He said she did sit up in her chair and attend meals in the dining room. He said he could not remember if she had any pressure ulcers. She was discharged to the hospital on 7/16/21. Registered dietician (RD) was interviewed on 9/2/21 at 2:20 p.m. The RD said the resident ' s nutritional status intakes were variable 50-75% and sometimes 0-26%. The RD reviewed the medical record and said Resident #218 was hospitalized on [DATE]. She said she did have a weight loss from 139.5 to 134 pounds. At this point she was on weekly weights then started trending down so she was placed on weekly weights. She said she added 750 calories per day the breeze and then house made shake. The RD said the resident was also offered a substantial snack multiple times per day (half a sandwich, cookie with yogurt). The RD said that prior to hospitalization she was treating the resident for a pressure ulcer on her coccyx. She said the resident was consuming the health shakes and she increased protein calories and carbohydrates to promote wound healing. The RD said she was notified of new pressure wounds through weekly rounds, interdisciplinary team (IDT) conferences. In general nutritional supplements were reserved for residents with venous wounds and diabetic ulcers. The amount of pain and pain medications could have led to her early satiety and decreased PO intake but her nutritional needs would remain the same. States that this resident also had chronic constipation. Feels like she gets updates on resident changes in condition both from nurses and her own investigation of the residents records in PCC. If meals are missed and the resident can make their needs known they are able to get a replacement meal or supplement but if they cannot make their needs known then she relies on nursing and ancillary staff to catch this and then provide a meal alternative. The director of nursing (DON) was interviewed on 9/2/21 at 3:25 p.m. The DON said she was aware of Resident #218 coccyx pressure wound and that the wound was discovered on the day that the wound care doctor was rounding on residents. She stated that a new care plan was put into place by the wound care doctor. She was not aware the resident had also an unstageable right heel pressure injury. The DON further stated, that the licensed nurses had not had any training on pressure injuries, since October 2020. She said the staff lacked knowledge on how identify, and report the pressure injuries. 3. Resident #99 A. Resident status Resident #99, age [AGE], was admitted on [DATE]. According to the September 2021 computerized physician orders (CPOs), diagnoses included fibromyalgia, muscle weakness, and spinal stenosis. The 7/30/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 13 out of 15. The resident required extensive, two person assist, for activities of daily living. It indicated the resident was at risk of developing pressure injuries. B. Resident interview Resident #99 was interviewed on 8/30/21 at 2:59 p.m. She said she had a broken back and preferred to stay in bed. She said her back itched frequently and the staff applied cream to it regularly. She said she was supposed to wear boots on her feet but that staff did not put them on her. She was not wearing the boots at the time. C. Observations On 9/1/21 at 9:35 a.m., care for Resident #99 was observed. Certified nurse aide (CNA) #1 and CNA #12 brought in a hoyer lift, sling, and a shower chair to initiate a transfer. The CNAs rolled Resident #99 onto her side and her back was observed with a white tint due to barrier cream previously applied. A dark purple circular spot, approximately two centimeters in diameter was observed on her right heel. The right heel was not being floated nor had a pressure relieving boot on either foot. D. Staff interviews Licenced practical nurse (LPN) #2 was interviewed on 8/31/21 at 1:48 p.m. She said there were no pressure injuries on the hallway. She said skin checks were completed at admission and then weekly. She said a risk management assessment was completed should any skin issues be observed. Staff development coordinator (SDC) was interviewed on 8/31/21 at 3:45 p.m. She said she had not provided any recent training on pressure injuries. She said she went over all the different types of assessments with the nurses upon hire LPN #2 was interviewed on 9/1/21 at 4:17 p.m. She said Resident #99 had a pressure-like injury on her heel that was healing and the wound nurse was notified when the wound was first identified. She said it was a blister and it had now popped. She said the resident should have boots on in bed to prevent an injury. She said the resident refuses care frequently and has her own preference for positioning in bed. Registered nurse (RN) #2 (facility wound nurse) was interviewed on 9/1/21 at 4:46 p.m. RN #2 said she was the facility ' s wound care nurse. She said when a skin issue was observed, she was notified or the director of nursing (DON) was notified. She said the nurse would write a note as well. She said if a wound or skin issue was not brought to her attention, she would not know about the wound. She said she was not aware of a wound for Resident #99. The DON was interviewed on 9/2/21 at 3:09 p.m. She said she was not aware of Resident #99 having a wound on heel. She said according to documentation, an interdisciplinary team meeting was conducted on 8/3/21 regarding a new skin issue for Resident #99 on the right heel. She said risk management was done and a palliative consult was offered but the resident declined the consult. She said a border gauze was applied on 8/3/21 to the right heel, but that it was not an order. She said the nurse should have obtained an order for wound care to the heel. She said the wound nurse was notified on 8/10/21 according to documentation. Although the facility had identified the right heel pressure injury on 8/3/21, the facility failed to obtain physician order, and failed to continue to treat the pressure injury. The resident was not referred to the wound clinic for further treatment. D. Record review The skin care plan was last updated on 5/14/2020, identified Resident #99 had the potential for altered skin integrity related to decreased mobility, pain, and incontinence. It indicated the therapy department had offered different pressure relieving equipment with resident refusing. A weekly skin assessment was completed on 8/3/2. It indicated redness on the right heel. A nursing progress note was completed on 8/3/21. It indicated a foam border gauze applied to the right heel. It noted the DON and the physician were notified. An interdisciplinary team progress note was completed on 8/4/21. It indicated Resident #99 had a blister on right heel. It noted a palliative consult would be offered. A nursing progress note was completed on 8/4/21. It indicated a possible pressure wound on the right heel. No treatments noted. A nursing progress note was completed on 8/5/21. It noted redness was observed on heels. It indicated resident refused to float heels. A nursing progress note was completed on 8/6/21. It noted redness was observed on heels. It indicated the resident refused to float heels and was uncooperative with repositioning. A nursing progress note was completed on 8/7/21. It noted the resident was cooperative with skin treatment and allowed heels to be floated. The weekly skin assessment from 8/10/21 indicated a blister-like area on the right heel. The note indicated the wound nurse was notified. The weekly skin assessment from 8/17/21 indicated the blister on the right heel popped. The note indicated the skin was not torn and there were no signs of infection. The weekly skin assessment from 8/24/21 indicated blister on the right heel. The weekly skin assessment from 8/31/21 indicated a blister on the right heel and that it was healing progressively. The resident had no physician orders for wound care to the heel. E. Wound care observation Wound care rounds were observed on 9/3/21 at 7:40 a.m. Wound care was completed by RN #2 and the wound care nurse practitioner (WCN). Resident #99 was observed in bed with a boot on her right foot. WCN removed the boot. WCN said she observed a two inch by one and a half inch deep tissue injury on right foot and she staged it as a stage II pressure injury. She treated the wound and ordered daily wound care. She then lifted the resident ' s left foot. Resident #99 cried out in pain. WCN said she observed a red spot on the left malleolus. She said it was a stage I pressure injury. She asked RN #2 to order an air mattress and have an order for heels to be floated. 2. Resident #73 A. Resident status Resident #73, age [AGE], was admitted on [DATE]. According to the August 2021/September 2021 computerized physician orders (CPO), diagnoses included schizoaffective disorder, bipolar type (a mental health condition including schizophrenia and mood disorder symptoms), and morbid obesity. The 7/28/21 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 14 out of 15. He required extensive assistance with one person physical assistance for bed mobility, transfers, and dressing. Limited assistance with one person for walking in the room, locomotion on unit with an electric wheelchair, eating, toilet use, and personal hygiene. Bathing/showering requires physical help limited to transfer only. No behavioral symptoms or rejection of care. The MDS further documented that the resident was at risk of developing pressure ulcers/injuries. No pressure ulcers/injuries at time of admission. B. Resident observation and interview On 9/1/21 at 10:02 a.m., Resident #73 reported he had a right heel blood blister that had popped. He said he got the blister three to four days ago. The resident's right heel had a white bandage at the right heel. Theresident had slippers on both of his feet. The resident said his right heel hurt, and the nurses usually changed the bandage once per day. He said he was mad because he asked them to change the bandage that morning and they said they would do it later. The resident said the blister had developed on 8/28/21 or 8/29/21. On 9/1/21 at 4:26 p.m., the resident ' s right heel was observed with a registered nurse (RN #1). The RN #1 said she was the charge nurse and worked regularly with the resident. She said the resident was not currently seen by the wound clinic. The resident told RN #1 that the pressure injury happened four days ago. The RN #1 did not respond to the answer. After observing the wound RN #1 said there was no drainage as it was intact and they were permitted to use a dry bandage. She said the resident would see the wound physician when it opened up. Resident #73 said it was open, and it drained on his bed last night. He said it was a big blister and it had been draining. RN #1 said the wound physician would be here Friday. RN #1 said she did not know if the wound was reported to the physician. Resident #73 said I told you this morning and you changed my bandage. RN #1 said she should have reported to the physician and wound nurse right away. RN #1 said she had not done an assessment beyond looking at it. On 9/3/21 at 7:28 a.m., the resident ' s heel was observed with the wound care nurse practitioner specialist (WCN). The resident ' s heel was laying directly on the bed. The WCN removed the dressing from his right heel. The dressing was wet, and the heel wound was macerated. The WCN measured the wound and said it was 8 X 10 X 0. She said the pressure injury was a stage II. The WCN painted it with betadine. The WCN gave the order to keep a dry dressing on the pressure wound. She also said to order [NAME] boots (pressure relieving boots). While the WCN was cleaning the wound, the resident said it hurt and grimaced his face. The WCN asked the resident if he moved his foot in bed a lot, the Resident #73 said yes, and the WCN said that was probably how he got the pressure wound. On 9/5/21 at 10:43 a.m., the resident was sitting in his electric wheelchair in the common area. The resident ' s right heel was sitting directly on the foot rest on an incontinence pad. The resident said they had not received the pressure relief boots as of yet. On 9/6/21 at 9:58 a.m., the resident was observed to have his right heel directly on the foot rest. The resident said he was only offered to offload his heel while in bed. He said they continue to not have the pressure relief boots as of yet. On 9/7/21 at 9:30 a.m., the resident was observed sitting in his eclectic wheelchair. Observed the resident ' s right foot bandage, it was marked 9/7/21. There was a drainage pad on the foot rest under his foot, but no pressure relief boot or heel offloading was observed. C. Record review Review of the August/September 2021 computerized physician orders revealed there were no physician orders for wound care to the resident ' s right heel. The August and September 2021medication administration records (MAR) and treatment administration records (TAR) revealed no wound care orders. The care plan dated 8/15/2021 failed to identify that the resident was at risk for a pressure injury, therefore there was no plan in place. The weekly head-to-toe skin assessment dated [DATE] at 8:10 p.m., revealed there was no documentation of a heel blister. It specifically documented that the heel was intact with no blister. Resident #73 said the heel blister had developed on 8/28/21 or 8/29/21. Review of progress notes dated from 8/27/21 to 9/1/21 revealed no documentation of a heel blister in the progress notes. After the pressure injury was brought to the nurse's attention, progress notes revealed the first documentation on the wound/blister was on 9/1/21 at 4:42 p.m. It read, Nurses note: Right heel blister: dressing changed twice this shift, second time, colorless fluids dripping on the floor with no noted odor upon opening old dressing, skin still there. Right heel was cleaned with a wound cleanser, pat dry then dry dressing was applied. No sign of facial grimacing noted. Resident appeared comfortable with the procedure. D. Staff interviews RN #2 was interviewed on 9/1/21 at 4:46 p.m. She said she could not recall Resident #73 being added to the wound care list, she looked up on the computer record and confirmed that he had not been. She said she had not received any report of a skin issue or wound on his heel. She said if he had a big blister on his heel that the nurse staff should notify her and his physician right away. The RD was interviewed on 9/2/21 at 2:20 p.m. She said she was informed about wounds at morning meetings, looking at the wound log, 24 hour report, and from the wound physician/nurse rounding once per week. She said the pressure injuries were staged by the wound care physician. She said she was not currently addressing Resident #73 ' s skin issue because it was a blister, and she had not been made aware of prior to yesterday. She said they use protein for wound healing, and nutritional supplements are mainly used for pressure wounds. The DON was interviewed on 9/2/21 at 3:09 p.m. The DON said she first heard about Resident #73 ' s right heel wound/blister yesterday. She said she trained her staff to do a skin assessment, document in the risk management system and notify the physician. She said the risk management system included measuring the wound, alert charting to check for redness/infection, and follow up with the wound. She said we would notify RN #2 (wound nurse) through texting her, or writing on a paper wound log. She said she had not seen Resident #73 ' s wound/blister yet. She said they did an interdisciplinary team (IDT) meeting today and Resident #73 was observed rubbing his right foot on the power chair. She said he either wears socks or slippers. The DON said at this point he was not putting on a lot of pressure because of how he was reclined in his electric wheelchair, so they were not off-loading his heel. The DON said she wished she knew where the system failed when it was not reported when it first occurred. She said her staff had been educated ad nauseam. She said she gave the staff an example of how notes should look. She said at this point it was going to have to be a weekly education. She said the nurses should be documenting each shift about wounds/blisters. The DON acknowledged that Resident #73 had a wound/blister for four days and the nurses were treating it with a dry dressing but it had not been assessed or documented. The DON acknowledged the failure to identify wounds, or pressure injuries, whether stage one or worse. She said it was concerning to her also.