**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to protect one (#70) of four residents out of 64 sample residents from abuse by Resident #120. On 6/2/22, Resident #120 verbally abused and threatened his roommate, Resident #70, with physical harm, stating he was going to kill someone. Record review and interview revealed the facility failed to protect Resident #70 from further abuse. Specifically, aware of the abuse, the facility failed to immediately separate the residents even though, per staff, Resident #120 was throwing items, calling names, and slamming doors. Further, there was no documentation Resident #120's behaviors and Resident #70's safety were monitored prior to Resident #120's transfer to the hospital later that evening. Resident #70 reported that until Resident #120 was transferred, he feared for his safety, afraid to close his eyes and go to bed. Cross-reference F609 failure to identify and report abuse. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation Prevention Program policy, revised September 2019, was provided by the director of nursing (DON) on 6/15/22 at 11:30 a.m. It revealed in pertinent part: The purpose of this program is to provide a mechanism for the prompt identification, investigation, and reporting of any allegation or complaint of abuse, neglect, or exploitation, and to educate staff about state and federal regulation regarding reporting suspected abuse, neglect, and /or exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment, resulting in physical harm, pain, or mental anguish. This includes verbal abuse, sexual abuse, physical abuse, and mental abuse. Verbal abuse is oral, written, or gestures language towards residents to include threats of harm or saying things to frighten a resident. Mental abuse is humiliation, harassment, threats, deprivation, or other actions that result in mental anguish experienced by a resident. The policy guidelines read in pertinent part: Every resident has the right to be free from verbal, sexual, physical, and mental abuse. Each community takes reasonable, appropriate steps to ensure that each resident is free from abuse, neglect, and exploitation by anyone including but not limited to staff and other residents. Prompt, thorough investigations are conducted in response to complaints or allegations of abuse, neglect, and/or exploitation, and all proper notifications are made to the proper individuals and authorities according to state and federal regulations. The administrator is responsible for the oversight and implementation of the abuse, neglect, and exploitation prohibition and prevention program. II. Resident #70 A. Resident status Resident #70, age [AGE], was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), the resident's diagnoses included hypertensive heart disease and chronic kidney disease, type 2 diabetes, chronic obstructive pulmonary disease and muscle wasting atrophy. The 4/19/22 significant change minimum data set (MDS) assessment revealed the resident had intact cognitive function with a brief interview for mental status (BIMS) score of 13 out of 15. The resident required one person assistance with activities of daily living and used a wheelchair for mobility. The resident did not have any care areas related to behaviors or mood disorders. Review of the resident's clinical record revealed there was no documentation related to a resident to resident altercation on 6/2/22. B. Resident interview Resident #70 was interviewed on 6/6/22 at 11:18 a.m. He said he had a new roommate a week ago that did not work out and the roommate had been sent to the hospital for psychiatric concerns. He said his roommate (Resident #120) moved in and wanted the window bed. He said Resident #120 asked him to switch beds and said he would pay him $50.00 for the window bed. Resident #70 said he felt pressured to say yes, and then changed his mind when the floor nurse told him he did not need to agree to move from the window bed. He said when he told Resident #120 that he did not want to move, Resident #120 became very upset and told him he was going to kill someone, but then Resident #120 said he was just kidding. Resident #70 said he did not feel safe and did not think Resident #120 was kidding so he did not want to close his eyes and go to bed that night until Resident #120 was removed from the room and sent to the hospital. He said he was afraid. He said he told the social services director (SSD) that he did not want Resident #120 back as a roommate and told the SSD he would move out if they put the resident back in his room. III. Resident #120 A. Resident status Resident #120, age [AGE], was admitted on [DATE]. According to the June 2022 CPO, the diagnosis included metabolic encephalopathy (imbalance in the brain), dysphagia (difficulty swallowing), atrial fibrillation and schizophrenia. The 5/12/22 admission MDS assessment revealed the resident had intact cognitive function with a brief interview for mental status (BIMS) score of 15 out of 15. The resident required one person assistance with activities of daily living and used a walker for mobility. His care areas identified were for mood, psychosocial well being, psychotropics and pain management. B. Record review The 5/15/22 care plan revealed Resident #120 had a diagnosis of bipolar disorder, schizophrenia and borderline personality disorder. He verbalized feelings of distress with a history of paranoia and delusions. His goal was to improve his sleep patterns and lessen the daily thoughts of delusions and distress. The interventions in place included redirection for inappropriate social behaviors, observing signs and symptoms for mania and mood changes and educating the staff regarding treatment and maintenance regarding medications and behaviors. Review of Resident #120's nurses progress note dated 6/2/22 at 5:04 p.m. revealed the resident was rude and disrespectful towards his roommate (Resident #70), throwing stuff, calling names, and slamming doors. Nurse notified social services and social services was involved. Resident continued showing aggressive behaviors towards his roommate and the nurse on duty offered to send him to the emergency room for further evaluation, however, the resident refused. Physician assistant (PA) was contacted for further evaluation. Review of Resident #120's record revealed there was no documentation Resident #120 behaviors were monitored after he refused a transfer to the hospital and until he agreed to the transfer later that evening. IV. Staff interviews Interviews revealed staff failed to recognize and protect Resident #70 from further abuse by Resident #120. A. The SSD was interviewed on 6/8/22 at 11:19 a.m. He said he was aware of the resident to resident incident that occurred on 6/2/22. He said he met with both residents on that day; however, he did not document his communication in either resident's clinical record. He said he had a soft copy of notes in his office related to the incident and would enter a late entry for both residents regarding the incident. He said he understood Resident #120 became verbally aggressive towards his roommate (Resident #70) and said Resident #120 declined to go to the emergency room during the afternoon. He said the residents were not separated and continued to be in the room together until later that evening when Resident #120 eventually agreed to go to the emergency room to be evaluated for his hallucinations and aggressive behaviors. He said Resident #70 felt threatened and was relieved when Resident #120 left the room. He said Resident #70 requested not to have him back as his roommate. The SSD said he did not report the incident as abuse to the State Agency (cross-reference F609). However, he agreed, based on the verbal aggression and the fear reported by Resident #70, it should have been reported as abuse. B. The registered nurse unit manager (RN #4) was interviewed on 6/15/22 at 10:00 a.m. He said he was working on 6/2/22 and wrote a progress note in Resident #120 ' s clinical record. He said Resident #120 became very upset and verbally aggressive towards his roommate and was throwing things in his room. He said Resident #120 moved in with Resident #70 that day and thought he would have the window bed. He said Resident #120 became very upset and verbally aggressive towards his roommate because Resident #70 did not want to move from the window to the door bed. He said he asked the SSD to meet with Resident #120 to calm him down, but he did not separate the two residents or have Resident #120 move out of the room. He said he suggested Resident #120 should go to the emergency room, however, the resident declined to leave. He said he had his PA assess him and she made a change in his medications to assist him with his hallucinations and aggression. He said he did not write a progress note in Resident #70's clinical record because he was not the aggressor. He said he notified the SSD and Resident #120's PA but he did not report it to the nursing home administrator (NHA) because there was no physical abuse. When asked further about not reporting the incident to the NHA, RN #4 said he did not take into consideration the verbal abuse that occurred until now. C. The director of nursing (DON) and assistant director of nursing (ADON) were interviewed together on 6/14/22 at 3:09 p.m. They said RN #4 wrote a note on 6/2/22 in Resident #120's record regarding the resident to resident incident. They acknowledged Resident #120 was verbally abusive towards Resident #70 based on the nurse's documentation. They said that residents had the right to be free from abuse and, based on the nurse's progress note and Resident #70's interview, the incident should have been investigated and reported to the state as an occurrence. The DON said she was notified by RN #4 that Resident #120 was upset and verbally aggressive and had social services meet with him. She said if she had known Resident #70 felt threatened and unsafe, she would have removed Resident #120 immediately and reported the incident as abuse. She said because there was no physical harm to Resident #70, she did not think it was abuse. She agreed now, however, that verbal abuse was abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for six (#266, #56, #61, #147, #6 and #119) of eleven residents reviewed for ADL care assistance out of 64 sample residents. Resident #266 was newly admitted to the facility after a medical setback, on 6/1/22, for skilled nursing services including occupational and physical therapy services. The resident goal was to restore as much independence and physical function as possible. The resident required extensive assistance from staff with most of her ADLs. The resident expressed not getting out of bed, not having a wheelchair for mobility and not bathing since her admission on [DATE]. The resident felt uncomfortable, itchy and dirty due to not being bathed and felt lonely and isolated with not getting out of bed. Due to the lack of getting out of her room to move her muscles and not being provided bathing, she felt more depressed and she would lose her independence. Resident #56, who required extensive assistance from staff for toileting, expressed anger and anxiety for the feeling she developed when staff were not able to provide timely ADL care assistance. On 6/6/22 the resident had to wait over an hour for the staff to assist her with incontinence care and expressed she did not like sitting in a soiled brief for long periods of time.When able to use the bathroom, she relied on a bed pan, due to the long waits for staff assistance it would cause her pain from sitting on the bed pan for long periods of time. In addition, the facility failed to: -Ensure dependent Residents #61, #147, #6 and #119 received regular bathing in accordance with their assessed care needs; -Ensure dependent Residents #61, #147 and #6 received timely toileting assistance in accordance with their assessed care needs; -Ensure dependent Residents #61, #147 and #6 received positioning assistance in accordance with their assessed care needs; -Ensure Residents #147 and #6 was assisted to get dressed and out of bed; and, -Ensure Resident #61 was assisted with drinking water needs in accordance with their need for hydration. Cross-reference F725 for insufficient staffing. Findings include: I. Professional reference [NAME], P.A., [NAME], A.G., et.al. (2017) Fundamental of Nursing (9th ed.), pp. 179, 823, 264, and 841, read in pertinent part, Functional status in older adults include the day to day ADLs involving activities within physical, psychological, cognitive, and social domains. A decline in function was often linked to illness or disease and is its degree of chronicity. However, ultimately it is the complex relationship among all of these areas that influences older adults ' functional abilities and overall well-being. Keep in mind that it may be difficult for older adults to accept the changes that occur in all areas of their lives, which in turn have a profound effect on their functional status. -The fear of becoming dependent is overwhelming for older adults who are experiencing functional decline as a result of aging. When you identify a decline in a patient's function, focus your nursing interventions on maintaining, restoring and maximizing an older adult's functional status to maintain independence while preserving (the resident ' s) dignity. Personal hygiene affects patients ' comfort, safety and wellbeing. Hygiene care includes cleaning and grooming activities that maintain personal body cleanliness and appearance. Personal hygiene activities such as taking a bath or shower promotes comfort and relaxation, foster a positive self-image, promote healthy skin and help prevent infection and disease. A person's appearance and feeling of well-being often depends on the way the hair looks and feels. When patients are immobilized their hair soon becomes tangled. -Basic hair and scalp and care includes brushing, calming and shampooing. II. Facility policy and procedure A policy and procedure for providing activities of daily living (ADLs) for dependent residents was requested from the nursing home administrator (NHA) on 6/10/22. The facility provided a policy titled Lifestyles 360 Program Overview, effective date 8/1/18, in response to the request. -The policy was directed towards activities/recreational programming and did not document expectations for providing ADL care (bathing, toileting, dressing, grooming, transfer assistance, bed mobility, and feeding/hydration assistance) type activities for dependent residents. The Care Plans, Comprehensive Person-Centered policy, undated, was provided by the NHA on 6/13/22 at 8:20 a.m. The policy read in pertinent part: A comprehensive person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. III. Resident #266 A. Resident status Resident #266, age [AGE], was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included diabetes mellitus, depression, history of transient ischemic attack/stroke without residual effects, urge incontinence and history of urinary tract infections. The 6/8/22 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. The resident interview for daily preferences indicated it was important to the resident to choose between a tub bath, shower, bed bath or sponge bath; choose bedtime; and be able to go outside to get fresh air when the weather was good. The resident required extensive assistance involving staff providing weight bearing assistance from staff for bed mobility, transfers, toileting, dressing with limited assistance from staff to complete personal hygiene. Bathing services did not occur during the assessment period but it was documented that the resident would need assistance from staff to complete the task. The resident was not steady with standing and balancing and was not able to walk. The resident was always incontinent of both bowel and bladder and was at risk for developing pressure injuries. The resident's mood interview revealed the resident scored a five on the depression scale indicating the resident was experiencing mild depression. The interview revealed the resident was feeling down, depressed or hopeless; was having trouble falling asleep, staying asleep or sleeping too much; was feeling tired or having little energy; and was feeling bad about herself. The resident did not reject care assistance or present with any behavioral symptoms. B. Resident interview and observation Resident #266 was interviewed on 6/8/22 at 3:55 p.m. Resident #266 said she had not been assisted out of bed since admission [DATE]) and had not been given a shower or even a bed bath. All they do is wipe my private areas when they assist me with brief changes, it's not enough and I need a shower. The resident said she felt uncomfortable, itchy and dirty. Towards the end of the interview, Resident #266 said because she had been stuck in bed and in her room since her admission five days ago, she was lonely and felt isolated. Resident #266 said staff only come in infrequently to provide minimal care and were in and out of the room quickly. Additionally, she said her roommate (Resident #262) who was also dependent on staff to complete ADLs and had cognitive deficits was constantly asking her for help with care and getting in and out of bed. When Resident #266 tried to explain to her roomate, Resident #262 was not able to understand and got mad and distressed. Resident #266 said she called for staff assistance to help Resident #262 but it took time for staff to respond to help Resident #262 because they were short staffed. Resident #266 said she did not have a wheelchair at the facility or clothing and no staff had approached her to discuss plans for being able to get her out of bed and get her into the shower, which was preferred. Resident #266 was observed from 6/6/22 to 6/9/22 and 6/13/22 to 6/14/22 to be lying in bed with matted hair. Resident #266 was interviewed again on 6/13/22 at 3:22 p.m. Resident #266 said she still had not been assisted out of bed and had still had not been provided showering or bathing assistance other than staff cleaning her private area with brief changes. Resident #266 still wanted a shower and was feeling unclean. Resident #266 said she was starting to feel depressed and worried that she would lose more independence if staff did not start getting her out of bed so she could move her muscles, leave the room and get into the shower. C. Record review The 6/1/22 admission Data Collection with Care Plan documented the resident preferred to get up at 7:00 a.m., take showers twice a week and go to bed at 9:00 p.m. The interim care pan portion of the document read in part: Does the resident have an ADL self-care deficit? Yes. The goal: staff will assist me to maintain my functional status and decrease my risk for functional decline to perform and /or assist with completing my ADLs. Interventions: Discuss with resident care any concerns related to loss of independence, decline in function. The resident's comprehensive care plan initiated 6/2/22 revealed Resident #266 had impaired ability or care for herself and needed staff assistance with ADLs. Interventions included need for limited to extensive assistance with bed mobility, dressing needs, personal hygiene, oral care, toileting and transfers. -There was no detail on how much assistance the resident needed with each task and no mention of personal preferences. -The resident's tasks record for showers, dated 6/14/22, revealed the resident had no record of showers being offered, refused or provided. The director of nursing (DON) was interviewed on 6/14/22 at 12:30 p.m. The DON confirmed the resident record did not have any record of the resident receiving a shower since admission on [DATE]. The DON said she would talk to the resident and staff and get the resident on a regular showering schedule. IV. Resident #56 A. Resident status Resident #56, age [AGE], was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included Alzheimer's disease, emphysema and chronic respiratory failure. The 4/7/22 minimum data set (MDS) assessment revealed the resident had moderately impaired cognition with a brief interview for mental status (BIMS) score of 12 out of 15. The resident interview for daily preferences indicated it was somewhat important to the resident to choose between a tub bath, shower, bed bath or sponge bath; choose bedtime. The resident required extensive assistance involving staff providing weight bearing assistance from staff for bed mobility, transfers, toileting, dressing with limited assistance from staff to complete personal hygiene. The resident was totally dependent on staff for bathing services. The resident was not able to stand or balance alone and was not able to walk. The resident was always incontinent of bladder, frequently incontinent of bowel and was at risk for developing pressure injuries. The resident's mood interview revealed the resident was feeling bad about herself. The resident did not reject care assistance or present with any behavioral symptoms. B. Resident interview and observation Resident #56 was observed on 6/6/22 from 2:30 p.m. to 4:15 p.m. Resident #56 was in bed she used the call light for staff assistance to get her up and incontinence care at 2:40 p.m. Certified nurse aide (CNA) #15 entered Resident #56's room, talked with Resident #56, turned off the call light and exited the room and went down the hall to help other residents. CNA #15 returned to the nurses desk at 3:38 p.m. CNA #15 was then alerted that a dependent resident across the hall from Resident #56 had a bowel accident and was trying to get up unassisted while using the bedside table as a walking device. CNA #15 responded to that resident. Once CNA #15 finished assisting the resident across the hall from Resident #262, CNA #15 had to respond to Resident #262, who was engaging in unsafe wandering off the unit. The CNA did not return to Resident #56's room during the time of the observation. Resident #56 was interviewed on 6/6/22 at 3:47 p.m. Resident #56 said she had put her call light on to request that staff change her and get her washed up, but that was over an hour ago, because she had gone to the bathroom in her brief and needed assistance getting cleaned up. Resident #56 said CNA #15 responded to the call light but said she would be back to assist with the request to get washed up. Resident #56 expressed anger and said she had been waiting for over an hour for staff to return to check her brief and give her a bed bath, and that CNA #15 had not returned. Resident #56 was interviewed on again on 6/9/22 at 2:21 p.m. Resident #56 said the staff did finally return the other day to get her changed and cleaned up but it was a long wait. Long waits for staff assistance was why she got anxious when she got the urge to go to the bathroom. Resident #56 said she did not like the feeling of having a wet or soiled brief; and she did not like to sit on the bed pan for longer periods of time. The resident said she was sometimes able to know when she had to use the bathroom but it made her very anxious about calling staff for the bedpan because she knew that she would have to sit on the bed pan for long periods of time, which caused her pain. I almost hate to ask staff for the bed pan; just the thought makes me anxious, to think about how long I will have to sit on the bedpan waiting for staff to return to get me off and clean me up. Resident #56 said waiting for staff was a frequent occurrence when the building was short on staff. C. Record review The 3/31/22 admission Data Collection with Care Plan documented the resident preferences were to take bath twice a week. The resident's comprehensive care plan initiated 4/4/22 revealed Resident #56 had impaired ability or care for herself and needed staff assistance with ADLs. The resident was able to make some needs known and some needs were anticipated and met by staff. Resident #56 preferred to take a shower or a bath Sunday and Wednesday during the night shift. Interventions included need for limited to extensive assistance with bed mobility, dressing needs, personal hygiene, oral care, toileting and transfers. -There was no detail on how much assistance the resident needed with each task; there was no care plan intervention to document how to assist the resident with continent episodes and use of the bedpan. -The resident's shower sheet record documented no showers offered, refused or provided. The resident's shower sheet record, for May 2022 and June 2022, was provided by the DON on 6/14/22. The record for the dates from 5/8/22 to 6/14/22 were reviewed. The shower record documented the resident was not offered consistent bathing assistance on Sunday and Monday night shift. Out of two possible showers a week for the reviewed period, the resident should have had 12 total showers/bathing assistance; the resident was not offered or assisted to bathe on five of those occasions. -The resident showers were missed on 5/8/22, 5/11/22, 5/15/22 5/18/22, 5/22/22 and 6/1/22 when offered a shower on the next day 5/9/22, 5/12/22, 5/16/22, 5/19/22 and 6/2/22 the resident refused three of the five make up shower dates. The record did not document if the facility staff explored the reason for the refusals. -From 5/25/22 through 5/29/22 the resident received no bathing assistance or documented offers for showering assistance and missed two-scheduled shower dates that week with no documented explanation. -From 6/5/22 through 6/12/22 the resident received no bathing assistance or documented offers for showering assistance and missed three-scheduled shower dates that week with no documented explanation. V. Resident #61 A. Resident status Resident #61, age [AGE], was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included Alzheimer's disease, encephalopathy (brain disease), and chronic kidney disease stage three. The 4/15/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She required extensive assistance with two people for bed mobility, and total dependence for transfers, locomotion on/off the unit in a wheelchair, bathing, and toilet use. Extensive assistance with one person for dressing, eating, and personal hygiene. She was incontinent of bowel and bladder and at risk for developing pressure injuries. No behaviors or rejection of care. The resident interview for daily preferences, 7/17/21 admission MDS, indicated it was somewhat important to the resident to choose between a tub bath, shower, bed bath or sponge bath; and very important to have family or a close friend involved in discussions about her care. B. Resident observations On 6/13/22 a continuous observation was performed from 9:57 a.m. to 1:09 p.m. -At 9:57 a.m. the resident was in her room in bed. The resident was positioned on her right side, facing the wall. An unidentified certified nurse aide (CNA) went around the unit picking up the breakfast trays. The resident was wearing a hospital gown. There was a plastic cup with water on the resident's dresser, but it was not within reach of the resident. -At 10:13 a.m. the resident was still in bed, in the same position. -At 10:56 a.m. the resident was still in bed, in a gown, in the same position on the right side. -At 11:09 a.m. the resident was still in bed, in the same position, on the right side. -At 11:14 a.m. lunch service started in the dining room on the second floor. -At 11:29 a.m. the resident was still in bed, in the same position on her right side. -At 11:45 a.m. CNA #3 went into the resident's room briefly (less than 10 seconds) and came back out of the room. The resident was still in bed, in the same position on her right side. -At 12:01 p.m. Resident #61's roommate returned to the room in her wheelchair and put on the call light. The roommate requested to be transferred to a bedside chair after her lunch at the dining room. Resident #61 was still in bed, in the same position on her right side facing the wall. Licensed practical nurse (LPN) #5 helped the roommate into a bedside chair and left the room. -At 12:14 p.m. unit manager (UM) #1 brought the wound care cart to Resident #61's door, she said she was providing wound care treatments and Resident #61 was the last resident. She prepared the wound care treatment on a cart. UM #1 went into the room and shut the door. UM #1 was in the room for five minutes. Observed that Resident #61 was still in the same position on her right side following the wound care treatment to her sacrum. -At 12:16 p.m. an unnamed dietary aide brought a drink cart to the end of the hall. -At 12:28 p.m. an unnamed CNA entered Resident #61's room and placed a fall mat on the floor in front of the resident's bed and left. Resident #61 was still in the same position on her right side. -At 12:50 p.m. an unnamed CNA dropped Resident #61's lunch tray off in her room and placed it on the dresser, not within reach of the resident. There was no offer of hydration to the resident. There was one cup of juice on the residents lunch tray. Resident #61 was still in the same position on her right side. -At 1:09 p.m. CNA #17 assisted Resident #61 with eating her lunch, the resident was now sitting up in bed. CNA #17 said that Resident #61 was up in the morning for breakfast and her daughter helped assist her with eating, but the resident vomited, so they put her back to bed. The glass of juice on the tray was not given yet. -During the continuous observation the resident was not encouraged or offered anything to drink for over three hours. In addition, she continued to lay on her right side during the observation and she was identified as being at risk for pressure ulcers/injuries, she was not offered incontinence care during the observation. C. Record review Documentation of activities of daily living (ADL) care for May and June 2022 was provided by the DON on 6/14/22 at 12:45 p.m. it revealed the following: Preferred bath days Wednesday and Saturday. The resident's May 2022 shower sheet record documented two showers on 5/7/22 and 5/18/22 and two bed baths 5/21/22 and 5/25/22. There were no refusals documented. Out of two possible showers a week for May 2022, the resident should have had eight total showers/bathing assistance but only four were offered and completed. The resident's June 2022 (6/1-6/14/22) shower sheet record documented one shower on 6/11/22 and two bed baths on 6/1/22, and 6/8/22. There were no refusals documented. Out of the two possible showers a week from 6/1-6/14/22, the resident should have had four total showers/bathing assistance but only three were offered and completed. The resident's ADL comprehensive care plan, initiated 7/10/21 and revised 4/18/22, revealed impaired mobility and ability to care for herself and dependent assistance with ADLs. The resident's risk for dehydration comprehensive care plan, initiated 7/12/21, and revised 1/17/22, revealed most needs are anticipated and met by staff due to Alzheimer's dementia and memory loss. Interventions included to encourage fluid intake and to offer fluids frequently. The resident's bowel and bladder incontinence comprehensive care plan, initiated 7/10/21, and revised 10/18/21, revealed she has functional incontinence. Interventions include to check on rounds and as required for incontinence. The resident's risk for skin breakdown comprehensive care plan, initiated 7/12/21, revised 10/18/21, revealed she was at risk for skin breakdown and was incontinent. Interventions included pressure relieving bed mattress and wheel chair cushion. -However there was no intervention for re-positioning, changing positions, rotating positions, or pressure relief (other than to offload heels), fluids being offered between meals or frequently, and lack of incontinence rounds. Cross reference F686 pressure ulcers, for the resident acquiring a facility-acquired stage three sacral pressure injury.\ VI. Resident #147 A. Resident status Resident #147, age [AGE], was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included chronic respiratory failure with hypoxia (low blood oxygen levels), atherosclerosis of aorta (hardening of the arteries), and emphysema (air sacs of the lungs are damaged, causing breathlessness). The 5/25/22 minimum data set (MDS) assessment revealed the resident with moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. She required total dependence with two people for physical assistance for transfers. Extensive assistance with one person for bed mobility, locomotion on/off unit in a wheelchair, dressing, toilet use, bathing, and personal hygiene. No behaviors or rejection of care. The resident interview for daily preferences indicated it was not very important to the resident to choose between a tub bath, shower, bed bath, or sponge bath; and very important to keep up with the news. B. Resident observations and interviews On 6/6/22 at 1:35 p.m. the resident was supine in bed, her hair was greasy and not combed. The resident was wearing pajamas. Resident #147 said she has had no shower since her admission [DATE]) to the facility. She said her preference was a shower at least one time per week. On 6/13/22 at 11:00 a.m. The resident's fingernails were about one fourth of an inch and had brown/yellow matter under her nails and around her fingertips. Resident #147 said she preferred a shower instead of a bed bath. She said a bed bath was ok for in-between showers but that she felt good when she had an actual shower. Resident #147 said she would like to have her hair washed. She said the nursing staff had not taken her to the shower room since she was admitted to the facility. C. Record review Documentation of activities of daily living (ADL) care for May and June 2022 was provided by the DON on 6/14/22 at 12:45 p.m. it revealed the following: Preferred bath days Monday and Friday. The resident's May 2022 shower sheet record documented zero showers in the month of May and three bed baths on 5/19/22, 5/23/22, and 5/30/22. There were no refusals documented. Out of two possible showers a week for May 2022, the resident should have had four total showers/bathing assistance but only three were offered and completed. The resident's June 2022 (6/1-6/14/22) shower sheet record documented zero showers and three bed baths on 6/3/22, 6/10/22, and 6/13/22. There were no refusals documented. Out of two possible showers a week for June 6/1-6/14/22, the resident should have had four total showers/bathing assistance but only three were offered and completed. -However, according to the resident interview she preferred showers two times a week. She was provided with bed baths since her admission on [DATE] and not showered as she preferred. The resident's ADL comprehensive care plan, initiated 5/23/22, revealed a need for moderate to extensive assistance with ADLs. Interventions for bathing and showering included, Use short, simple instructions such as hold your washcloth in your hand; put soap on your washcloth; wash your face; to promote independence. VII. Resident #6 A. Resident status Resident #6, age [AGE], was admitted [DATE] and readmitted on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure, depressive episodes, and heart failure. The 6/3/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He required extensive assistance with one person for bed mobility, locomotion on/off the unit in a wheelchair, dressing, toilet use, personal hygiene, and bathing. No behaviors or rejection of care. The resident interview for daily preferences indicated it was somewhat important to the resident to choose between a tub bath, shower, bed bath, or sponge bath; and very important to have family or a close friend involved in discussions about his care. B. Observations and interview Resident #6 was interviewed on 6/6/22 at 10:43 a.m. He said he rarely gets showers. His hair was combed but greasy with large (size of fingernails) white patches and flakes. Resident #6 said he cannot reach his hair to comb it because of his limited shoulder range of motion (ROM) and he was unable to wash his own hair. On 6/7/22 at 11:24 a.m. Resident #6's hair continued to be greasy with large white patches and flakes. On 6/8/22 at 10:25 a.m. Resident #6 said he had received a shower yesterday and the CNA had tried to wash his hair but he did not have any shampoo. He said the facility did have soap for his body but not shampoo. His hair remained greasy with large white patches and flakes. On 6/8/22 at 10:28 a.m. the shower room was toured on unit four and observed that there was a soap dispenser but no shampoo. CNA #18 said most residents have their own shampoo. She said if they did not have their own shampoo they tried to use the soap in the dispenser on the wall. Resident was interviewed again on 6/8/22 at 2:16 p.m. He said his hair did not feel clean since his shower yesterday since they were not able to wash it due to lack of shampoo. On 6/8/22 at 2:19 p.m. the shower room on unit four was toured with UM #1 and UM#1 was unable to locate any facility shampoo. UM #1 said she would find out why shampoo was not provided in the shower. UM #1 said she would notify the unnamed physician assistant who was in the building, to check with Resident #6 to see if he would benefit from a specially medicated shampoo for his dandruff symptoms. C. Record review Documentation of activities of daily living (ADL) care for May and June 2022 was provided by the DON on 6/14/22 at 12:45 p.m. it revealed the following: Preferred bath days Tuesday and Saturday. The resident's May 2022 shower sheet record documented one shower on 5/17/22 and three bed baths on 5/7/22, 5/21/22, and 5/28/22. There were no refusals documented. Out of two possible showers a week for May 2022, the resident should have had eight total showers/bathing assistance but only four were offered and completed. The resident's June 2022 (6/1-6/14/22) shower sheet record documented two showers on 6/7/22 and 6/11/22 and one bed bath on 6/4/22. There were no refusals documented. Out of the two possible showers a week for 6/1-6/14/22, the resident should have had four total showers/bathing assistance but only three were offered and completed. -However, the admission data collection preference plan, dated 1/19/22, revealed the resident had a preference for showers two times a week, not a bed bath. The resident was inconsistently provided showers as he prefered in May and June 2022. The resident's ADL comprehensive care plan, initiated 6/1/21 and revised 1/20/22, revealed impaired mobility and ability to care for himself. Interventions for bathing and showering included, Use short, simple instructions such as hold your washcloth in your hand; put soap on your washcloth; wash your face; to promote independence. A progress note dated 6/8/22 at 3:08 p.m. documented, Resident showered last night but refused head wash due to shampoo was not available; found it in his dresser today. -However there was no documentation why shampoo was not provided by the facility during his shower. D. Staff interview UM #1 was interviewed on 6/8/22 at 2:19 p.m. She said the staff did wash the residents' hair as part of a shower unless the resident declined. UM #1 said the facility provided shampoo and soap, although there were a few residents who provided their own shampoo. UM #1 said if a resident's hair was greasy the doctor could order a special kind of shampoo and if there were white flakes in a resident's hair, it may require a special medicated shampoo. UM #1 acknowledged Resident #6 white flakes and greasy hair, saying I saw his hair today. -However, the progress note on 6/8/22 identified the resident did have shampoo located in his dresser. VIII. Resident #119 A. Resident status Resident #119, age [AGE], was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), the diagnoses included acute respiratory failure with hypoxia, transient ischemic attack, and cerebral infarction without residual deficits. The 5/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident required one-person physical help for bathing. B. Resident interview Resident #119 was interviewed on 6/9/22 at 1:22 p.m. The resident stated a month or two ago, he went three weeks without a shower because the facility did not have hot water. He said he finally received a shower last week. He stated he would like to have had two showers per week but was lucky to get one. He said of the three facilities he had been in, he felt as if he had not received the best care. He said he deserved better care than he received. C. Record review The 2/2/22 admission Data Collection Preferences section was [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for two (#26 and #256) of six residents out of 64 sample residents. Resident #26, an insulin dependent diabetic, was experiencing problems with low blood glucose (BG) levels on 3/19/22. The resident was prescribed to have a BG check three times a day prior to each insulin administration. Physician's order dictated the resident's insulin injection was to be held when the result was under 80 and/or the resident was refusing meals. When the nurse assessed the resident's 4:30 p.m. BG level by finger stick, the resident's BG had lowered to 79, under the prescribed parameter of 80. The resident's insulin was held in line with the physician's ordered parameters. One and one half hours later the resident became unresponsive with stroke-like facial paralysis; the resident was only responsive to painful stimuli. The nurse on duty called 911 for emergency medical services (EMS). There was no documentation of the nurse reassessing the resident's vital signs including BG level, after noticing the resident decline. EMS arrived at the facility and assessed the resident at approximately 6:03 a.m., and found the resident BG level had dropped to 31, a dangerously low result. EMS treated the resident for low blood glucose and took the resident to the hospital for further assessment and medical treatment. The facility's failure to fully assess the resident's condition, put the resident in a critical state and in need of hospital level care for hypoglycemia. Additionally, the facility nurse failed to document any details of the resident's change in condition, emergency state and reason for EMS and hospital care. In addition, the facility failed to ensure Resident #256's change in condition was identified, assessed, monitored and treated appropriately and timely. The resident was found by his representative on 5/23/22 with rapid breathing and declining condition. Subsequently, the resident was sent to the hospital for emergent treatment and diagnosed with aspiration pneumonia and newly prescribed antibiotic treatment. Findings include: I. Facility policy The Resident Condition Changes that Require Physician Notification Guidelines policy, effective 5/1/18, was provided by the nursing home administrator (NHA) on 6/13/22 at 8:20 a.m. It read in pertinent part: Clinical policies and procedures serve as clinical guidelines to assist in clinical staff decision-making, staff education/training, and evaluation of employee performance. -In the event of any doubt, the physician is notified. Provision and procedure -Licensed nurses (staff and management) are expected to recognize resident situations/conditions that require physician notification. -The nurse completes an assessment of the condition, including level of urgency. The nurse implements appropriate interventions and has accurate information available when contacting the physician. -Documentation of the resident condition change and proper notification is the responsibility of the nurse who observes and assesses the change. -Changes in resident condition must be documented in the following locations: Resident chart - notation made by all shifts for 72 hours . -The licensed nurse also notifies the unit/nurse manager or nursing supervisor -The unit/nurse manager or nursing supervisor is responsible for: Assessing any resident with a condition change. Verifying proper notification and documentation of the condition change. The Charting and Documentation, revised July 2017, was provided by the NHA on 6/13/22 at 8:20 a.m. It read in pertinent part: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. II. Other facility documents The Facility Assessment, updated 4/1/22, was provided by the nursing home administrator (NHA) on 6/7/22, it reads in pertinent part: Services provided based on resident need. Specific care of practice: Management of Medical conditions-Assessment, early identification of problems/deterioration, management of medical and psychiatric symptoms and conditions such as heart failure, diabetes, chronic obstructive pulmonary disease COPD), gastroenteritis, infections such as UTI (urinary tract infections) and gastroenteritis, pneumonia, hypothyroidism. III. Resident #26 A. Resident Status Resident #26, age [AGE], was admitted on [DATE] and discharged on 6/10/22 to the hospital. According to the June 2022 computerized physician orders (CPO), diagnosis included type two diabetes mellitus, acute and respiratory failure, and hypertension. The 3/22/22 minimum data set (MDS) assessment revealed the resident had intact cognition with a brief interview for mental status (BIMS) score of 13 out of 15. The resident had no aggressive behaviors, delirium and did not reject care. The resident was on daily insulin injections. B. Interview The resident was no longer residing in the facility so observation and interview were not possible. Emergency medical service (EMS) personal #3 was interviewed on 6/10/22 at 10:31 a.m. EMS #3 said they responded to an emergency call on 3/19/22 at 6:03 p.m. During this call, it was determined there was one nurse that was taking care of a large number of patients. The nurse walked the EMS responder to the resident's room. Resident #26 was found to be unresponsive, exhibited stroke-like facial paralysis and only responded to painful stimuli. The EMS responders questioned the nurse about the resident's change in condition and were told the resident had been in that condition for approximately 45 minutes, but all vital signs were stable. EMS gathered diagnostic information and began an assessment of the resident's condition. Upon discovering that the resident's blood glucose (BG) level was 31, the EMS responders asked the nurse if she had recently checked the resident's BG levels. The nurse said yes, the resident's BG level was 79 at last check. The EMS provider asked to see the resident's record for more detail. EMS #3 said the team was concerned because the resident's record failed to document a recent BG assessment or treatment for the declining BG levels. The EMS responders provided the resident treatment hypoglycemia and transported the resident to the emergency room for further assessment. C. Record review The resident's March 2022 CPO revealed an order for insulin Lispro solution 100 units/ml (milliliter). Inject 26 units subcutaneously before meals. Hold if not eating or BG is less than 80. Start date 2/10/22, discontinued 3/19/22. The resident's March 2022 medication administration record (MAR) revealed the resident's BGs on 3/19/22 were: -The resident's 7:18 a.m. BG level was 201 and insulin was administered; -The resident's 11:47 a.m. BG level was 179 and insulin was administered; and -The resident's 4:16 p.m. BG level was 79 and insulin was held. 3/19/22-Hospital emergency room note read in part: Nursing staff called EMS because the patient was not acting right. EMS found blood sugar was 31 and brought up to 164 after treatment. -Progress notes for 3/19/22 were reviewed; there was no documentation of the resident change in condition or nursing assessment leading up to 911 being called for emergency services; what nursing interventions were conducted prior to the nurse calling 911; or why the resident was sent to the hospital for assessment. The first documented note was: 3/19/22 at 6:46 p.m., nursing progress note: (Hospital name) called and given report to charge emergency department nurse. -There were no other notes about the emergency event. IV. Resident #256 A. Resident status Resident #256, age [AGE], was admitted on [DATE] and discharged on 5/23/22 to the hospital. According to the May 2022 computerized physician orders (CPO), diagnosis included anoxic brain damage, chronic obstructive pulmonary disease (COPD) dysphagia, gastrostomy (an opening into the stomach from the abdominal wall made surgically for the introduction of food). The 5/23/22 minimum data set (MDS) assessment revealed the resident had severely impaired cognition and was not able to participate in a brief interview for mental status (BIMS) exam. Staff assessment of the resident revealed the resident had short and long-term memory deficits and severely impaired cognitive skills for daily decision making. The resident required extensive assistance from staff to complete all activities of daily living including bed mobility, transfers and eating. The resident did not reject care. The assessment documented the resident was on antibiotic treatment B. Interview The resident was unavailable for interview and observations. The resident's representative was interviewed on 6/2/22 at 4:57 p.m. The resident's representative said the Resident #256 had a change in condition. Upon arrival to the facility for a visit on 5/23/22, they found the resident in a declining state. The resident appeared visibly sick and was breathing rapidly. The resident representative approached nursing staff about concerns over the resident condition and staff were not aware the resident was experiencing a change in condition. After speaking with nursing staff, the resident representative requested they send Resident #256 to the emergency room for assessment. 2. Record review Review of the resident progress notes revealed no nursing notes to document the resident status or condition from 5/20/22 through discharge 5/23/22, to the hospital. There was one note on 5/20/22 indicating the resident's regular tube feeding supplement was out of stock so a substitute supplement was ordered and prescribed to be administered at a higher rate than the recommended feeding supplement. -There were no notes to document if the resident was tolerating the new feeding rate or if he was having any other complications with swallowing or breathing. -The resident's record failed to document the resident's change of condition or how long the resident had been experiencing the abnormal rapid breathing or other symptoms. There was no indication of what type or if the nursing staff were providing regular monitoring of the resident change in condition. Per the hospital notes (see below), the resident was recently diagnosed with aspiration pneumonia and prescribed antibiotic treatment. The resident record did not document this new diagnosis or antibiotic treatment; it is unclear where this information came from. Relevant Progress notes read in pertinent part: -5/20/22 at 2:11 p.m. Nutrition note: Resident's ordered enteral formula is out of stock. Ordered to receive Jevity 1.2 (formula) until Nepro (formula) is available. Recommend increasing rate to 80 ml/hr (milliliters per hour) when Jevity 1.2 is being used to better meet needs. Jevity 1.2 at 80 ml/hr for 24 hours to provide 2304 kcal (calories), 106 g (gram) protein and 1549 ml of water. Once Nepro is available, recommend decreasing rate back to 60 ml/hr. Informed nursing of enteral feed change. Will continue to monitor. The next note read: - 5/24/22 at 6:50 a.m. Health Status Note: Transported to (hospital name) via ambulance. -This discharge note was a late entry and did not document the resident's change in condition or why the resident was sent to the hospital. The resident was sent to the hospital the afternoon of 5/23/22 and admitted at 1:31 p.m. Hospital progress note: Emergency department to hospital admission (admission 5/23/22, discharged [DATE]); dated 6/9/22, read in pertinent part: admission diagnosis: Acute respiratory failure with hypoxia (low oxygen levels in the bodily tissues). Health and physical from admission Patient with a history of recent cardiac arrest and anoxic encephalopathy (a process that begins with the cessation of cerebral blood flow to brain tissue) who currently resides in a skilled facility admitted to the ICU (intensive care unit) with possible seizure, respiratory failure and aspiration pneumonia. He presides in a skilled nursing facility and is alert and oriented times zero at baseline. Per records from the skilled nursing facility he was recently diagnosed with aspiration pneumonia and started on Augmentin today. He then developed tonic-clonic (rapid jerky) movements concerning seizure today and EMS (emergency medical services) was called. He was given 2 mg (milligrams) of IV (intravenous) midazolam (antiseizure/sedative medication) in route. Improvement in the tonic-clonic movements. While in the emergency department he was noted to have worsening respiratory distress and he was intubated after the case was discussed with the patient's family. He was given IV fluids and started on empiric antibiotics. Current Outpatient Medications (included): -Amoxicillin-potassium clavulanate (AUGMENTIN) 250-62.5 mg/5 mL suspension by peg tube, every 8 (eight) hours scheduled, History of present illness: -Presented with myoclonic (quick movements) jerking and seizure-like activity. He was hypoxic and intubated (providing an airway by placing a tube down the patient's windpipe) in the emergency room with copious white secretions noted upon intubation. He was tachypneic (abnormally rapid breathing) and gurgling prior to intubation. Final diagnosis: Severe sepsis, acute respiratory failure, seizure-like activity and aspiration pneumonia. V. Staff interviews Licensed practical nurse (LPN) #3 was interviewed on 6/8/22 at 3:19 p.m. LPN #3 said the nurse should notify the resident physician to discuss any changes in health condition. The nurse should document the physician's response and provide treatments and medication as ordered as well as resident response to treatment. The nurses should also notify the unit manager and or DON of the resident change in condition. LPN #11 was interviewed on 6/8/22 at 3:52 p.m. LPN #11 said the nurse was responsible to monitor the resident for changes in condition if a mild change was suspected or if the nurse was unfamiliar with the resident the nurse should speak with the charge nurse or DON to confirm the resident status. If there was a major change in condition the nurse should assess the resident and take a full set of vital signs and report to the resident physician for further orders. If the resident was experiencing a life-threatening emergency the nurse should respond to the emergency and treat the resident according to nurse practice. If the resident could not be treated in the facility, the nurse should call 911 for emergency assistance. All assessment and treatment should be documented in the resident's chart and reported to the oncoming nurse at the end of shift. If the resident was diabetic and experiencing a change in condition the nurse should assess the resident's BG level if the BG levels were low the nurse could give the resident juice if the resident was unable to drink or eat the nurse could use the glucagon kit to inject the resident with a glucose elevating solution. Hypoglycemia should be assessed and treated quickly to avoid further complications. LPN #10 was interviewed on 6/9/22 at 11:35 p.m. LPN #10 said if a resident presented with a significant change of condition, such as, having a change in baseline that cannot be explained such as being less alert; confusion; presenting with new pain; weakness; respiratory symptom; etc. the nurse should immediately assess. The assessment should include a full set of vital signs and other assessments as applicable to the condition. Once the resident was fully assessed, the nurse should call the resident physician to present the resident assessment and ask for treatment recommendations/orders. The nurse should document and provide the physician's orders. Once the resident was stable the nurse can document the assessment, conversation with the physician and new orders and resident response. LPN #10 said the resident BG level should be included in the full set of vital signs if the resident was diabetic. This should be done immediately upon discovery of a change in condition. The DON and assistant director of nursing (ADON) were both interviewed on 6/15/22 at 11:31 a.m. The DON said the nurse should respond immediately when a resident experiences a change in condition to assess and provide treatment as soon as possible. As soon as the floor nurse notices a change of condition they should assess the resident and notify the house manager. The house manager would respond to the unit and assist the nurse to provide treatment and assess the resident's condition. The DON was not sure where the failures in treating Resident #26 and #256 and would have to review the records to be able to respond accurately. The DON acknowledged the nurse should have retested the Resident #26's BG level as part of assessing the resident for a change of condition where she was found to be unresponsive since she was diabetic. The DON said the staff should have responded to Resident #256's call light. If the staff had responded to Resident #256's complaints of being short of breath and checking the oxygen typing they could have offered the resident reassurance and helped the resident's breathing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to provide care and services necessary to prevent the formation of pressure ulcers and the worsening of existing pressure ulcers, for two (#61 and #143) of five residents reviewed for wounds, out of 64 sample residents. Resident #61 was at risk for developing pressure injuries due to being admitted to the facility on [DATE] with a deep tissue injury to her left side of foot/heel, diagnosis of Alzheimer's disease, encephalopathy (brain disease), and chronic kidney disease stage 3. She required extensive assistance with two people for bed mobility, and total dependence for transfers. There was a delay in assessment by an appropriate staff member, registered nurse (RN) or wound care physician when a new open sacral/coccyx pressure ulcer was discovered 1/27/22 for Resident #61. The sacral wound was not assessed by the wound care physician until 3/1/22 which was approximately five weeks later and at that time was a stage 3 pressure injury. The facility failed to stage the new pressure ulcer, according to professional standards, so that the appropriate treatment options could be selected to prevent the wound from worsening and minimize the resident's risk. There was no repositioning program in the care plan to prevent or cause further progression of the pressure ulcer. An air mattress was implemented on 2/28/22, which was over one month since the development of the sacral open area. Due to facility failure's, the resident developed an avoidable facility acquired stage 3 pressure injury to her sacrum. Additionally, the facility failed to accurately assess Resident #143's wounds on admission 5/13/22. Resident #143's wounds were not assessed until observed by the wound physician on 5/24/22 which was eleven days later (Resident #143 was found to have two pressure ulcers one unstageable and one a stage 3 see below); Resident #143 did not have wound treatment orders initiated until 5/19/22 which was six days after admission, and failed to complete wound care treatment on 6/8/22. Findings include: I. Professional References The National Pressure Ulcer Advisory Panel (2017) NPUAP Pressure Injury Stages, retrieved on 6/15/22 from http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/ revealed the following pertinent information: Pressure injuries can be numerically staged (i.e. Stage 1, 2, 3, or 4), if the type of tissue injured can be visualized or directly palpated (e.g., in case of Stage 4 when exposed bone is visible or directly palpated). The NPUAP also recognizes the very real clinical limitations of being able to visualize the types of tissue exposed by injury. Based on these limitations, the NPUAP staging system provides two additional options: (1) unstageable pressure injuries to address situations where the wound base is obscured by slough and/or eschar and (2) Deep Tissue Pressure Injury (DTPI) where the skin may still be intact, but is purple or maroon indicating deeper tissue damage has occurred. After DTPIs evolve, or unstageable pressure injuries are debrided, these injuries can be numerically staged. Due to the unique anatomy in mucosal membranes, pressure injuries in these tissues should be noted, but can never be staged. -In many situations, the level of tissue injury can be accurately assessed with visual inspection. However, the tissue surrounding the visible injury should be assessed for changes in sensation (e.g., pain), temperature (e.g., warmer from inflammation, colder as tissues die), firmness (firmer or boggy with tissue destruction and edema), color (signs of inflammation consistent with skin tone) and drainage expressed from surrounding tissues as they are palpated. This more thorough assessment of surrounding tissue may alert the clinician to more extensive damage than is readily visible. These additional findings should be described and documented. II. Facility policy and procedure The Skin and Wound Management Program Overview policy, revised on 11/26/18, was provided by the director of nursing (DON) on 6/9/22 at 2:20 p.m. It read, in pertinent part, The goal of the Program is to prevent the development of pressure injury unless clinically unavoidable and delineate the provision of care and services to: -Promote the prevention of pressure injury development; -Promote the healing process of pressure injuries that are present; -Prevent the development of additional pressure injury; and, -Ensure the resident's plan is monitored during treatment. Clinical policies and procedures serve as clinical guidelines to assist in clinical staff decision-making, staff education/training, and evaluation of employee performance. (Name of corporation) is committed to providing optimal care and services to attain and/or maintain the highest practicable physical well-being regarding skin and wound management. This is achieved through an interdisciplinary approach, which includes screenings, comprehensive evaluations, reviews and monitoring, and plans of care. The Program is the responsibility of everyone who provides care to the residents, each with their own set of responsibilities. Initial and ongoing education is provided to staff; competency is established and accountability for compliance is determined. Oversight of the program is a shared responsibility at both the corporate and community levels, with reporting to their appropriate level Quality Assurance/Improvement Committees. Data/outcomes are collected, analyzed, and evaluated to determine the efficacy of the Program and allow for program/practice changes as necessary. Unless otherwise indicated, the Program uses definitions provided by the Centers for Medicare & Medicaid Services (CMS) and/or National Pressure Injury Advisory Panel (NPUAP) and NPUAP guidelines and standards. A licensed nurse performs a visual head-to-toe skin review within 8 (eight) hours of admission or readmission to determine general skin condition and identify any pre-existing skin concerns and/or wounds. Findings are documented on the Admission/readmission Skin Review Form. Whenever a new wound is identified, a licensed nurse conducts a comprehensive evaluation and documents the findings on the Initial Wound Review Form. Pressure injuries are numerically staged, by a Registered Nurse or licensed nurse with a current certification as a wound care nurse (unless otherwise indicated by state regulation or standards of nursing practice), according to the classification System specific to pressure injuries. III. Resident #61 A. Resident status Resident #61, age [AGE], was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included Alzheimer's disease, encephalopathy (brain disease), and chronic kidney disease stage 3. The 4/15/22 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She did not exhibit behaviors or reject care. She required extensive assistance with two people for bed mobility, and total dependence for transfers, locomotion on/off the unit in a wheelchair, bathing, and toilet use. She required extensive assistance with one person for dressing, eating, and personal hygiene. She was always incontinent of bowel and bladder and at risk for developing pressure injuries. The MDS documented Resident #61 had one stage 3 pressure ulcer which was not present upon admission. The MDS assessment documented Resident #61 was on a turning/repositioning program. -However, there was no such program documented on the care plan (see record review below). B. Resident observations On 6/8/22 at 12:58 p.m. wound care was observed being performed by unit manager (UM) #1 and certified nursing aide (CNA) #3, who assisted with positioning the resident. UM #1 said the resident had a stage 3 wound to her coccyx which was healing. The resident was observed lying in bed. UM #1 and CNA #3 washed their hands and donned gloves. UM #1 gathered supplies and placed them on the overbed table with a clean surface. CNA #3 positioned the resident on her right side, UM #1 removed the resident's dressing, and there was scant serous (thin watery) drainage. UM #1 doffed her gloves, performed hand hygiene, donned clean gloves, and cleansed the resident's wound. There were no signs of infection to the wound. The wound bed was red with 100% granulation; the surrounding skin was intact. UM #1 applied Medihoney (antibacterial/anti-inflammatory gel) and foam dressing to the wound bed. They doffed their gloves and washed their hands. UM #1 said the wound assessment with measurements would be completed by the wound physician on Friday 6/10/22. On 6/13/22 at 9:57 a.m. a continuous observation was performed from 9:57 a.m. to 1:09 p.m. -At 9:57 a.m. the resident was in her room in bed wearing a hospital gown. The resident was positioned on her right side, facing the wall. An unidentified CNA went around the unit picking up the breakfast trays. -At 10:13 a.m. the resident was still in bed, in the same position. -At 10:56 a.m. the resident was still in bed, in the same position on the right side. -At 11:09 a.m. the resident was still in bed, in the same position, on the right side. -At 11:29 a.m. the resident was still in bed, in the same position on her right side. -At 11:45 a.m. CNA #3 went into the resident's room briefly (less than 10 seconds) and came back out of the room. The resident was still in bed, in the same position on her right side. -At 12:01 p.m. Resident #61's roommate returned to the room in her wheelchair and put on the call light. The roommate requested to be transferred to a bedside chair Resident #61 was still in bed, in the same position on her right side facing the wall. Licensed practical nurse (LPN) #5 helped the roommate into a bedside chair and left the room. -At 12:14 p.m. unit manager (UM) #1 brought the wound care cart to Resident #61's door, she said she was providing wound care treatments and Resident #61 was the last resident. She prepared the wound care treatment on a cart. UM #1 went into the room and shut the door. UM #1 was in the room for five minutes. Observed that Resident #61 was still in the same position on her right side following the wound care treatment to her sacrum. -At 12:28 p.m. an unnamed CNA entered Resident #61's room and placed a fall mat on the floor in front of the resident's bed and left. Resident #61 was still in the same position on her right side. -At 12:50 p.m. an unnamed CNA dropped Resident #61's lunch tray off in her room. Resident #61 was still in the same position on her right side. -At 1:09 p.m. CNA #17 assisted Resident #61 with eating her lunch, the resident was now sitting up in bed. CNA #17 said that Resident #61 was up in the morning for breakfast and her daughter helped assist her with eating, but the resident vomited, so they put her back to bed. -During the continuous observation the resident continued to lay on her right side during the observation and she was identified as being at risk for pressure ulcers/injuries, she was not offered incontinence care during the observation or offered repositioning. -Cross-reference F677 for lack of ADL care for dependent residents. C. Record review The quarterly Braden scale for predicting pressure injuries was conducted 10/15/21 with a score of 15 (indicating mild risk). However, the Braden scale checklist question asked if the total score was 16 or less-and the facility answered no (incorrectly since the score was 15). If it had been marked correctly, yes, there would have been a completion of a checklist by the facility to select appropriate care plan options. 1. Care plan The resident's ADL comprehensive care plan, initiated 7/10/21 and revised 4/18/22, revealed impaired mobility and ability to care for herself and dependent assistance with ADLs. The resident's bowel and bladder incontinence comprehensive care plan, initiated 7/10/21, and revised 10/18/21, revealed she has functional incontinence. Interventions include to check on rounds and as required for incontinence. The resident's pressure injury comprehensive care plan initiated 7/13/21 for the stage 3 pressure injury to her left heel, and revised 6/7/22 (during the survey) adding the stage 3 pressure ulcer to her coccyx. -However the coccyx pressure ulcer was discovered 1/27/22 and there was no coccyx care plan until 6/6/22 (during the survey). There were no new interventions added to the care plan for care of the coccyx pressure ulcer, stage 3, on 6/6/22. -The air mattress was not added until 2/28/22, the coccyx pressure ulcer was discovered 1/27/22 (see orders below). The resident's risk for skin breakdown comprehensive care plan, initiated 7/12/21, revised 10/18/21, revealed she was at risk for skin breakdown and was incontinent. Interventions included pressure relieving bed mattress and wheel chair cushion. -However, there was no intervention for re-positioning, changing positions, rotating positions, or pressure relief (other than to offload heels). 2. Progress notes/assessments Review of the admission progress note, dated 7/11/21 at 7:22 p.m late entry, revealed on admission, a head to toe assessment completed. The resident did not have any open areas. The daughter reported deep tissue injury (DTI) on the left side of foot that was assessed by a nurse, no discoloration or edema noted on the side. Review of the progress note, dated 7/13/22 at 1:37 p.m. revealed Resident #61 had DTI to her left heel and her right heel was boggy. Review of the total body skin assessment, dated 1/24/22, identified no new wounds. Review of the total body skin assessment, dated 1/27/22, identified one new wound, however there was no documentation of wound measurements or staging or location. Review of the total body skin assessments for February and March 2022, identified no new wounds. Review of the first progress note to mention an open area to the coccyx, dated 1/27/22 at 1:54 p.m. It revealed the resident with a small open area on the coccyx 0.5 centimeters (cm) by (x) 0.5 cm. The area was cleaned with normal saline, applied medihoney and covered with bordered foam dressing. Resident #61 was incontinent of bowel and bladder, and got up out of bed every day. The plan was to put the resident in bed after lunch and continue to reposition while in bed. The medical doctor (MD) and family were notified. Review of progress notes/assessments related to the coccyx wound revealed: -1/27/22 at 5:46 p.m. The resident remained on charting for a new open area to coccyx. She was alert and oriented to person, staff to assist with the resident's needs. Continued to encourage fluids, reposition resident in bed, and offer supplements. The resident remained at baseline, and did not complain of pain at that time. -1/28/22 at 3:32 a.m. The resident was being monitored related to open area to coccyx. She was repositioned frequently. No signs or symptoms of infection noted. Will continue to monitor. -1/28/22 at 8:09 a.m. Order changed to barrier cream per MD. -1/28/22 at 10:47 a.m. The resident was being monitored for a small open area on the coccyx. Barrier cream was being applied. Resident was sitting up in a wheelchair and had just had breakfast. She had no complaints of pain or signs/symptoms of infection. -1/29/22 at 6:42 a.m. The resident was on alert charting related to open area on coccyx. Barrier cream applied as indicated. She was repositioned frequently. No signs/symptoms of infection noted. -1/29/22 at 11:11 a.m. The resident was being monitored for an open area to coccyx and just applying cream and leaving it open to air. No signs/symptoms of infection. -1/29/22 at 10:36 p.m. The resident was being monitored for a small open area to the coccyx, cream applied and open to air, no signs/symptoms of infection. The resident went to bed after lunch. -1/30/22 at 1:18 a.m. The resident was on alert charting related to a small open area to coccyx. Barrier cream applied as indicated and was repositioned frequently. No signs/symptoms of infection. -2/4/22 at 12:00 p.m. The skin/wound progress note discussed the progress of the right medial foot wound, and left heel wound, but made no mention of the coccyx wound. -2/14/22 at 12:22 p.m. interdisciplinary team (IDT) note read, IDT met on 2/10/22 to discuss residents' wound quality and status, reviewed current treatment modalities. -However, the IDT note did not discuss which wounds and their specific treatments. -2/25/22 at 1:59 p.m. Resident noted with open area to coccyx that measures approximately 3 cm x 3.5 cm and 0.2 cm depth. Resident also noted with open area to right posterior thigh that measures about 3 cm x 2.5 cm with 0.2 cm depth. Resident is incontinent of bowel/bladder, gets up every day in a wheelchair. Area cleansed with normal saline, medi honey applied and covered with bordered foam dressing. Will continue to reposition resident while in bed. MD and family notified. Will continue to monitor. -However, the coccyx wound had increased in size since initial discovery on 1/27/22 (see above) despite documentation of repositioning. -2/25/22 at 11:14 p.m. The resident on a change of condition related to the open areas to coccyx and right posterior thigh. The resident repositioned every two hours. No signs/symptoms of distress noted. -2/26/22 at 1:58 a.m. The resident was being monitored related to having open areas to the coccyx and right posterior thigh. Dressing intact and no signs/symptoms of infection noted. -2/26/22 at 11:43 a.m. The resident was being monitored related to having open areas to the coccyx and right posterior thigh. Resident was repositioned every two hours. No signs/symptoms of distress noted. -2/27/22 at 1:17 a.m. The resident was on alert charting related to having open areas to the coccyx and right posterior thigh. Dressing intact. No indication of infection or pain was noted. -2/27/22 at 10:15 a.m. Resident was being monitored for the wound on her coccyx. Today she was in bed and being turned from side to side every two hours. She had a treatment done and wound was red and there was some drainage. -2/27/22 at 7:57 p.m. The resident monitored for coccyx and right posterior thigh pressure wounds, repositioned every two hours. Resident had no signs/symptoms of pain. -2/28/22 at 2:12 a.m. The resident was being monitored related to having open areas to the coccyx and right posterior thigh. She had been repositioned to the side frequently. Dressing intact and no signs/symptoms of infection noted. -2/28/22 at 4:08 p.m. The resident received an air mattress to her bed. Dressing intact to coccyx and right posterior upper thigh. Review of the initial consultation note by the wound care physician (PHY) #2, dated 3/1/22 revealed the following. Wound #1 coccyx was a stage 3 pressure ulcer injury and had received a status of not healed. Initial wound encounter measurements are 3 cm length, 2.5 cm width, 0.2 cm depth. The patient reported a pain level 0/10. Wound bed had 20% slough, and 80% granulation. The periwound skin was normal. -However, the coccyx wound was discovered 1/27/22 and the first physician wound evaluation was 3/1/22, nearly five weeks later. -3/3/22 at 1:01 p.m. IDT reviewed skin and wounds, some improvement noted to areas, interventions were in place. Staff continued with wound care per MD order, and the wound team continued to round and follow closely. -However, there was no indication which wounds were reviewed and which areas were improving. The nurse's daily wound evaluation notes for the coccyx did not begin until 3/11/22, which was more than one week after the wound physician saw the resident on 3/1/22. -4/11/22 at 2:42 p.m. The nutrition progress note revealed the first mention in the progress notes of the staging of the coccyx wound, Skin: Left heel-deep tissue injury; Coccyx-stage 3 pressure ulcer. -Review of progress notes 4/11/22-6/8/22 revealed no further mention of the coccyx pressure ulcer stage 3 wound and if the resident was provided repositioning. D. Staff interview The director of nursing (DON) and assistant director of nursing (ADON) were interviewed on 6/14/22 at 2:49 p.m. The DON said Resident #61's coccyx wound was discovered 1/27/22 from a skin assessment. The DON said when Resident #61 developed her coccyx wound the facility did not have a wound care physician, just a wound care nurse that performed weekly wound assessments; however that wound care nurse did not assess Resident #61's coccyx, she only assessed Resident #61's heel wound. The DON said the wound care physician began rounding at the end of March 2022. Between 1/18/22 and March 2022, the nursing staff followed the resident's wounds until referral to a new wound care doctor began in March 2022. The DON said that registered nurses were able to assess wounds, complete wound care and staging of the wounds, however a licensed practical nurse/unit manager (UM) #1 found the sacral wound and did not ask an RN to completely assess the wound. The DON said staging should have been done right away when the wound was first identified on the coccyx (1/27/22). The DON said the primary care physician (PCP) did not come in to stage or assess the coccyx wound. The DON said the first documented assessment of Resident #61's wound was with the wound care physician on 3/29/22. The DON and ADON said they could not locate any wound staging notes for Resident #61 prior to the wound care doctors' visit. The DON and ADON said Resident #61's pressure ulcer was acquired in-house as a stage 3 wound. The DON said the protocols the facility had to prevent resident pressure injuries was an air mattress, especially if the resident was dependent on staff for care. The DON said the facility used the Braden scale to identify if a resident was at risk for pressure injuries and a score of 15-18 would alert the staff that a resident was at risk. The DON said every resident in a wheelchair would have a cushion and their protein intake was monitored. The DON said a change of condition form should be completed right away when a new pressure injury or new skin concern was discovered. The DON said there had been a gap with wound care documentation, treatment and the facility did a quality assurance and performance improvement (QAPI) meeting and did an in-house audit. The DON said she was not the DON during that time period of January-March 2022 and acknowledged that there were some problems with the wound care process at that time. IV. Resident #143 A. Resident status Resident #143, age [AGE], was admitted on [DATE]. According to the June 2022 CPO, diagnoses included Parkinson's disease, pressure ulcer stage 2, diabetes mellitus and adult failure to thrive. The 5/20/22 MDS assessment revealed Resident #143 was moderately impaired with a BIMS score of 12 out of 15. He required extensive two-person assistance with bed mobility, transfers and toilet use; and extensive one-person assistance with dressing and personal hygiene. He was always incontinent of bowel and bladder. Resident #24 had one stage 3 pressure ulcer and one unstageable pressure ulcer. He had a pressure reducing device for her bed/chair, was on a turning/repositioning program, had nutrition or hydration intervention and received pressure ulcer/injury care including application of ointments/medications and nonsurgical dressings. The resident was at risk for pressure ulcer/injury development. B. Resident interview Resident #143 was interviewed on 6/7/22 at 10:27 a.m. He said that since his admission, staff have not gotten him out of bed. He said staff would come in once a day to reposition him. Resident #143 was interviewed a second time on 6/8/22 at 3:20 p.m. He said the staff had not been in to change his dressing. C. Record review 1. Care plan The skin care plan, initiated 5/16/22 and revised on 5/25/22 revealed Resident #143 admitted to the facility with a pressure injury to his buttock stage 3 and unstageable pressure ulcers. Interventions included to assess, record, and monitor wound healing. Administer treatments as ordered and monitor for effectiveness. Monitor nutritional status, obtain and monitor lab work as ordered, air mattress and report decline and improvements to the physician. -The care plan did not document which buttock (right or left) Resident #143 had pressure injuries (stage 3 and unstageable) to. 2. admission assessment The 5/13/22 admission assessment documented Resident #143 had three pressure ulcers to his right buttock, two to mid to lower buttock and one to lateral lower buttock; however there was only one measurement of 2.4 cm (centimeters) x (by) 2.2 cm x 2.5 cm. -Additionally, it was not documented which of the three wounds the measurement belonged to. -The assessment did not include tissue type, stages of the three wounds, surrounding skin, if the wounds had any drainage, signs of infection or documentation of the surrounding skin. Furthermore, it was documented Resident #143 had stage 2 pressure wound to his buttock. A Mepilex (absorbent dressing) was applied per hospital treatment with a verbal report to leave dressing on and the wound team would follow-up. 3. CPO and treatment administration record (TAR) -Review of the May 2022 CPO revealed there were no treatment orders initiated for any of the wounds (see above) until 5/17/22 and treatment was not performed until 5/19/22 according to the TAR, which was six days after admission. -Additionally, on 6/8/22 Resident #143's wound treatment was not completed (see interviews below). 4. History and physical (H&P) The 5/19/22 H&P documented per patient, buttock wound stage 2 healed, the resident had an air mattress overlay and a wound consult. -However, documentation above revealed Resident #143 had a stage 3 and unstageable wound to his right buttock and coccyx per the wound physician (see below). 5. Wound assessment The 5/24/22 wound assessment revealed Resident #143 had an abrasion to his right hip which measured 1 cm x 1 cm with zero depth, no drainage and 100% epithelialization. He had a stage 3 pressure injury to his right buttock which measured 0.5 cm x 0.5 cm x 0.1 cm, minimal drainage and 100% granular tissue. He had an unstageable pressure injury to his coccyx which measured 2 cm x 1 cm x 0.2 cm, minimal drainage and 10% granular tissue and 90% slough. The wound assessment documented the three wounds decreased in measurement (prior dimensions to Resident #143's right hip was 2 cm x 1.5 cm x 0.1 cm, prior dimensions to Resident #143's right buttock was 1 cm x 1 cm x 0.2 cm and prior dimensions to Resident #143's coccyx was 2.5 cm x 1 cm x 0.2 cm). -However, prior to the 5/24/22 wound assessment, there was no other assessments available in the resident's clinical record to show the wounds had decreased in measurement. 6. Skin assessments The skin assessments for 5/20/22, 5/27/22 and 6/3/22 were reviewed, there was no assessment of Resident #143's wounds documented on the skin assessments. 7. Nutrition assessment The 5/17/22 Nutrition Risk Review documented Resident #143 did not have any unstageable pressure injuries and Resident #143 had a stage 2 pressure ulcer to his buttock. 8. Progress notes Review of progress notes from 5/13/22 to 6/9/22 revealed no documentation of Resident #143's wound status of a stage 3 pressure ulcer to right buttock or unstageable pressure ulcer to his coccyx. The 5/17/22 Nutrition Risk Review note documented Resident #143 having a stage 2 pressure ulcer to his buttock. D. Staff interviews Licensed practical nurse (LPN) #8 was interviewed on 6/8/22 at 3:21 p.m. She said she worked PRN (as needed) and picked up the evening shift from 2:00 p.m. to 10:00 p.m. She said LPN #6 (the day nurse) changed Resident #143's dressing before she left. She said she did not receive in her report from LPN #6 that she needed to complete the treatment on 6/8/22. The director of nursing (DON) and nursing home administrator were interviewed on 6/8/22 at 3:24 p.m. They said the facility had four residents with facility acquired wounds. The DON said the nurses should complete a head to toe assessment, on admission, contact the physician and confirm and follow orders. She said a registered nurse (RN) needed to assess wounds, document the pressure wound stage, what the wound bed looked like, if the wound had drainage or signs and symptoms of infection. She said if an LPN was completing the assessment he/she would ask the house RN to complete the assessment, and the interdisciplinary team (IDT) would add the resident to the wound rounds. They acknowledged there were concerns with assessing, monitoring and obtaining treatment orders in a timely manner for resident wounds. The DON said the nurse received in his/her report to leave the dressing intact. She acknowledged the expectation would be to notify the physician and obtain physician orders to keep the Mepilex intact. She said she felt the wound physician assessed Resident #143's wounds sooner than 11 days after admission, but needed to track down the assessment. Physician assistant (PA) #1 was interviewed on 6/8/22 at 3:39 p.m. She said she would expect the admitting nurse to complete a full skin assessment and contact the physician for wound treatment orders. She said if the nurse received orders from the hospital to leave Resident #143 dressed intact, she would expect the nurse to obtain an order from the physician. LPN #6 was interviewed on 6/9/22 at 10:10 a.m. She said she was not able to complete Resident #143's wound treatment on 6/8/22 before she left and she passed it on to LPN #8 (the evening nurse) to complete. She acknowledged it was not completed. E. Facility follow-up On 6/8/22 at 5:48 p.m. the DON provided an action plan for wounds. The action plan dated 5/9/22 documented the concern that staff were not utilizing (name of electronic system) for documentation of wounds as expected by the facility. There was miscommunication between the provider and facility expectations. The wound nurse's end date was 12/25/21 and the wound physician position was implemented in March 2022. Interventions included the following: -Create onboarding program (completed 6/7/22); -Started wound care, following wound physician with wound pictures and documentation (ongoing); -A full house audit to ensure treatment orders were in place and evaluations were completed start date 6/7/22 and estimated date of completion 6/13/22; and, -Wound certification start date 5/1/22 and estimated date of completion 10/1/22. -The action plan did not include any training or education being provided to the nursing staff. The DON said she was not sure if education was initiated. -There was no additional information provided by the facility during survey (6/6/22 to 6/15/22) to include nurse education or wound assessments for Resident #143 prior to the wound physician assessment 5/24/22.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the residents' environment remained free from accident hazards as possible, affecting one resident (#264) out of 64 sample residents. The facility failed to develop and implement an effective system of oversight and safety interventions to prevent and reduce the risk of Residents #264 having a smoking accident. Failures included a lack of identification that Resident #264 continued to smoke despite telling the intake coordinator he would not. Failure to assess Resident #264's risks for potential injuries and side effects from smoking. Failure to implementing appropriate interventions to promote Resident #264 being a safer independent smoker; and offering supplies for safer smoking. The facility's failure to identify that Resident #264 would continue to smoke, even with the facility being a non-smoking facility, when admission documentation and physician's notes indicated the resident was an active smoker. The facility failed to develop a smoking care plan with interventions to promote safe smoking for the resident. Due to the facility's failures, on 5/29/22 Resident #264 sustained second degree burns to his head, face and neck with burning pain around his face and lips and hypoxemia (an abnormally low concentration of oxygen in the blood) these injuries required hospital treatment over several days. Findings include: I. Facility policy The Smoking Policy Agreement, updated 4/18/18, was provided by the director of nursing (DON) on 6/8/22 p.m. at 12:06 p.m., it read: To ensure the safety of the community, (facility name) is smoke free. All residences, including but not limited to private units of residents, will be smoke free. Smoking includes the use of cigarettes and electronic cigarettes (e-cigs or personal vaporizers). So as not to impede resident rights, each community will make available a designated area where residents, staff, and visitors can smoke. 1. Smoking is strictly prohibited in any interior area, including your apartment, at all times by you, visitors, other residents, and staff. 2. Smoking is allowed only in designated areas. These areas have signage indicating such. 3. Residents who smoke must appropriately dispose of cigarette butts and associated garbage. 4. Residents who display unsafe smoking habits may not be permitted to smoke. 5. Residents who do not agree to and/or comply with smoking regulations will not be permitted to reside at this assisted living residence. Smoking Violation Procedure Step 1: Upon moving in, all residents will receive a copy of the Smoking Policy. They will sign the policy. It will be kept in their file and they will be given a copy. Step 2: In the event the resident violates any of the above listed requirements, they will be counseled by a supervisor. This will be documented with a date and written note in file. Step 3: The resident's cigarettes will be kept at the front desk for smoking outside in appropriate areas. Step 4: If the resident violates the smoking policy again, the resident will be given a written warning that indicates that the next violation will result in a 30-day notice. Step 5: If the smoking policy is violated a 3rd (third) time, the resident will be issued a 30-day notice of discharge. II. Resident #264 A. Resident status Resident #264, [AGE] years of age, was admitted to the facility on [DATE], after a couple of discharges and readmissions the resident was readmitted on [DATE] and discharged to a hospital on 5/30/22. According to the May 2022 computerized physician orders (CPO), diagnoses included chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease (COPD), heart failure, and hypertension. According to the 3/14/22 minimum data set (MDS) assessment, the resident had intact cognition with a brief interview for mental status (BIMS) score 13 out of 15. The resident had no signs of psychosis, no negative aggressive behavioral expressions and did not reject care. The resident required supervision and oversight encouragement and cuing in order to complete all areas of activities of daily living (ADLs). The resident was able to walk with a walker. The resident was on oxygen therapy. B. Record review admission order dated 3/7/22 documented the resident had tobacco dependence and was still smoking. admission progress notes read in pertinent part: -3/10/22 at 2:14 a.m. Evaluation summary: Daily skilled charting for (resident name) .has a history of smoking, . impaired mobility and impaired ability to care for himself, he needs one person limited to extensive assistance with ADLs. -3/11/22 at 11:59 a.m. Medication administration note (MAR). Nicotine patch 24 hour 21mg (milligrams) for 24 hours. Apply 21 mg transdermally in the morning for smoking cessation for 4 (four) weeks. -3/23/22 at 9:48 a.m. Summary for providers-Situation: The change in condition reported on this evaluation are/were: Altered mental status functional decline (worsening function and/or mobility). Other change in condition-seems different than usual. -4/12/22 at 5:09 p.m. Physician progress note: Physical examination. Stable today at facility visit. Patient with repeated hospitalizations due to inability to care for himself and take his medications. Tobacco dependence-Still smoking. Refilled on 4/12/22, nicotine 21 mg/24 hour transdermal patch for smoking cessation. -5/7/22 at 11:41 a.m. MAR note: Nicotine patch .for smoking cessation-refused. -5/24/22 at 2:08 p.m. Physician progress note: Follow up visit for issues/symptoms . Facility reports that the patient is doing well however he was recently found to have smoking paraphernalia in his room. Facility also concerned about possible substance abuse as the patient has a lock box he takes with him outside and refuses to allow staff to search the box. The resident's comprehensive care plan revised 6/6/22 revealed the resident had three-care focuses related to the use of oxygen. The care plan focuses read: -I have a potential/actual risk for alteration in cardiovascular status. Goal: I shall have decreased risks for development of cardiovascular and systemic complications such as shortness of breath (SOB), edema, chest pain (angina) and pain. Intervention: I will be free of SOB and/or difficulty breathing. I will have increased ability to participate in activities of my choosing with decreased risks for injury associated with changes in hemodynamic status. I will need my oxygen as ordered and observation for any signs of new onset of shortness of breath, adventitious breath sounds, and oxygen saturation levels less than 90%. -COPD with oxygen use. Goal: (resident name) will display optimal breathing patterns daily. Interventions: Avoid extremes of hot and cold. Encourage small frequent feedings instead of large meals. Give supplements if needed to maintain adequate nutrition. Encourage good fluid intake. Monitor for difficulty breathing (dyspnea) on exertion. Remind me not to push beyond endurance. Monitor for signs and symptoms of acute respiratory insufficiency and anxiety, confusion, restlessness, SOB at rest, cyanosis, and somnolence. Monitor/document for anxiety. Offer support, encourage me to vent frustrations and fears. Reassure. Give PRN (as needed) medications for anxiety as ordered or per my request. Oxygen settings: Oxygen via NC (nasal Cannula, as ordered or as needed. -I have increased risks for potential ineffective respiratory patterns related to the need of oxygen therapy secondary to:COPD with chronic respiratory failure. Goal: I shall demonstrate an effective respiratory pattern as evidenced by regular respiratory pattern, unlabored breathing, no complaints of SOB, absence of dyspnea. No interventions listed. None of the care focuses provided interventions for safe use of oxygen. Nor did the interventions including assessing the resident ability to smoke safely or providing the resident education for safe smoking and oxygen use, where smoking was allowed and assessment needs for safe smoking based on needs and smoking habits. The interventions did not include assessing the resident ability to smoke safely or providing the resident education for safe smoking and oxygen use, where smoking was allowed and assessment needs for safe smoking based on needs and smoking habits. III. Smoking injury A. Record review Progress note revealed on 5/29/22 at approximately 11:00 a.m., Resident #264 engaged in unsafe smoking while wearing oxygen. As a result, Resident #264 received superficial burns to the face and negative effects to the respiratory tract. The resident was sent to the hospital for assessment and medical treatment. Progress notes read in pertinent part: -5/29/22 at 11:10 a.m. Summary for providers-Situation: The change in condition reported on this evaluation are/were: Other change in condition . Nursing observations, evaluation, and recommendations are: Burns to face. -5/29/22 at 12:25 p.m. Resident got face burned, called physician, got order to transfer patient to emergency department, called 911 for transport. The 5/29/22 Smoking Data Collection form documented the resident was not able to communicate why oxygen must always be shut off prior to lighting cigarettes and was not able to communicate the risks associated with smoking. Based on observation the resident did not smoke safely. The conclusion is that the resident is an unsafe smoker. Summary of evaluation Resident must be supervised by staff, volunteers or family members at all times when smoking. B. Facility investigation The facility investigation, dated 5/30/22, documented on 5/29/22 the resident went off the facility property to the park behind the facility to smoke and returned at approximately 11:00 a.m. with superficial burns to his face. The resident said he left facility property to smoke because he knew the facility did not permit smoking on facility property. The resident returned to the facility with superficial burns on his face and told facility staff he burnt himself while smoking. The nursing staff assessed the resident, applied burn ointment and sent the resident to the hospital for further assessment and treatment. Following the incident, the resident was referred to another nursing facility for placement where staff could provide supervised smoking as part of his care plan. C. Hospital treatment records Hospital records revealed resident injury from smoking while using oxygen. Notes read in pertinent part: 5/29/22 Hospital note Initial greet date/time 5/29/22 at 11:38 a.m. -Chief Complaint: facial burn, lighting a cigarette on 02 (oxygen). History: COPD on 4-5 L (liters) of 02 at baseline .presented by EMS (emergency medical service) for sudden onset of difficulty breathing through his nose after lighting a cigarette while on 02. The lighter ignited the tubing and ran up and through his nares. Incident occurred an hour and 20 minutes ago. Patient reports associated constant, burning pain around his face and lips. He denies associated difficulty swallowing, throat pain, tongue swelling, chest pain, or abdominal pain. - Exam: Superficial burns to the nose and upper lip, moist mucous membranes, no meningismus (clinical syndrome of headache, neck stiffness, and photophobia, often with nausea and vomiting). Differential Diagnosis: Superficial burns, partial-thickness burns, airway obstruction, hypoxemia. He had hypoxia with his baseline oxygen, likely because of nasal swelling. Discussed with burn surgery, we will admit for observation, burn management. Smoking status: Current everyday smoker. Years smoked 50. 5/31/22 Hospital note: Seen today sitting up in a chair. States he is doing ok overall, still some issues with breathing through nose-feels stuffed up, but breathing through mouth ok. Tolerating PO (oral), pain present but controlled. Afebrile. Oxygen requirements remain at baseline. 6/1/22 Hospital note: Pain mostly in throat when swallowing. Hard for him to chew/swallow due to pain with moving lips. 6/6/22 Hospital note: Discharge 6/6/22 at 5:28 p.m. Problems: Admitting diagnosis: Burn of unspecified degree of the head, face and neck. Working diagnosis: Burns involving less than 10% of body surface; nicotine dependence. General appearance: awake, no acute distress, no respiratory distress Head: 2nd (second) degree superficial burns to cheeks, mouth, chin. IV. Staff interview Licensed practical nurse (LPN) #3 was interviewed on 6/7/22 at 3:56 p.m. LPN #3 said Resident #264 violated the smoking policy. On 5/29/22, Resident #264 was discovered in the parking lot with burns to his face underneath and around his oxygen tubing. He said he had been smoking and caught himself on fire. Nursing staff assessed Resident #264s injuries and treated superficial burns to the nares (nose), cheeks and upper lips. His injuries were treated with burn cream and he was sent to the hospital for further assessment and treatment. He was short of breath and was visibly upset. The nursing home administrator (NHA) and director of nursing (DON were interviewed on 6/7/22 at 11:33 a.m. The NHA said they were a non-smoking facility and they told Resident #264 when he admitted that the facility did not permit smoking in the facility. When Resident #264 admitted to the facility he was informed he could not smoke in the facility; he told us he understood and would not smoke. The NHA said the facility did not conduct a smoking assessment or see the need for a smoking care plan because we took him on his word that he would not smoke. The NHA said if the resident had cigarettes in his possession in the facility, he probably convinced his family to bring them into him, but as far as he knew the day the resident got the facial burns, he got cigarettes from a person in the park behind the facility. The DON was interviewed on 6/15/22 at 1:02 p.m. The DON said the facility did not perform smoking assessments on any residents admitted to the facility because the facility was a non-smoking facility and did not have the supplies to test a residents' smoking ability. The DON said upon admission they provide every resident with the facility's smoking policy and get verbal agreement that the resident would not smoke while they were at the facility. If the staff found smoking paraphernalia in a resident's possession they would take it away; ask the resident's family to take the supply away; and educate the resident and the resident family that smoking while in the facility was not permitted. The DON said going forward the facility would continue to offer residents who chose to start or continue smoking referrals to smoking facilities; if the resident wanted to remain in the facility and was unable to stop smoking the nursing staff would contact the resident's physician to discuss a smoking cessation treatment options.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to ensure one (#147) of three residents out of 64 sample residents had an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences. Resident #147, who had a diagnosis of respiratory failure, and history of cerebrovascular accident (CVA, or stroke) with right side hemiparesis (paralysis of the right side of the body), right arm weakness, and contracture in the right hand, was admitted to the facility on [DATE]. The resident stated she had pain in her right hand/forearm with edema and right arm weakness. According to the resident's medical record, the facility failed to address right forearm/hand edema and pain for Resident #147 through proper pain and positioning management. The facility was aware of Resident #147s right hand/forearm pain and edema, however, failed to provide person-centered individualized interventions in the care plan and adjust her pain medications accordingly. There was no consistent monitoring or recording of the resident's pain characteristic, no monitoring of quality, severity, anatomical location, onset, duration, aggravating or relieving factors or goal setting related to the resident's pain. Due to the facility's failure to manage Resident #147's pain management, the resident said night time pain was the worst and it was hard to sleep because of the pain. Resident #147 said she told the nurse, but they did not do much except give her Tylenol. Resident #147 said Tylenol did not helped the pain. Resident #147 said she had pain daily, and it was constant. Resident #147 rated the pain at an 8 out of 10 (with 10 being the worst pain on the scale). I. Resident #147 A. Resident status Resident #147, age [AGE], was admitted on [DATE]. According to the June 2022 computerized physician orders (CPO), diagnoses included chronic respiratory failure with hypoxia (low blood oxygen levels), atherosclerosis of aorta (hardening of the arteries), and emphysema (air sacs of the lungs are damaged, causing breathlessness). The 5/25/22 minimum data set (MDS) assessment revealed the resident with moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required total physical assistance from two staff in order to complete activities of daily living and for transfers. Extensive assistance from one staff member for bed mobility, locomotion on/off unit in a wheelchair, dressing, toilet use, bathing, and personal hygiene. The resident had no behaviors or rejection of care. The pain assessment portion of the MDS assessment revealed the resident was on a scheduled pain medication regimen. A pain assessment interview was conducted. The pain assessment interview documented the resident did no have pain during the past 5 days. There was not documentation if pain ever affected daily function. B. Resident observation and interview On 6/7/22 at 2:40 p.m. observed Resident #147 seated in a wheelchair with the right arm sitting on the seat with the right hand curled into a fist and wrist bent forward (flexed). Resident #147 said the right hand and forearm were painful with swelling. The resident had edema in the right hand and forearm. There was no pillow under the right arm or hand, but there was a pillow under the left side which had no pain or edema. Resident #147 said when she first moved to the facility an injury caused some pain in her right hand, her physician prescribed her ibuprofen for a couple of days. The ibuprofen was effective for the injury as well as the pain and swelling in her right hand and forearm. However, she no longer has an order for ibuprofen. Resident #147 was interviewed on 6/13/22 at 10:16 a.m. Resident #147 was supine (on back) in bed, her right hand/arm were down by her side. There was no pillow or elevation of the right hand or arm. Resident #147 said her right hand and arm were painful and swollen. The resident's right hand had edema on the top of hand and forearm. Resident #147's right hand was curled in a fist with wrist bent (flexed) forward. Unit manager (UM) #1 was notified of the pain and an unnamed CNA placed a pillow under the right arm after bringing it to the CNA's attention. UM #1 said she was not sure if elevating with pillow was the best position for her arm but said she would ask the nurse practitioner (NP) #1 to evaluate. UM #1 asked Resident #147 if her hand was painful and the resident answered yes. Resident #147 was interviewed again on 6/13/22 at 11:00 a.m. She said night time pain was the worst and it was hard to sleep because of the pain. Resident #147 said she told the nurse, and the nurse gave her Tylenol for the pain but it did not help the pain. Resident #147 said she had pain daily. She said it was constant and frequent, 8/10 presently. Resident #147 said she did not remember a nurse asking her about her pain. Resident #147 said she also got tremors in both hands and described her pain as throbbing and achy. -Review of the resident's electronic medical record (EMR) revealed there was no recording of pain levels since admission; it was blank. (see record review below) C. Record review Review of the June 2022 CPO revealed the following pain medications: -Gabapentin capsule 100 milligrams (MG), give two capsules by mouth as bedtime for pain control give total of 200 MG at bedtime, start date 5/19/22. -Gabapentin capsule 100 MG, give two capsules by mouth in the afternoon for pain control, give total of 200 MG in the afternoon, start date 5/19/22. -Gabapentin capsule 100 MG, give three capsules by mouth in the morning for pain control, give a total of 300 MG in the morning, start date 5/19/22. -Acetaminophen tablet 500 MG, give two tablets by mouth three times a day for pain control, not to exceed three grams/24 hours, start date 5/19/22. -Aspercreme Lidocaine cream 4% (Lidocaine hydrochloride), apply to right hand and fingers topically three times a day for right hand pain, start date 5/23/22. -Ibuprofen 400 mg every eight hours as needed for pain and swelling, for three days, start date 5/23/22, discontinue date 5/26/22. -Review of the physician's orders failed to show the resident's pain regime changed despite Resident #147s complaints of unrelieved pain; except the order for Aspercreme on 5/23/22, which according to the resident interview did not manage her pain with her indicating she had 8 out of 10 pain. The resident was prescribed ibuprofen for three day from 5/23/22 to 5/25/22 for pain and swelling but the medication was only a temporary remedy to an injury the resident received in the facility and not the resident's ongoing problems with pain, swelling and edema. The resident said in interview she felt better when receiving the ibuprofen but her pain levels increased once the temporary order was completed and discontinued. -Review of the resident's comprehensive care plan related to pain revealed there was no care plan specific to assessing, treating and monitoring the resident's right hand and forearm pain or edema. -Review of the resident's electronic medical record (EMR) revealed there was no documentation of assessment of Resident #147's pain levels anywhere in the record and the pain assessment field in the clinical weight and vitals section; was blank. -Review of the resident's June 2022 medical administration record and treatment administration record (MAR/TAR) revealed there was no documentation of pain levels when administering pain medications or documentation of the effectiveness of the pain medication treatment. There was no monitoring or recording of pain characteristic, no monitoring of quality, severity, anatomical location, onset, duration, aggravating or relieving factors. -Review of the admission data collection, MDS pain assessment, dated 5/18/22, revealed section four, Pain, was not completed; it was blank. -Review of the resident's computerized physician orders revealed there were no orders regarding positioning or care of right hand/forearm edema and related pain for Resident #147. Review of nurse pain interview instrument, dated 5/23/22, revealed, the resident received scheduled pain medication regimen; did not receive as needed pain medication or if offered was not declined; did not receive non-medication intervention for pain; should pain assessment interview be conducted-yes; Ask resident have you had pain or hurting at any time in the last five days-no; Ask resident, how much of the time have you experienced pain or hurting over the last five days?-occasionally; Ask resident, over the past five days, has pain made it hard for you to sleep at night?-no; Ask resident, over the past five days, have you limited your day-to-day activities because of pain?-no; Numeric rating scale box-no documentation, left blank; verbal descriptor scale-mild; Frequency with which resident complains or shows evidence of pain or possible pain?-no documentation, left blank. -Two assessment areas were left incomplete and there was conflicting data with the resident receiving scheduled pain medications yet assessment documents showed no pain or hurting at any time in the last five days. In addition, the resident said in this assessment that she had pain occasionally, so the documentation of no pain or hurting was not accurate. Review of physician visit note, dated 5/23/22, revealed chief complaint as right hand pain. Documented history of cerebrovascular accident (CVA, or stroke) with right side hemiparesis (paralysis of the right side of the body), right arm weakness, and contracture in the right hand. -However the facility failed to update the care plan to monitor right hand pain, or contracture following physician visit. Review of all progress notes revealed the following: 5/21/22 at 7:07 pm New order for aspercreme with lidocaine to right fingers every four hours as needed (PRN) for pain. Resident complained of right finger pain. 5/21/22 at 11:54 p.m.aspercreme not effective to reduce right finger pain, resident asked to speak to provider concerning this. 5/22/22 at 12:01 a.m. Right sided weakness/paresis with new pain to right fingers, Apsercream somewhat effective for pain relief. 5/23/22 at 2:39 p.m. New order for right hand and fingers x-ray for increased pain and swelling, also ibuprofen 400 mg every eight hours as needed for pain and swelling. 5/23/22 at 3:54 p.m. Resident is being monitored related to increased pain and swelling to right fingers and hand. X-ray ordered and started ibuprofen 400 mg by mouth every eight hours as needed for three days. No complaint of pain after she took her night medications during the evening shift . 5/23/22 at 10:40 a.m. Resident is having an x-ray of right fingers and hand for pain and swelling. X-ray had been taken no results yet . 5/24/22 at 5:42 p.m. Received hand/finger x-ray results .no abnormalities noted on results. Resident has no indications of pain or discomfort this shift. 5/24/22 at 6:29 p.m. Resident monitored for swelling and pain at right index finger. X-ray showed osteoporosis, arthritic disease, no fracture. aspercreme with lidocaine applied to right hand and fingers for moderate relief, resident declined ibuprofen. 5/25/22 at 12:48 a.m. Resident is being monitored related to complaint of increased pain and swelling to her right fingers and hand. X-ray revealed no fracture but soft tissue edema, osteoporosis and arthritic disease of fingers and hand. No complaint of pain this shift . 5/25/22 at 10:32 a.m. Resident is being monitored for a x-ray to right hand for edema and she has had pain. She has osteoarthritis in hand. She is in bed resting and has had her morning medications she is not complaining of pain. 6/13/22 at 4:30 p.m. Aspercreme Lidocaine Cream 4 %, Apply to right hand and fingers topically three times a day for right hand pain, refused, ' Doesn't relieve the pain per resident. 6/14/22 at 4:30 p.m. Aspercreme Lidocaine Cream 4 %, Apply to right hand and fingers topically three times a day for right hand pain, refused x3 doesn't help. -The facility was aware of Resident #147 right hand/forearm pain and edema, however, failed to provide a person-centered individualized intervention in the care plan and or review her pain management regimen except adding Aspercreme cream on 5/23/22. According to progress notes above, the resident indicated the Aspercreme cream was not effective to manage her pain. D. Staff interview The director of rehabilitation (DOR) was interviewed on 6/9/22 at 10:24 a.m. The DOR said he was not familiar with Resident #147. The DOR said the therapy department had not discussed therapy for Resident #147, or screened her for a restorative program, although there were standard orders to do so. The DOR said the therapy department, was trying to catch up on physician ordered assessment and therapeutic treatments but they were facing staffing challenges. The DOR said they were using more agency therapy staff and the occupational therapist contract had just ended. The DOR said there was a big increase in facility census and adjusting for therapy had been challenging to keep up with new admissions. The DOR said he would complete a screening of Resident #147 today. NP #1 was interviewed on 6/13/22 at 10:36 a.m. NP #1 completed a visit with Resident #147 per UM#1 request for right hand/arm pain and edema after being brought to the facility's attention. NP #1 said she noticed there was increased right hand/arm edema/swelling upon evaluation. NP #1 said the pillow elevation did make the resident more comfortable (less pain) from the shoulder to hand. NP #1 said she will call guardian to make her aware. NP #1 said she would also order an ultrasound due to the increased swelling to rule out other concerns. The director of nursing (DON) was interviewed on 6/15/22 at 1:08 p.m. She said there should have been a care plan specific to Resident #147 right hand contracture, and right hand/forearm pain and edema. A care plan was established after it was brought to the facility's attention; however it had the wrong information (left side instead of right side). The DON said she would get this information corrected. The DON said that pain levels and effectiveness of pain medication should be tracked by nurse staff. The DON acknowledged, after viewing Resident #147's MAR/TAR and vitals sections, that it had not been done. The DON said if the pain was not adequately controlled the nurse staff should call the provider. II. Facility follow-up New physician orders added after being brought to the facility's attention, Elevate right hand/arm with pillow. Dated 6/13/22. 6/13/22 10:45 a.m. progress note by NP #1 after being brought to the facility's attention, Resident noted with increased swelling and pain to the right hand, the resident has contracture to the right hand. skin remains intact, no discoloration noted. Right hand and arm were repositioned/elevated with a pillow. Resident is on Pradaxa for prophylaxis. Medical doctor (MD) notified. New order for ultrasound to right hand. Guardian notified. Will continue to monitor. 6/14/22 at 11:35 p.m. progress note revealed, Doppler results faxed to physician (PHY #1) : no evidence for venous thrombus in visualized right upper extremity (RUE). Right hand knuckles were less swollen this evening shift, continued tender and painful for the resident, Tylenol 650 mg given for partial relief. -After identification of the resident's inadequate pain management during the survey, besides the doppler of her right upper extremity, only Tylenol was administered for partial relief. There was no additional review of her pain medication, or addition of non-pharmacological orders for pain management except for elevating her right hand/arm with a pillow.

Based on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. As a result of inadequate staffing, the facility failed to provide services and treatment to prevent multiple areas of concern including that resulted in actual harm; abuse prevention, accident prevention, identifying residents who had changes in health conditions so they could receive proper treatment, ensure wound care was provided, and daily provided care such as dressing, toileting, and identify residents who had pain. Cross-reference citations related to resident care that were cited at actual harm: -F600 failure to prevent verbal abuse; -F677 failure to provide dependent residents assistance with activities of daily living (ADLs);. -F684 failure to identify and treat a resident experiencing a change of condition in a resident; -F686 failure to assess and treat a resident's wound; -F689 failure to prevent accident/hazards; and, -F697 failure to manage a resident's pain. Additional cross-reference citations related to resident care for a potential for more than minimal harm: -F695 failure to provide respiratory services; and, -F744 failure to provide residents with dementia the appropriate care and treatment. I. Resident census and conditions According to the 6/9/22 Resident Census and Conditions of Residents report, the resident census was 168. The following care needs were as identified: -140 residents needed assistance of one or two staff with bathing and 28 residents were dependent on staff to complete all bathing tasks. -152 residents needed assistance from one or two staff members for toilet use and six residents were dependent on staff to use the toilet. -158 residents needed assistance from one or two staff members for dressing and six residents were dependent on staff to get dressed. -127 residents needed assistance from one or two staff members for transfers and 32 were dependent on staff to move from surface to surface. -47 residents needed assistance from one or two staff members with eating and five residents were dependent on staff to eat their meals. -168 residents received preventative skin care. -61 residents required special respiratory treatments. -34 residents had behavioral health care needs. II. Resident interviews On 6/8/22 at 2:43 p.m. six interviewable (#36, #133, #89, #127, #85 and #22) residents were interviewed during the resident council meeting. All six residents said the facility failed to provide sufficient nursing staff, which resulted in delayed and/or inadequate care. -The resident group said the facility had increased resident census over the past few months but provided no increase in staffing to keep up with the addition of new residents and their needs. The residents said with more people moving in there needed to be more staff to work to prevent residents from going without care. -The resident group said they were speaking for themselves and other members of the resident council because of short staffing they were not able to get showers when the wanted and needed showering assistance, some did not receive proper assistance getting their teeth brushed, and some missed getting help getting dressed and changed because the facility did not have enough staff to do the work. -The residents group said typically there were two certified nurse aides (CNAs) on a wing, sometimes just one, and with the increased number of residents admitted to the facility there needed to be three CNAs on each wing. -The resident group said over the last five months they had voiced their concerns that the facility needed more nursing staff numerous times with management as well as the corporate office and had got no response. III. Nursing schedule The staffing schedule for 6/6/22 through 6/13/22 was provided by the nursing home administrator (NHA) on 6/13/22 at 12:30 p.m. The staffing schedule revealed the facility had six units each were staffed similarly. The provided schedule showed shortages in the staffing patterns based on the NHA explanation of how staff were to be scheduled per resident census (see NHA interview below). Staffing patterns did not match with the staffing ratio staff per number of residents as the NHA explained (see NHA interview above). The schedule revealed the following staffing ratios: -Each day of the provided schedule was calculated per the NHAs formula for staffing needs. The calculation each day indicated the number of residents (census) multiplied by 3.2 direct care hours for nursing staff. The answer to the equation was then compared to the actual number of hours of direct care staff per day. The results were: -On 5/6/22: resident census 165 multiplied by 3.2 equaled 528 hours needed for direct care staff. The total hours of staffing were 446 hours. The facility was short 82 hours for staffing. -On 5/7/22: resident census 167 multiplied by 3.2 equaled 534.40 hours needed for direct care staff. The total hours of staffing were 418 hours. The facility was short 116.40 hours for staffing. -On 5/8/22: resident census 167 multiplied by 3.2 equaled 534.40 hours needed for direct care staff. The total hours of staffing were 372. The facility was short 162.40 hours for staffing. -On 5/9/22: resident census 167 multiplied by 3.2 equaled 534.40 hours needed for direct care staff. The total hours of staffing were 324. The facility was short 210.40 hours for staffing. -On 5/10/22: resident census 167 multiplied by 3.2 equaled 534.40 hours needed for direct care staff. The total hours of staffing were 316. The facility was short 218.40 hours for staffing. -On 5/11/22: resident census 161 multiplied by 3.2 equaled 515.20 hours needed for direct care staff. The total hours of staffing were 251 hours. The facility was short 264.20 hours for staffing. -On 5/12/22: resident census 163 multiplied by 3.2 equals 521.60 hours needed for direct care staff. The total hours of staffing were 243 hours. The facility was short 278.60 hours for staffing. -On 5/13/22: resident census 170 multiplied by 3.2 equals 544 hours needed for direct care staff. The total hours of staffing were 468 hours. The facility was short 76 hours for staffing. IV. Staff interviews Certified nursing aide (CNA) #6 was interviewed on 6/9/22 at 2:40 p.m. She said she worked the evening shift. She said she had worked several times when there were only two CNAs working on the hallway with 36 residents to care for. She said two CNAs were not enough to meet the activities of daily living (ADL) for the residents. She said the residents did not get the care required because they did not have extra help to meet the ADL needs for all of the residents. She said she only had time to refill the residents' water cups on her floor one time even if the residents needed more. CNA #8 was interviewed on 6/13/22 at 10:59 a.m. She said since there were usually just two CNAs caring for 36 residents. She said the staff had to prioritize ADL care by not doing certain care for the residents. She stated her priority for care was changing and feeding the residents. She said with only two CNAs on a wing some care did not happen like taking out the residents trash and giving showers to the residents. She said a CNA could not do everything for the residents that were needed or wanted on a shift because there were not enough staff to do everything. The director of nursing (DON) was interviewed on 6/7/22 at 11:35 a.m. She said she had been the DON for only five days.The DON said currently the facility had 168 residents. She said she did not have an answer as to how to increase staff with 47 residents being admitted in the last two months. She said she would need to speak with the nursing home administrator (NHA) to get an answer as to how the facility would adjust to increase staff with the increase of residents they were accepting. Licensed practical nurse (LPN) #3 was interviewed on 6/7/22 at 3:56 p.m. She said it was always a challenge with there being enough nursing staff on the floor to help the residents, and nursing staff were usually short staffed on the weekends. LPN #3 said that only one CNA worked on each wing for the weekends. She said residents needed to wait for things and to be cared for by the staff because there was not enough staff to help. She said on the weekends residents were not getting out of bed. She said she felt there was not enough staff to meet the needs of all the residents. She said she would then help a CNA to provide resident care. She said she could not always answer the resident's call lights in a timely manner, or get the residents out of bed. She said residents often did not get showers. She said the unit did not get what was called a float CNA, meaning they went wherever they were needed. She said she had never had a float CNA to help her. She said the nursing staff was told the facility was no longer allowed by the corporation to use agency nursing and CNAs because it cost too much money. She said only recently had the facility tried to schedule a second CNA on wings to help but two CNAs were not always available on each wing. The nursing home administrator (NHA) was interviewed on 6/7/22 at 4:50 p.m. He said according to the company that owned the facility he was to staff the facility according to a mathematical formula. He said the formula used was to take the total number of residents admitted in the facility (census) and multiply that number by 3.2 hours. He said 3.2 hours was what was projected that each resident in the facility needed for direct care by nursing. He said the census multiplied by 3.2 hours provided the number of hours required to staff the facility each day. He said according to the 4/2/22 facility assessment the census on average were 110-121 residents in the facility. He said the facility had increased in new admissions over the last five months. He said not all residents required 3.2 hours per day. He said the rehabilitation unit required more staffing for those residents.He said he looked at what residents needed mechanical lifts for their nursing care and he looked at the residents' acuity needs. He said he also calculated the staffing ratio based upon the MDS (resident's minimum data set assessment). He said he also calculated staffing hours based upon the facility numbers in the [NAME] Reports (Certification and Survey Provider Enhanced Reports). He said he used both of the reports to evaluate triggers to indicate specific needs of residents. He said the formula his company used to calculate resident to staffing hours needed daily were: He said he scheduled the staffing needs of the facility with that formula because it made scheduling easier. He said family members always want more with staffing than the facility could provide the residents. He said he knew when the facility was short staffed because falls had increased and the residents who had skin breakdown. He said he discussed staffing needs during his quality assurance meetings. -However, according to the resident census and condition the facility had 168 residents with high acuity needs: 158 residents required staff assistance with toileting, 164 residents required assistance with dressing, 168 residents required staff assistance with bathing and 159 residents required staff assistance for transfers. The staffing coordinator (SC) was interviewed via the phone on 6/15/22 at 11:00 a.m. She said she planned the schedule the month prior so that the day and evening shift would have one nurse and three CNAs on each of the six wings. She said the night shift had one nurse and two CNAs on each wing. She said if there were further staffing needs she communicated with the NHA and the DON to get approval for additional staffing based on resident care needs. She said agency staff had been difficult to utilize because they often did not show up to work. She said she would then send out a text to the facility staff or call the facility staff to help fill any missed positions.