**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Facility staff failed to provide adequate supervision to Resident #3, who was not secured in the transportation van with a seatbelt and subsequently sustained an injury when he flipped out of his wheelchair during transport to an appointment. Review of the facility's policy entitled, Resident Transportation To and From Medical Appointment (revised 07/2022) documented, The assigned Certified Nursing Assistance (Certified Nursing Aide/CNA) or designee will ensure the resident is safe and well strapped and secure with the belt .while in the transportation van. Resident #3 was re-admitted to the facility on [DATE] with diagnoses that included: Acute Osteomyelitis, Atherosclerosis of Native Arteries of Extremities with Intermittent Claudication Right Leg, Hemiplegia, Spinal Instabilities of the Cervical Region and Generalized Muscle Weakness. A Quarterly Minimum Data Set (MDS) dated [DATE] documented that facility staff coded: severely impaired cognition; upper and lower extremity impairment on one side; required extensive assistance for transfers; and using an (electrical) wheelchair for mobility. A facility reported incident (DC00010380) received by the State Agency on 11/04/21 at 5:20 PM documented, Resident left the facility this morning at about 10:20 AM, for a scheduled Vascular appointment .with his electric wheelchair accompanied by the facility escort with a Medicaid transportation . At about 11:36 AM on 11/3/2021, the escort who accompanied the resident for the appointment called the facility and stated ,'When we got into the van, the residents ('s) wheelchair was secured by the van driver. The car in front of us made an illegal stop to make a left turn, the driver of our van made an abrupt stop to prevent hitting the car in front of us, and [Resident #3] fell from his chair and landed on the floor . I then called the facility, and the facility asked for the resident to be transferred to the emergency room for further evaluation and treatment.' .the resident was transported to hospital . Per ER (Emergency Room) nurse, a CT (Computed Tomography) , spine cervical w/o contrast and a CT Head w/o (without) contrast were completed with the result showing: 'Comminuted fractures of the right lateral mass of C1 and anterior and posterior ring of C1. Nondisplaced fracture of the right lateral mass of C3' . A review of Resident #3's medical record revealed: 11/03/21 at 5:02 PM, SBAR Situation: The resident had a motor vehicle accident (MVA) on the way to a scheduled vascular appointment at [Local Hospital] and sustained a fracture .Additional Comments: The resident left the facility this morning at about 10:20 AM for a scheduled vascular appointment .At about 11:00 AM on 11/3/2021, per the escort, 'The car in front of us made an illegal stop to make a left turn, the driver of our van made an abrupt stop to prevent hitting the car in front of us and [Resident #3] fell from his chair and landed on the floor. I immediately told the driver to pull over and stop so we can attend to [Resident #3] which he did.' During a face-to-face interview on 09/22/22 at 2:03 PM, Employee #27 (CNA and escort assigned to Resident #3) stated, The driver put the resident on the van using the lift, and I locked the resident's wheelchair. When asked who secured the resident with the seatbelt, the Employee responded, I went to secure the resident, but the driver said, 'Sit down, I got it.' Normally, I would have grabbed the seatbelt to put it on the resident, but the driver told me to sit down, so I did .The driver was on his phone and wasn't paying attention. I tried to let him [the driver] know that my resident was not secure as we pulled off, but he continued to ignore me. The next thing I knew, the driver hit the brakes. [Resident #3] was thrown out of his wheelchair, and [was] lying beside me on the floor of the van. I yelled, 'Sir, Stop, Stop, my resident,' The van driver then pulled over. I called the Nurse Manager to let her know what happened and to see if the resident needed to be transported to the hospital. Facility staff failed to ensure that Resident #3 was well strapped and secure with a seatbelt prior to the transport van being put into motion. Subsequently, when the van drive hit the brakes on the van, the resident was thrown out of his wheelchair and sustained a fracture. These failures resulted in harm to the resident. Based on record review and staff interview, for two (2) of 63 sampled residents, facility staff neglected to provide the needed care and services evidenced by 1. Resident #204 developing pressure ulcers that were first observed at an advanced stage, and 2. Resident #3 flipping out of a wheelchair in a transportation vehicle due to staff neglecting to secure him with a seatbelt. These failures resulted in actual harm to Resident #204 and Resident #3. The findings included: 1. Review of a Complaint, DC00010905, received by the State Agency on 07/29/22 revealed allegations that the facility failed to provide the proper to Resident #204. The complaint alleged the resident was neglected and sustained significant physical injuries over an unknown period which resulted in hospitalization. Medical record review indicated Resident #204 was admitted to the facility on [DATE] with multiple diagnoses that included: Mild Protein-Calorie Malnutrition, Dementia, Altered Mental Status, Muscle Weakness and Osteoporosis. Review of physician orders revealed: -07/14/21, Monitor skin for easy bruising (EB), bleeding (B), Skin Discoloration (SD), None (N) every shift and alert MD with any changes, Resident on Aspirin (blood thinner) EC (enteric coated) daily. -08/26/21, Provide incontinent care with each incontinent episode. Wash peri area with soap and water, pat dry and apply barrier cream every shift and as needed. Review of the facility's Wound/Pressure Ulcer Management policy, revised on 10/01/21 showed, . Any alteration in skin integrity will be reported to the physician immediately . Review of the facility's Wound Prevention Program policy (not dated) showed, .Weekly skin checks will be conducted by the license nurse. This will be documented in the resident's Electronic Medical Record (EMR). Daily, during routine care, the Certified Nursing Assistant will observe the resident's skin. When abnormalities are noted this will be communicated to the licensed nurse . Review of the facility's Treatment/Services to Prevent/Heal Pressure policy (not dated) showed, . The facility will ensure that . a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers . a resident with pressure ulcers receive necessary treatment and services . to promote healing, prevent infection and prevent e ulcers from developing . the nurse will notify the physician anytime the pressure sore is showing signs of non-healing or infection . Per a 03/03/22 physician's order, Resident #204 was to have a Shower twice a week on Monday and Wednesday and per patient request . This order was discontinued on 4/20/22. An Annual Minimum Data Set (MDS) dated [DATE], showed that facility staff coded Resident #204 as having severe cognitive impairment; requiring total dependence with one to -two persons physical assist for bed mobility and transfers; extensive assistance with one person physical assist for toilet use and personal hygiene; frequently incontinent of urine and bowel; active diagnoses of Anemia; no significant weight loss; at risk for pressure ulcers; and no pressure ulcers, wounds or other skin problems. A. Skin area #1- right foot: 04/18/22 at 4:28 PM Nurses Note .Skin warm to touch and no new skin issues noted. Continued to require total care with all ADL (activities of daily living) cares. Turned and repositioned for pressure relief . 04/19/22 at 5:14 PM Skin Observation Tool (Licensed Nurse) . skin is intact, warm and well lubricated. No wound; 04/20/22 [Treatment Administration Record (TAR)] facility staff documented, yes, a check mark (meaning administered), and initialed to indicate that a shower was completed; 04/20/22 [physician's order] Skin Assessment weekly on shower day by license nurse every day shift every Thu (Thursday); 04/20/22 [physician's order] Shower twice a week and per patient request every day shift every Thu, Sat (Saturday); 04/21/22 (Thursday) [Shower/Bath Shower] .12 (skin intact/no irritation); complete bed bath; 04/21/22 treatment administration record [TAR] - facility staff initialed to indicate that the weekly skin assessment was completed; 04/22/22 at 7:34 PM Social Services Note . IDT (interdisciplinary team) meeting was held . No sig. (significant) changes to report resident is stable. A care plan with a review date of 4/22/22 documented the following: -Focus area [Resident #204] has an ADL self-care performance deficit r/t (related to) impaired balance and other conditions .Provide incontinent care with each incontinent episode. Wash peri area with soap and water, pat dry and apply barrier cream every shift and as needed. The resident requires assistance by staff with bathing/showering routinely and as necessary .The resident requires assistance by staff for toileting. -Focus area, [Resident #204] has bladder and bowel incontinence r/t deconditioning . Apply moisture barrier cream to skin after each incontinent care .Report any signs of skin breakdown. -Focus area, [Resident #204] has potential for impairment to skin integrity r/t fragile skin and Aspirin use . Keep skin clean and dry. Use lotion on dry skin. Provide incontinent care routinely and as needed. -Focus area, [Resident #204] is at risk for pressure ulcer development r/t immobility .administer medications as ordered . administer treatments as ordered . assess/record/monitor wound healing every shift . report improvements and declines to the D. On Resident #204's 04/23/22 treatment administration record (TAR) facility staff documented yes, a check mark, and initialed to indicate that a shower was completed. The 04/23/22 (Saturday) [Shower/Bath Sheet] documented .complete bed bath, however there was no licensed nurse signature on the form. The 04/26/22 at 11:29 AM Skin Observation Tool from the Licensed Nurse documented .No new skin issues noted. Review of the April 2022 TAR from 04/01/22 to 04/28/22, showed that facility staff documented N, meaning no or none, in the area that directed, Monitor skin for easy bruising, bleeding, skin discoloration .every shift and alert MD (medical doctor) with any changes. Staff also documented no refusal of care behaviors and that the resident was turned and repositioned every two hours. A 04/28/22 at 4:56 PM Podiatry Note documented, .Patient is seen bedside for thick, elongated toenails and wound right foot . Skin: Distal aspect of right hallux with noted sanguinous (sp) scab and eschar (dead tissue) to distal aspect, noted purulence and deep probing sinus . distal aspect of right 5th toe with noted dry sanguinous scab and eschar to distal aspect . recommend vascular consult to evaluate for healing potential. Ulcer right 5th toe. Dry eschar right 5th toe . Ulcer right Hallux. Pain right Hallux. Partial debridement of ulcer to patient tolerance. Noted deep probing and purulence during exam .Recommend starting antibiotics. Please obtain labs: CBC (complete blood count) with Diff (differential), CMP (complete metabolic panel), ESR (erythrocyte sedimentation rate) Please obtain x-rays of right foot to rule out osteomyelitis of right hallux. 04/29/22 at 9:23 AM Tissue Analytics . Right heel .Length: 2.45 cm; width: 2.67 cm; Wound acquired 4/29/22; [percent] epithelialization 100.00; Stat-s - new; Acquired in house? Yes; Etiology- pressure ulcer - Suspected DTI (deep tissue injury) .Dressing change frequency - daily, dressings- skin prep 04/29/22 at 1:55 PM Tissue Analytics Right great toe . Length: 1.40 cm, width: 1.60 cm; Wound Acquired 4/28/22, [percent] slough/eschar 100.00 .Stat-s - New; Acquired in House? Yes; Etiology Arterial .Dressing change frequency BID (twice a day), cleanse wound with- Normal Saline, dressing- Betadine A 04/29/22 at 10:20 AM Situation Background Assessment Request (SBAR) communication form documented the following: Situation: skin areas on right great toe red right heel. Date problem or symptom started: 04/29/2022 . resident had podiatry foot care at the bed side and then was observed with a right arterial area to the right great toe. Reddened area to the right heel. Skin intact. MD and RP (representative) aware. Treatment order in placed. A 04/29/22 at 11:10 AM late entry note indicated, Nurses Note Late Entry . Resident had Podiatry foot care at the bedside on 4/28/22 and a right great toe ulcer was observed after the podiatry care and Resident has reddened right heel, skin is intact. Responsible party . was made aware. No indication of pain. Right heel elevated on a pillow. The medical record contained wound notes stating: -04/29/22 at 2:18 PM Skin/Wound Note . Comprehensive skin and wound evaluation for consult: right heel, right great toe . Dermatologic - wound(s) present .Right heel DTI. Right great toe arterial ulcer .Patient seen by podiatry 4/28/22. Per podiatry, recommend vascular consultation to evaluate healing potential, recommend x-ray of right foot to rule out osteomyelitis of right hallux -04/29/22 at 2:21 PM Skin/Wound Note Late Entry . MD, R/P . made aware of resident's right heel wound and right great toe (podiatry-caused) wound. Nursing staff aware. The physician gave orders related to these areas on 05/2/22 to request the following: -05/02/22, Right great toe surgical site- Paint with Betadine (antiseptic) and secure with bordered gauze twice daily every day and evening shift for wound healing; and, -05/02/22, Right heel D-I - Apply Skin prep and leave open to air daily every day shift for wound healing. This order was discontinued on 5/9/22. Although the Tissue Analytics documented dressing orders on 4/29/22, there were no physician orders documented until '05/02/22, 4 days later. Furthermore, there was no documented evidence that licensed nursing staff performed dressing changes during those 4 days. Resident #204's care plan was updated on 5/4/22 to show the following: -focus area, [Resident #204] has a right great [toe] wound related to arterial insufficiency initiated on 05/04/22 showed .Administer treatment per physician orders. Notify physician and family/responsible party of skin condition. -focus area, [Resident #204] has right heel [DTI] initiated on 05/04/22 showed, .Apply skin moisturizers to skin as needed. Apply skin prep as ordered. Offload right heel with wedge/cushion foam as ordered. The podiatrist documented on 05/05/22 at 6:02 PM . follow-up wound right foot . Bandage to right heel left intact, deferred to wound care. Distal aspect of right hallux with noted eschar to distal aspect, noted scant purulence however improved since last exam .distal aspect of right 5th toe with noted dry sanguinous scab and eschar to distal aspect . recommend vascular to evaluate for healing potential (ordered) .Discussed with charge nurse as concern for deep infection . Consider antibiotics pending labs. Please obtain labs . order has been placed. Please obtain X-rays of right foot to rule out osteomyelitis of right hallux (noted order has been placed). Subsequent physician orders revealed: -05/05/22 [physician's order] CBC (complete blood count) with Diff (differential), ESR (erythrocyte sedimentation rate), CRP (c-reactive protein) next lab day, -05/05/22 [physician's order] X rays 3 views of right foot to r/o (rule out) osteomyelitis- deep wound, pain, physical limitation one time only, -05/05/22 [physician's order] Consult for vascular evaluation for healing potential . It should be noted that these treatments were recommended on 04/28/22, however the physician's order was not placed until 05/05/22, 8 days later. The orders were completed, and the results were: -05/07/22 at 10:23 PM Radiology Results Note .Date of Test: 5/6/2022. Type of Test: Right foot, complete, 3+ views . Findings . No evidence of osteomyelitis . -05/24/22 Report of Consultation . Vascular consult for wound healing potential . findings: dry stable gangrene of r (right) hallux . Diagnosis: toe gangrene . -06/08/22 at 10:04 PM Laboratory Note Results. Date of test: 6/8/2022. Type of test . CBC W/Diff . Actions/New Orders: Waiting for doctor's review . Although it was ordered on 05/05/22, the labs were not obtained until 06/08/22, 34 days later. The Nurse Practitioner documented on 06/09/22 at 1:04 PM, .Labs and medications reviewed. For Resident #204's right foot, the evidence mentioned above revealed that although facility staff documented to implementing the interventions for Resident #204 from 04/01/22 to 04/27/22, the resident was first observed with a right great toe wound at 100 percent eschar and a right 5th toe wound at 30 percent eschar on 04/28/22. Facility staff failed to have a doctor's order for dressing changes to the right foot for 4 days and failed to obtain ordered labs in a timely manner. B. Skin area #2- sacrum: 06/28/22 at 9:30 AM Skin Observation Tool (Licensed Nurse) . Site: Right heel. Type -pressure, length 3.79cm, width-4.58cm, depth, 0.0cm, stage -Suspected Deep Tissue Injury; R. (right) great toe site - type - arterial, length-1.28cm, width-0.71cm, depth -0.0cm, stage-N/A. Resident has treatment orders for the sites and is followed by the wound team. 06/29/22 at 12:26 AM Nurses Note . Resident is stable and verbally response .Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Continue monitoring skin wound on right foot. Wound dressing intact on right heel and right great toe. No drainage noted. Paint with Betadine prep on right great toe in this shift. Provide incontinent care with each incontinent episode. Wash peri- area with soap and water, pat dry and apply barrier cream in the evening shift. Extensive assist for ADL care provided . 06/30/22 at 3:25 PM Nurses Note . Resident is alert and verbally response .Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Both heels elevated with pillow to prevent pressure ulcer. Right heel and right great toe wound dressing intact, no drainage and redness noted, ADLS and oral hygiene provided by staff . 06/30/22 (Thursday) [Shower/Bath Sheet] .12 (skin intact/no irritation); condition of skin section was left blank; complete bed bath given. 07/01/22 at 8:02 AM Nurses Note .skin remain unchanged dry and warm to touch .Turned and repositioned every two hours . Right heel and right great toe wound dressing intact . 07/02/22 [Shower/Bath Sheet] condition of skin section showed facility staff documented a line and 12, indicating skin intact/no irritation and bed bath 07/02/22 at 11:40 PM Nurses Note . Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Continue monitoring skin wound on right foot. Wound dressing intact on right heel and right great toe .Provide incontinent care with each incontinent episode. Wash peri- area with soap and water, pat dry and apply barrier cream in the evening shift. Extensive assist for ADL care provided . 07/03/22 at 7:43 AM Nurses Note . Turned and repositioned every two hours. Both heels elevated with pillow to prevent pressure ulcer. Right heel and right great toe wound dressing intact . 07/03/22 at 3:35 PM Nurses Note .skin dry and warm to touch .Right heel and right big toe wound dressing is changed .ADL provided by staff. 07/03/22 at 11:35 PM Nurses Note .Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Continue monitoring skin wound on right foot. Changed wound dressing on right heel and right great toe .Provide incontinent care with each incontinent episode. Wash peri- area with soap and water, pat dry and apply barrier cream in the evening shift. The pressure ulcer is a little wider in the resident's coccyx area. Dressing done . There was no documented evidence that further actions such as further assessment of the resident, notifying the physician, or documenting a request for intervention was taken by the licensed staff on 07/03/22. 07/04/22 at 1:57 PM Nurses Note . Skin is warm to touch, well moisturized. No skin bruising, No skin bruising and bleeding noted . Right heel and right great toe wound dressing intact . Care plan focus area, [Resident #204] has potential for impairment to skin integrity r/t fragile skin and Aspirin use showed, .07/04/22 IDT meeting held. Care plan reviewed and updated .Patient has an actual wound/sacral DTI. Although it was discussed at the care plan meeting, there was no documented evidence that further actions such as further assessment of the resident, notifying the physician, or documenting a request for intervention was taken by the IDT on 07/04/22. 07/05/22 at 10:44 PM SBAR .Communication Tool . Situation Pressure ulcer on coccyx, approx. 10cm*10cm*0.2 .Date problem or symptom started 7/3/2022 . Identify whether the problem/symptom has gotten worse/better/stayed the same since it started- Worse . Pressure ulcer of coccyx area got wider and worse .Assessment: In my opinion, residents need active pressure ulcer treatment and care . The above SBAR showed that the licensed nurse completing the form listed her own name under the section person contacted. 07/05/22 at 11:09 PM Nurses Note .Continue monitoring skin wound on right foot and coccyx area. Wound dressing intact on right heel and right great toe .The pressure ulcer of coccyx area is more wider and worse. Approx. 10cm*10cm*0.2, drainage noted. Dressing changed. I notified to Dr. (doctor) about resident's condition via SBAR . Review of the July 2022 TAR from 07/01/22 to 07/05/22, showed that facility staff documented: N, meaning no or none, in the area that directed, Monitor skin for easy bruising, bleeding, skin discoloration .every shift and alert MD with any changes; no refusal of care behaviors; a check mark, and initials to indicate that incontinent care was provided with barrier cream applied to peri area every shift; and that the resident was turned and repositioned every two hours, every shift. From 07/03/22 to 07/05/22 (3 days), there was no documented evidence facility staff notified the physician or requested any intervention for Resident #204's sacral area. 07/06/22 at 3:30 PM SBAR .Communication Tool . Situation suspected DTI on the sacral . Date problem/symptom started 07/06/2022 .Person contacted . son [RP] . Provider visit [medical doctor's name] . 07/06/22 at 5:04 PM Skin Observation Tool (Licensed Nurse) . Site: sacrum. Type- pressure, length- 9.0cm, width-12.0cm, depth-0.0cm, stage- suspected deep tissue injury. Resident has a new area to the sacrum suspected DTI. Thin. Frail skin. Pressure relief mattress. Treatment order in place. Repositioning every 2 hours. Labs and Dietary consult. 07/06/22 [physician's order] Sacral Wound: Cleanse with normal saline solution; pat dry, apply silver alginate on wound bed and secure with borded (sp) gauge daily and PRN every day shift for skin care (discontinued 07/08/22) Care plan focus area, [Resident #204] has a new wound site DTI on the sacrum, fragile, thin skin initiated on 07/06/22 showed, Monitor/document wound . Notify physician as indicated. Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of infection . 07/07/22 at 11:22 AM Tissue Analytics . Location; sacrum; length 10.80 cm; width 9.48 cm; depth 0.10 cm . Date wound acquired 7/6/22; [percent] slough/eschar 30.00; Wound status - new; acquired in house? Yes . For Resident #204's sacrum area, the above evidence revealed that facility staff failed to: accurately assess, document on the resident's skin on 07/03/22 and report signs of worsening skin breakdown. Additionally, facility staff failed to notify the physician for 3 days after the sacrum wound was first documented as more wider. Subsequently, when seen by the wound Nurse Practitioner on 07/07/22, the sacral area measured 10.80 cm by 9.48 cm by 0.10 cm deep with 30% eschar. During a face-to-face interview on 09/15/22 at 3:25 PM, Employee #2 (Director of Nursing/DON) reviewed the shower/bath sheets for Resident #204 and stated, When the CNA (Certified Nurse Aide) is giving the resident a shower or bath, the nurse is to go in to do the head-to-toe skin assessment with the CNA present. The nurse documents what she sees and they both [CNA and nurse] sign the bath sheet. The Condition of Skin section should always be completed. It documents the resident's current wounds or skin issues and anything new that is noted. If the resident refuses the shower, bath or skin assessment, it is documented on the form, the progress note and the MD and RP are notified. During a telephone interview on 09/15/22 at 4:34 PM, Employee #6 (Podiatrist) stated, I saw [Resident #204] in April (2022) as part of regular podiatry services at the facility done every Thursday. I noted a dry, stable, eschar wound on the right 5th toe and a dry, eschar area near the right big toe. I started to debride the area [right big toe] and pus just started coming out. The nurse was in there with me. I wrote the recommendations [labs, x-ray, and ultrasound] in my note. When I came in on May 5th (2022), I saw that none of the recommendations were followed, so I wrote them again and they were finally ordered. During a face-to-face interview conducted on 09/16/22 at 9:32 AM, Employee #7 (Staff Educator/1 north Unit Manager) reviewed the progress notes and licensed skin assessments for Resident #204 for April 2022 and stated, Looking at the resident's feet is part of the skin assessment. [Resident #204] started getting the wounds on her right foot treated after she was seen by the podiatrist. The staff [nurses and CNAs] did not mention to me that they observed any skin issues on [Resident #204's] feet. Employee #7 then reviewed the July 2022 progress notes and the 07/05/22 SBAR for Resident #204 and stated, The staff documented to doing skin assessments but there's no mention of anything being on her sacrum area until July 3rd [2022]. Whoever first notices the change in the skin is the one who makes the doctor and family aware. The nurses know to notify the doctor immediately for any changes and to document it in the progress notes. This SBAR [dated 07/05/22] was not done properly. Another one was done on the 6th [07/06/22] where the family and doctor were notified.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident and staff interviews, for one (1) of 63 sampled residents, facility staff failed to ensure residents received care consistent with the professional standards of practice to prevent the development of pressure ulcers. Resident #204. These failures resulted in actual harm to Resident #204 when the resident obtained facility acquired ulcers first observed at advanced stages. The findings included: Review of the facility's Wound Prevention Program policy (not dated) showed, .Weekly skin checks will be conducted by the license nurse. This will be documented in the resident's Electronic Medical Record (EMR). Daily, during routine care, the Certified Nursing Assistant will observe the resident's skin. When abnormalities are noted this will be communicated to the licensed nurse . Review of the facility's Treatment/Services to Prevent/Heal Pressure policy (not dated) showed, . The facility will ensure that . a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers . a resident with pressure ulcers receive necessary treatment and services . to promote healing, prevent infection and prevent e ulcers from developing . the nurse will notify the physician anytime the pressure sore is showing signs of non-healing or infection . Review of the facility's Wound/Pressure Ulcer Management policy, revised on 10/01/21 showed, . Any alteration in skin integrity will be reported to the physician immediately . Facility staff failed to ensure Resident #204 received care, consistent with professional standards of practice, to prevent pressure ulcer development found at advanced stages. Resident #204 was admitted to the facility on [DATE] with multiple diagnoses that included: Mild Protein-Calorie Malnutrition, Dementia, Altered Mental Status, Muscle Weakness and Osteoporosis. Review of a Complaint, DC00010905, received by the State Agency on 07/29/22 showed, . [Facility Name] failed to provide the proper care and appropriate care owed to its long-term resident . [Resident #204] was neglected and sustained significant physical injuries over an unknown period which resulted in her current hospitalization . Review of Resident #204's medical record revealed the following: 07/14/21 [physician's order] Monitor skin for easy bruising (EB), bleeding (B), Skin Discoloration (SD), None (N) every shift and Alert MD with any changes, Resident on Aspirin EC (enteric coated) daily 08/26/21 [physician's order] Provide incontinent care with each incontinent episode. Wash peri area with soap and water, pat dry and apply barrier cream every shift and as needed 03/03/22 [physician's order] Shower twice a week on Monday and Wednesday and per patient request . (Discontinued on 04/20/22) An Annual Minimum Data Set (MDS) dated [DATE], showed that facility staff coded: A Brief interview for Mental Status (BIMS) summary score of 7, indicating severe cognitive impairment; required total dependence with one to -two persons physical assist for bed mobility, transfers; extensive assistance with one person physical assist for toilet use and personal hygiene; frequently incontinent of urine and bowel; active diagnoses of Anemia; no significant weight loss; at risk for pressure ulcers; and no pressure ulcers, wounds or other skin problems. Skin area #1- right foot: 04/18/22 at 4:28 PM Nurses Note .Skin warm to touch and no new skin issues noted. Continued to require total care with all ADL (activities of daily living) cares. Turned and repositioned for pressure relief . 04/19/22 at 5:14 PM Skin Observation Tool (Licensed Nurse) . skin is intact, warm and well lubricated. No wound 04/20/22 [Treatment Administration Record (TAR)] facility staff documented yes, a check mark (meaning administered), and initialed to indicate that a shower was completed. 04/20/22 [physician's order] Skin Assessment weekly on shower day by license nurse every day shift every Thu (Thursday) 04/20/22 [physician's order] Shower twice a week and per patient request every day shift every Thu, Sat (Saturday) 04/21/22 (Thursday) [Shower/Bath Sheet] .12 (skin intact/no irritation); complete bed bath 04/21/22 [TAR] - facility staff initialed to indicate that the weekly skin assessment was completed 04/22/22 at 7:34 PM Social Services Note . IDT (interdisciplinary team) meeting was held . No sig. (significant) changes to report resident is stable . Care plan focus area, [Resident #204] has an ADL self-care performance deficit r/t (related to) impaired balance and other conditions, reviewed on 04/22/22 showed, Provide incontinent care with each incontinent episode. Wash peri area with soap and water, pat dry and apply barrier cream every shift and as needed. The resident requires assistance by staff with bathing/showering routinely and as necessary .The resident requires assistance by staff for toileting . Care plan focus area, [Resident #204] has bladder and bowel incontinence r/t deconditioning reviewed on 04/22/22 showed, Apply moisture barrier cream to skin after each incontinent care. Calazime (skin protectant paste) cream to buttocks and perineal area with incontinent changes every shift. Incontinent check every two hours and change when soiled and PRN (as needed). Report any signs of skin breakdown. Care plan focus area, [Resident #204] has potential for impairment to skin integrity r/t fragile skin and Aspirin use reviewed on 04/22/22 showed, Keep skin clean and dry. Use lotion on dry skin. Provide incontinent care routinely and as needed . Care plan focus area, [Resident #204] is at risk for pressure ulcer development r/t immobility reviewed on 04/22/22 showed, .administer medications as ordered . administer treatments as ordered . assess/record/monitor wound healing every shift . report improvements and declines to the MD. 04/23/22 [TAR] facility staff documented yes, a check mark, and initialed to indicate that a shower was completed 04/23/22 (Saturday) [Shower/Bath Sheet] .complete bed bath. There was no licensed nurse signature on the form. 04/26/22 at 11:29 AM Skin Observation Tool (Licensed Nurse) .No new skin issues noted Review of the April 2022 TAR from 04/01/22 to 04/28/22, showed that facility staff documented: N, meaning no or none, in the area that directed, Monitor skin for easy bruising, bleeding, skin discoloration .every shift and alert MD (medical doctor) with any changes; no refusal of care behaviors; and that the resident was turned and repositioned every two hours. 04/28/22 at 4:56 PM Podiatry Note . Patient is seen bedside for thick, elongated toenails and wound right foot . Skin: Distal aspect of right hallux with noted sanguinous (sp) scab and eschar (dead tissue) to distal aspect, noted purulence and deep probing sinus . distal aspect of right 5th toe with noted dry sanguinous scab and eschar to distal aspect . recommend vascular consult to evaluate for healing potential. Ulcer right 5th toe. Dry eschar right 5th toe . Ulcer right Hallux. Pain right Hallux. Partial debridement of ulcer to patient tolerance. Noted deep probing and purulence during exam .Recommend starting antibiotics. Please obtain labs: CBC with Diff, CMP, ESR, CMP. Please obtain x-rays of right foot to rule out osteomyelitis of right hallux . 04/29/22 at 9:23 AM Tissue Analytics . Right heel .Length: 2.45 cm; width: 2.67 cm; Wound acquired 4/29/22; [percent] epithelialization 100.00; Status - new; Acquired in house? Yes; Etiology- pressure ulcer - Suspected DTI (deep tissue injury) .Dressing change frequency - daily, dressings- skin prep . 04/29/22 at 1:55 PM Tissue Analytics Right great toe . Length: 1.40 cm, width: 1.60 cm; Wound Acquired 4/28/22, [percent] slough/eschar 100.00 .Status - New; Acquired in House? Yes; Etiology Arterial .Dressing change frequency BID (twice a day), cleanse wound with- Normal Saline, dressing- Betadine . 04/29/22 at 10:20 AM Situation Background Assessment Request (SBAR) .Communication Tool .Situation: skin areas on right great toe red right heel. Date problem or symptom started: 04/29/2022 . resident had podiatry foot care at the bed side and then was observed with a right arterial area to the right great toe. Reddened area to the right heel. Skin intact. MD and RP (representative) aware. Treatment order in place. 04/29/22 at 11:10 AM Nurses Note Late Entry . Resident had Podiatry foot care at the bedside on 4/28/22 and a right great toe ulcer was observed after the podiatry care and Resident has reddened right heel, skin is intact. Responsible party . was made aware. No indication of pain. Right heel elevated on a pillow. 04/29/22 at 2:18 PM Skin/Wound Note . Comprehensive skin and wound evaluation for consult: right heel, right great toe . Dermatologic - wound(s) present .Right heel DTI. Right great toe arterial ulcer .Patient seen by podiatry 4/28/22. Per podiatry, recommend vascular consultation to evaluate healing potential, recommend x-ray of right foot to rule out osteomyelitis of right hallux . 04/29/22 at 2:21 PM Skin/Wound Note Late Entry . MD, R/P . made aware of resident's right heel wound and right great toe (podiatry-caused) wound. Nursing staff aware. 05/02/22 [physician's order] Right great toe surgical site- Paint with Betadine (antiseptic) and secure with bordered gauze twice daily every day and evening shift for wound healing 05/02/22 [physician's order] Right heel DTI - Apply Skin prep and leave open to air daily every day shift for wound healing (discontinued on 05/09/22) The evidence showed that the Tissue Analytics documented dressing orders however, there was no physician's orders until 05/02/22, 4 days later. Furthermore, there was no documented evidence that licensed staff performed dressing changes during those 4 days. 05/05/22 at 6:02 PM Podiatry Note .follow-up wound right foot . Bandage to right heel left intact, deferred to wound care. Distal aspect of right hallux with noted eschar to distal aspect, noted scant purulence however improved since last exam .distal aspect of right 5th toe with noted dry sanguinous scab and eschar to distal aspect . recommend vascular to evaluate for healing potential (ordered) .Discussed with charge nurse as concern for deep infection . 05/05/22 [physician's order] Consult for vascular evaluation for healing potential . 05/07/22 at 10:23 PM Radiology Results Note .Date of Test: 5/6/2022. Type of Test: Right foot, complete, 3+ views . Findings . No evidence of osteomyelitis . 05/24/22 Report of Consultation . Vascular consult for wound healing potential . findings: dry stable gangrene of r (right) hallux . Diagnosis: toe gangrene . For Resident #204's right foot, the evidence mentioned above revealed that although facility staff documented to implementing the interventions for Resident #204 from 04/01/22 to 04/27/22, the resident was first observed with a right great toe wound at 100 percent eschar and a right 5th toe wound at 30 percent eschar on 04/28/22. Facility staff failed to have a doctor's order for dressing changes to the right foot for 4 days. Skin area #2- sacrum: 06/28/22 at 9:30 AM Skin Observation Tool (Licensed Nurse) . Site: Right heel. Type -pressure, length 3.79cm, width-4.58cm, depth, 0.0cm, stage -Suspected Deep Tissue Injury; R. (right) great toe site - type - arterial, length-1.28cm, width-0.71cm, depth -0.0cm, stage-N/A. Resident has treatment orders for the sites and is followed by the wound team. 06/29/22 at 12:26 AM Nurses Note . Resident is stable and verbally response .Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Continue monitoring skin wound on right foot. Wound dressing intact on right heel and right great toe. No drainage noted. Paint with Betadine prep on right great toe in this shift. Provide incontinent care with each incontinent episode. Wash peri- area with soap and water, pat dry and apply barrier cream in the evening shift. Extensive assist for ADL care provided . 06/30/22 at 3:25 PM Nurses Note . Resident is alert and verbally response .Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Both heels elevated with pillow to prevent pressure ulcer. Right heel and right great toe wound dressing intact, no drainage and redness noted, ADLS and oral hygiene provided by staff . 06/30/22 [Shower/Bath Sheet] .12 (skin intact/no irritation); condition of skin section was left blank; complete bed bath given. 07/01/22 at 8:02 AM Nurses Note .skin remain unchanged dry and warm to touch .Turned and repositioned every two hours . Right heel and right great toe wound dressing intact . 07/02/22 [Shower/Bath Sheet] condition of skin section showed facility staff documented a line and 12, indicating skin intact/no irritation and bed bath 07/02/22 at 11:40 PM Nurses Note . Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Continue monitoring skin wound on right foot. Wound dressing intact on right heel and right great toe .Provide incontinent care with each incontinent episode. Wash peri- area with soap and water, pat dry and apply barrier cream in the evening shift. Extensive assist for ADL care provided . 07/03/22 at 7:43 AM Nurses Note . Turned and repositioned every two hours. Both heels elevated with pillow to prevent pressure ulcer. Right heel and right great toe wound dressing intact . 07/03/22 at 3:35 PM Nurses Note .skin dry and warm to touch .Right heel and right big toe wound dressing is changed .ADL provided by staff. 07/03/22 at 11:35 PM Nurses Note .Skin is warm to touch, well moisturized. No skin bruising, bleeding noted. Continue monitoring skin wound on right foot. Changed wound dressing on right heel and right great toe .Provide incontinent care with each incontinent episode. Wash peri- area with soap and water, pat dry and apply barrier cream in the evening shift. The pressure ulcer is a little wider in the resident's coccyx area. Dressing done . There was no documented evidence that further actions such as further assessment of the resident, notifying the physician, or documenting a request for intervention was taken by the licensed staff on 07/03/22. 07/04/22 at 1:57 PM Nurses Note . Skin is warm to touch, well moisturized. No skin bruising, No skin bruising and bleeding noted . Right heel and right great toe wound dressing intact . Care plan focus area, [Resident #204] has potential for impairment to skin integrity r/t fragile skin and Aspirin use showed, .07/04/22 IDT meeting held. Care plan reviewed and updated .Patient has an actual wound/sacral DTI. Although it was discussed at the care plan meeting, there was no documented evidence that further actions such as further assessment of the resident, notifying the physician, or documenting a request for intervention was taken by the IDT on 07/04/22. 07/05/22 at 10:44 PM SBAR .Communication Tool . Situation Pressure ulcer on coccyx, approx. 10cm*10cm*0.2 .Date problem or symptom started 7/3/2022 . Identify whether the problem/symptom has gotten worse/better/stayed the same since it started- Worse . Pressure ulcer of coccyx area got wider and worse .Assessment: In my opinion, residents need active pressure ulcer treatment and care . The above SBAR showed that the licensed nurse completing the form listed her own name under the section person contacted. 07/05/22 at 11:09 PM Nurses Note .Continue monitoring skin wound on right foot and coccyx area. Wound dressing intact on right heel and right great toe .The pressure ulcer of coccyx area is more wider and worse. Approx. 10cm*10cm*0.2, drainage noted. Dressing changed. I notified to Dr. (doctor) about resident's condition via SBAR . Review of the July 2022 TAR from 07/01/22 to 07/05/22, showed that facility staff documented: N, meaning no or none, in the area that directed, Monitor skin for easy bruising, bleeding, skin discoloration .every shift and alert MD with any changes; no refusal of care behaviors; a check mark, and initials to indicate that incontinent care was provided with barrier cream applied to peri area every shift; and that the resident was turned and repositioned every two hours, every shift. From 07/03/22 to 07/05/22 (3 days), there was no documented evidence facility staff notified the physician or requested any intervention for Resident #204's sacral area. 07/06/22 at 3:30 PM SBAR .Communication Tool . Situation suspected DTI on the sacral . Date problem/symptom started 07/06/2022 .Person contacted . son [RP] . Provider visit [medical doctor's name] . 07/06/22 at 5:04 PM Skin Observation Tool (Licensed Nurse) . Site: sacrum. Type- pressure, length- 9.0cm, width-12.0cm, depth-0.0cm, stage- suspected deep tissue injury. Resident has a new area to the sacrum suspected DTI. Thin. Frail skin. Pressure relief mattress. Treatment order in place. Repositioning every 2 hours. Labs and Dietary consult. 07/06/22 [physician's order] Sacral Wound: Cleanse with normal saline solution; pat dry, apply silver alginate on wound bed and secure with borded (sp) gauge daily and PRN every day shift for skin care (discontinued 07/08/22) Care plan focus area, [Resident #204] has a new wound site DTI on the sacrum, fragile, thin skin initiated on 07/06/22 showed, Monitor/document wound . Notify physician as indicated. Monitor/document/report PRN (as needed) any s/sx (signs and symptoms) of infection . 07/07/22 at 11:22 AM Tissue Analytics . Location; sacrum; length 10.80 cm; width 9.48 cm; depth 0.10 cm . Date wound acquired 7/6/22; [percent] slough/eschar 30.00; Wound status - new; acquired in house? Yes . For Resident #204's sacrum area, the above evidence revealed that facility staff failed to: accurately assess, document on the resident's skin on 07/03/22 and report signs of worsening skin breakdown. Additionally, facility staff failed to notify the physician for 3 days after the sacrum wound was first documented as more wider, subsequently, when seen by the wound Nurse Practitioner on 07/07/22, the sacral area measured 10.80 cm by 9.48 cm by 0.10 cm deep with 30% eschar. During a face-to-face interview on 09/15/22 at 3:25 PM, Employee #2 (Director of Nursing/DON) reviewed the shower/bath sheets for Resident #204 and stated, When the CNA (Certified Nurse Aide) is giving the resident a shower or bath, the nurse is to go in to do the head-to-toe skin assessment with the CNA present. The nurse documents what she sees and they both [CNA and nurse] sign the bath sheet. The Condition of Skin section should always be completed. It documents the resident's current wounds or skin issues and anything new that is noted. If the resident refuses the shower, bath or skin assessment, it is documented on the form, the progress note and the MD and RP are notified. During a telephone interview on 09/15/22 at 4:34 PM, Employee #6 (Podiatrist) stated, I saw [Resident #204] in April (2022) as part of regular podiatry services at the facility done every Thursday. I noted a dry, stable, eschar wound on the right 5th toe and a dry, eschar area near the right big toe. I started to debride the area [right big toe] and pus just started coming out. The nurse was in there with me. I wrote the recommendations [labs, x-ray, and ultrasound] in my note. When I came in on May 5th (2022), I saw that none of the recommendations were followed, so I wrote them again and they were finally ordered. During a face-to-face interview conducted on 09/16/22 at 9:32 AM, Employee #7 (Staff Educator/1 north Unit Manager) reviewed the progress notes and licensed skin assessments for Resident #204 for April 2022 and stated, Looking at the resident's feet is part of the skin assessment. [Resident #204] started getting the wounds on her right foot treated after she was seen by the podiatrist. The staff [nurses and CNAs] did not mention to me that they observed any skin issues on [Resident #204's] feet. Employee #7 then reviewed the July 2022 progress notes and the 07/05/22 SBAR for Resident #204 and stated, The staff documented to doing skin assessments but there's no mention of anything being on her sacrum area until July 3rd [2022]. Whoever first notices the change in the skin is the one who makes the doctor and family aware. The nurses know to notify the doctor immediately for any changes and to document it in the progress notes. This SBAR [dated 07/05/22] was not done properly. Another one was done on the 6th [07/06/22] where the family and doctor were notified. Cross Reference DCMR 3211.1

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews, for three (3) of 63 sampled residents, facility staff failed to provide adequate supervision and assistance to residents to prevent accidents and injury as evidenced by: 1. failure to secure Resident #3's wheelchair with the seatbelt in the transportation van; 2. failure to assign a 1:1 monitor to Resident #505; and 3. failure to provide Resident #176 with 1:1 supervision while in the courtyard. (Residents' #3, #505 and #176) These failures resulted in actual harm to Resident #3, example #1. The findings included: 1. Facility staff failed to provide adequate supervision to Resident #3, who was not secured in the transportation van with a seatbelt and subsequently sustained an injury when he flipped out of his wheelchair during transport to an appointment. Review of the facility's policy entitled, Resident Transportation To and From Medical Appointment (revised 07/2022) documented, The assigned Certified Nursing Assistance (Certified Nursing Aide/CNA) or designee will ensure the resident is safe and well strapped and secure with the belt .while in the transportation van. Resident #3 was re-admitted to the facility on [DATE] with diagnoses that included: Acute Osteomyelitis, Atherosclerosis of Native Arteries of Extremities with Intermittent Claudication Right Leg, Hemiplegia, Spinal Instabilities of the Cervical Region and Generalized Muscle Weakness. A Quarterly Minimum Data Set (MDS) dated [DATE] documented that facility staff coded: severely impaired cognition; upper and lower extremity impairment on one side; required extensive assistance for transfers; and using an (electrical) wheelchair for mobility. A facility reported incident (DC00010380) received by the State Agency on 11/04/21 at 5:20 PM documented, Resident left the facility this morning at about 10:20 AM, for a scheduled Vascular appointment .with his electric wheelchair accompanied by the facility escort with a Medicaid transportation . At about 11:36 AM on 11/3/2021, the escort who accompanied the resident for the appointment called the facility and stated ,'When we got into the van, the residents ('s) wheelchair was secured by the van driver. The car in front of us made an illegal stop to make a left turn, the driver of our van made an abrupt stop to prevent hitting the car in front of us, and [Resident #3] fell from his chair and landed on the floor . I then called the facility, and the facility asked for the resident to be transferred to the emergency room for further evaluation and treatment.' .the resident was transported to hospital . Per ER (Emergency Room) nurse, a CT (Computed Tomography) , spine cervical w/o contrast and a CT Head w/o (without) contrast were completed with the result showing: 'Comminuted fractures of the right lateral mass of C1 and anterior and posterior ring of C1. Nondisplaced fracture of the right lateral mass of C3' . A review of Resident #3's medical record revealed: 11/03/21 at 5:02 PM, SBAR Situation: The resident had a motor vehicle accident (MVA) on the way to a scheduled vascular appointment at [Local Hospital] and sustained a fracture .Additional Comments: The resident left the facility this morning at about 10:20 AM for a scheduled vascular appointment .At about 11:00 AM on 11/3/2021, per the escort, 'The car in front of us made an illegal stop to make a left turn, the driver of our van made an abrupt stop to prevent hitting the car in front of us and [Resident #3] fell from his chair and landed on the floor. I immediately told the driver to pull over and stop so we can attend to [Resident #3] which he did.' During a face-to-face interview on 09/22/22 at 2:03 PM, Employee #27 (CNA and escort assigned to Resident #3) stated, The driver put the resident on the van using the lift, and I locked the resident's wheelchair. When asked who secured the resident with the seatbelt, the Employee responded, I went to secure the resident, but the driver said, 'Sit down, I got it.' Normally, I would have grabbed the seatbelt to put it on the resident, but the driver told me to sit down, so I did .The driver was on his phone and wasn't paying attention. I tried to let him [the driver] know that my resident was not secure as we pulled off, but he continued to ignore me. The next thing I knew, the driver hit the brakes. [Resident #3] was thrown out of his wheelchair, and [was] lying beside me on the floor of the van. I yelled, 'Sir, Stop, Stop, my resident,' The van driver then pulled over. I called the Nurse Manager to let her know what happened and to see if the resident needed to be transported to the hospital. Facility staff failed to ensure that Resident #3 was well strapped and secure with a seatbelt prior to the transport van being put into motion. Subsequently, when the van drive hit the brakes on the van, the resident was thrown out of his wheelchair and sustained a fracture. These failures resulted in harm to the resident. 2. Facility staff failed to provide Resident #505 with a 1:1 monitor on 09/20/22, subsequently the resident went missing for 30 minutes in the facility. Resident #505 was admitted to the facility on [DATE] with diagnoses that included: Other Symptoms and Signs Involving Cognitive Awareness, Altered Mental Status, Anxiety Disorder, Schizoaffective Disorder, Unspecified Dementia with Behavioral Disturbance, and Disorientation. Review of Resident #505's medical record revealed: 09/02/22 [admission Minimum Data Set (MDS)] documented that facility staff coded Resident #505 with a Brief Interview for Mental Status (BIMS) summary score of 07, indicating severely impaired cognition. Under Section E (Behaviors), facility staff coded the resident for displaying behavior symptoms of hitting, kicking, pushing, scratching, grabbing, threatening, screaming, and cursing others, as well as wandering and intruding on the privacy of others. 09/02/22 [Physician's Order]: Psychological consult and treatment as needed. 09/03/22 [Physician Order] Resident on 1:1 Nursing Supervision for Elopement and Fall Risk every shift . During a unit tour of 3 North conducted on 09/20/22 at 2:52 PM, the surveyor observed that Resident #505 was not in his room. At the time of the observation when asked where Resident #505 was Employee #33 (Unit Manager) stated that she thought the resident was attending a group activity on the first floor. A second observation on 09/20/22 at approximately 2:53 PM revealed that Resident #505 was not in the activity room on the first floor. Employee #34 (Activities Staff), confirmed that the resident was not in attendance for the activity. During a face-to-face interview on 09/20/22 at 3:00 PM, when asked if Resident #505 was still on 1:1 monitoring, Employee #2 (DON) stated, Yes. The surveyor then informed Employee #2 that at approximately 2:55 PM, Resident #505 was not observed in his room, or in the activity group on the first floor. The Employee then stated that she would go to the unit to investigate this herself. At 3:15 PM on Unit 3 North, the surveyor observed Employee #2 (DON) checking the unit's assignment board. Employee #2 then asked Employee #33 (Unit Manager), Who was assigned as the one to one monitor for [Resident #505] today? Employee #33 replied, I asked Employee #35 (Staffing Coordinator) about this, and he told me there was no one to one coverage for residents on the unit today. It should be noted at 3:20 PM, a Code Pink-Elopement Risk was initiated and Resident #505 was located by staff at 3:25 PM in the 3 North dining room. During a second face-to-face interview on 09/20/22 at 3:40 PM, Employee #2 (DON) stated that both Employee #33 (3rd Floor Unit Manager) and Employee #35 (Staffing Coordinator) knew that Resident #505 had orders for 1:1 monitoring, and should have called her if there was any question. Employee #2 acknowledged that facility staff failed to provide adequate 1:1 monitoring and supervision to Resident #505. 3. Facility staff failed to provide 1:1 supervision of Resident #176 while in the courtyard. Review of the facility's policy titled Smoking policy with a revision date of 10/01/21, documented Residents will be supervised by staff when smoking . Resident #176 was admitted to the facility on [DATE] with diagnoses that included: Alcohol Abuse with Intoxication, Anemia and Atrial Fibrillation. Review of Resident #176's medical record revealed the following: Care plan focus area, [Resident #176] has a behavior problem of drinking liquor in the facility r/t (related to) life style revised on 08/19/22 showed, .can go to [Store] with facility staff or family member .1:1 supervision while in courtyard (initiated 06/08/22) . A Quarterly Minimum Data Set (MDS) dated [DATE] showed facility staff coded: intact cognition; no physical or verbal behavioral symptoms directed towards others; independent with activities of daily living (ADLs); required supervision for locomotion off the unit; and used a wheelchair for mobility. The facility's visitor log for 09/20/22 showed that Resident #176 had a visitor that took him out of the facility at 12:21 PM and returned at 2:00 PM. During an observation on 09/22/22 at approximately 4:30 PM on unit 4 South, Resident #176 was observed yelling profanities at facility staff as he wheeled himself past the nurses' station with two security officers behind him. When asked what was going on, Employee #12 (Security Officer) stated, I saw [Resident #176] coming in from the courtyard (smoking area) with a bottle of alcohol in his lap that was 75% already drunken. I said to him he's not allowed to have that and he started yelling and cussing at me and got in the elevator. I called [Employee #1/Administrator]. The other security officer came with me and we followed him up here. Review of the smoke aide schedule for 09/22/22 evening shift 3:00 PM - 11:00 PM showed that two employees were scheduled for the courtyard, Employees' #16 and #17, both Smoke Aides. During a face-to-face interview conducted on 09/23/22 at 11:39 AM, when asked if she was aware that Resident #176 required 1:1 supervision at all times when in the courtyard, Employee #16 stated, No. During a telephone interview conducted on 09/23/22 at 11:45 AM, Employee #17 stated that he also was not aware that Resident #176 required 1:1 supervision while in the courtyard. During a face-to-face interview conducted on 09/23/22 at 5:49 PM, Employee #2 (Director of Nursing) stated that administration and the IDT have been trying to work with Resident #176 regarding his drinking alcohol on the premises. Regarding the 1:1 supervision, the employee stated, We don't have the staff for it.