**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, and staff interview, it was determined the facility failed to ensure resident's right were protected to be free from abuse. This was true for 1 of 1 resident (Resident #87) reviewed for abuse. This failure caused harm to Resident #87 and placed all residents at risk for ongoing abuse and potential physical and psychosocial harm. Findings include:The facility's Reporting Reasonable Suspicion of a Crime policy revision date April 2025, documented it was the policy of the facility to protect its residents from abuse, neglect, exploitation, and misappropriate of resident property.Resident #87 was admitted to the facility on [DATE], with the multiple diagnoses including parkinson's and dementia.Review of Resident #87's quarterly MDS, dated [DATE], indicated Resident #87 had a BIMS (Brief Interview For Mental Status) of 15, indicating no cognitive impairment.Resident #113 was admitted to the facility on [DATE], with multiple diagnoses including cerebral infarction (when blood flow to the brain is interrupted, leading to cell death and brain damage) and anxiety.A review of Resident #113's discharge MDS dated [DATE], indicated he had a BIMS of 15, indicating no cognitive impairment.A Nurse Practitioner note dated 1/17/25, documented Resident #113 stated that while he was out of facility, he was having significant anxiety and restlessness with suicidal ideations with a plan for self-harm and means to carry this out. Now that he is in the facility, he feels safe but continues to have fluctuating moods and behaviors with anxiety, he has declined to restart citalopram (an antidepressant medication).A Nurses Notes dated 3/7/25 at 12:43 PM, documented Resident #113 approached the nurse for a Norco (opioid pain medication). The nurse explained to Resident #113 that his Norco was not due until 2 AM. The nurse offered Tylenol, and he declined it. Resident #113 stated that he needed to get out of the building so he can self-medicate. The nurse reminded Resident #113 that he was on a pain contract and that it needed to be followed. Resident #113 then told the nurse that she better have his pain pill at 2:00 AM, and she better not be late. Resident #113 then stated the nurse better not write any notes on him or else.Resident #113's Behavior Noted dated 3/8/25, documented he approached the nurse and told the nurse I am going to leave this place I am tired of waiting for you to give me my meds. Resident #113 then told the nurse he was going to go to the overpass, jump Infront of the first diesel truck he could find and kill himself. The nurse asked the patient to clarify his intentions, and the patient repeated that if he did not get his goddamn pills. that he was going to kill himself. The nurse then requested he remain at the first-floor nurses' station and CNAs monitored Resident #113 from a safe distance while the nurse contacted and spoke to the second-floor nurse regarding this change in cognition and the statement he had made.A facility incident report, dated on 3/13/25 at 4:30 PM, documented Resident #113 was observed hitting Resident #87 in the face causing bruising and facial laceration to left orbital area with redness to the sclera and nose.The facility's incident report documented the following immediate actions were taken:Residents were separated.Both residents assessed for injuries and treated as needed.Resident #113 was placed on 1:1 observation. Police were notified and Resident #113 was arrested.Psychosocial evaluation was completed on Resident #87 with no additional findings.Residents were interviewed and no reported concerns were noted.Resident #87 and Resident #113's family resident representative were notified of the incident.On 9/10/25 at 3:52 PM, the Executive Director stated the resident-to-resident abuse did happen and the staff immediately separated the residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, review of the State Agency's Long Term Care Reporting Portal, and staff interview, it was determined the facility failed to ensure residents' rights were protected to be free from sexual abuse. This was true for 1 of 9 residents (Resident #63) reviewed for abuse. Application of the reasonable person concept caused harm to Resident #63 when she was inappropriately touched by Resident #42. Findings include: The Centers for Medicare and Medicaid Services (CMS) Psychosocial Outcome Severity Guide, dated October 2022, states: The following are examples of circumstances in which a resident's psychosocial outcome may not be readily determined through the investigative process and the reasonable person concept should be used: - When a resident may not be able to express their feelings, there is no discernable response, or when circumstances may not permit the direct evaluation of the resident's psychosocial outcome. Such circumstances may include, but are not limited to, the resident's death, cognitive impairments, physical impairments, or insufficient documentation by the facility; or - When a resident's reaction to a deficient practice is markedly incongruent (or different) with the level of reaction a reasonable person in the resident's position would have to the deficient practice. The Guide further states: In addition to the evidence gathered by the surveyor, the use of the reasonable person concept should be applied and may reveal that the resident is likely to, or may potentially, suffer a greater psychosocial outcome. For example, in the case of a sexual assault, the resident did not exhibit a change in behavior as a result of the incident. The facility's Abuse Prevention Policy, revised December 2016, documented residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. - Resident #63 was admitted to the facility on [DATE], with multiple diagnosis including heart failure and dementia. An annual MDS assessment, dated 10/20/23, documented Resident #63 was severely cognitively impaired. - Resident #42 was readmitted to the facility on [DATE], with multiple diagnoses including respiratory failure and liver disease. A quarterly MDS assessment, dated 9/14/23, documented Resident #42 was moderately cognitively impaired. a. A Facility Reported Investigation, dated 10/1/23 at 9:50 AM, documented There were two staff members sitting at the nurses' station doing some charting. On the other side of the counter [Resident #63] was sitting as she does often. At that time [Resident #42] walked up next to [Resident #63]. The staff at the desk said they were just talking but when another staff member walked up on the same side these two residents were sitting it was noted [Resident #42] was massaging [Resident #63's] breasts on top of her clothes. She was not upset and appeared to be enjoying this. The staff member who saw this separated them and alerted the nurse. Both residents are severely cognitively impaired and unable to make their own choices. The nurse assessment found no injury and no pain reported. {Resident #42] was moved downstairs to separate the two. Families were notified and facility leadership also immediately called. Both residents placed on alert charting and frequent checks. The report conclusion documented after interviews, observation, and record reviews, that Resident #42 thought Resident #63 was his wife because he remembered that she passed away. The report documented Resident #63 was pleasant and seemed to enjoy interactions with Resident #42 and did not protest when his interactions turned inappropriate. The report further documented both residents' cognition was at a level they were not able to make these kinds of decisions. The facility moved Resident #42 to a downstairs room so the residents would have little or no contact. b. A second Facility Reported Investigation, dated 10/6/23 at 4:37 PM, documented [Resident #63 was sitting in the dining room. Staff had placed her there just 10 minutes prior. [Resident 42] somehow came upstairs via the elevator and came into the dining room. No staff member had seen him come into the dining room. At 4:30 AM a CNA came into the dining room right as [Resident #42] was walking away from [Resident #63] at a quick pace. [Resident #63] was saying to him to get out of here. Staff did not see what happened, but it appeared [Resident #63's blouse was disheveled. [Resident #42] was escorted downstairs. [Resident #63] was unable to say if or what had happened. The nurse's assessment showed no bruising, swelling or any injury. Staff were alerted to redirect [Resident #42] to stay downstairs where his room is now located. There have been some staff who have been off and did not realize [Resident #42] had moved downstairs and have directed him up the elevator. All staff working have now been informed and we will ensure all staff will be informed. The report conclusion documented after interviews, observation, and record reviews the facility concluded Resident #42 possibly touched Resident #63 inappropriately. The conclusion documented the incident was not witnessed, but Resident #63 answered Yes to the nurse's question about Resident #42 touching her breast. On 6/27/24 at 11:14 AM, the DON stated Resident #42 did touch Resident #63's breast. When he did it the first time the residents were separated. She stated Resident #63 was assessed and there was no change in her behavior. When she notified Resident #63's daughter what had happened the daughter stated she understood. The DON stated Resident #42's daughter stated the female resident did look like Resident #42's late wife and he forgot that she had passed and had been looking for her, and it was determined by the facility Resident #42 would be moved to the first floor to separate the residents. The DON stated Resident #42 had not touched other female residents. He had tried touching female staff members but was redirected without incident. She said there were no further incidents with Resident #42. The facility took the following actions: - The nurse assessed both residents for harm and evidence of injury - none noted. - Administrator, Regional Director of Operations notified. - Families of both residents notified. - The State Agency Long Term Care Program was notified via the portal - Staff members were interviewed. - Care plans for both residents were reviewed and updated. - Social Services interviewed other residents and no further concerns were found. - Staff education was provided to remind and redirect Resident #42 to stay downstairs. - Frequent checks were initiated for both residents. - Resident #42 was fully moved downstairs to a new room with all of his belongings set up to his preferences. These findings represent past noncompliance with this regulatory requirement. There was sufficient evidence the facility corrected the noncompliance as of 10/6/23, and there were no other occurrences of alleged sexual abuse. At the time of this survey the facility was in substantial compliance and therefore does not require a plan of correction.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, record review, review of the State Agency's Long Term Care Reporting Portal, review of facility documents, and staff interview, it was determined the facility failed to ensure residents were free from abuse by other residents and staff. This was true for 4 of 8 residents (Residents #53, #60, #63, and #233) reviewed for abuse and neglect. This failure resulted in the potential for residents to ongoing abuse and potential harm. Findings include: The facility's policy Recognizing Signs and Symptoms of Abuse/Neglect, revised 1/2011, defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. The facility's Abuse Investigation and Reporting policy, revised 7/2017, stated our facility will not condone any form of resident abuse or neglect. These policies were not followed. a. Resident #63 was admitted to the facility on [DATE], with multiple diagnoses including hemiparesis (weakness of one side of the body), hemiplegia (paralysis of one side of the body), and dysarthria (difficulty in speech due to weakness of speech muscles) following a stroke. An annual MDS assessment, dated 12/3/22, documented Resident #63 was cognitively intact. A facility investigation report, dated 11/19/22, documented Resident #63 was woken up at night when CNA #8 moved her to change her incontinence brief. Resident #63 was startled and cried out Ouch. CNA #8 told Resident #63 she needed to get her changed and continued. Resident #63 stated she cried out a few more times as CNA #8 was holding her tight on her legs as she was being changed. The investigation documented Resident #25 (Resident #63's roommate) was interviewed and stated she heard Resident #63 said ouch a couple of times and told CNA #8 to be careful. Resident #25 also stated she did not like how CNA #8 treated Resident #63. The investigation documented Resident #63 did have pain during incontinence care and CNA #8 was in a hurry and did not properly communicated to Resident #63. The investigation documented CNA #8 should have stopped when Resident #63 cry of pain and figured out a better way to change her. The investigation also documented CNA #8's agency was notified, and she would not be allowed to return to the facility. b. Resident #233 was admitted to the facility on [DATE], with multiple diagnoses including non-traumatic subdural hemorrhage (bleeding under the membrane covering the brain), chronic pain and osteoporosis (a condition when bone strength weakens and is susceptible to fracture). An admission MDS assessment, dated 9/1/22, documented Resident #233 was cognitively intact. A facility investigation report, dated 9/1/22, documented Resident #233's family member mentioned to a staff member Resident #233 called at 2:00 AM because CNA #10 was very disrespectful and aggressive to Resident #233. Resident #233's family member reported CNA #10 used a rough tone with Resident #233 when she asked to use the bathroom and CNA #10 stated to Resident #233 that she used a catheter and did not need to go to the toilet. Resident #233 was interviewed and stated CNA #10 was not nice to her when she told her she needed to use the restroom. Resident #233 stated CNA #10 gave her an attitude and was pushy, and did not want to attend to her needs. The investigation documented CNA #9 was giving report to CNA #10 and CNA #10 got angry because there were three call lights on. CNA #9 stated CNA #10 became real mad and started to yell by clapping her hands and was disrespectful to her. CNA #11 was also interviewed and stated CNA #10 seemed agitated and was not paying attention when she was giving her report. CNA #11 stated CNA #10 stood and cussed at her and CNA #9. CNA #11 stated CNA #10 started screaming, smacking her hands together and was becoming aggressive, and began turning the call lights off and yelling down the hallway. The investigation documented CNA #10 stated she was mad because there were three call lights that were on. CNA #10 stated there were more staff during the day and they should be able to get the residents ready for bed so that its not more work for them. CNA #10 stated she was confused that Resident #233 wanted to use the bathroom when she had a catheter. The investigation concluded CNA #10 was possibly angry when she started her shift and Resident #233 felt CNA #10 was angry with her. The investigation documented CNA #10 gave her notice of resignation due to how she treated the staff and her poor customer service towards Resident #233. c. Resident #60 was admitted to the facility on [DATE], with multiple diagnoses including hemiparesis (weakness of one side of the body), hemiplegia (paralysis of one side of the body), and dysarthria (difficulty in speech due to weakness of speech muscles) following a stroke. A Significant Change MDS assessment, dated 10/24/22, documented Resident #60 was severely cognitively impaired. A facility investigation report, dated 10/25/22, documented Resident #60 was having behaviors and flipped off a staff. Multiple CNAs witnessed CNA #13 return the hand gesture to Resident #60. The investigation report documented the following CNAs were interviewed: - CNA #14 stated he remembered Resident #60 was wandering the hallway and tried to enter into a room when CNA #13 told Resident #60 sternly not to go in the room. CNA #14 stated Resident #60 flipp [sic] us off and curse [sic] at us, and that CNA #13 flipped her off back to Resident #60. - CNA #12 stated she remembered an incident where a resident was flipping off staff. CNA #12 stated she heard CNA #13 told the resident Well I have two of them. CNA #12 stated she took it as that CNA #13 flipped off the resident back but did not see it. - CNA #13 stated Resident #60 flipped her off, but she never did it. The investigation concluded two CNAs witnessed CNA #13 flipping off the resident and the facility terminated her employment. d. Resident #53 was admitted to the facility on [DATE], with multiple diagnoses, including anxiety, depression, urinary tract infection and high blood pressure. A facility investigation report, documented on 12/28/22, Resident #53' s family member reported to the DON that on 12/25/22 in the dining room, while visiting Resident #53, Resident #377 bumped his wheelchair into Resident #53's wheelchair. This upset Resident #377 and he cussed at Resident #53. Resident #377 then grabbed the clothing protector off Resident #53, and Resident #53 grabbed the clothing protector back from Resident #377. Resident #377 then started hitting Resident #53 on his left arm. The investigation documented Resident #377 yelled obscenities to Resident #53. The investigation documented Resident #377 had a verbal outburst when things upset him but it was almost always directed at staff members or his wife when she visited him. After learning about the incident, the IDT decided Resident #377 would have his meals in the dining room downstairs and each staff member would bring him down the elevator and set him up in the dining room. The investigation concluded the incident between Resident #53 and Resident #377 did occur. Resident #53 was upset, but not injured. Resident #377 was monitored for his aggression and his care plan was revised. On 5/2/23 at 4:06 PM, the Administrator stated he started in the facility about four months ago and he was the abuse coordinator. He stated the staff were educated to report any incident of abuse such as verbal, physical or any altercation between staff and resident or any resident to resident altercations. The Administrator stated staff were educated to protect the resident and make sure they were safe first and assess for injury. The Administrator stated the alleged staff would be suspended immediately from work. When asked about Resident #63's pain during her pericare. The Administrator stated the CNA was from an agency and based on their investigation the CNA was in a hurry when she provided pericare to Resident #63. The Administrator stated the CNA should have stopped when Resident #63 stated she was hurting during pericare. The Administrator stated the CNA's agency was called and told them they would not allow the CNA to work in the facility again. The Administrator stated the previous administration terminated CNA #13. The Administrator stated if staff observed/heard any incidents of abuse, they should report it immediately to their supervisor or contact him directly. The facility failed to ensure Residents #53, #60, #63 and #233 were free from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Resident #1 was admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition, fibromyalgia (a widespread pain condition affecting muscles and bones), and osteoarthritis of the right and the left shoulder. Resident #1's physician orders, dated 1/27/22- 4/21/23, documented Resident #1 was to receive the following treatments: - 1/27/22: Resident #1 was to receive barrier cream to buttocks following incontinence. - 2/20/23: Resident #1 was to have a hybrid air mattress with an air pump. - 4/17/23: Resident #1 was to have buttocks cleansed with wound cleanser. - 4/21/23: Resident #1 was to receive barrier cream every evening shift and staff were to monitor and document signs and symptoms of infection to the wounds on the buttocks until healed. A Hospice Nursing Visit note, dated 4/4/23, documented Resident #1 had 4 superficial excoriated wounds on her buttocks/sacrum area. A ROHO cushion (pressure relieving cushion) was ordered for Resident #1's recliner and a new air mattress with bolsters were ordered. Resident #1 wounds were measured and were as follows: - 2 cm x 2 cm - 1.5 cm x 1.5 cm - 1.0 cm x 1.0 cm - 0.5 cm x 0.5 cm A Wound Care Provider note, dated 4/6/23, documented Resident #1 had stage 2 wounds on her buttocks. The wounds were measured and were as follows: - 0.6 cm x 0.4 cm and the depth of the wound was less than 0.1 cm, left buttock. - 0.3 cm x 0.4 cm and the depth of the wound was less than 0.1 cm, midline. - 0.6 cm x 0.9 cm and the depth of the wound was less than 0.1 cm, right buttock. A Wound Care Provider note, dated 4/13/23, documented education was provided to Resident #1 on the importance of offloading (relieving pressure), proper nutrition, and supplemental protein to promote wound healing. A Wound Care Provider note, dated 4/20/23, documented staff were to ensure Resident #1 was offloading, and had an air mattress and seat cushion. On 4/30/23 at 11:37 AM, Resident #1 was in her room and sitting in a recliner that contained a ROHO cushion. On 4/30/23 at 3:50 PM, Resident #1 was in her room and sitting in a recliner that contained a ROHO cushion. On 5/3/23 at 8:30 AM, Resident #1 was laying in bed and was on her back. At 9:07 AM, Resident #1 was laying in bed and was on her back. At 9:30 AM, Resident #1 was in the same position in bed. At 10:21 AM, Resident #1 was in the same position in bed and her ROHO cushion was noted to be deflated. Resident #1's care plan, initiated 4/21/23, stated Resident #1 was to be provided with pressure injury treatment, her care coordinated by the facility wound nurse and the outside wound provider, and weekly pressure injury assessments were to be completed. Resident #1's care plan did not contain information related to consistently repositioning Resident #1 and her need for proper nutrition to promote wound healing. On 5/3/23 at 1:20 PM, the RD stated Resident #1 was followed weekly in Skin and Weight meetings. The RD stated Resident #1 received a nutritional supplement 3 times a day. The RD stated she did not know what type of supplement was used and stated, whatever nursing is using. The RD stated she was not monitoring Resident #1's nutritional intake. The RD stated the MDS Coordinator completed the care plans related to nutrition and skin issues, and she (the RD) only entered diet orders into the care plans. On 5/5/23 at 11:20 AM, Therapy Staff #1 stated they assessed ROHO cushions after they were notified by nursing staff. Therapy Staff #2 was present and stated therapy had been notified to look at Resident #1's ROHO cushion. Therapy Staff #2 stated he would assess the cushion during therapy with Resident #1. On 5/3/23 at 2:20 PM, the Hospice Nurse stated she had not observed Resident #1's wounds and the ROHO cushion was not properly inflated. The facility failed to ensure professional standards of practice were followed to prevent the development and worsening of wounds. Based on policy review, record review, and staff interview, it was determined the facility failed to ensure professional standards of practice were followed to prevent the development and worsening of a wound. This was true for 3 of 9 residents (Residents #1, #326, and #329) reviewed for pressure ulcers. This failure resulted in harm when Resident #1, Resident #326, and Resident #329 developed new pressure ulcers, and Resident #326 and Resident #329's pressure ulcers worsened. Findings include: The National Pressure Injury Advisory Panel website, accessed on 5/10/23, defined pressure ulcer injuries for stage 2, stage 3, and unstageable as follows. - Stage 2 - Partial-thickness skin loss with exposed dermis (thick layer of living tissue below the epidermis which forms the true skin, containing blood capillaries, nerve endings, sweat glands, hair follicles, and other structures). The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible, and deeper tissues are not visible. Granulation tissue (new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process), slough (non-viable yellow, tan, gray, green, or brown tissue), and eschar (dead or weakened tissue that is hard or soft in texture - usually black, brown, or tan in color) are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. - Stage 3 - Full-thickness loss of skin, in which adipose is visible in the ulcer and granulation tissue and epibole are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining (when the tissue under the wound edges becomes eroded, resulting in a pocket beneath the skin at the wound's edge) and tunneling (channels that extend from a wound into and through the tissue or muscle below) may occur. Fascia (thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber, and muscle in place), muscle, tendon, ligament, cartilage, or bone is not exposed. If slough or eschar obscures the extent of tissue loss, this is an Unstageable Pressure Injury. - Unstageable - Obscured full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be softened or removed. The facility's Prevention of Pressure Ulcer Injuries policy, revised 2018, documented pressure ulcer injury prevention included risk evaluation, nutritional and mobility repositioning interventions, as follows: - Evaluate the resident on admission for existing pressure ulcer risk factors. Repeat the risk evaluation as needed and with significant changes in condition. - Conduct a skin evaluation upon admission, including skin integrity for any evidence of existing or developing pressure ulcers or injuries. - Use a screening tool to determine if the resident is at risk for undernutrition or malnutrition. - Inspect the skin routinely when performing or assisting with personal care or ADLs. - Monitor the resident for weight loss and intake of food and fluids. Include nutritional supplements in the resident's diet to increase calories and protein as indicated in the care plan. - Reposition based on the resident's mobility, the supportive surface in use, skin condition and tolerance, and the resident's preferences. - Reposition frequently as needed based on the condition of the skin and the resident's comfort. - Evaluate, report, and document potential changes in the skin. - Review the interventions and strategies for effectiveness. The facility's Pressure Ulcers Skin Break Down Clinical Protocol policy, revised 2022, documented the protocol was to evaluate and identify the causes, provide wound treatments, management, and monitor, including evaluating and documenting a resident's's significant risk factors for developing pressure ulcers, for example, immobility, recent weight loss, and history of pressure ulcers. The policy stated the nurses were to describe, document, and report the following: - Full assessment of pressure sore, including location, stage, length, width, depth, presence date, and necrotic tissue. - Pain assessment. - Resident's mobility status. - Current treatments, including support surfaces. - All active diagnoses. These policies were not followed. 1. Resident #326 was admitted to the facility on [DATE], with multiple diagnoses including left sided hemiplegia (paralysis on one side of body), stage 3 pressure ulcer of the right heel, stage 2 pressure ulcer of the right buttock, and left buttock. Resident #326's hospital Discharge summary, dated [DATE], documented Resident #326 presented with a chronic non-healing pressure ulcer to his right heel and a small sacral wound. The hospital discharge instructions included daily dressing changes. a. Resident #326's MAR and TAR for 8/2022 did not include all pressure ulcer related care and monitoring as ordered by the physician was completed. Examples included the following: i. Resident #326's TAR, dated 8/2022, directed staff to question Resident #326 about presence of pain, including sore points every shift. The documentation for the following shifts were blank: - 8/11/22 night shift - 8/12/22 evening shift and night shift - 8/13/22 night shift - 8/14/22 night shift - 8/19/22 night shift - 8/20/22 evening shift - 8/26/22 day shift ii. Resident #326's TAR, dated 8/2022, directed staff to ensure he wore Prevalon boots (pressure relief boot for the heel) while in bed or sitting up in a chair every shift. The documentation for the following shifts were blank: - 8/12/22 evening shift and night shift - 8/13/21 night shift - 8/14/22 night shift - 8/20/22 evening shift iii. Resident #326's MAR, dated 8/2022, directed staff to apply Boston Butt Cream to the area around his buttock dressing and groin area every shift. The documentation for the following shifts were blank: - 8/12/22 evening shift and night shift - 8/13/22 night shift - 8/14/22 night shift - 8/20/22 evening shift b. A practitioner's visit note, dated 8/12/22 and 8/15/22, documented Resident #326 had a right foot ulcer and sacral wound. Resident #326's record did not include documentation a wound assessment was performed including location, stage, length, width, depth, presence date, and necrotic tissue upon his admission as per policy. A nurse's note, dated 8/13/22 at 11:49 AM, documented Resident #326's pressure area over coccyx (tailbone) measured 12.6 cm x 10.5 cm with no depth. c. Resident #326's admission MDS, dated [DATE], documented Resident #326 was moderately impaired. He required a two person extensive assistance for bed mobility, transfer, dressing, and bathing, and one person extensive assistance for toileting. Resident #326 was admitted with two stage 2 pressure ulcers and one stage 3 pressure ulcer. Resident #326 was not in the turning and repositioning program. Resident #326's record did not include documentation frequent position changes were completed per facility policy. d. A physician's note, dated 8/16/22, documented Resident #326 had a right heel pressure ulcer, coccyx wound, and a new left toe blister. Resident #326's record did not include treatment or prevention interventions for the newly developed toe blister. e. A weekly head-to-toe skin check assessment, dated 8/16/22, documented wound to the right heel blanchable redness to buttocks treatment in place. The assessment did not include wound measurements, or descriptions for Resident #326's pressure ulcer to his right heel, right buttock, left buttock, and the new left toe blister. f. A weekly wound review assessment, dated 8/17/22, documented Resident #326 had a right buttock stage 2 pressure ulcer which measured 0.5 cm x 0.4 cm x 0.2 cm. Resident #326's physician's wound note, dated 8/17/22 at 2:01 PM, documented Resident #326 had a stage 3 pressure ulcer to the right heel, a stage 2 pressure ulcer to the right buttock, and a stage 2 pressure ulcer to the left buttock. The right heel wound measured 9 cm x 2 cm x0.4 cm. The note instructed staff to offload the wound by using an air mattress on the bed and to reposition Resident #326 every 2 to 3 hours. Resident #326's records did not include documentation a wound assessment was completed of his right heel, left buttock, and the toe blister including location, stage, length, width, depth, presence date, and necrotic tissue as per facility policy. Resident #326's record did not include documentation he was repositioned consistently every 2 to 3 hours. g. A weekly head-to-toe skin check assessment, dated 8/23/22, documented wound to the right heel blanchable redness to buttocks treatment in place. The assessment documented Resident #326 had two pressure ulcers: one stage 2 pressure ulcer on the left buttock and one stage 3 pressure ulcer on the right heel. Resident #326's skin assessment was not consistent with the 8/17/22 physician documentation related to the second stage 2 pressure ulcer to the right buttock. The assessment did not include documentation including location, stage, length, width, depth, presence date, and necrotic tissue for all three pressure ulcer wounds as per facility policy. h. A practitioner's note, dated 8/24/22, documented Resident #326 had multiple pressure ulcers to his buttock and heels. Resident #326 stated did not sleep well last night because he was having pain on his bottom where he had a sore. He did not think he had taken any pain medication. He tried to change positions frequently but was unable to move himself. Resident #326's ADL assistance report for August 2022, documented bed mobility assistance was not completed on the 8/12/22 night shift, 8/16/22 day shift, 8/18/22 night shift, 8/20/22 day shift, and 8/27/22 night shift. i. A nurse's note, dated 8/26/22 at 11:26 AM, documented Resident #326's daughter and the provider observed a black eschar area to the bottom of his left foot. Resident #326's daughter stated it was from Resident #326's prior facility and they would attempt to locate records from the prior facility. A weekly wound review assessment, dated 8/26/22, documented Resident #326 had two pressure ulcers. One stage 2 pressure ulcer on the right buttock without measurement was first observed upon admission. One new unstageable diabetes foot ulcer with eschar was measured at 0.7 cm x 1.4 cm on the left foot and was first observed on 8/26/22. Resident #326's skin assessment was not consistent with the practitioner's documentation on 8/24/22. It was not clear how many pressure ulcers were present. Resident #326's records did not include documentation all the pressure ulcers were assessed, including location, stage, length, width, depth, and necrotic tissue per facility policy. j. A nurse's note, dated 8/28/22 at 8:39 PM, documented Resident #326 complained of pain at a 10 (the highest pain rating) out of 10 pain scale when he moved. The nurse called the physician to get an additional as-needed pain medication to replace the current Tylenol. The physician ordered Tramadol 50 mg three times a day as needed for pain. A nurse's note, dated 8/29/22 at 2:15 AM, documented Resident #326 needed the new pain medication to be filled and the physician's signature was needed for the new order. Resident #326's MAR documented the Tramadol was not administered from the time it was ordered. A nurse's note, dated 8/29/22 at 8:30 PM, documented Resident #326 was sent to the hospital. k. A discharge MDS assessment, dated 8/29/22, documented Resident #326 presented with 2 unhealed pressure ulcers, one stage 2 and one stage 3, both were present on admission. Resident #326 was not in the turning and repositioning program. Resident #326 did not have ulcers, wounds, or skin problems to his foot. Resident #326 was not receiving skin and ulcer treatment, including pressure reducing devices for the chair and bed, pressure ulcers and wound care, or in the turning and repositioning program. It was not clear how many pressure ulcers were present when Resident # 326 discharged . Resident #326's record did not include documentation frequent position changes were completed as per the facility policy. On 5/5/22 at 10:40 AM, the DON said bed mobility assistance should be performed at least 2 to 3 times every shift and documented in the CNAs' ADL task report. She stated for residents on bed rest, the staff should be providing bed mobility assistance up to 5 times every shift. On 5/5/23 at 5:20 PM, when asked, the DON reviewed Resident #326's pressure ulcer records, ADL assistance report, MAR, and TAR. The DON said there was no other documentation that Resident #326's pressure ulcers were measured. She said the ADL assistance report, MAR, and TAR for pain medication, wound care and monitoring should be completed and documented, and not have blanks. The DON stated there were only 1 or 2 progress notes documenting Resident #326's repositioning every 2 hours, and she expected it should be documented each time. 2. Resident #329 was admitted to the facility on [DATE] with multiple diagnoses including right femur fracture, dementia, and required assistance with personal care. Resident #329's admission MDS assessment, dated 7/20/21, documented Resident #329 was cognitively intact. She required one person extensive assistance for bed mobility, transfers, dressing, and required physical assistance for bathing. A progress note, dated 7/14/21 at 6:37 PM, documented Resident #329 complained of pain in the right heel. The heel was boggy but blanchable, and a pillow was to be placed under both legs to float heels, and Resident #326 was instructed to keep her heels elevated. A pressure injury risk assessment, dated 7/20/21, documented Resident #329 was at moderate risk of developing a pressure injury. a. Resident #329's MAR and TAR, dated 7/2021 through 10/2021, documented pressure ulcer related care was not consistently completed. Examples include: i. Staff were instructed to apply barrier cream to Resident #329's peri area every shift or after each incontinent episode. The following shifts were blank: - 7/15/21 day shift, evening shift, and night shift - 7/16/21 night shift - 7/17/21 night shift - 7/22/21 day shift and night shift - 7/23/21day shift - 7/25/21 day shift - 8/1/21 night shift - 9/24/21 night shift - 10/9/21 day shift - 10/20/21 night shift Resident #329's ADL assistance report, dated July 2021 through October 2021, documented the bed mobility assistance was not completed as follows: Day shift: 8/8/21, 8/15/21, 9/20/21, 10/19/21. Evening shift: 7/22/21, 7/31/21, 8/24/21, 9/26/21, 10/19/21. Night shift: 7/15/21, 7/21/21, 7/26/21, 7/28/21, 8/2/21, 8/9/21, 8/21/21, 8/27/21, 8/31/21, 9/2/21, 9/10/21, 9/12/21, 9/14/21, 9/18/21, 9/24/21, 9/28/21, 10/10/21, 10/8/21, 10/18/21, 10/20/21. b. A weekly head-to-toe skin check assessment, dated 8/16/21, documented Resident #329's heel was clear with no skin issues. A weekly head-to-toe skin check assessment, dated 8/23/21 and 8/30/21, documented Resident #329 had no skin issues. A nurse's note, dated 9/6/21 at 11:14 AM, documented Resident #329 had a change of condition on 9/1/21. On 9/6/21, a CNA reported Resident #329 had a new open area on her coccyx (tailbone). The center of the new open area had eschar measuring 0.5 cm x 0.3 cm with surrounding slough tissue, and both right and left buttocks had superficial open areas. A weekly head-to-toe skin check assessment, dated 9/6/21, documented Resident #329 developed nine new skin issues as follows: - Right elbow: red. - Left elbow: red. - Coccyx: 2.5 cm x 2 cm eschar center with yellow tissue at the center of the tailbone. - Right buttock: 1 cm x 1 cm shear area. - Left buttock: 0.5 cm x 0.5 cm shear area superficial. - Right heel: 4 cm x 4 cm mushy area and red - Left heel: 3 cm x 3 cm red area. - Right rear shoulder: 4 cm x 4 cm red area. - Left rear shoulder: 2 cm x 2 cm red area. The assessment note further documented new interventions Resident #329 were to have; air bed, heel and elbow protectors, treat the coccyx with a barrier cream and hydroid dressing (dressing for non infected wounds), and educate staff about preventive measures. The facility failed to provide consistent pressure ulcer preventive care including barrier cream use and bed mobility for position changes. c. A nurse's note, dated 9/12/21 at 12:22 AM, documented Resident #329's coccyx wound remained open with slough. Resident#392's dressing was changed and her heels were pink and slightly boggy. A weekly head-to-toe skin check assessment, dated 9/13/21 and 9/20/21, did not document Resident #329 had skin issues as the 9/6/21 weekly head-to-toe skin check assessment indicated. The assessment documented continuing the plan of care to treat the coccyx with a barrier cream and hydroid dressing and to educate staff with preventive measures. d. A weekly wound review assessment, dated 9/15/21, documented Resident #329 had a coccyx unstageable pressure wound that measured 2 cm x 1.5 cm x 0 cm. Resident #329's weekly wound review assessment was not consistent with the weekly head-to-toe skin check assessment, dated 9/6/21. It was not clear how many wounds Resident #329's had. e. A progress note, dated 9/18/21 at 10:45 PM, documented Resident #329 continued with wound care to the coccyx and reported that it was painful at times. A progress note, dated 9/19/21 at 9:43 PM, documented there was no change in wound or treatment. Resident complained of pain to the coccyx when sitting up. A progress note, dated 9/22/21 at 2:28 PM, documented Resident #329 was seen by the wound clinic. The coccyx wound was debrided, new orders were received, and the MAR was updated. A weekly wound review assessment, dated 9/22/21, documented Resident #329 had an unstageable pressure wound to her coccyx measuring 2.8 cm x 2.2 cm x 0 cm. A wound clinic progress note, dated 9/22/21 documented Resident #329's coccyx wound was deteriorating, the wound had doubled in size, and the wound was full of stringy malodorous slough. The wound was surgically debrided. f. A weekly head-to-toe skin check assessment, dated 9/27/21, documented Resident #329 had skin issues on the same nine sites as her 9/6/21 weekly head-to-toe skin check assessment had documented: - Right elbow - Left elbow - Coccyx - Right buttock - Left buttock - Right heel - Left heel - Right rear shoulder - Left rear shoulder The assessment did not include documentation including location, stage, length, width, depth, presence date, and necrotic tissue for all the pressure ulcer wounds as per facility policy. It was not clear how many pressure ulcers Resident #329 had. g. A weekly wound review assessment, dated 9/29/21, documented Resident #329 had an unstageable pressure wound that measured 4.2 cm x 4 cm x 3 cm. A wound clinic progress note, dated 9/29/21 documented Resident #329's coccyx wound had significantly deteriorated in the last week with a strong odor. Nursing expressed Resident #329's family agreed to place her on hospice. The provider suggested changing the wound dressing type and frequency to twice daily and as needed. A weekly head-to-toe skin check assessment, dated 10/4/21, documented Resident #329's coccyx had an open area, the color was black and gray with a foul odor and dark drainage. Resident #329's dressing was changed per the physician's order. A progress note, dated 10/5/21, documented the hospice nurse was in the facility and requested not to transfer Resident #329 out of bed and to change her position from side to side to maintain skin integrity and to offload pressure from the coccyx wound. A weekly wound review assessment, dated 10/6/21, documented Resident #329 had an unstageable pressure wound to her coccyx that measured 4 cm x 4 cm x 2cm. h. A weekly head-to-toe skin check assessment, dated 10/11/21, documented Resident #329 had skin issues on the same nine sites as his 9/6/21 weekly head-to-toe skin check assessment had documented: - Right elbow - Left elbow - Coccyx - Right buttock - Left buttock - Right heel - Left heel - Right rear shoulder - Left rear shoulder The assessment did not include documentation including location, stage, length, width, depth, presence date, and necrotic tissue for all the pressure ulcer wounds as per facility policy. It was not clear how many pressure ulcers Resident #329 had. i. A medication administration note, dated 10/12/21 at 1:46 PM, documented Resident #329's wound had a foul odor. It had string-like black flesh hanging around the edges and green drainage. A progress note, dated 10/14/21 at 4:31 PM, documented Resident #329's coccyx wound was deeper and wider with a foul odor. Resident #329 moaned in pain when turned and the skin was becoming darker on the bilateral lower extremities. The hospice nurse was there and was informed. Resident #329's weekly head-to-toe skin check assessment, dated 10/18/21, documented Resident #329 had no skin issues. On 5/5/23 at 10:40 AM, the DON said bed mobility assistance should be performed at least 2 to 3 times every shift and documented in the CNAs' ADL task report. For residents on bed rest, the staff should be providing bed mobility assistance up to 5 times every shift. On 5/5/23 at 10:44 AM, the DON reviewed Resident #329's record and said the MAR, TAR, and ADL task report for bed mobility was blank whcih meant there was no documentation that the tasks had been completed. She said it should be completed and documented. The facility failed to timely, accurately, and consistently, assess, measure, document, and provide pressure ulcer care to prevent pressure injury development and promote the healing of existing pressure ulcers.