**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer a resident's (R1) sodium tablets for 12 days following his admission to the facility. This failure resulted in R1 experiencing a critically low sodium level, confusion, hallucinations, and a 15 day hospital stay to correct his sodium levels. This applies to 1 of 3 residents reviewed for medications in the sample of 5. The findings include: R1's electronic face sheet printed on 7/8/25 showed R1 has diagnoses including but not limited to permanent atrial fibrillation, syndrome of inappropriate secretion of antidiuretic hormone (SIADH), chronic kidney disease, and malignant neoplasm of bladder. R1's census report showed R1 was admitted to the facility on [DATE], and discharged to a local hospital on 6/16/25. R1 did not return to the facility. R1's local hospital discharge orders, dated 6/5/25, showed, NEW: Sodium Chloride 1gm PO (oral) QID (4 times per day) .Discontinued: sodium chloride 1,000mg PO TID (3 times per day) . R1's physician's orders for June 2025 showed no orders for R1 to receive Sodium Chloride 1gm PO QID. R1's medication administration record for June 2025 showed no evidence R1 ever received Sodium Chloride during his stay at the facility from 6/5/25-6/16/25. R1's nurse practitioner visit note, dated 6/9/25, showed: 4. SIADH- chronic- managed with sodium chloride 1gm po qid . On 7/8/25 at 10:23AM, V4 (R1's son) stated, (R1) went to an appointment which required them to draw blood and his sodium level was 115. The facility called my sister to let her know because she was at a different appointment with (R1), and she took him to the emergency room. He went back to (local hospital) where they had to slowly increase his sodium levels back up to normal. When she got him to (local hospital), he was hallucinating and saying he was seeing people outside of his eyes and was completely disoriented. I have no idea how she even handled him at the appointment. He knew he wasn't right, and he told us he felt disoriented, and he knew he was hallucinating. It took 2 weeks in the hospital before they got his levels regulated again. The orders were clearly on his discharge paperwork so I'm unsure why (facility) never gave him his medications. On 7/8/25 at 9:48AM, V5 (R1's Nurse Practitioner) stated, SIADH is usually the reason we see someone on a sodium replacement and that's what (R1) was getting it for. 10 days without the sodium tabs could have detrimental effects and create a critically low sodium level which would put him at risk for nausea, vomiting, increased confusion, and potentially seizures depending how low his sodium was. I never saw what his labs were because he was out at an appointment at the time, and they drew the labs and got the critical lab value. I saw him on 6/9/25 and nobody ever reported to me that he wasn't getting his sodium tabs, so I assumed what I saw on the discharge report was being given because I certainly did not discontinue his sodium tabs. I never received any notification that there were any issues with getting the medication or entering it into the system. On 7/8/25 at 9:57AM, V3 (Licensed Practical Nurse) stated, If my name was next to the orders for admission then I must have been the nurse who admitted (R1), but I don't remember much about him. When I do an admission, I look at discharge paperwork and reconcile the orders. Sometimes the hospital will send the orders before the resident comes but it usually comes with the resident. I don't recall having any issues entering any medications or not being able to find medications. If I was the nurse that put the orders in, then there is another nurse from night shift that checks orders so someone besides me should have caught this. If a resident is not receiving sodium as ordered, they could potentially have cardiac effects. I can't really say much because I'm not a doctor or anything. On 7/8/25 at 10:07AM, V2 (Director of Nursing) stated, When a resident is admitted , the floor nurse enters the medications. Usually, it is the nurse from that hall but if another nurse is available, they will do it. Third shift nurses are then responsible for double checking the discharge orders from the hospital and reconciling it with our list. I remember (R1) a little bit, but he wasn't here long. He went to the hospital because of low sodium and change in mental status. He was out at an appointment at the time we got the call about his low sodium, so his daughter drove him to the hospital. I'm not even sure when the labs were done or what the level was. On 7/8/25 at 11:42AM, V2 stated, We were able to get the labs from the hospital and it showed (R1's) sodium levels were 115 when he got to the hospital, which is a critically low level. He was confused and hallucinating which are signs of low sodium. I have no idea how this order was missed when he was admitted to the facility because 2 nurses checked the orders so it should have been caught. This is a perfect example of a significant medication error. R1's local hospital records showed, 6/16/25 Sodium 115 (Critical Lab Value) 6/17/25 119 (Critical Lab Value) . The facility's policy titled, admission of A Resident revised 01/04 showed, Objective: 1. To facilitate the transition from prior living arrangement to long-term in a caring, professionally comprehensive manner .Procedure .13. Obtain physician's orders . The facility's policy titled, Medication Administration revised 02/04 showed, Objective: 1. To provide the resident with those medications deemed necessary by the physician to improve and/or stabilize specified diagnosis of the resident .Procedure .5. All physician's orders must be accurately transcribed to the MAR (medication administration record). 6. All medications must be administered to the resident in the manner and method prescribed by the physician. 7. In the event that a medication cannot be given, the reason must be documented in the Nurses Medication Notes on the MAR (Medication Administration Record) .

Based on observation, interview, and record review, the facility failed to identify a pressure wound prior to becoming advanced stages, failed to identify deterioration of an existing pressure ulcer, failed to perform weekly wound assessments, failed to perform accurate wound assessments for 2 residents (R75, R63), failed to provide wound treatments, failed to maintain documentation of wound assessments for 1 resident (R16), and failed to ensure pressure ulcer prevention measures were in place for 1 resident (R63). These failures resulted in R75 experiencing sepsis requiring hospitalization, surgical debridement of his necrotic wound, and placement of a colostomy due to an infected wound. These failures also resulted in R63's bilateral heel wounds not being identified until they were unstageable wounds and becoming necrotic. These failures apply to 3 of 6 (R75, R63, R16) residents reviewed for pressure ulcers in the sample of 23. The findings include: 1. R75's electronic face sheet, printed on 8/29/24, showed R75 has diagnoses including but not limited to pressure ulcer stage 4, infection following sacral debridement, Parkinson's disease, Alzheimer's disease, dementia without behaviors, and colostomy. R75's care plan, dated 6/23/24, showed, Resident is at increased risk for pressure ulcers related to decreased mobility, generalized muscle weakness following recent illness and hospitalization . R75's admission nursing assessment, dated 7/17/24, showed R75 had no skin alterations upon admission. R75's care plan, dated 7/18/24, showed, (R75) has a colostomy related to sacral wound infection and need to keep the area clean. R75's facility assessment, dated 8/22/24, showed R75 has no cognitive impairment, has one stage 4 pressure ulcer, and utilizes and ostomy. R75's wound assessment report, dated 6/26/24, showed, dermatitis-7x6cm (centimeters). Red, open blisters to inner natal cleft. Scar tissue to coccyx and buttocks. Wound bed 50% slough and 50% granulated. Not recorded as pressure injury due to between skin folds. R75's wound assessment report, dated 7/3/24, showed, dermatitis-10x5cm-declining-macerated and excoriated scar tissue, grey in color. R75's nursing progress notes showed, 7/4/24 Writer was taking resident to supper and noted his face appeared red and flushed. Writer took temperature and temperature was 101.2. Resident had some confusion to what time it was and seemed a bit slower than usual to respond. (Physician on call) notified gave order to restart cefdinir 300mg (milligrams) bid (twice per day) x 5 more days and if resident worsens tonight may send to emergency room. 7/5/24 Power of Attorney here and concerned that (R75) has confusion and was not acting like himself. Vitals taken temperature was 101.4. He is on antibiotic for UTI (urinary tract infection) .911 called and took resident to local emergency room . R75's local hospital records, dated 7/5/24, showed, .brought in for evaluation from nursing home after developing fever and altered mental status again yesterday. Daughter states he appeared to have some labored breathing from time to time as well .evidence of sepsis with urinary catheter has a large unstageable sacral decubitus foul-smelling necrotic wound that requires debridement sepsis criteria likely secondary to wound to coccyx. R75's operative note, dated 7/6/24, showed, Reason for operation: sepsis with necrotic decubitus ulcer .findings: necrotic decubitus involving skin and subcutaneous tissue with purulence (drainage) .scalpel was used to excise necrotic infected tissue . R75's surgery progress note, dated 7/8/24, showed, May need to consider diverting ostomy as patient seems to be intermittently incontinent of stool .wound is approximately 8-9cm in diameter and 5-6cm in depth . R75's surgery progress note, dated 7/9/24, showed, Discussed with patient and daughter that we suggest additional debridement of wound as well as construction of diverting ostomy for stool incontinence. They are in agreement .surgery within 24-48 hours. (R75's ostomy surgery was completed on 7/10/24) R75's hospital physician note, dated 7/10/24, showed, Sacral ulcer: wound cultures reporting prevotella and morgnella (bacteria). On 8/27/24 at 11:40AM, R75 stated, I have a horrible sore on my bottom. I got it while I was here and needed surgery on it, and then they gave me this (pointing to colostomy) because the sore was so bad. On 8/28/24 12:30PM, V17 (Wound Care Nurse) stated, (R75) had dermatitis, but I'm not exactly sure when it started. We were watching it and he had some areas that were red. I guess it broke open. I was doing the wound assessments for (R75) at the time. I don't really recall much about him, but looking at the physician communication notes, he must have had some chapped skin that we were trying to soften up or something. It's strange that there are no wound assessments other than the physician communication forms. I'm not sure where they would be or even how to find them. I would think if the nurse saw a change in the wound, she would notify the physician for new orders and document that. I'm only here one day a week, so if there is something new with the wound, then that is up to the floor staff to notify the physician. On 8/28/24 at 12:38PM, V2 (Director of Nursing) stated, There are nursing skin assessments in (R75's) chart, dated 6/18/24 and 6/26/24, but they do not show any open areas. I don't see any full wound assessments documented in (R75's) chart. It is the expectation that (V17) does a full wound assessment including measurements and characteristics of every resident with a wound when she is in the facility. If a new wound is identified when she is not here, then the floor staff do the assessment and initiate orders. It is also the expectation that if a change is seen with a wound, the staff notify the physician for new orders. We now have a Wound Physician that comes once a week, but he started after all of this with (R75), so he did not start seeing him until 7/22/24. On 8/29/24 at 11:07AM, V26 (Wound Care Physician) stated, It's not normal to change from dermatitis to an unstageable wound. It might have started as a stage one and then progressed to a higher stage, but this was never dermatitis. When you have granulation and slough, you don't have dermatitis. There is no broken skin with dermatitis. From the wound assessments that were performed initially, this wound should have been classified as a pressure ulcer and treated as such. It should have been reclassified as soon as his skin broke open. With the slough and granulation present, I would have probably classified this as a Stage 3 pressure ulcer initially. A wound can become necrotic within a few days if not receiving the proper wound care. The nurses should have noticed the wound was necrotic and odorous, and he should have been seen by a Wound Care Physician as soon as possible. When a wound becomes necrotic, it becomes very dark and liquified and very noticeable. He was not receiving the proper treatments for this wound, which led to the complications he had. The facility's policy titled, Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol, dated 10/24/22, showed, 6. When a resident is admitted to the facility or develops a pressure injury in the facility, the following will occur: A. Assess the pressure injury for location, size (measure length x width x depth), wound bed, drainage (amount, color, type), odor, tunneling, undermining or sinus tract, wound edges, surrounding tissue and pain at site. B. determine the injury's current stage of development: Stage 3 Pressure ulcer: full thickness skin loss: Full thickness loss of skin, in which subcutaneous fat is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slouch and/or eschar may be visible but does not obscure the depth of tissue loss .if slough or eschar obscures the wound bed, it is an unstageable pressure ulcer/injury . 2. R63's face sheet, printed on 8/29/24, showed R63 has diagnoses including but not limited to peripheral vascular disease, pneumonia, pressure-induced deep tissue damage of left hip, atherosclerosis, and anxiety disorder. R63's facility assessment, dated 6/25/24, showed R63 has mild cognitive impairment and has 1 unstageable pressure ulcer. R63's care plan, dated 11/22/23, showed, (R63) is at increased risk for pressure ulcers related to decreased mobility, generalized muscle weakness following recent illness and hospitalization. Pressure areas present to heel, foot and hip. Apply pressure reducing waffle boots to lower extremities when at rest .pressure reducing device in wheelchair and bed. R63's wound management detail report, dated 12/13/23, showed, Right heel pressure ulcer-unstageable 2.5 x 5cm, 100% eschar, dark purple or rusty discoloration. R63 did not have a wound assessment performed 12/20/23 and 12/27/23. R63's wound management detail report, dated 1/3/24, showed, Right heel pressure ulcer-unstageable deep tissue 2x5.8cm 100% necrotic eschar. On 8/27/24 at 11:02AM, R63 was laying in his bed with no heel protectors in place, and both of his heels were resting on the mattress. R63's heel protectors were observed on the spare bed in R63's room. On 8/27/24 at 11:26AM, V30 (hospice aide) provided incontinence care to R63, and stated R63 should always have his heel boots on because he has many wounds on his feet. V30 then transferred R63 to his wheelchair with no cushion in the chair. V30 stated R63 used to have a cushion, but she is unsure of where it is at. On 8/28/24 at 2:15PM, V2 (Director of Nursing) stated, All residents that are at risk for pressure ulcers and cannot reposition themselves should have heel protectors on at all times when they are in bed. If (R63) has that many wounds, then it is critical that all of the interventions are in place. I don't really know a lot about his wounds, but any wound should be identified as early as possible to allow for early intervention to try to heal the wounds. On 8/29/24 at 11:07AM, V26 (Wound Care Physician) stated, A deep tissue injury is intact skin with discoloration underneath. You cannot have a deep tissue injury with necrotic eschar. That is when the wound is open and becomes unstageable, so this assessment is incorrect. I wouldn't be surprised if that developed over a day or 2 without wearing heel protectors. If his skin was being assessed every day, this would have been caught when it was a red area; I would see a stage 1 red area. Wounds with eschar should be caught earlier and are signs that the wound is declining and is now open. 3. R16's 8/27/24 Wound Clinic assessment showed she had a Stage 3 pressure injury to her left heel and two unstageable pressure wounds to her right foot. On 8/27/24 at 3:45 PM, R16 stated she has wounds on both of her feet. R16 stated her pressure wounds developed after she fell and sustained a fracture to her right ankle. R16 stated some of the pressure injuries developed while she had the cast on, and were not discovered until the cast was removed. R16 stated the pressure ulcer dressings were changed at the wound clinic on 8/27/24; however, prior to this, they had not been changed since Friday, 8/23/24. On 8/27/24 at 4:02 PM, V28, R16's daughter, stated she attended R16's wound clinic appointment that day. R16 stated the dressing was dated 8/23/24. On 8/28/24 at 12:19 PM, V16 (Wound Clinic Registered Nurse) stated she was the nurse who removed R16's dressing. V16 stated the dressings to both of R16's feet were dated 8/23/24. V16 stated the date on the dressing means the date that it was last changed. On 8/28/24 at 1:28 PM, V2 (Director of Nursing) stated the facility does not have the assessments for R16's wounds because the assessments are done at the wound clinic. V2 stated she did not believe the facility needed to keep records of R16's wounds if the weekly assessments were done outside the facility. R16's August 2024 Treatment Administration History (provided on 8/28/24, Commonly referred to as a TAR, Treatment Administration Record) showed an order to provide treatment and dressings to the left heel every 3 days. The TAR showed the treatment due on Monday 8/26/24 was left blank. R16's August 2024 TAR showed an order to treat and dress the wounds to the right foot every other day. The TAR showed the treatment due on Monday 8/26/24 was left blank. R16's Progress Notes from 8/26/24 (Monday, when the dressing changes were scheduled to be completed.) showed she left for an appointment at an unknown time; however, she returned at 4:30 PM. The progress notes do not show a refusal for dressing change. On 8/28/24 at 1:20 PM, V17 (Wound Nurse) (facility's wound nurse) stated, The date on the dressing is the date that it was changed. The purpose of the dressing is to removed exudate, promote healing and prevent infection. After a dressing change is done, they should document in the treatment list that the dressing change is done. The floor nurses do dressing changes when I am not here. I am here Wednesday. The dressings to both heels should have been changed Monday. If she (R16) refused, it should have been documented. I didn't assess them (foot wounds) she went to the wound clinic (the wound clinic assesses the wounds). One of them was pressure the other was due to a cast, I think. V17 stated she does not assess R16's wounds. The facility's Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol (revised 10/24/22) showed, .Weekly measurement will be conducted and entered in the chart under Wound Management .All treatments and charting of pressure ulcers/injuries will be done by licensed staff .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R70's electronic face sheet, printed on 8/29/24, showed R70 has diagnosed including but not limited to dementia without behaviors, type 2 diabetes, peripheral vascular disease, and cognitive communication deficit. R70's care plan, dated 8/28/24, showed, Resident has experienced weight loss. Monitor and record intake of food. On 7/11/24, R70 weighed 125 lbs. On 8/10/24, R70 weighed 112 pounds which is a 10.40 % weight loss within 1 month. R70's progress notes, dated 8/15/24, showed, (Nurse Practitioner) noted weight loss. No new orders. R70's Registered Dietician note, dated 8/20/24, showed, Per nursing note 8/15 (Nurse Practitioner) notified of weight loss with no new orders. Recommend Hi calorie diet. Will continue current nutrition interventions. Will continue to monitor intakes, weight, skin, and plan of care. R70's meal intake record for July and August 2024 had no documentation of meal intakes. R70's progress notes, dated 8/27/24, showed, (Nurse Practitioner) agreed with Dietician's request to change diet to Hi calorie diet due to recent weight loss. (17 days after weight loss identified). 3. R83's electronic face sheet, printed on 8/29/24, showed R83 has diagnoses including but not limited to dementia with behaviors, hypertension, and anxiety disorder. R83's facility assessment, dated 6/11/24, showed R83 has experienced a weight loss of 5% or more within 1 month or 10% or more within 6 months. R83's care plan, dated 8/28/24, showed, Resident has experienced weight loss. Monitor and record intake of food. On 5/8/24, R83 weighed 124lbs. On 8/8/24, R83 weighed 101lbs, which is a 18.55% loss in three months. On 7/11/24, R83 weighed 115 lbs. On 8/8/24, R83 weighed 101lbs, which is a 12.17% loss in one month. R83's progress notes, dated 8/15/24, showed, (Nurse Practitioner) noted weight loss no new orders. R83's Registered Dietician note, dated 8/20/24, showed, Resident continues to drop significant weight. Recommend increasing protein supplement to 8 oz three times a day and weekly weights. Will continue current nutrition interventions. Will continue to monitor intakes, weight, skin, and plan of care. R83's meal intake record for July and August 2024 had no documentation of meal intakes. R83's progress notes, dated 8/27/24, showed, (Nurse Practitioner) agreed with Dietician's request to increase residents' protein supplements and to add weekly weights due to recent weight loss. On 8/28/24 at 3:46PM, V23 (Assistant Director of Nursing) stated, We do not have meal intakes for these residents. We only chart by exception typically, so the only thing we have documented on them is whether they consume their supplements. I guess it would be helpful to know how much our residents are eating over time, but that's not our policy to document meal intakes on all residents. The facility's policy titled, Weight Monitoring, dated 06/21, showed, Objective: To consistently assess residents for significant weight loss or gain .4. Licensed Staff will notify the physician of the following: A. 5% or more gain or loss in a 30-day period B. 7 1/2% or more gain or loss in a 90-day period C. 10% or more gain or loss in a 180-day period. 5. The weight committee will review all residents with significant weight gains or losses and other residents of concern and refer to the Registered Dietician as needed. 6. The Registered Dietician will review significant weight losses and any other residents referred by the weight committee on a monthly basis, and make recommendations to physicians as necessary. Based on observation, interview, and record review, the facility failed to implement interventions for residents with significant weight loss for 3 of 4 residents (R82, R70, R83) reviewed for weight loss in the sample of 24. These failures caused R82 to experience a 9.91% weight loss in 1 month, R70 to experience a 10.40% weight loss in 1 month, and R83 to experience a 12.18% weight loss in 1 month and a 18.55% weight loss in 3 months. The findings include: 1. R82's face sheet showed he was admitted to the facility on [DATE], with diagnoses to include chronic atrial fibrillation, congestive heart failure, pressure ulcer of sacral region, anxiety disorder, anemia in chronic kidney disease, and obstructive and reflux uropathy. On 8/28/24 at 9:12 AM, R82 said he has lost weight since he has been at the facility. R82 said he thinks maybe they may want him to lose weight. R82 said he is not on any nutritional supplements. R82's record showed on 7/11/2024, he weighed 212 lbs. (pounds) and on 8/08/2024, the resident weighed 191 pounds which is a 9.91 % weight loss in 30 days. R82's record showed the Nurse Practitioner was notified of the significant weight loss on 8/14/24 (6 days after the significant weight loss was identified). R82's Registered Dietitian Note dated 8/20/24 (12 days after the significant weight loss was identified) showed recommendations to complete weekly weights, nutritional shake twice daily, and continue to monitor intakes. R82's care plan for nutrition was started 8/28/24 (20 days after significant weight loss was identified). R82's care plan showed, Resident has experienced weight loss . Diet: Regular, high protein; encourage oral intake of food and fluids; monitor and record intake of food . There was not nutritional care plan in place prior to 8/28/24. On 8/28/24 at 3:46 PM, V3, ADON (Assistant Director of Nursing), said there are no meal intakes documented for R82. On 8/29/24 at 10:39 AM, V6 (Dietary Manager) said they have a few people who get fortified milk as a supplement, but they have no residents on fortified foods. V6 said if V27 (Registered Dietitian) recommends fortified foods, the resident would receive either mashed potatoes, soup, a cookie, or pudding. V6 said the CNAs get the weights and turn them in to him. He enters the weights and generates a report from the electronic health record which he gives to V2 (Director of Nursing), V3 (Assistant Director of Nursing), and V27 (Registered Dietitian, RD). V6 said the report is sent to V27 by email, since the facility does not have a permanent RD at this time. V6 said it has been about 4-6 months since they have had a permanent RD. V6 said the RD responds to let him know she received it and works on it at her convenience, whenever she has time. V6 said if V27 has recommendations, she emails them back to the DON to generate the changes. V6 said the nursing department puts the changes in to place and they change the diet card. V6 said R82 is on a high protein/high calorie diet and has no other nutritional supplements. V6 said the facility usually does an IDT (interdisciplinary team) meeting to discuss weights, but they have not had that meeting for the last few months since the kitchen has been short staffed. On 8/28/24 at 4:00 PM, V2, DON (Director of Nursing), said the facility does not start any nutritional supplements without a physician order. V2 said they notify the physician of weight changes, and they give the orders. The facility has no standing orders for nutritional supplements. On 8/29/24 at 12:09 PM, V2 said the RD does all her work remotely and does not come into the facility. V2 said she thinks the Registered Dietitian reviews residents with weight loss, new admissions, and those with their facility assessments coming up. V2 said she is not included in weight monitoring; all weights are given to V6, Dietary Manager. V2 said if the RD has recommendations, she writes it up and sends an email to her and to V6. V2 said recommendations are forwarded to the Nurse Practitioner, the resident's physician, or the Medical Director. V2 said those recommendations should be in place no later than 3 days after receiving them and they try and get them in place the same day or the next day. V2 said after the weight loss is identified, the RD should be reviewing as soon as possible. V2 said they don't monitor and document meal intakes on everyone, but they would do them for residents with weight loss. V2 said monitoring meal intakes would be put into place when the Dietary Manager enters the weight and identifies the weight loss. On 8/29/24 at 1:22 PM, V27 (Registered Dietitian) said she has been hired by the facility to cover until they find a permanent RD. V27 said she does all her work for the facility remotely, and was hired to work 8 hours per month. V27 said she lives out of state, and she goes in and enters notes on the residents she was referred to review every 2 weeks. V27 said V6 (Dietary Manager) sends her a list of residents to review, and she does a progress note for those. V27 said if she has recommendations, she writes those down and sends them to V6, Dietary Manger, and V2, DON. V27 said she would hope they would have those recommendations in place within the week of receiving them, but she would want interventions started right away. V27 said the gap between identifying the significant weight loss and starting interventions (18 days for R82) is too long because the residents could be losing more weight during that time. V27 said residents with a high protein/high calorie diet are supposed to receive fortified oatmeal at breakfast and fortified milk at all meals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure residents were free from physical abuse for 2 of three residents (R1, R3) reviewed in the sample of three. This failure resulted in R2 physically abusing R1 and R3 on 4/20/23 when R2 twisted R1's arm and caused a skin tear to her left hand. R2 sat on R3 while she was in bed and hit her. On 4/28/23 R2 hit R3 repeatedly with a call light. The findings include: 1. The Event Documentation dated 4/20/23 at 1:28 AM for R1 showed she was called into a resident's room by a CNA (Certified Nursing Assistant). R1 was lying in bed with a bloody gown covering her left hand. R1 had a skin tear on the top of her left hand that measured 4.5 cm. The edges were approximated, cleansed, (Brand) thin adhesive wound closure strips placed, and covered. When I asked what happened R1 stated, She squeezed my hand with her hands and told me to leave her house; she pushed on my chest really hard. The CNA stated around 1:00 AM he redirected R2 back to her room after he found her standing in the doorway of R1's room. R1 complained of pain; Ibuprofen given. On 5/2/23 at 9:00 AM, V1 (Administrator) stated on Thursday (4/27/23) V16 (R1's daughter/Power of Attorney) came in to visit R1 and reported to us that R1 had bruises and a skin tear from another resident. V16 asked what we were going to do about her mother's situation, and I had no idea what she was talking about until she told me. V1 stated V2 took over this incident. V1 stated that the incident was resident to resident abuse. On 5/2/23 at 11:01 AM, V4 (Registered Nurse/RN) stated she was called to the dementia unit. The CNA told her that R2 was standing in the doorway of R1's room. The CNA did not think to check R1 at that time or to tell her about it. V7 (Certified Nurse Assistant/CNA) went to do a bed check and came back saying R1 was bleeding. V4 stated R1 had a skin tear to her hand that she cleaned, applied (Brand) thin adhesive wound closure strips and a dressing to. V4 stated R1 told her someone pushed her on her chest. On 5/2/23 at 11:22 AM, V7 (CNA) stated, R2 was by R1's room and I told her to go back to her room. I called the nurse. I went to change R1 at bed check, and there was blood on the sheets. I screamed for my co-worker and the nurse. R1 had a skin tear to her left arm. The nurse talked to R1, and R1 told her that the lady (R2) was trying to fight her. R2 wanders in rooms and is difficult. R2 is very difficult to watch. R2 goes in other rooms thinking she is in her house. R2 constantly moves around. R2 gets irritated when you talk to her. R2 is hard to re-direct. On 5/2/23 at 11:38 AM, V6 (Certified Nurse Assistant/CNA) stated that she was in a resident's room when V7 (CNA) found R2 in the doorway of R1's room. At bed check, V7 screamed for her and V4 (RN) and said that R1 was bleeding. R1 said a lady came in and grabbed her. V6 stated that was all she knew. On 5/2/23 at 1:03 PM, V9 (Certified Nurse Assistant/CNA) stated R2 is a resident who wanders and can be combative. V9 stated R2 goes into other residents' rooms. V9 stated staff can redirect R2 unless she is really worked up. If R2 is worked up, they have to back off her and make sure no residents are around her. When R2 gets into her moods, she can be out of control. On 5/2/23 at 1:41 PM, V10 (Certified Nurse Assistant/CNA) stated she found out about R2 and R1 in report after the incident happened. R2 went into R1's room and caused a skin tear to her arm. V10 stated that all R1 said was that some lady did it. V10 stated after the incident with V2 and other residents on 4/20/23, the facility did not tell them to do anything different with R2. V10 stated no education was given and nothing was done. On 5/2/23 at 3:32 PM, V12 (Certified Nurse Assistant/CNA) stated she was not aware of anything happening between R2 and any other residents. V12 was not aware of R2 being a wanderer or needing any closer supervision. On 5/2/23 at 3:40 PM, R1 was sitting in a chair in the common area of the dementia unit. R1 had a long, curved, scabbed red line across her left hand. R1 had several bruises to her left arm and a bruise to her right hand. R1 stated, She cut me with her nail across here and pointed to her left hand. R1 stated, She was squeezing me and grabbed her left arm with her right hand to show how she was being squeezed. R1 stated it hurt when the lady did that. R1 stated that the lady hit her in her shoulder. R1 pointed to her right shoulder. R1 stated it was scary when the lady grabbed her arm and hit her. On 5/3/23 at 7:47 AM, V2 (Director of Nursing/DON) stated someone told her the next day that R2 had given R1 a skin tear. V2 stated the nurse on the night shift did not tell her that it happened. V2 stated she was not told about it until 4/21/23. V2 stated it was resident-to-resident abuse. V2 stated abuse training is done when staff are hired and annually. On 5/3/23 at 9:05 AM, V15 (Nurse Practitioner/NP) stated she has received paperwork about R2's behaviors, and for a while she was increasing R2's medications. V15 stated she was leery of increasing the medications too much because there needs to be some time in there to see how the medications are working. V15 stated sometimes residents with dementia will have behaviors because they are not being attended to. Residents will wander and get upset. V15 stated that for R2, she would expect staff to redirect R2 and spend more time with her. If R2 becomes aggressive then back off, remove other residents from the area if they can't move R2. V15 stated she would expect staff to keep other residents safe. They should be monitoring R2 closer and the types of behaviors she has. V15 stated she reviews the progress notes when she comes in. If there isn't any documentation of what was happening for the resident, then she would not know about it. On 5/3/23 at 9:16 AM, V16 (R1's daughter/Power of Attorney) stated, last Thursday, on 4/27/23, I came into the facility for my weekly visit. R1 was lying down, and I saw her arms and hand. R1's left forearm was swollen and bruised to her fingertips. R1 had a large cut that was nasty looking to her left hand. R1 had a bruise to her right hand. I asked R1 what happened, and she said someone came in her room in the middle of the night, squeezed her arms and it hurt really bad. I went out of the room and asked V10 (CNA) about R1's arms. She said I should talk to V5 LPN (Licensed Practical Nurse). I asked V5 what happened. She looked in the computer and said R1 was attacked by a resident. V5 said it happened on 4/20/21 between 1-1:30 AM. V5 said I should talk to V1 (Administrator) or V2 (DON). We just want our mom to be safe, feel safe, and be content. R1 is [AGE] years old and doesn't have much time left. If R1 didn't have dementia she would be horrified and have trauma. R1 maybe wouldn't be able to sleep because she would be worried it would happen again. R1 would probably want to leave. R2's Face Sheet dated 5/3/23 showed medical diagnoses including dementia, anxiety, type 2 diabetes mellitus, chronic kidney disease, post-traumatic stress disorder, unsteadiness on her feet, pain, fall, and disorientation. The Physician Order's for R2 dated 4/3/23 - 5/3/23 showed, walk with assistance and walker. The Progress Notes for R2 showed she was admitted to the facility on [DATE]. The MDS (Minimum Data Set) assessment dated [DATE] for R2 showed severe cognitive impairment; physical, verbal, and other behaviors; and no assessment of her functional status. The Care Plan for R2 dated 4/28/23 showed she has diagnoses of anxiety, dementia, and post-traumatic stress disorder. Due to these she is displaying physical behaviors, verbal behaviors and wandering. At times she wanders the unit or into other resident's rooms disturbing them. At times, it is difficult to redirect R2. The Care Plan was updated on 5/2/23 and did not show frequent monitoring. The Facility's Abuse Prohibition and Reporting policy (11/28/19) showed the purpose of the policy was to protect the residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms. Special attention will be given to identifying behavior that increases the resident's potential for abusing self or others or being a victim of abuse. These behaviors would include residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident rooms, residents with self-injurious behaviors, residents with communication disorders, and those who require heavy nursing care and/or are totally dependent on staff. Appropriate interventions to address identified behaviors will be included on resident care plans and reviewed as/when change occurs. These interactions will be communicated to the direct care staff. If another resident is the suspected perpetrator of abuse, then the suspected resident shall be supervised 1:1 or kept physically separate from other residents until further orders. 2. The Nurse's Note dated 4/20/23 at 1:21 AM for R3 showed the nurse was called into R3's room by the CNA. The CNA stated she entered R3's room and her roommate (R2) was sitting on top of R3. R3 stated R2 was yelling at her; telling her to get out of her bed. R3 stated R2 punched her. R3 was pointing to the area just below her right clavicle. R3 stated she told R2 that it hurt and reached for her call light. R2 was removed from the room. On 5/2/23 at 11:01 AM, V4 (RN) stated she was called to the dementia unit on 4/20/23 around 1:00 AM or 1:30 AM by the CNAs. V4 stated she went to R3's room and R2 was sitting on top of R3. V4 stated she wasn't sure if she notified V1 (Administrator) or V2 (DON). V4 stated Sure and I don't know when she was asked if V1 (Administrator) and V2 (DON) are supposed to be notified of resident-to-resident abuse. On 5/2/23 at 11:22 AM, V7 (CNA) stated R2 was sitting on top of R3 and was trying to fight her. R2 was screaming to get R3 out of there. The nurse went in and talked to R2. On 5/2/23 at 11:38 AM, V6 (CNA) stated at some point in the night R2 was sitting on R3. V6 stated her and V7 saw it and told the nurse. V6 couldn't remember if R2 stated R3 had hit her or not. V6 stated R2 said that R3 talks and talks and wants to fight. On 5/2/23 at 1:51 PM, V1 (Administrator) stated he did not know anything about R2 sitting on R3 or hitting her on 4/20/23. V1 stated it was never reported to him and it should have been. V1 stated it was resident to resident abuse. On 5/3/23 at 7:47 AM, V2 (DON) stated no one told her about what happened between R3 and R2 on 4/20/23. V2 stated she was reading a note and R2 had hit and sat on R3. V2 stated she read about it the next day when she was looking at R2's information. V2 stated it was resident to resident abuse. The Facility's Abuse Prohibition and Reporting policy (11/28/19) showed the purpose of the policy was to protect the residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms. Special attention will be given to identifying behavior that increases the resident's potential for abusing self or others or being a victim of abuse. These behaviors would include residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident rooms, residents with self-injurious behaviors, residents with communication disorders, and those who require heavy nursing care and/or are totally dependent on staff. Appropriate interventions to address identified behaviors will be included on resident care plans and reviewed as/when change occurs. These interactions will be communicated to the direct care staff. These interactions will be communicated to the direct care staff. If another resident is the suspected perpetrator of abuse, then the suspected resident shall be supervised 1:1 or kept physically separate from other residents until further orders. 3. On 5/3/23 at 1:03 PM, V9 (CNA) stated she saw R2 hit another resident. On Friday, 4/28/23, she stated she came into work in the morning and got report. At around 6:30 AM, there was a call light going off and she went to answer it. When she went into the room R2 had the call light and was hitting R3 with it. R3 was trying to get out of bed on her own to get away. V9 stated she yelled for help and V10 (CNA) came down. On 5/3/23 at 1:18 PM, V10 (CNA) stated on Friday 4/28/23 R3's call light went off and V9 (CNA) caught R2 whipping the call light at R3's back. R2 was in the first bed and R3 was in the second bed. V10 stated they cleaned R3 up and removed her from the room. On 5/3/23 at 2:35 PM, V1 (Administrator) stated V2 (DON) sent him a text message on Friday, 4/28/23 at 6:31 AM, that we needed to do something with R2 because she had been hitting people with a call light. It didn't get reported to IDPH. V1 stated it was abuse. V1 stated he thought it didn't get reported because they were busy with R1's daughter and what happened to R1. A review of R3's medical record did not show any documentation of her being hit by another resident on 4/28/23. The last Progress Note for R3 was dated 4/26/23. On 5/2/23 at 3:50 PM, V1 stated the last Progress Note in R3's chart was dated 4/26/23. V1 stated he asked V2 (DON) why the incident on 4/28/23 between R3 and R2 was not documented in the progress notes. V2 said V5 (Licensed Practical Nurse/LPN) should have documented it in the progress notes. On 5/3/23 at 7:47 AM, V2 (DON) stated the morning (4/28/23) that they said R2 hit R3 with a call light she sent a message to V1 (Administrator) and V14 (Social Services). V2 stated she told them R2 needed to be put in a different room, so they were aware of what happened. V2 stated V5 (LPN) should have put a note in the resident's medical record. V2 stated the incident was reported to her and she reported it to V1. V2 stated it was resident-to-resident abuse. On 5/3/23 at 8:45 AM, V5 (LPN) stated she was the nurse on duty on 4/28/23 on the dementia unit. V5 stated a CNA went to answer R3's call light. V5 stated she was told that R2 was over R3's bed, hitting R3 with the call light. V5 stated they got R3 dressed and out of the room. V5 stated she asked V14 (Social Services) to ask V1 (Administrator) how to chart the incident. V5 stated no one got back to her on charting. V5 stated another nurse had told her they wanted things charted a certain way. V5 stated she could have documented, but the day got away from her and she didn't do it. V5 stated she reported what happened to V2 (DON) because it was resident-to-resident abuse. The Facility's Abuse Prohibition and Reporting policy (11/28/19) showed the purpose of the policy was to protect the residents from any kind of abuse such as verbal, sexual, mental, physical, including corporal punishment, involuntary seclusion, neglect, misappropriation of property, exploitation and any physical or chemical restraint not required to treat the resident's symptoms. Special attention will be given to identifying behavior that increases the resident's potential for abusing self or others or being a victim of abuse. These behaviors would include residents with a history of aggressive behaviors, residents who have behaviors such as entering other resident rooms, residents with self-injurious behaviors, residents with communication disorders, and those who require heavy nursing care and/or are totally dependent on staff. Appropriate interventions to address identified behaviors will be included on resident care plans and reviewed as/when change occurs. These interactions will be communicated to the direct care staff. These interactions will be communicated to the direct care staff. If another resident is the suspected perpetrator of abuse, then the suspected resident shall be supervised 1:1 or kept physically separate from other residents until further orders. The following will be documented in the resident's medical record: a. The nature and extent of any injuries sustained or the condition resulting from the alleged incident. b. Whether the resident was sent to the hospital. c. Whether the resident's physician was called.