**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 41 residents with 13 residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure residents remained free from resident-to-resident abuse when on 01/25/25 Resident (R)1 grabbed R3's breast, and the facility failed to place any interventions to protect R3 and other residents from R1's unwanted sexual advances and touching. The facility placed R1 on a one-to-one with staff and sent the resident to a geriatric psychiatric (geri-psych) facility but did not implement interventions to prevent further resident-to-resident abuse when R1 returned on 02/22/25 other than medication for sexual aggression. On 03/01/25 staff observed R1 rubbing the leg of an unidentified female resident. The facility did not implement interventions in response to this incident. On 03/05/25 R1 grabbed R2's breast and staff directed R1 to his room but did not implement interventions to prevent further sexual contact. On 03/10/25 the facility placed R1 on visual one-to-one when R1 was outside his room though on 03/19/25, R1 again attempted to touch a female resident's leg but was redirected by staff back to his room with no further interventions noted. On 03/20/25 the facility documented R1 was on one-to-one when out of his room and there had been no inappropriate incidents. On 03/27/25 staff observed R1 stroking his penis next to an unidentified male resident but did not implement any interventions related to this incident. On 03/30/25 staff observed R1 stroking R3's leg. The facility noted that R1 gravitated to R3 as R3 resembled R1's spouse and the facility-initiated arms-length one-to-one. The facility's failure to ensure cognitively impaired residents remained free from sexual and/or physical resident-to-resident abuse placed R2, R3, and all cognitively impaired female residents unable to consent in immediate jeopardy. Findings included: - R1's Electronic Health Record (EHR) included the diagnoses of altered mental status, psychotic disorder (a mental disorder characterized by gross impairment in reality perception) with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), high-risk sexual behavior, and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. R1 displayed no behaviors to indicate psychosis. The assessment documented R1 utilized a walker and/or wheelchair for locomotion. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/21/25 documented R1 had dementia (a progressive mental disorder characterized by failing memory, and confusion) with short-term and long-term memory loss. The Psychosocial Well-Being CAA dated 01/21/25 documented R1 lacked interest in interacting with or participating in activities. R1's Care Plan, reviewed 04/08/25, documented on 01/19/25, the resident had a cognitive loss that affected memory. Interventions dated 01/19/25 directed staff to help R1 establish a regular daily schedule with tasks divided into several steps. The plan directed staff to be patient with R1, remind R1 who they were, and explain care prior to initiation; staff would provide one instruction at a time in a calm tone. An update dated 01/27/25 noted R1 was placed on one-to-one monitoring for redirecting of behaviors, initiated on 01/25/25, created on 01/27/25, and revised on 03/10/25. The plan noted that R1 would be evaluated by geriatric psychiatry for behaviors of touching another person without their approval, which was initiated on 01/25/25, created on 01/27/25, and revised on 04/02/25. R1's Care Plan reviewed 04/08/25 documented on 01/27/25, R1 was at risk for sexually inappropriate behaviors related to maladaptive (unhealthy or ineffective ways of coping with something difficult or stressful) mood and behavior. The care plan included an intervention dated 01/27/25 that directed staff to administer medications as ordered to manage R1's behavior, created on 01/28/25. Interventions created on 01/2825 effective for 01/27/25 included staff observing R1's mood and behaviors, staff obtaining a psychiatric evaluation as ordered, staff redirecting inappropriate behavior with alternative activities, and staff reporting changes in behavior to the nurse and physician being informed as indicated. The plan documented that staff would ensure R1 was on one-on-one observation at an arm's length when not in his room, created on 01/28/25 and revised on 04/02/25 The Progress Notes section of R1's EHR documented the following notes: On 01/25/25 at 11:14 AM, staff observed R1 walked up to R3, a cognitively impaired resident, and touched her breast. Staff redirected R1 to his room. On 02/03/25 at 01:59 PM, staff documented a root cause analysis of the incident on 01/25/25 and documented that, according to R1's responsible person, R1 had a history of sexual aggression and grabbed R3's left breast. R1 was immediately removed from the area back to his room and placed on one-on-one monitoring when not in his room; R1 was started on medication for sexual aggression. On 03/01/25, Licensed Nurse (LN) I documented staff observed R1 rubbing the leg of an unidentified female resident. On 03/05/25, LN I documented R1 grabbed R2's (a cognitively impaired resident) breast, and staff directed R1 to his room. LN I documented the notification of Administrative Staff A and Administrative Nurse B of the incident. On 03/06/25 at 11:56 AM, Administrative Nurse B documented that LN I reported R1 had grabbed R2's breast in the dining area. On 03/10/25 at 01:03 PM, staff documented a root cause analysis of the incident on 03/05/25 and documented that according to R1's responsible person, R1 had a history of sexual aggression and R1 grabbed R2's left breast. R1 was immediately removed from the area back to his room and placed on one-on-one monitoring when not in his room. On 03/19/25 at 05:51 AM, staff documented R1 was up and down during the night and wandered from his room to the common area and back; redirection attempts were unsuccessful. Additionally, staff documented an unknown Certified Nurse Aide (CNA) stopped R1 from reaching for an unidentified female resident's leg. The CNA told R1 to stop and R1 walked back to his room before physical contact was made. Staff documented that Administrative Staff A and Administrative Nurse B were notified. On 03/20/25 at 03:16 PM, Social Services Designee (SSD) M documented R1 was observed throughout the week related to a previous incident (undated) and R1 remained on one-on-one observation when outside of his room. SSD M documented R1 had no inappropriate incidents. On 03/27/25 at 02:15 AM, staff documented R1 was observed stroking his penis while seated next to another male resident at 02:05 AM. Staff documented there was no physical contact observed between the two residents, and Administrative Staff A and Administrative Nurse B were notified. On 03/30/25 at 06:20 AM, LN F documented R1 stroked R3's left lower leg. Staff moved R3 and R1 returned to his room. On 03/30/25 at 07:51 AM, staff documented R1 looked up the dresses on wooden the Easter decorations in the dining room and stated, Let me get that [expletive]. On 03/30/25 at 06:02 PM, staff documented R1 continued to try and look up the dresses on the Easter decorations. On 04/03/25 at 02:17 PM, SSD M documented the facility sent a referral for R1 to be transferred to a different facility. On 04/02/25 at 10:44 AM, LN F documented that on 03/30/25 R1 was observed slowly rubbing R3's lower left leg. The note documented LN F placed herself between R1 and R3 and remained there until R1 returned to his room. LN F assessed R3 and determined her to be free of injury. The note recorded R1 continued to be on one-on-one observation. LN F documented she notified Administrative Staff A and Administrative Nurse B. On 04/08/25 at 02:14 PM, staff documented a root cause analysis, and the facility noted that R1 gravitated to R3 as R3 resembled R1's spouse; the facility-initiated arms-length one-on-one monitoring for R1 and continued to try to get the resident transferred to an all-male facility. A review of the facility's investigation and witness statements for the 01/25/25 incident revealed no additional information. The investigation report lacked documentation that the facility notified Law Enforcement (LE). The facility lacked an investigation report for the incident on 03/01/25. A review of the facility's investigation and witness statements for the 03/05/25 incident revealed no additional information. The investigation report lacked documentation that the facility notified. The facility lacked an investigation report for the incident on 03/27/25. A review of the facility's investigation for the 03/30/25 incident revealed no additional information. The investigation report lacked witness statements and lacked documentation that the facility notified LE. On 04/08/25 at 01:40 PM, R1 was unable to be interviewed due to the resident's cognitive impairment. During an interview on 04/08/25 at 04:40 PM, LN F stated on 03/30/25 R1 was observed rubbing the lower left leg of R3. LN F stated she placed herself between R1 and R3 until R1 went back to his room. During an interview on 04/09/25 at 03:20 PM, Administrative Staff A stated the facility did not notify LE of any of the documented incidents from 01/25/25 to 04/09/25. During an interview on 04/09/25 at 03:42 PM, CNA H stated she was unaware of the details of the events and stated R3 looks like R1's wife. CNA H stated R1 was confused and continued to attempt to touch R3 and rub her leg. CNA H stated if staff observed R1 with this type of behavior, staff had to stand between R1 and the female residents and report the incidents to the nurse on duty. During an interview on 04/09/25 at 03:46 PM, CNA J stated if R1 reached for a female resident staff would protect the female resident and attempt to redirect R1 with a different activity and report the incident to the nurse or a member of management. During an interview on 04/09/25 at 04:15 PM, LN K stated she was aware of the incidents with R1 and inappropriate contact and stated if staff observed R1 attempt inappropriate contact, R1 should be removed as quickly as possible to ensure the safety of the other residents. LN K stated she would report the incident to management immediately and then follow management's discretion as to whether to call law enforcement. During an interview on 04/09/25 at 04:25 PM, Administrative Nurse C stated the facility's expectation in the event of unwanted or inappropriate sexual contact staff should separate the residents to ensure resident safety and perform any required assessments and document everything in the EHR. Staff would then notify management who would immediately develop and implement an intervention to prevent the incident from happening again. This included notifying and educating all the staff and obtaining signatures. Administrative Nurse C stated after the incident on 01/25/25, R1 was placed under visual one-on-one monitoring until R1 was sent to a behavioral health unit (BHU). Administrative Nurse C stated she was unaware if the management team was aware of the incident on 03/01/25, and after the incident on 03/05/25 R1 was placed on one-on-one monitoring when he was out of his room. Administrative Nurse C stated when the incident occurred on 03/30/25 R1 was placed on one-on-one monitoring where staff must stay within an arms-reach of R1 when out of his room with a staff member placed outside the door to his room. Administrative Nurse C stated the management team was actively trying to find alternate placement for R1 at a more appropriate facility. Administrative Nurse C stated LE should be contacted for any unwanted physical or sexual contact and confirmed that LE was not contacted for any incidents that involved R1 between 01/25/25 and 04/09/25. During an interview on 04/09/25 at 04:54 PM Administrative Staff A revealed that after the incident on 01/25/25, R1 was placed under one-on-one visual monitoring until he was transferred to the behavioral health unit. Administrative Staff A said when R1 returned to the facility, he was self-isolating and would only come out of his room for meals and after the incident on 03/05/25, R1 was placed on one-on-one visual monitoring when he was outside of his room. Administrative Staff A stated after the incident on 03/30/25, R1 was placed on one-on-one monitoring within arm-length reach of staff except when he was in his room, then staff would be outside his room. Administrative Staff A stated the facility continued to try to find alternative placement at an all-male dementia unit. Administrative Staff A in the event of unwanted physical or sexual contact between residents, she expected staff to immediately separate the residents, assess the residents involved, and then notify management. Administrative Staff A stated staff followed the appropriate procedure for all the events reviewed involving R1. Administrative Staff A stated the event on 03/01/25 was not fully investigated or called to LE because the contact was not believed to be sexual in nature. Administrative Staff A confirmed the Progress Note dated 03/19/25 and stated she was unaware of the information and stated it would be considered a near-miss. Administrative Staff A stated the event documented on 03/27/25 was not investigated or reported because the other male resident in the area was unaware of R1's actions, R1's genitals were not exposed and R1 was not aggressive. Administrative Staff A stated LE should only be notified if another resident is harmed or if the resident's family wants LE involved. Administrative Staff A confirmed if someone touched anyone's breast without consent, LE should be notified and further confirmed R2 and R3 were incapable of providing consent and the touching from R1 was sexual in nature so it should have been reported to LE. The facility's Abuse, Neglect and Exploitation policy dated 10/2022 documented that residents have the right to be free from verbal, sexual, physical, and mental abuse. The facility would keep residents free from abuse and take swift and immediate action to investigate allegations of abuse. The policy documented every employee had the responsibility to report allegations of abuse and the Administrator or Director of Nursing (DON) would investigate allegations and report the results to the proper authorities. All reports or suspicions of abuse would result in an investigation and all reasonable suspicions of a crime would be reported as required. On 04/10/25 at 11:35 AM, Administrative Staff L and Administrative Nurse C were provided the Immediate Jeopardy (IJ) template and informed that the facility's failure to ensure cognitively impaired residents remained free from sexual and/or physical resident-to-resident abuse placed R2, R3, and all cognitively impaired female residents unable to consent in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediate jeopardy on 04/10/25 at 02:56 PM which included the following: The facility placed R1 on one-on-one monitoring until an appropriate alternate placement was secured. The facility notified Law Enforcement on 04/10/25. LN I received disciplinary action for failure to report the incident on 03/10/25. LN F received disciplinary action for failure to report the incident on 03/30/25 until 04/02/25. The facility updated R2 and R3's Care Plans to include social services follow-up with each resident weekly and as needed for their psychosocial well-being. The facility updated R1's Care Plan to include one-on-one monitoring until appropriate alternate placement was secured. Staff would assist R1 to a private location when fondling his genitals. The facility immediately educated all staff on 04/10/25 regarding abuse prevention, reporting, and expectations related to immediate interventions and investigations. The facility re-educated all staff on the definition of one-on-one monitoring with associated documentation. The facility held an Ad-hoc Quality Assurance Process Improvement (QAPI) meeting by telephone on 04/10/25. Implementation of the corrective measures to remove the immediacy was verified on-site on 04/10/25 at 03:35 PM. The deficient practice remained at a scope and severity level of a G (isolated actual harm) to represent the psychosocial impact of the abuse for R2 and R3 using the reasonable person concept, due to the residents' inability to self-identify and/or verbally express their feelings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 41 residents, including 11 female residents with moderate to severe cognitive impairment. The sample included 13 residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to report allegations of resident-to-resident abuse to the Licensed Nursing Home Administrator (LNHA), State Agency (SA) and/or Law Enforcement (LE) as appropriate when Resident (R) 1 repeatedly touched cognitively impaired female residents, R2 and R3, and displayed sexual behaviors such as masturbating in the presence of other residents. On 01/25/25 R1 grabbed R3's breast. The facility placed R1 on one-to-one with staff and sent the resident to an acute behavioral facility, but did not implement interventions to prevent further resident-to-resident abuse when R1 returned on 02/22/25 other than a medication for sexual aggression. The facility failed to notify LE. On 03/01/25 staff observed R1 rubbing the leg of an unidentified female resident. On 03/05/25 R1 grabbed R2's breast and staff directed R1 to his room but did not notify LE. On 03/10/25 the facility placed R1 on visual one-to-one when R1 was outside his room. On 03/19/25 R1 attempted to touch a female resident's leg but was redirected by staff back to his room with no further interventions noted. On 03/20/25 the facility documented R1 was on one-to-one when out of his room and there had been no inappropriate incidents. On 03/27/25 staff observed R1 stroking his penis next to an unidentified male resident but did not implement any interventions related to this incident or report the incident as alleged abuse to the SA. On 03/30/25 staff observed R1 stroking R3's leg. The facility noted that R1 gravitated to R3 as R3 resembled R1's spouse and the facility-initiated arms-length one-to-one. The facility's failure to report allegations of resident-to-resident abuse to the LNHA, SA, and LE as appropriate placed R2, R3 and all cognitively impaired female residents in immediate jeopardy. Findings included: - R1's Electronic Health Record (EHR) included the diagnoses of altered mental status, psychotic disorder (a mental disorder characterized by gross impairment in reality perception) with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), high-risk sexual behavior, and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of three, which indicated severely impaired cognition. R1 displayed no behaviors to indicate psychosis. The assessment documented R1 utilized a walker and/or wheelchair for locomotion. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/21/25 documented R1 had dementia (a progressive mental disorder characterized by failing memory, and confusion) with short-term and long-term memory loss. The Psychosocial Well-Being CAA dated 01/21/25 documented R1 lacked interest in interacting with or participating in activities. R1's Care Plan, reviewed 04/08/25, documented on 01/19/25, the resident had a cognitive loss that affected memory. Interventions dated 01/19/25 directed staff to help R1 establish a regular daily schedule with tasks divided into several steps. The plan directed staff to be patient with R1, remind R1 who they were, and explain care prior to initiation; staff would provide one instruction at a time in a calm tone. An update dated 01/27/25 noted R1 was placed on one-to-one monitoring for redirecting of behaviors, initiated on 01/25/25, created on 01/27/25, and revised on 03/10/25. The plan noted that R1 would be evaluated by geriatric psychiatry for behaviors of touching another person without their approval, which was initiated on 01/25/25, created on 01/27/25, and revised on 04/02/25. R1's Care Plan reviewed 04/08/25 documented on 01/27/25, R1 was at risk for sexually inappropriate behaviors related to maladaptive (unhealthy or ineffective ways of coping with something difficult or stressful) mood and behavior. The care plan included an intervention dated 01/27/25 that directed staff to administer medications as ordered to manage R1's behavior, created on 01/28/25. Interventions created on 01/2825 effective for 01/27/25 included staff observing R1's mood and behaviors, staff obtaining a psychiatric evaluation as ordered, staff redirecting inappropriate behavior with alternative activities, and staff reporting changes in behavior to the nurse and physician being informed as indicated. The plan documented staff would ensure R1 was on one-on-one observation at an arm's length when not in his room, created on 01/28/25 and revised on 04/02/25 The Progress Notes section of R1's EHR documented the following notes: On 01/25/25 at 11:14 AM, staff observed R1 walked up to R3, a cognitively impaired resident, and touched her breast. Staff redirected R1 to his room. On 02/03/25 at 01:59 PM, staff documented a root cause analysis of the incident on 01/25/25 and documented, according to R1's responsible person, R1 had a history of sexual aggression and grabbed R3's left breast. R1 was immediately removed from the area back to his room and placed on one-on-one monitoring when not in his room; R1 was started on medication for sexual aggression. On 03/01/25, Licensed Nurse (LN) I documented staff observed R1 rubbing the leg of an unidentified female resident. On 03/05/25, LN I documented R1 grabbed R2's (a cognitively impaired resident) breast, and staff directed R1 to his room. LN I documented the notification of Administrative Staff A and Administrative Nurse B of the incident. On 03/06/25 at 11:56 AM, Administrative Nurse B documented LN I reported R1 had grabbed R2's breast in the dining area. On 03/10/25 at 01:03 PM, staff documented a root cause analysis of the incident on 03/05/25 and documented according to R1's responsible person, R1 had a history of sexual aggression and R1 grabbed R2's left breast. R1 was immediately removed from the area back to his room and placed on one-on-one monitoring when not in his room. On 03/19/25 at 05:51 AM, staff documented R1 was up and down during the night and wandered from his room to the common area and back; redirection attempts were unsuccessful. Additionally, staff documented an unknown Certified Nurse Aide (CNA) stopped R1 from reaching for an unidentified female resident's leg. The CNA told R1 to stop and R1 walked back to his room before physical contact was made. Staff documented the notification of Administrative Staff A and Administrative Nurse B. On 03/20/25 at 03:16 PM, Social Services Designee (SSD) M documented R1 was observed throughout the week related to a previous incident (undated) and R1 remained on one-on-one observation when outside of his room. SSD M documented R1 had no inappropriate incidents. On 03/27/25 at 02:15 AM, staff documented R1 was observed stroking his penis while seated next to another male resident at 02:05 AM. Staff documented there was no physical contact observed between the two residents, and Administrative Staff A and Administrative Nurse B were notified. On 03/30/25 at 06:20 AM, LN F documented R1 stroked R3's left lower leg. Staff moved R3 and R1 returned to his room. On 03/30/25 at 07:51 AM, staff documented R1 looked up the dresses on wooden Easter decorations in the dining room and stated, Let me get that [expletive]. On 03/30/25 at 06:02 PM, staff documented R1 continued to try and look up the dresses on the Easter decorations. On 04/03/25 at 02:17 PM, SSD M documented a referral for R1 to be transferred to a different facility was sent. On 04/02/25 at 10:44 AM, LN F documented on 03/30/25 R1 was observed slowly rubbing R3's lower left leg. The note documented LN F placed herself between R1 and R3 and remained there until R1 returned to his room. LN F assessed R3 and determined her to be free of injury. The note recorded R1 continued to be on one-on-one observation. LN F documented she notified Administrative Staff A and Administrative Nurse B. On 04/08/25 at 02:14 PM, staff documented a root cause analysis, and the facility noted that R1 gravitated to R3 as R3 resembled R1's spouse; the facility-initiated arms-length one-on-one monitoring for R1 and continued to try to get the resident transferred to an all-male facility. A review of the facility's investigation and witness statements for the 01/25/25 incident revealed no additional information. The investigation report lacked documentation that Law Enforcement (LE) was notified. The facility lacked an investigation report for the incident on 03/01/25. A review of the facility's investigation and witness statements for the 03/05/25 incident revealed no additional information. The investigation report lacked documentation that LE was notified. The facility lacked an investigation report for the incident on 03/27/25. A review of the facility's investigation for the 03/30/25 incident revealed no additional information. The investigation report lacked witness statements and lacked documentation that LE was notified. On 04/08/25 at 01:40 PM, R1 was unable to be interviewed due to the resident's cognitive impairment. During an interview on 04/08/25 at 04:40 PM, LN F stated on 03/30/25 R1 was observed rubbing the lower left leg of R3. LN F stated she placed herself between R1 and R3 until R1 went back to his room. During an interview on 04/09/25 at 03:20 PM, Administrative Staff A stated the facility did not notify LE of any of the documented incidents from 01/25/25 to 04/09/25. During an interview on 04/09/25 at 03:42 PM, CNA H stated she was unaware of the details of the events and stated R3 looks like R1's wife. CNA H stated R1 was confused and continued to attempt to touch R3 and rub her leg. CNA H stated if staff observed R1 with this type of behavior, staff had to stand between R1 and the female residents and report the incidents to the nurse on duty. During an interview on 04/09/25 at 03:46 PM, CNA J stated if R1 reached for a female resident staff would protect the female resident and attempt to redirect R1 with a different activity and report the incident to the nurse or a member of management. During an interview on 04/09/25 at 04:15 PM, LN K stated she was aware of the incidents with R1 and inappropriate contact and stated if staff observed R1 attempt inappropriate contact, R1 should be removed as quickly as possible to ensure the safety of the other residents. LN K stated she would report the incident to management immediately and then follow management's discretion as to whether to call law enforcement. During an interview on 04/09/25 at 04:25 PM, Administrative Nurse C stated the facility's expectation in the event of unwanted or inappropriate sexual contact staff should separate the residents to ensure resident safety and perform any required assessments and document everything in the EHR. Staff would then notify management who would immediately develop and implement an intervention to prevent the incident from happening again. This included notifying and educating all the staff and obtaining signatures. Administrative Nurse C stated after the incident on 01/25/25, R1 was placed under visual one-on-one monitoring until R1 was sent to a behavioral health unit (BHU). Administrative Nurse C stated she was unaware if the management team was aware of the incident on 03/01/25, and after the incident on 03/05/25 R1 was placed on one-on-one monitoring when he was out of his room. Administrative Nurse C stated when the incident occurred on 03/30/25 R1 was placed on one-on-one monitoring where staff must stay within an arms-reach of R1 when out of his room with a staff member placed outside the door to his room. Administrative Nurse C stated the management team was actively trying to find alternate placement for R1 at a more appropriate facility. Administrative Nurse C stated LE should be contacted for any unwanted physical or sexual contact and confirmed that LE was not contacted for any incidents that involved R1 between 01/25/25 and 04/09/25. During an interview on 04/09/25 at 04:54 PM Administrative Staff A revealed that after the incident on 01/25/25, R1 was placed under one-on-one visual monitoring until he was transferred to the behavioral health unit. Administrative Staff A said when R1 returned to the facility, he was self-isolating and would only come out of his room for meals and after the incident on 03/05/25, R1 was placed on one-on-one visual monitoring when he was outside of his room. Administrative Staff A stated after the incident on 03/30/25, R1 was placed on one-on-one monitoring within arm-length reach of staff except when he was in his room, then staff would be outside his room. Administrative Staff A stated the facility continued to try to find alternative placement at an all-male dementia unit. Administrative Staff A in the event of unwanted physical or sexual contact between residents, she expected staff to immediately separate the residents, assess the residents involved, and then notify management. Administrative Staff A stated staff followed the appropriate procedure for all the events reviewed involving R1. Administrative Staff A stated the event on 03/01/25 was not fully investigated or called to LE because the contact was not believed to be sexual in nature. Administrative Staff A confirmed the Progress Note dated 03/19/25 and stated she was unaware of the information and stated it would be considered a near-miss. Administrative Staff A stated the event documented on 03/27/25 was not investigated or reported because the other male resident in the area was unaware of R1's actions, R1's genitals were not exposed and R1 was not aggressive. Administrative Staff A stated LE should only be notified if another resident is harmed or if the resident's family wants LE involved. Administrative Staff A confirmed if someone touched anyone's breast without consent, LE should be notified and further confirmed R2 and R3 were incapable of providing consent and the touching from R1 was sexual in nature so it should have been reported to LE. The facility's Abuse, Neglect and Exploitation policy dated 10/2022 documented residents have the right to be free from verbal, sexual, physical, and mental abuse. The facility would keep residents free from abuse and take swift and immediate action to investigate allegations of abuse. The policy documented every employee had the responsibility to report allegations of abuse and the Administrator or Director of Nursing (DON) would investigate allegations and report the results to the proper authorities. All reports or suspicions of abuse would result in an investigation and all reasonable suspicions of a crime would be reported as required. On 04/10/25 at 11:35 AM, Administrative Staff L and Administrative Nurse C were provided the Immediate Jeopardy (IJ) template and informed that the facility's failure to report allegations of resident-to-resident abuse to the LNHA, SA, and/or LE as appropriate placed R2, R3 and all cognitively impaired female residents in immediate jeopardy The facility submitted an acceptable plan for removal of the immediate jeopardy on 04/10/25 at 02:56 PM which included the following: The facility placed R1 on one-on-one monitoring until an appropriate alternate placement was secured. The facility notified Law Enforcement on 04/10/25. LN I received disciplinary action for failure to report the incident on 03/10/25. LN F received disciplinary action for failure to report the incident on 03/30/25 until 04/02/25. The facility updated R2 and R3's Care Plans to include social services follow-up with each resident weekly and as needed for their psychosocial well-being. The facility updated R1's Care Plan to include one-on-one monitoring until appropriate alternate placement was secured. Staff would assist R1 to a private location when fondling his genitals. The facility immediately educated all staff on 04/10/25 regarding abuse prevention, reporting, and expectations related to immediate interventions and investigations. The facility re-educated all staff on the definition of one-on-one monitoring with associated documentation. The facility held an Ad-hoc Quality Assurance Process Improvement (QAPI) meeting by telephone on 04/10/25. Implementation of the corrective measures to remove the immediacy was verified on-site on 04/10/25 at 03:35 PM. The deficient practice remained at a scope and severity level of E (patterned, potential harm).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 41 residents and 11 female residents with moderate to severe cognitive impairment. The sample included 13 residents reviewed for abuse. Based on observation, interview, and record review, the facility failed to immediately implement protective measures to prevent further potential abuse, after an allegation of resident-to-resident abuse and further failed to conduct thorough investigations when Resident (R) 1 repeatedly touched cognitively impaired female residents, R2 and R3, and displayed sexual behaviors such as masturbating in the presence of other residents. On 01/25/25 R1 grabbed R3's breast. The facility placed R1 on one to one with staff and sent the resident to the acute behavioral facility but did not implement interventions to prevent further resident to resident abuse when R1 returned on 02/22/25 other than a medication for sexual aggression. On 03/01/25 staff observed R1 rubbing the leg of an unidentified female resident. The facility did not implement interventions in response to this incident or investigate the incident. On 03/05/25 R1 grabbed R2's breast and staff directed R1 to his room but did not implement interventions to prevent further sexual contact. On 03/10/25 the facility placed R1 on visual one to one when R1 was outside his room. On 03/19/25 R1 attempted to touch a female resident's leg but was redirected by staff back to his room with no further interventions noted. On 03/20/25 the facility documented R1 was on one to one when out of his room and there had been no inappropriate incidents. On 03/27/25 staff observed R1 stroking his penis next to an unidentified male resident but did not implement any interventions related to this incident or investigate the incident. On 03/30/25 staff observed R1 stroking R3's leg. The facility noted that R1 gravitated to R3 as R3 resembled R1's spouse and the facility-initiated arms -length one to one. The facility's failure to immediately implement protective measures to prevent further potential abuse, after an allegation of resident-to-resident abuse, and to conduct thorough investigations placed R2, R3 and all cognitively impaired female residents in immediate jeopardy. Findings included: - R1's Electronic Health Record (EHR) included the diagnoses of altered mental status, psychotic disorder (a mental disorder characterized by gross impairment perception) with delusions (untrue persistent belief or perception held by a person although evidence shows it was untrue), high-risk sexual behavior and Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure). The admission Minimum Data Set (MDS) dated [DATE], documented a Brief Interview for Mental Status (BIMS) of three, which indicated severely impaired cognition. R1 displayed no behaviors to indicate psychosis. The assessment documented R1 utilized a walker and/or wheelchair for locomotion. The Cognitive Loss/Dementia Care Area Assessment (CAA) dated 01/21/25 documented R1 had dementia (a progressive mental disorder characterized by failing memory, and confusion) with short-term and long-term memory loss. The Psychosocial Well-Being CAA dated 01/21/25 documented R1 lacked interest in interacting with or participating in activities. R1's Care Plan, reviewed 04/08/25, documented on 01/19/25, the resident had a cognitive loss that affected memory. Interventions dated 01/19/25 directed staff to help R1 establish a regular daily schedule with tasks divided into several steps. The plan directed staff to be patient with R1, remind R1 who they were, and explain care prior to initiation; staff would provide one instruction at a time in a calm tone. An update dated 01/27/25 noted R1 was placed on one-to-one monitoring for redirecting of behaviors, initiated on 01/25/25, created on 01/27/25, and revised on 03/10/25. The plan noted that R1 would be evaluated by geriatric psychiatry for behaviors of touching another person without their approval, which was initiated on 01/25/25, created on 01/27/25, and revised on 04/02/25. R1's Care Plan reviewed 04/08/25 documented on 01/27/25, R1 was at risk for sexually inappropriate behaviors related to maladaptive (unhealthy or ineffective ways of coping with something difficult or stressful) mood and behavior. The care plan included an intervention dated 01/27/25 that directed staff to administer medications as ordered to manage R1's behavior, created on 01/28/25. Interventions created on 01/2825 effective for 01/27/25 included staff observing R1's mood and behaviors, staff obtaining a psychiatric evaluation as ordered, staff redirecting inappropriate behavior with alternative activities, and staff reporting changes in behavior to the nurse and physician being informed as indicated. The plan documented staff would ensure R1 was on one-on-one observation at an arm's length when not in his room, created on 01/28/25 and revised on 04/02/25 The Progress Notes section of R1's EHR documented the following notes: On 01/25/25 at 11:14 AM, staff observed R1 walked up to R3, a cognitively impaired resident, and touched her breast. Staff redirected R1 to his room. On 02/03/25 at 01:59 PM, staff documented a root cause analysis of the incident on 01/25/25 and documented, according to R1's responsible person, R1 had a history of sexual aggression and grabbed R3's left breast. R1 was immediately removed from the area back to his room and placed on one-on-one monitoring when not in his room; R1 was started on medication for sexual aggression. On 03/01/25, Licensed Nurse (LN) I documented staff observed R1 rubbing the leg of an unidentified female resident. On 03/05/25, LN I documented R1 grabbed R2's (a cognitively impaired resident) breast, and staff directed R1 to his room. Additionally, Administrative Staff A and Administrative Nurse B were notified of the incident. On 03/06/25 at 11:56 AM, Administrative Nurse B documented LN I reported R1 had grabbed R2's breast in the dining area. On 03/10/25 at 01:03 PM, staff documented a root cause analysis of the incident on 03/05/25 and documented according to R1's responsible person, R1 had a history of sexual aggression and R1 grabbed R2's left breast. R1 was immediately removed from the area back to his room and placed on one-on-one monitoring when not in his room. On 03/19/25 at 05:51 AM, staff documented R1 was up and down during the night and wandered from his room to the common area and back; redirection attempts were unsuccessful. Additionally, staff documented an unknown Certified Nurse Aide (CNA) stopped R1 from reaching for an unidentified female resident's leg. The CNA told R1 to stop and R1 walked back to his room before physical contact was made. Staff documented Administrative Staff A and Administrative Nurse B were notified. On 03/20/25 at 03:16 PM, Social Services Designee (SSD) M documented R1 was observed throughout the week related to a previous incident (undated) and R1 remained on one-on-one observation when outside of his room. SSD M documented R1 had no inappropriate incidents. On 03/27/25 at 02:15 AM, staff documented R1 was observed stroking his penis while seated next to another male resident at 02:05 AM. Staff documented there was no physical contact observed between the two residents, and Administrative Staff A and Administrative Nurse B were notified. On 03/30/25 at 06:20 AM, LN F documented R1 stroked R3's left lower leg. Staff moved R3 and R1 returned to his room. On 03/30/25 at 07:51 AM, staff documented R1 looked up the dresses on wooden Easter decorations in the dining room and stated, Let me get that [expletive]. On 03/30/25 at 06:02 PM, staff documented R1 continued to try and look up the dresses on the Easter decorations. On 04/03/25 at 02:17 PM, SSD M documented a referral for R1 to be transferred to a different facility was sent. On 04/02/25 at 10:44 AM, LN F documented on 03/30/25 R1 was observed slowly rubbing R3's lower left leg. The note documented LN F placed herself between R1 and R3 and remained there until R1 returned to his room. LN F assessed R3 and determined her to be free of injury. The note recorded R1 continued to be on one-on-one observation. LN F documented she notified Administrative Staff A and Administrative Nurse B. On 04/08/25 at 02:14 PM, staff documented a root cause analysis, and the facility noted that R1 gravitated to R3 as R3 resembled R1's spouse; the facility-initiated arms-length one-on-one monitoring for R1 and continued to try to get the resident transferred to an all-male facility. A review of the facility's investigation and witness statements for the 01/25/25 incident revealed no additional information. The investigation report lacked documentation that Law Enforcement (LE) was notified. The facility lacked an investigation report for the incident on 03/01/25. A review of the facility's investigation and witness statements for the 03/05/25 incident revealed no additional information. The investigation report lacked documentation that LE was notified. The facility lacked an investigation report for the incident on 03/27/25. A review of the facility's investigation for the 03/30/25 incident revealed no additional information. The investigation report lacked witness statements and lacked documentation that LE was notified. On 04/08/25 at 01:40 PM, R1 was unable to be interviewed due to the resident's cognitive impairment. During an interview on 04/08/25 at 04:40 PM, LN F stated on 03/30/25 R1 was observed rubbing the lower left leg of R3. LN F stated she placed herself between R1 and R3 until R1 went back to his room. During an interview on 04/09/25 at 03:20 PM, Administrative Staff A stated the facility did not notify LE of any of the documented incidents from 01/25/25 to 04/09/25. During an interview on 04/09/25 at 03:42 PM, CNA H stated she was unaware of the details of the events and stated R3 looks like R1's wife. CNA H stated R1 was confused and continued to attempt to touch R3 and rub her leg. CNA H stated if staff observed R1 with this type of behavior, staff had to stand between R1 and the female residents and report the incidents to the nurse on duty. During an interview on 04/09/25 at 03:46 PM, CNA J stated if R1 reached for a female resident staff would protect the female resident and attempt to redirect R1 with a different activity and report the incident to the nurse or a member of management. During an interview on 04/09/25 at 04:15 PM, LN K stated she was aware of the incidents with R1 and inappropriate contact and stated if staff observed R1 attempt inappropriate contact, R1 should be removed as quickly as possible to ensure the safety of the other residents. LN K stated she would report the incident to management immediately and then follow management's discretion as to whether to call law enforcement. During an interview on 04/09/25 at 04:25 PM, Administrative Nurse C stated the facility's expectation in the event of unwanted or inappropriate sexual contact staff should separate the residents to ensure resident safety and perform any required assessments and document everything in the EHR. Staff would then notify management who would immediately develop and implement an intervention to prevent the incident from happening again. This included notifying and educating all the staff and obtaining signatures. Administrative Nurse C stated after the incident on 01/25/25, R1 was placed under visual one-on-one monitoring until R1 was sent to a behavioral health unit (BHU). Administrative Nurse C stated she was unaware if the management team was aware of the incident on 03/01/25, and after the incident on 03/05/25 R1 was placed on one-on-one monitoring when he was out of his room. Administrative Nurse C stated when the incident occurred on 03/30/25 R1 was placed on one-on-one monitoring where staff must stay within an arms-reach of R1 when out of his room with a staff member placed outside the door to his room. Administrative Nurse C stated the management team was actively trying to find alternate placement for R1 at a more appropriate facility. Administrative Nurse C stated LE should be contacted for any unwanted physical or sexual contact and confirmed that LE was not contacted for any incidents that involved R1 between 01/25/25 and 04/09/25. During an interview on 04/09/25 at 04:54 PM Administrative Staff A revealed that after the incident on 01/25/25, R1 was placed under one-on-one visual monitoring until he was transferred to the behavioral health unit. Administrative Staff A said when R1 returned to the facility, he was self-isolating and would only come out of his room for meals and after the incident on 03/05/25, R1 was placed on one-on-one visual monitoring when he was outside of his room. Administrative Staff A stated after the incident on 03/30/25, R1 was placed on one-on-one monitoring within arm-length reach of staff except when he was in his room, then staff would be outside his room. Administrative Staff A stated the facility continued to try to find alternative placement at an all-male dementia unit. Administrative Staff A in the event of unwanted physical or sexual contact between residents, she expected staff to immediately separate the residents, assess the residents involved, and then notify management. Administrative Staff A stated staff followed the appropriate procedure for all the events reviewed involving R1. Administrative Staff A stated the event on 03/01/25 was not fully investigated or called to LE because the contact was not believed to be sexual in nature. Administrative Staff A confirmed the Progress Note dated 03/19/25 and stated she was unaware of the information and stated it would be considered a near-miss. Administrative Staff A stated the event documented on 03/27/25 was not investigated or reported because the other male resident in the area was unaware of R1's actions, R1's genitals were not exposed and R1 was not aggressive. Administrative Staff A stated LE should only be notified if another resident is harmed or if the resident's family wants LE involved. Administrative Staff A confirmed if someone touched anyone's breast without consent, LE should be notified and further confirmed R2 and R3 were incapable of providing consent and the touching from R1 was sexual in nature so it should have been reported to LE. The facility's Abuse, Neglect and Exploitation policy dated 10/2022 documented residents have the right to be free from verbal, sexual, physical, and mental abuse. The facility would keep residents free from abuse and take swift and immediate action to investigate allegations of abuse. The policy documented every employee had the responsibility to report allegations of abuse and the Administrator or Director of Nursing (DON) would investigate allegations and report the results to the proper authorities. All reports or suspicions of abuse would result in an investigation and all reasonable suspicions of a crime would be reported as required. On 04/10/25 at 11:35 AM, Administrative Staff L and Administrative Nurse C were provided the Immediate Jeopardy (IJ) template and informed of the facility's failure to immediately implement protective measures to prevent further potential abuse, after multiple allegations and/or incidents of resident-to-resident abuse, and to conduct thorough investigations, placed R2, R3, and all cognitively impaired female residents in immediate jeopardy. The facility submitted an acceptable plan for removal of the immediate jeopardy on 04/10/25 at 02:56 PM which included the following: The facility placed R1 on one-on-one monitoring until an appropriate alternate placement was secured. The facility notified Law Enforcement on 04/10/25. LN I received disciplinary action for failure to report the incident on 03/10/25. LN F received disciplinary action for failure to report the incident on 03/30/25 until 04/02/25. The facility updated R2 and R3's Care Plans to include social services follow-up with each resident weekly and as needed for their psychosocial well-being. The facility updated R1's Care Plan to include one-on-one monitoring until appropriate alternate placement was secured. Staff would assist R1 to a private location when fondling his genitals. The facility immediately educated all staff on 04/10/25 regarding abuse prevention, reporting, and expectations related to immediate interventions and investigations. The facility re-educated all staff on the definition of one-on-one monitoring with associated documentation. The facility held an Ad-hoc Quality Assurance Process Improvement (QAPI) meeting by telephone on 04/10/25. Implementation of the corrective measures to remove the immediacy was verified on-site on 04/10/25 at 03:35 PM. The deficient practice remained at a scope and severity level of E (patterned, potential harm).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 34 residents with three sampled and reviewed for skin and wound management. Based on record review and interview, the facility failed to prevent neglect through the failure to ensure licensed nursing staff assessed a wound on Resident (R)1's right lateral foot weekly, from 12/21/22 to 02/16/23, failed to initiate a treatment for a wound identified on 12/26/23 until 01/27/23 (31 days later), failed to complete treatments as ordered, failed to notify the primary care physician when the wound deteriorated, and failed to notify the primary care physician in a timely manner with critical radiology results. The facility's lack of action led to the deterioration of the wound on R1's foot, which developed osteomyelitis and required hospitalization and possible amputation below the knee pending. This deficient practice placed this resident in immediate jeopardy and those in the facility which had wounds present. Findings included: - The Medical Diagnosis tab for R1 included diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, open wound of foot, long term use of insulin, and aphasia (condition with disordered or absent language function). The Minimum Data Set (MDS) tab for R1 revealed he entered the facility on 12/16/22. The admission MDS dated 12/22/22 revealed R1 had absence of speech, could rarely make himself understood, rarely understood others, and had severely impaired decision making. The MDS lacked an assessment of his cognition. R1 required two or more staff to assist him with bed mobility, transfers, and dressing. He had range of motion impairment to the right side of his upper and lower extremity and used a wheelchair for mobility. He was at risk for developing pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), has no ulcers or other wounds present, had a pressure relieving device for his chair and bed, was not on a turning and repositioning program, and had applications of ointments/medications other than to his feet. The Pressure Ulcer/Injury Care Area Assessment dated 12/22/22 for R1 revealed he had no skin conditions but was at risk due to needing extensive to total assistance with mobility and repositioning. He had right side paralysis, severe cognitive and physical deficits, no current skin concerns, and had a pressure reducing mattress on the bed and chair. The Quarterly MDS dated 03/20/23 assessed R1 with a short and long-term memory problem, continued to have absence of speech and could rarely make himself understood and could rarely understand others. There was no change in his assistance needed for bed mobility, transfers, and dressing. R1 continued to have limited range of motion to one side of his upper and lower extremities and used a wheelchair for mobility. R1 continued to be at risk for pressure ulcers/injuries and had one stage three pressure ulcer (full thickness loss of skin usually over a bony prominence, a result of pressure, or pressure in combination with shear and/or friction) that was not present on admission. R1 had an infection of the foot, other open lesions on the foot, and did not have any diabetic ulcers. He continued to have a pressure reducing device for bed and chair and was not on a turning/repositioning program. R1 was on a nutrition/hydration program to manage skin problems, received pressure ulcer/injury care, received applications of ointments/medications other than to feet, and applications of dressings to feet (with or without topical medications). The Care Plan initiated 12/16/22 revealed R1 required staff extensive to total assistance with activities of daily living (ADLs) related to his physical limitations and right-side paralysis. R1 was at risk for skin breakdown due to incontinence and needing extensive to total assistance for positioning. The staff were to assist to alter his weight/body position, provide appropriate pressure relieving devices to the bed and wheelchair, monitor and report any changes while providing cares or assisting with bathing such as bruising or skin tears, and to provide skin assessments per protocol and as indicated. The staff were to contact R1's physician as needed if there were changes in his skin condition. Additions to the care plan included on 02/12/23 R1 had an open area to his right outer foot, on 02/14/23 to encourage and assist to consume all the offered flood/fluids to assist in maintaining adequate nutrition/hydration and to see the treatment administration record (TAR) for current skin concerns, orders, and treatments. Additionally, on 03/09/23, R1 was to receive Clindamycin (antibiotic which can be prescribed to treat skin infections), 150 milligrams (mg), four times a day, daily, for foot wound. The Clinical Health Review dated 12/16/22 for R1 revealed a Braden Pressure Ulcer Risk score of 10, indicating high risk for pressure ulcer development. The assessment identified a skin tear to his right hand and MASD (moisture associated skin damage - superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration). The Skin/Wound Condition Assessment dated 12/21/22 for R1 revealed no new skin issues and lacked presence of the issues included in the Clinical Health Review on 12/16/22. The assessment tab lacked further Skin/Wound Condition Assessment completion by the licensed staff until 02/16/23. The facility failed to conduct a weekly skin inspection between 12/21/22 until 02/16/23, eight weeks total without a licensed nurse skin assessment. The Nurse's Note dated 12/26/22 for R1 revealed after his shower was given and staff noted two open areas on his right foot. The wound to the right great toe measured 0.8 centimeters (cm) by 0.5 cm and the right outer foot measured 1.9 cm by 0.9 cm. The areas were cleansed, and a staff applied a dry sterile dressing to each. The TAR and the Licensed Medication Administration Record (MAR) dated December 2022 for R1 lacked treatment orders for the right foot, for five days following the identification of the open areas. The TAR dated January 2023 for R1 revealed an order dated 01/27/23 to cleanse the open area to the right outer foot with normal saline, pat dry, apply calcium alginate (a highly moisture absorbent product/dressing), and cover with bordered gauze daily for the open area. R1 went 26 days in January 2023, for a total of 31 days without treatment to the right outer foot from 12/27/22 until 01/27/23. The TAR dated February 2023 for R1 included the order dated 01/27/23 for the treatment to the right foot and discontinued on 02/14/23. The TAR lacked signature on 02/06/23, 02/07/23, and 02/11/23 to verify the licensed nursing staff completed the physician ordered treatment. On 02/15/23, a new order instructed the staff to cleanse the open area to the right outer foot with normal saline, pat dry, apply Medihoney (gel used to wound to aid in wound healing and removal of necrotic [dead] tissue), and cover with border gauze daily for the open area. The Orders tab included an order dated 02/16/23 for R1 for a weekly skin assessment to be done on Thursday at AM Pass time. The Skin/Wound Condition Assessment dated 02/16/23 for R1 revealed an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green, or brown tissue]) and/or eschar (dead tissue that may be tan, brown, or black and appear scab like) to the wound bed of a pressure ulcer to the left (rather than right) lateral foot. The assessment included preventive measures of floating heels, heel/elbow protectors, and repositioning. The assessment lacked measurements of the area, notification to the physician, and notification to the resident or responsible party. The Physician Order tab located in the paper chart, revealed R1's primary care physician signed an order, dated 02/14/23 for wound treatment to the right outer foot. The Orders tab located in the electronic medical record (EMR) revealed a physician order for R1 dated 02/22/23 for Wound Care Plus (contracted wound care company) to evaluate and treat. The Wound Care Center Progress Note dated 02/22/23 for R1 revealed the wound to the right foot identified as a [NAME] Grade 3 Diabetic Ulcer (an ulcer with bone involvement) and measured 2.5 cm by 2 cm by 0.1 cm with 76-100 percent (%) slough present to the wound bed. This assessment revealed an increase in size in the wound when measured by the facility on 12/26/23. Consultant Wound Care Staff HH performed a skin/subcutaneous tissue level excisional/surgical debridement (removal of dead tissue from the wound). The wound had signs and symptoms of infection, and she obtained a tissue culture for submission to microbiology. The Skin/Wound Condition Assessment dated 02/28/23 revealed an open area to the right foot, treatment ordered by the wound center in place, and notification to the resident or responsible party and physician on 02/28/23. The Progress Note dated 03/01/23 by Consultant Wound Care Staff HH revealed R1's wound measured 3.0 cm by 3 cm by 0.1 cm and continued to have 76-100 % slough present in the wound bed. The note lacked results of the culture obtained from the wound on 02/22/23. The Skin/Wound Condition Assessment dated 03/02/23 for R1 revealed he had a Stage three pressure ulcer to the left (prior wounds documented on the right) foot, which lacked measurements, and noted the wound care team was debriding the wound. The facility failed to perform any further assessments until 03/30/23. The Progress Note dated 03/08/23 by Consultant Wound Care Staff HH for R1 revealed the right outer foot wound measured 2.5 cm by 2.5 cm by 0.1 cm, a decrease in size, and continued to have 76-100 % slough and one to 25 % granulation (healing) tissue. The note included additional orders of clindamycin, 150 mg, oral capsule, one, by mouth, four times a day, for ten days, starting 03/08/23. Review of the resident's progress notes lacked any additional documentation related to the wounds until 03/22/23. The Physician Order tab located in the paper chart for R1 revealed the primary care physician signed the order for the wound care center dated 02/22/23, on 03/10/23. The Progress Notes located in the EMR for R1 revealed on 03/15/22 at 12:59 PM an order for Lidocaine External Ointment (used to prevent and treat pain), apply to right outer foot wound, topically, one time a day, every Wednesday, for pain, 30 minutes before wound care arrived. Consultant Wound Care Staff HH arrived at 11:30 AM and would not wait 15 minutes for blood sugar check and insulin, and stated they would be back next Wednesday. The facility failed to perform a wound assessment for R1. The Progress Note dated 03/22/23 by Consultant Wound Care Staff HH revealed R1's right foot wound measured 2.7 cm by 2.3 cm by 0.1 cm, an increase in the length and decrease in the width. The wound continued with 76-100 % slough and one to 25 % granulation. Consultant Wound Care Staff HH performed excisional/surgical debridement with post debridement measurements the same except a depth of 0.2 cm. The Physician Order tab located in the paper chart for R1 revealed the primary care physician signed the wound care orders on 03/23/23 for 03/08/23. The Progress Note dated 03/29/23 by Consultant Wound Care Staff HH revealed R1's right foot wound measured 3.0 cm by 2.0 cm by 0.1 cm, an increase in length and decrease in width, however, the wound bed had 26-50 % slough and 26-50 % granulation. The area appeared to have some hyper-granulation and the note lacked that surgical debridement occurred at this visit. Consultant Wound Care Staff HH changed the treatment orders to include Mysalt (Mesalt - used to absorb wound drainage to promote wound healing process) to the wound bed and changed the dressing change schedule to daily. Additionally, she prescribed silver nitrate applicators (used to stop bleeding after debridement or treat hyper-granulation of wounds and has antibacterial properties), topical, 75% - 25% stick, weekly, by Wound Care Plus, starting 03/28/23. The note included to continue current treatment orders until able to obtain supplies/medications for updated orders. The Skin/Wound Condition Assessment dated 03/30/23 for R1 revealed a stage 3 pressure ulcer to the left (rather than right) foot and the wound care team managed the wound. The assessment lacked notification to the physician and resident or responsible party. The EMR lacked further skin assessments for R1 until 04/13/23. The TAR dated March 2023 for R1 lacked changes to the treatment orders made by the wound care center on 03/29/23. The Progress Note dated 04/05/23 by Consultant Wound Care Staff HH revealed R1's right foot wound had the same length and width measurements however, the depth increased from 0.1 cm to 0.5 cm and there were no changes to the amount of slough and granulation. A chemical cautery of hyper-granulation tissue was performed using silver nitrate. The laboratory section of the note indicated bacteria identified in specimen by anaerobe culture (test done without letting oxygen get to the sample), fungus identified in specimen culture, bacteria identified in specimen by aerobe culture (allowing the culture to be exposed to air). There were no changes to the orders for this visit. The Progress Note dated 04/12/23 by Consultant Wound Care Staff HH for R1 revealed no changes to wound measurements from the prior week, no changes to slough or granulation. General notes included they rounded with Administrative Nurse E, hyper-granulation continues to wound, silver nitrate applied, no Mesalt available, spoke with staff about ordering, and staff were educated on orders. Procedures for this visit included chemical cautery (method used to burn or dissolve tissue) of hyper-granulation using silver nitrate. Additional orders included to continue current treatment orders until able to obtain supplies/medications for updated orders. The Nurse's Notes dated 04/12/23 for R1 revealed the wound care center was at the facility and new orders received for the wound to the right foot, the orders were entered and sent to the primary care physician. The TAR dated April 2023 for R1 revealed the facility changed the treatment orders for the right foot to include the Mesalt on 04/12/23 (two weeks after the order) and the silver nitrate. The staff charted O indicating other see progress note on 04/12/23 and 04/13/23 and performed the treatment on 04/14/23. The staff changed the treatment from 09:00 PM to AM Pass on 04/16/23, the TAR was blank on 04/17/23, and the treatment time changed on 04/17/23 to PM Pass. On 04/17/23 for the treatment at the PM Pass time, which included the silver nitrate, had O charted for 04/17/23 and was blank on 04/18/23, 04/21/23, and 04/23/23. The facility failed to perform wound care to R1's foot wound for two days in a row. Additionally, the TAR included an order for silver nitrate, to the right foot wound, topically, daily starting 04/12/23 and discontinued on 04/14/23. The facility failed to enter the order correctly, as on 03/29/23, Consultant Wound Care Staff HH ordered the silver nitrate to be done weekly by Wound Care Plus. The TAR: revealed the staff coded O indicating other see progress note on 04/12/23 and 04/13/23 and documented administered on 04/14/23. An additional order was on the TAR for the silver nitrate daily, start 04/16/23 and discontinued 04/16/23 (Sunday), however, the staff did not sign that they administered the treatment. The order added to the TAR on 04/17/23 continued to include the silver nitrate, the staff documented administration of the treatment on 04/19/23, 04/20/23, 04/22/23, 04/24/23, 04/25/23, and 04/26/23. The order discontinued on 04/26/23 and a new order on the TAR dated 04/27/23 excluded the silver nitrate. The Progress Notes dated 04/13/23 at 06:37 AM for R1 revealed the treatment to the right foot was done by wound nurse today. The Progress Notes dated 04/13/23 at 06:38 AM for R1 revealed the silver nitrate was done by the wound nurse today. The Progress Note dated 04/13/23 at 08:19 PM revealed R1's wound was covered with a dressing, no drainage note, and no pain reported. The Skin/Wound Condition Assessment dated 04/13/23 for R1 continued to reveal he had a stage three pressure ulcer to his left (rather than right) lateral foot, wound care done as ordered by the wound care center. The EMR lacked further skin assessments for R1 until 04/27/23 (14 days later). The Physician Order tab, located in the paper chart, revealed the primary care physician signed a wound care order on 04/13/23 for 04/12/23 to the right foot. The Progress Note dated 04/17/23 at 02:50 PM revealed the supplies for the wound care (which included the silver nitrate and Mesalt) were not available as ordered and the staff cleansed the wound with wound cleanser and applied a sterile dressing. The Progress Note dated 04/19/23 by Consultant Wound Care Staff HH revealed she rounded with Licensed Nurse (LN) H and Mesalt ordered per staff. The wound measured 2.3 cm by 2.2 cm by 0.3 cm, indicating decrease in length, increase in width, decrease in depth. The wound bed had one to 25 % slough and 51-75 % granulation. Post surgical debridement did not change the wound measurements. The Progress Note dated 04/26/23 by Consultant Wound Care Staff HH for R1 revealed rounded with a staff nurse and the Mesalt remained unavailable, staff educated on continued use of alginate until the Mesalt becomes available, discontinued the silver nitrate order, and educated staff on current orders. There were no changes to the slough or granulation, the wound measured 2 cm by 2 cm by 0.2 cm, indicating a decrease in the size of the wound. The Skin/Wound Condition Assessment dated 04/27/23 for R1 continued to reveal a stage three pressure ulcer to the left (rather than right) foot and indicated the staff identified the wound on 02/16/23 (the staff found the wound on 12/26/23). The Assessment tab lacked any further assessments after this date through the time he transferred to the hospital on [DATE]. The Physician Order tab located in the paper chart revealed the primary care provider signed the right foot wound care order dated 04/26/23 on 04/27/23. The Progress Note dated 05/03/23 by Consultant Wound Care Staff HH for R1 revealed the same measurements as the prior week with no change to slough and granulation. Surgical debridement performed with a post debridement depth of 0.5 cm. The Progress Note dated 05/10/23 by Consultant Wound Care Staff HH for R1 revealed hyper-granulation persists, and revealed no changes to measurements, slough, or granulation. Chemical cautery of hyper-granulation tissue performed with use of silver nitrate. The records for R1 lacked a visit by Consultant Wound Care Staff HH on 05/17/23. The Skin Condition Note dated 05/18/23 at 07:30 AM revealed the open area continues to right side of foot, Wound Care Plus with treatment. The note lacked an assessment of the wound. The Progress Note dated 05/24/23 by Consultant Wound Care Staff HH for R1 revealed hyper-granulation resolved, area deteriorated in size, staff reported drainage through dressing, orders updated, attempted to discuss order changes with Administrative Nurse D however, he was unavailable at the time of visit, and staff were educated on orders. The wound measured 2.0 cm by 3.5 cm by 0.2 cm, revealing an increase in the width of the wound, no change to slough or granulation, however, tendon (strong, flexible tissue which connects muscle to bone) exposed. Surgical debridement performed with no change to wound measurements. Consultant Wound Care Staff HH changed the treatment orders to included calcium alginate in the wound base, removed the Mesalt from the treatment orders, and cover with bordered gauze, and change daily. The EMR lacked notification to the physician and the responsible party regarding a decline in the wound, which now had tendon exposed. The Skin Condition Note dated 05/25/23 for R1 revealed a stage three pressure area to right foot and being seen by Wound Care Plus. The facility staff measured the wound at 2.5 cm by 3.5 cm by 0.3 cm, indicating an increase in length and depth. The wound had a small amount of bleeding at the site, foul odor, and moderate drainage. The note indicated staff performed wound care as ordered on 05/24/23 except for covering of the wound with a silicone bordered dressing rather than a gauze dressing, per wound care orders. The note lacked notification to the primary care physician and the resident or responsible party. The TAR dated May 2023 revealed an order dated 05/25/23 to cleanse with wound to the foot with wound cleanser, apply calcium alginate to wound base, cover with silicone bordered foam, three times a week on Tuesday, Thursday, and Saturday. This order did not match the order from the wound care center. The Skin Condition Note dated 05/29/23 at 08:40 AM for R1 revealed wound to the left (rather than right) foot measured 4.0 cm by 2.5 cm, hyper-granulation with moderate amount of drainage and moderate amount of maceration (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine, or feces (or wounds for extended periods) surrounding the skin. The note revealed R1 had a second wound now present measuring 3.0 cm by 3.0 cm with hyper-granulation and moderate amount of drainage with only 0.5 cm of intact skin between the two wounds. Areas cleansed with wound cleanser, skin protectant applied to peri-wound, foam dressing with hole cut out for offloading, covered with a six by six bordered gauze dressing, and wrapped with Kerlix. R1's foot placed in a moon boot with area cut out for offloading. The noted included Consultant Wound Care Staff HH scheduled to be at facility on Wednesday (two days later) and lacked notification of the change of condition to the right foot with an additional wound present, to the physician and the responsible party. The Skin Condition Note dated 05/30/23 for R1 revealed the wound dressing completely saturated with seropurulent (a combination of serous [clear] and purulent [producing or containing pus]) drainage that continued to be foul smelling and peri-wound continued with maceration. The staff called Administrative Nurse D to come visualize/assess the difference in R1's wound from Thursday to yesterday and today. A wound culture was taken of the purulent drainage, cleaned wounds and periwound with wound cleanser, applied hydroconductive (draws fluid away) wound dressing, then covered with six by six bordered gauze dressing. Then a hole was cut in an ABD dressing (abdominal - used to absorb heavily draining wounds) to offload and entire foot wrapped with Kerlix. The staff placed R1's foot in a foam moon boot and changed the wound care orders to daily. The note lacked notification to the responsible party. The Progress Note dated 05/31/23 by Consultant Wound Care Staff HH for R1 revealed a wound measurement to the right foot of 8.0 cm by 3.5 cm by 0.5 cm, with tendon exposed, a large amount of purulent drainage, which had a strong odor. The wound bed had 26-50 % granulation, 26-50 % slough, and 1-25 % epithelialization (a process of wound healing). The note included she rounded with LN H, the area deteriorated, a culture was pending, area was debrided, and spoke with Administrative Nurse D about need for x-ray for possible osteomyelitis. Surgical debridement performed with post debridement measurements the same with the exception of an increase in depth to 1.0 cm. Consultant Wound Care Staff HH changed the treatment orders to the right foot. The Physician Orders tab located in the hard chart revealed the primary care physician signed orders on 06/01/23 for the wound culture on 05/30/23 and the treatment to the right foot for 05/30/23. A fax communication sheet dated 06/02/23 to the primary care physician revealed x-ray results of the right foot were attached, please advise, and a request for pain medication to give prior to dressing changes. The physician responded 06/09/23 patient is admitted for osteomyelitis. The Nurse's Note dated 06/02/23 for R1 revealed a mobile x-ray company was at the facility to x-ray the resident's right foot. The report showed abnormal cortical (outermost layer of the bone) erosion and bony lysis (destruction of area of bone) at the distal aspect of the right fifth metatarsal (bone of the foot) likely representing osteomyelitis. The staff faxed the final report to the primary care physician and awaiting wound culture results from the lab (done three days prior). The note lacked notification to the responsible party. The X-ray Examination dated 06/02/23 for R1 on the right foot revealed likely osteomyelitis and at the bottom of the report included a handwritten note faxed to PCP 06/02/23 noted 06/02/23. The facility failed to contact the physician with the critical x-ray results. The Culture report dated 06/03/23 of the right foot wound for R1 revealed moderate amount of five different organisms, one of which represented possible contamination of the culture. A note on the report revealed the staff faxed the report on 06/03/23 to the primary care physician. The Orders Note dated 06/03/23 for R1 revealed metronidazole (antibiotic) 500 mg, arrived from the pharmacy and initial dose given. The EMR lacked a progress note for the condition of the right foot wound for 06/03/23 or notification to the responsible party regarding the new medication order. The Nurse's Note dated 06/04/23 at 10:30 AM revealed R1's wound to foot had copious (abundant) amounts of very foul-smelling drainage, large, approximately 5.0 cm by 7.0 cm, fluid filled area on the medial lateral surface of the foot. Additionally, there were two small dime to quarter sized black areas medial to the large fluid filled area, moderate amount of slough to the wound bed, with redness around the entire foot. Administrative Nurse D called to room to visualize and assess. Responsible party notified of the deteriorating condition of the wounds, and she asked the staff to send R1 to the hospital. Administrative Nurse D notified the primary care physician and received orders to transfer R1 to the local hospital for evaluation. The Nurse's Note dated 06/04/23 at 04:02 PM for R1 revealed the facility received a call from the hospital that R1 admitted due to sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection, which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock) with a WBC (white blood cells - part of the body's immune system, help fight infection) of 24 thousands per cubic milliliter (K/uL) (the upper level of normal range, varies per lab, typically 11 K/uL) indicating infection. The hospital reported the plan was to surgically debride the wound and start intravenous (IV) antibiotics. The hospital Operative Procedure dated 06/05/23 for R1 revealed R1's condition discussed in detail with the responsible party. Due to the extent of muscle necrosis and soft-tissue loss, recommendation was below the knee amputation. R1 would have a long battle to recover from this amount of damage and would not have a functional foot in the future, therefore, amputation would likely provide him with the fastest recovery and a minimal damage to other body systems in the process. The Hospital Progress Note dated 06/06/23 for R1 revealed the recommendation was for R1 to have a below the knee amputation in an effort to prevent R1 from losing his life, however the responsible party refused that option. R1 would be transferred at that time to more aggressive wound care instead of having the recommended surgery done. On 06/13/23 at 10:15 AM an unidentified family member stated the facility really did not update them on R1's condition, and stated they thought it was healing in the beginning. The family member recalled the facility saying a wound care team was brought in and said it was almost healed in February, but it was not. The facility commented they were not going to put the house shoes on the resident because it rubbed a spot. The family member stated she would try to visit weekly but at one-point visits were infrequent due to medical issues, and when she visited, he would have a sock on. She did not recall seeing any kind of protector to his foot until the Friday before he went out to the hospital. R1 was nonverbal due to his stroke and was pretty dependent on staff to move him around and dress him. The facility called her Sunday before church and wanted to send him to the emergency room. The physician for the nursing home told her he did not know anything about the wound. The family member stated the hospital wanted to amputate his foot. On 06/13/23 at 12:28 PM LN J stated weekly skin assessments were to be done weekly, some were charted under assessments and some as a skin condition progress note. The weekly skin assessments would show up on the TAR for when they were to be done and there was a list at the desk. Documentation would include if no skin issues were present. A wound care nurse came to the facility for any wounds that were stageable. LN H stated the facility should notify the physician and resident or responsible party if there was no progress to the wound, and anytime there was not progress the physician should be notified. LN J stated she worked the night shift, and this was her first day shift. On the night shift R1 would wear boots in bed on that shift and he had a wound on his right foot. LN J stated she had changed the dressing about a month and a half ago and at that time it was around the size of a golf ball, maybe smaller. The staff would reposition him every two to three hours and R1 would also move around on his own too, he would slide his legs off the bed and the staff would move him. LN J believed R1 was on a pressure reducing mattress. On 06/13/23 at 01:09 PM Administrative Nurse D stated a Consultant Wound Staff HH came to the facility from the wound center and did R1's weekly wound assessments. Administrative Nurse D stated Consultant Wound Staff HH would just cut and cut the wound on R1's foot and made it worse. Administrative Nurse D stated Consultant Wound Staff HH would write orders for wound care, they would be on her progress note that would be available usually in 24 hours and he would go the wound center site to get the progress notes. Consultant Wound Staff HH saw R1 from 02/22/23 through 05/21/23, and the facility used those assessments as their weekly wound assessments. Administrative Nurse D stated he was not sure if the facility kept R1's physician informed of the wound status, he ordered the wound care center, and they would take ov[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility reported a census of 34 residents with three sampled and reviewed for skin and wound management. Based on record review and interview, the facility failed to ensure licensed nursing staff assessed a wound on Resident (R)1's right lateral foot weekly, from 12/21/22 to 02/16/23, failed to initiate a treatment for a wound identified on 12/26/23 until 01/27/23 (31 days later), failed to complete treatments as ordered, failed to notify the primary care physician when the wound deteriorated, and failed to notify the primary care physician in a timely manner with critical radiology results. The facility's lack of action led to the deterioration of the wound on R1's foot, which developed osteomyelitis and required hospitalization and possible amputation below the knee pending. This deficient practice placed this resident in immediate jeopardy and those in the facility which had wounds present. Findings included: - The Medical Diagnosis tab for R1 included diagnoses of hemiplegia (paralysis of one side of the body) and hemiparesis (muscular weakness of one half of the body) following cerebral infarction (stroke - damage to tissues in the brain due to a loss of oxygen to the area) affecting right dominant side, open wound of foot, long term use of insulin, and aphasia (condition with disordered or absent language function). The Minimum Data Set (MDS) tab for R1 revealed he entered the facility on 12/16/22. The admission MDS dated 12/22/22 revealed R1 had absence of speech, could rarely make himself understood, rarely understood others, and had severely impaired decision making. The MDS lacked an assessment of his cognition. R1 required two or more staff to assist him with bed mobility, transfers, and dressing. He had range of motion impairment to the right side of his upper and lower extremity and used a wheelchair for mobility. He was at risk for developing pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), has no ulcers or other wounds present, had a pressure relieving device for his chair and bed, was not on a turning and repositioning program, and had applications of ointments/medications other than to his feet. The Pressure Ulcer/Injury Care Area Assessment dated 12/22/22 for R1 revealed he had no skin conditions but was at risk due to needing extensive to total assistance with mobility and repositioning. He had right side paralysis, severe cognitive and physical deficits, no current skin concerns, and had a pressure reducing mattress on the bed and chair. The Quarterly MDS dated 03/20/23 assessed R1 with a short and long-term memory problem, continued to have absence of speech and could rarely make himself understood and could rarely understand others. There was no change in his assistance needed for bed mobility, transfers, and dressing. R1 continued to have limited range of motion to one side of his upper and lower extremities and used a wheelchair for mobility. R1 continued to be at risk for pressure ulcers/injuries and had one stage three pressure ulcer (full thickness loss of skin usually over a bony prominence, a result of pressure, or pressure in combination with shear and/or friction) that was not present on admission. R1 had an infection of the foot, other open lesions on the foot, and did not have any diabetic ulcers. He continued to have a pressure reducing device for bed and chair and was not on a turning/repositioning program. R1 was on a nutrition/hydration program to manage skin problems, received pressure ulcer/injury care, received applications of ointments/medications other than to feet, and applications of dressings to feet (with or without topical medications). The Care Plan initiated 12/16/22 revealed R1 required staff extensive to total assistance with activities of daily living (ADLs) related to his physical limitations and right-side paralysis. R1 was at risk for skin breakdown due to incontinence and needing extensive to total assistance for positioning. The staff were to assist to alter his weight/body position, provide appropriate pressure relieving devices to the bed and wheelchair, monitor and report any changes while providing cares or assisting with bathing such as bruising or skin tears, and to provide skin assessments per protocol and as indicated. The staff were to contact R1's physician as needed if there were changes in his skin condition. Additions to the care plan included on 02/12/23 R1 had an open area to his right outer foot, on 02/14/23 to encourage and assist to consume all the offered flood/fluids to assist in maintaining adequate nutrition/hydration and to see the treatment administration record (TAR) for current skin concerns, orders, and treatments. Additionally, on 03/09/23, R1 was to receive Clindamycin (antibiotic which can be prescribed to treat skin infections), 150 milligrams (mg), four times a day, daily, for foot wound. The Clinical Health Review dated 12/16/22 for R1 revealed a Braden Pressure Ulcer Risk score of 10, indicating high risk for pressure ulcer development. The assessment identified a skin tear to his right hand and MASD (moisture associated skin damage - superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration). The Skin/Wound Condition Assessment dated 12/21/22 for R1 revealed no new skin issues and lacked presence of the issues included in the Clinical Health Review on 12/16/22. The assessment tab lacked further Skin/Wound Condition Assessment completion by the licensed staff until 02/16/23. The facility failed to conduct a weekly skin inspection between 12/21/22 until 02/16/23, eight weeks total without a licensed nurse skin assessment. The Nurse's Note dated 12/26/22 for R1 revealed after his shower was given and staff noted two open areas on his right foot. The wound to the right great toe measured 0.8 centimeters (cm) by 0.5 cm and the right outer foot measured 1.9 cm by 0.9 cm. The areas were cleansed, and a staff applied a dry sterile dressing to each. The TAR and the Licensed Medication Administration Record (MAR) dated December 2022 for R1 lacked treatment orders for the right foot, for five days following the identification of the open areas. The TAR dated January 2023 for R1 revealed an order dated 01/27/23 to cleanse the open area to the right outer foot with normal saline, pat dry, apply calcium alginate (a highly moisture absorbent product/dressing), and cover with bordered gauze daily for the open area. R1 went 26 days in January 2023, for a total of 31 days without treatment to the right outer foot from 12/27/22 until 01/27/23. The TAR dated February 2023 for R1 included the order dated 01/27/23 for the treatment to the right foot and discontinued on 02/14/23. The TAR lacked signature on 02/06/23, 02/07/23, and 02/11/23 to verify the licensed nursing staff completed the physician ordered treatment. On 02/15/23, a new order instructed the staff to cleanse the open area to the right outer foot with normal saline, pat dry, apply Medihoney (gel used to wound to aid in wound healing and removal of necrotic [dead] tissue), and cover with border gauze daily for the open area. The Orders tab included an order dated 02/16/23 for R1 for a weekly skin assessment to be done on Thursday at AM Pass time. The Skin/Wound Condition Assessment dated 02/16/23 for R1 revealed an unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green, or brown tissue]) and/or eschar (dead tissue that may be tan, brown, or black and appear scab like) to the wound bed of a pressure ulcer to the left (rather than right) lateral foot. The assessment included preventive measures of floating heels, heel/elbow protectors, and repositioning. The assessment lacked measurements of the area, notification to the physician, and notification to the resident or responsible party. The Physician Order tab located in the paper chart, revealed R1's primary care physician signed an order, dated 02/14/23 for wound treatment to the right outer foot. The Orders tab located in the electronic medical record (EMR) revealed a physician order for R1 dated 02/22/23 for Wound Care Plus (contracted wound care company) to evaluate and treat. The Wound Care Center Progress Note dated 02/22/23 for R1 revealed the wound to the right foot identified as a [NAME] Grade 3 Diabetic Ulcer (an ulcer with bone involvement) and measured 2.5 cm by 2 cm by 0.1 cm with 76-100 percent (%) slough present to the wound bed. This assessment revealed an increase in size in the wound when measured by the facility on 12/26/23. Consultant Wound Care Staff HH performed a skin/subcutaneous tissue level excisional/surgical debridement (removal of dead tissue from the wound). The wound had signs and symptoms of infection, and she obtained a tissue culture for submission to microbiology. The Skin/Wound Condition Assessment dated 02/28/23 revealed an open area to the right foot, treatment ordered by the wound center in place, and notification to the resident or responsible party and physician on 02/28/23. The Progress Note dated 03/01/23 by Consultant Wound Care Staff HH revealed R1's wound measured 3.0 cm by 3 cm by 0.1 cm and continued to have 76-100 % slough present in the wound bed. The note lacked results of the culture obtained from the wound on 02/22/23. The Skin/Wound Condition Assessment dated 03/02/23 for R1 revealed he had a Stage three pressure ulcer to the left (prior wounds documented on the right) foot, which lacked measurements, and noted the wound care team was debriding the wound. The facility failed to perform any further assessments until 03/30/23. The Progress Note dated 03/08/23 by Consultant Wound Care Staff HH for R1 revealed the right outer foot wound measured 2.5 cm by 2.5 cm by 0.1 cm, a decrease in size, and continued to have 76-100 % slough and one to 25 % granulation (healing) tissue. The note included additional orders of clindamycin, 150 mg, oral capsule, one, by mouth, four times a day, for ten days, starting 03/08/23. Review of the resident's progress notes lacked any additional documentation related to the wounds until 03/22/23. The Physician Order tab located in the paper chart for R1 revealed the primary care physician signed the order for the wound care center dated 02/22/23, on 03/10/23. The Progress Notes located in the EMR for R1 revealed on 03/15/22 at 12:59 PM an order for Lidocaine External Ointment (used to prevent and treat pain), apply to right outer foot wound, topically, one time a day, every Wednesday, for pain, 30 minutes before wound care arrived. Consultant Wound Care Staff HH arrived at 11:30 AM and would not wait 15 minutes for blood sugar check and insulin, and stated they would be back next Wednesday. The facility failed to perform a wound assessment for R1. The Progress Note dated 03/22/23 by Consultant Wound Care Staff HH revealed R1's right foot wound measured 2.7 cm by 2.3 cm by 0.1 cm, an increase in the length and decrease in the width. The wound continued with 76-100 % slough and one to 25 % granulation. Consultant Wound Care Staff HH performed excisional/surgical debridement with post debridement measurements the same except a depth of 0.2 cm. The Physician Order tab located in the paper chart for R1 revealed the primary care physician signed the wound care orders on 03/23/23 for 03/08/23. The Progress Note dated 03/29/23 by Consultant Wound Care Staff HH revealed R1's right foot wound measured 3.0 cm by 2.0 cm by 0.1 cm, an increase in length and decrease in width, however, the wound bed had 26-50 % slough and 26-50 % granulation. The area appeared to have some hyper-granulation and the note lacked that surgical debridement occurred at this visit. Consultant Wound Care Staff HH changed the treatment orders to include Mysalt (Mesalt - used to absorb wound drainage to promote wound healing process) to the wound bed and changed the dressing change schedule to daily. Additionally, she prescribed silver nitrate applicators (used to stop bleeding after debridement or treat hyper-granulation of wounds and has antibacterial properties), topical, 75% - 25% stick, weekly, by Wound Care Plus, starting 03/28/23. The note included to continue current treatment orders until able to obtain supplies/medications for updated orders. The Skin/Wound Condition Assessment dated 03/30/23 for R1 revealed a stage 3 pressure ulcer to the left (rather than right) foot and the wound care team managed the wound. The assessment lacked notification to the physician and resident or responsible party. The EMR lacked further skin assessments for R1 until 04/13/23. The TAR dated March 2023 for R1 lacked changes to the treatment orders made by the wound care center on 03/29/23. The Progress Note dated 04/05/23 by Consultant Wound Care Staff HH revealed R1's right foot wound had the same length and width measurements however, the depth increased from 0.1 cm to 0.5 cm and there were no changes to the amount of slough and granulation. A chemical cautery of hyper-granulation tissue was performed using silver nitrate. The laboratory section of the note indicated bacteria identified in specimen by anaerobe culture (test done without letting oxygen get to the sample), fungus identified in specimen culture, bacteria identified in specimen by aerobe culture (allowing the culture to be exposed to air). There were no changes to the orders for this visit. The Progress Note dated 04/12/23 by Consultant Wound Care Staff HH for R1 revealed no changes to wound measurements from the prior week, no changes to slough or granulation. General notes included they rounded with Administrative Nurse E, hyper-granulation continues to wound, silver nitrate applied, no Mesalt available, spoke with staff about ordering, and staff were educated on orders. Procedures for this visit included chemical cautery (method used to burn or dissolve tissue) of hyper-granulation using silver nitrate. Additional orders included to continue current treatment orders until able to obtain supplies/medications for updated orders. The Nurse's Notes dated 04/12/23 for R1 revealed the wound care center was at the facility and new orders received for the wound to the right foot, the orders were entered and sent to the primary care physician. The TAR dated April 2023 for R1 revealed the facility changed the treatment orders for the right foot to include the Mesalt on 04/12/23 (two weeks after the order) and the silver nitrate. The staff charted O indicating other see progress note on 04/12/23 and 04/13/23 and performed the treatment on 04/14/23. The staff changed the treatment from 09:00 PM to AM Pass on 04/16/23, the TAR was blank on 04/17/23, and the treatment time changed on 04/17/23 to PM Pass. On 04/17/23 for the treatment at the PM Pass time, which included the silver nitrate, had O charted for 04/17/23 and was blank on 04/18/23, 04/21/23, and 04/23/23. The facility failed to perform wound care to R1's foot wound for two days in a row. Additionally, the TAR included an order for silver nitrate, to the right foot wound, topically, daily starting 04/12/23 and discontinued on 04/14/23. The facility failed to enter the order correctly, as on 03/29/23, Consultant Wound Care Staff HH ordered the silver nitrate to be done weekly by Wound Care Plus. The TAR: revealed the staff coded O indicating other see progress note on 04/12/23 and 04/13/23 and documented administered on 04/14/23. An additional order was on the TAR for the silver nitrate daily, start 04/16/23 and discontinued 04/16/23 (Sunday), however, the staff did not sign that they administered the treatment. The order added to the TAR on 04/17/23 continued to include the silver nitrate, the staff documented administration of the treatment on 04/19/23, 04/20/23, 04/22/23, 04/24/23, 04/25/23, and 04/26/23. The order discontinued on 04/26/23 and a new order on the TAR dated 04/27/23 excluded the silver nitrate. The Progress Notes dated 04/13/23 at 06:37 AM for R1 revealed the treatment to the right foot was done by wound nurse today. The Progress Notes dated 04/13/23 at 06:38 AM for R1 revealed the silver nitrate was done by the wound nurse today. The Progress Note dated 04/13/23 at 08:19 PM revealed R1's wound was covered with a dressing, no drainage note, and no pain reported. The Skin/Wound Condition Assessment dated 04/13/23 for R1 continued to reveal he had a stage three pressure ulcer to his left (rather than right) lateral foot, wound care done as ordered by the wound care center. The EMR lacked further skin assessments for R1 until 04/27/23 (14 days later). The Physician Order tab, located in the paper chart, revealed the primary care physician signed a wound care order on 04/13/23 for 04/12/23 to the right foot. The Progress Note dated 04/17/23 at 02:50 PM revealed the supplies for the wound care (which included the silver nitrate and Mesalt) were not available as ordered and the staff cleansed the wound with wound cleanser and applied a sterile dressing. The Progress Note dated 04/19/23 by Consultant Wound Care Staff HH revealed she rounded with Licensed Nurse (LN) H and Mesalt ordered per staff. The wound measured 2.3 cm by 2.2 cm by 0.3 cm, indicating decrease in length, increase in width, decrease in depth. The wound bed had one to 25 % slough and 51-75 % granulation. Post surgical debridement did not change the wound measurements. The Progress Note dated 04/26/23 by Consultant Wound Care Staff HH for R1 revealed rounded with a staff nurse and the Mesalt remained unavailable, staff educated on continued use of alginate until the Mesalt becomes available, discontinued the silver nitrate order, and educated staff on current orders. There were no changes to the slough or granulation, the wound measured 2 cm by 2 cm by 0.2 cm, indicating a decrease in the size of the wound. The Skin/Wound Condition Assessment dated 04/27/23 for R1 continued to reveal a stage three pressure ulcer to the left (rather than right) foot and indicated the staff identified the wound on 02/16/23 (the staff found the wound on 12/26/23). The Assessment tab lacked any further assessments after this date through the time he transferred to the hospital on [DATE]. The Physician Order tab located in the paper chart revealed the primary care provider signed the right foot wound care order dated 04/26/23 on 04/27/23. The Progress Note dated 05/03/23 by Consultant Wound Care Staff HH for R1 revealed the same measurements as the prior week with no change to slough and granulation. Surgical debridement performed with a post debridement depth of 0.5 cm. The Progress Note dated 05/10/23 by Consultant Wound Care Staff HH for R1 revealed hyper-granulation persists, and revealed no changes to measurements, slough, or granulation. Chemical cautery of hyper-granulation tissue performed with use of silver nitrate. The records for R1 lacked a visit by Consultant Wound Care Staff HH on 05/17/23. The Skin Condition Note dated 05/18/23 at 07:30 AM revealed the open area continues to right side of foot, Wound Care Plus with treatment. The note lacked an assessment of the wound. The Progress Note dated 05/24/23 by Consultant Wound Care Staff HH for R1 revealed hyper-granulation resolved, area deteriorated in size, staff reported drainage through dressing, orders updated, attempted to discuss order changes with Administrative Nurse D however, he was unavailable at the time of visit, and staff were educated on orders. The wound measured 2.0 cm by 3.5 cm by 0.2 cm, revealing an increase in the width of the wound, no change to slough or granulation, however, tendon (strong, flexible tissue which connects muscle to bone) exposed. Surgical debridement performed with no change to wound measurements. Consultant Wound Care Staff HH changed the treatment orders to included calcium alginate in the wound base, removed the Mesalt from the treatment orders, and cover with bordered gauze, and change daily. The EMR lacked notification to the physician and the responsible party regarding a decline in the wound, which now had tendon exposed. The Skin Condition Note dated 05/25/23 for R1 revealed a stage three pressure area to right foot and being seen by Wound Care Plus. The facility staff measured the wound at 2.5 cm by 3.5 cm by 0.3 cm, indicating an increase in length and depth. The wound had a small amount of bleeding at the site, foul odor, and moderate drainage. The note indicated staff performed wound care as ordered on 05/24/23 except for covering of the wound with a silicone bordered dressing rather than a gauze dressing, per wound care orders. The note lacked notification to the primary care physician and the resident or responsible party. The TAR dated May 2023 revealed an order dated 05/25/23 to cleanse with wound to the foot with wound cleanser, apply calcium alginate to wound base, cover with silicone bordered foam, three times a week on Tuesday, Thursday, and Saturday. This order did not match the order from the wound care center. The Skin Condition Note dated 05/29/23 at 08:40 AM for R1 revealed wound to the left (rather than right) foot measured 4.0 cm by 2.5 cm, hyper-granulation with moderate amount of drainage and moderate amount of maceration (softening and breaking down of skin as a result from prolonged exposure to moisture, such as sweat, urine, or feces (or wounds for extended periods) surrounding the skin. The note revealed R1 had a second wound now present measuring 3.0 cm by 3.0 cm with hyper-granulation and moderate amount of drainage with only 0.5 cm of intact skin between the two wounds. Areas cleansed with wound cleanser, skin protectant applied to peri-wound, foam dressing with hole cut out for offloading, covered with a six by six bordered gauze dressing, and wrapped with Kerlix. R1's foot placed in a moon boot with area cut out for offloading. The noted included Consultant Wound Care Staff HH scheduled to be at facility on Wednesday (two days later) and lacked notification of the change of condition to the right foot with an additional wound present, to the physician and the responsible party. The Skin Condition Note dated 05/30/23 for R1 revealed the wound dressing completely saturated with seropurulent (a combination of serous [clear] and purulent [producing or containing pus]) drainage that continued to be foul smelling and peri-wound continued with maceration. The staff called Administrative Nurse D to come visualize/assess the difference in R1's wound from Thursday to yesterday and today. A wound culture was taken of the purulent drainage, cleaned wounds and periwound with wound cleanser, applied hydroconductive (draws fluid away) wound dressing, then covered with six by six bordered gauze dressing. Then a hole was cut in an ABD dressing (abdominal - used to absorb heavily draining wounds) to offload and entire foot wrapped with Kerlix. The staff placed R1's foot in a foam moon boot and changed the wound care orders to daily. The note lacked notification to the responsible party. The Progress Note dated 05/31/23 by Consultant Wound Care Staff HH for R1 revealed a wound measurement to the right foot of 8.0 cm by 3.5 cm by 0.5 cm, with tendon exposed, a large amount of purulent drainage, which had a strong odor. The wound bed had 26-50 % granulation, 26-50 % slough, and 1-25 % epithelialization (a process of wound healing). The note included she rounded with LN H, the area deteriorated, a culture was pending, area was debrided, and spoke with Administrative Nurse D about need for x-ray for possible osteomyelitis. Surgical debridement performed with post debridement measurements the same with the exception of an increase in depth to 1.0 cm. Consultant Wound Care Staff HH changed the treatment orders to the right foot. The Physician Orders tab located in the hard chart revealed the primary care physician signed orders on 06/01/23 for the wound culture on 05/30/23 and the treatment to the right foot for 05/30/23. A fax communication sheet dated 06/02/23 to the primary care physician revealed x-ray results of the right foot were attached, please advise, and a request for pain medication to give prior to dressing changes. The physician responded 06/09/23 patient is admitted for osteomyelitis. The Nurse's Note dated 06/02/23 for R1 revealed a mobile x-ray company was at the facility to x-ray the resident's right foot. The report showed abnormal cortical (outermost layer of the bone) erosion and bony lysis (destruction of area of bone) at the distal aspect of the right fifth metatarsal (bone of the foot) likely representing osteomyelitis. The staff faxed the final report to the primary care physician and awaiting wound culture results from the lab (done three days prior). The note lacked notification to the responsible party. The X-ray Examination dated 06/02/23 for R1 on the right foot revealed likely osteomyelitis and at the bottom of the report included a handwritten note faxed to PCP 06/02/23 noted 06/02/23. The facility failed to contact the physician with the critical x-ray results. The Culture report dated 06/03/23 of the right foot wound for R1 revealed moderate amount of five different organisms, one of which represented possible contamination of the culture. A note on the report revealed the staff faxed the report on 06/03/23 to the primary care physician. The Orders Note dated 06/03/23 for R1 revealed metronidazole (antibiotic) 500 mg, arrived from the pharmacy and initial dose given. The EMR lacked a progress note for the condition of the right foot wound for 06/03/23 or notification to the responsible party regarding the new medication order. The Nurse's Note dated 06/04/23 at 10:30 AM revealed R1's wound to foot had copious (abundant) amounts of very foul-smelling drainage, large, approximately 5.0 cm by 7.0 cm, fluid filled area on the medial lateral surface of the foot. Additionally, there were two small dime to quarter sized black areas medial to the large fluid filled area, moderate amount of slough to the wound bed, with redness around the entire foot. Administrative Nurse D called to room to visualize and assess. Responsible party notified of the deteriorating condition of the wounds, and she asked the staff to send R1 to the hospital. Administrative Nurse D notified the primary care physician and received orders to transfer R1 to the local hospital for evaluation. The Nurse's Note dated 06/04/23 at 04:02 PM for R1 revealed the facility received a call from the hospital that R1 admitted due to sepsis (a systemic reaction that develops when the chemicals in the immune system release into the blood stream to fight an infection, which cause inflammation throughout the entire body instead. Severe cases of sepsis can lead to the medical emergency, septic shock) with a WBC (white blood cells - part of the body's immune system, help fight infection) of 24 thousands per cubic milliliter (K/uL) (the upper level of normal range, varies per lab, typically 11 K/uL) indicating infection. The hospital reported the plan was to surgically debride the wound and start intravenous (IV) antibiotics. The hospital Operative Procedure dated 06/05/23 for R1 revealed R1's condition discussed in detail with the responsible party. Due to the extent of muscle necrosis and soft-tissue loss, recommendation was below the knee amputation. R1 would have a long battle to recover from this amount of damage and would not have a functional foot in the future, therefore, amputation would likely provide him with the fastest recovery and a minimal damage to other body systems in the process. The Hospital Progress Note dated 06/06/23 for R1 revealed the recommendation was for R1 to have a below the knee amputation in an effort to prevent R1 from losing his life, however the responsible party refused that option. R1 would be transferred at that time to more aggressive wound care instead of having the recommended surgery done. On 06/13/23 at 10:15 AM an unidentified family member stated the facility really did not update them on R1's condition, and stated they thought it was healing in the beginning. The family member recalled the facility saying a wound care team was brought in and said it was almost healed in February, but it was not. The facility commented they were not going to put the house shoes on the resident because it rubbed a spot. The family member stated she would try to visit weekly but at one-point visits were infrequent due to medical issues, and when she visited, he would have a sock on. She did not recall seeing any kind of protector to his foot until the Friday before he went out to the hospital. R1 was nonverbal due to his stroke and was pretty dependent on staff to move him around and dress him. The facility called her Sunday before church and wanted to send him to the emergency room. The physician for the nursing home told her he did not know anything about the wound. The family member stated the hospital wanted to amputate his foot. On 06/13/23 at 12:28 PM LN J stated weekly skin assessments were to be done weekly, some were charted under assessments and some as a skin condition progress note. The weekly skin assessments would show up on the TAR for when they were to be done and there was a list at the desk. Documentation would include if no skin issues were present. A wound care nurse came to the facility for any wounds that were stageable. LN H stated the facility should notify the physician and resident or responsible party if there was no progress to the wound, and anytime there was not progress the physician should be notified. LN J stated she worked the night shift, and this was her first day shift. On the night shift R1 would wear boots in bed on that shift and he had a wound on his right foot. LN J stated she had changed the dressing about a month and a half ago and at that time it was around the size of a golf ball, maybe smaller. The staff would reposition him every two to three hours and R1 would also move around on his own too, he would slide his legs off the bed and the staff would move him. LN J believed R1 was on a pressure reducing mattress. On 06/13/23 at 01:09 PM Administrative Nurse D stated a Consultant Wound Staff HH came to the facility from the wound center and did R1's weekly wound assessments. Administrative Nurse D stated Consultant Wound Staff HH would just cut and cut the wound on R1's foot and made it worse. Administrative Nurse D stated Consultant Wound Staff HH would write orders for wound care, they would be on her progress note that would be available usually in 24 hours and he would go the wound center site to get the progress notes. Consultant Wound Staff HH saw R1 from 02/22/23 through 05/21/23, and the facility used those assessments as their weekly wound assessments. Administrative Nurse D stated he was not sure if the facility kept R1's physician informed of the wound status, he ordered the wound care center, and they would take over from there. Administrative Nurse D s[TRUNCATED]