**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. For Resident #69 the facility failed to a. ensure that treatment provided to a stage 4 left heel pressure ulcer was implemented in accordance with the wound consultant, and b. failed to ensure treatment to a deep tissue injury to Resident #69's left heel was provided in accordance with the physician's orders. Resident #69 was admitted to the facility in November 2024 with diagnoses that include but not limited to paralytic gait, acute respiratory failure with hypoxia, unspecified severe protein-calorie malnutrition, and Alzheimer's disease. Review of Resident #69's Minimum Data Set (MDS) assessment, dated 5/16/25 indicated Resident #69 scored a 4 out of 15 on the Brief Interview for Mental Status exam, indicating he/she as having severe cognitive impairment, requires partial/moderate assistance with self-care activities including bathing, toileting and dressing. Further, review of the MDS indicated Resident #69 was at risk for developing pressure ulcers and had 1 stage 4 pressure ulcer (Stage 4: Full thickness tissue loss with exposed bone, tendon or muscle). Review of Resident #69's MDSs dated 11/17/24 indicated 1 unstageable suspected deep tissue injury in evolution, and the MDS dated [DATE] indicated Resident #69 had 1 unstageable pressure ulcer due to coverage of wound bed by slough and/or eschar. On 6/3/25 at 12:17 P.M., Resident#69 was observed in the main dining room with a slipper sock on his/her left foot. On 6/4/25 at 8:34 A.M., Resident #69 was observed in the dining room in a wheelchair with his/her legs resting on the floor. He/she was wearing a red slipper sock on his/her left foot with a white dressing observed just above the top of the red slipper sock. Review of Resident #69's physician's orders indicated the following: -wound consult for left heel and right shin, dated 3/10/25. Review of the care plan with the focus Resident was admitted with a pressure (sic) to his/her left heel dated initiated 11/23/24, revision on 6/3/25. Interventions/Tasks included but not limited to, Administer treatments as ordered and monitor of effectiveness, date initiated 11/23/24. Follow the facility policies/protocols for the prevention/treatment of skin breakdown, date initiated 11/23/24. Review of Resident #69's clinical record indicated he/she was being seen by the wound consultant weekly beginning in 11/27/24. The 11/27/24 note indicated a pressure ulcer to the left heel, unstageable tissue type 100 % eschar (dead tissue). The wound consultant follow-up notes dated 12/2/24 indicated unstageable pressure ulcer left heel, Treatment recommendations: Wash with wound wash/cleanser. Pat dry. Apply skin prep to peri skin. Cover wound with Santyl/Ca (calcium) Alginate. Cover with ABD dressing and wrap with kerlix QD (once a day) and PRN (as needed). Review of wound consultant notes dated 12/9/24, 12/16/24, 12/27/24, 12/30/24, 1/6/25, 1/13/25, 1/26/25, 1/31/25, 2/3/25, 2/10,25, 2/18/25, 2/24/25, 3/3/25, 3/20/25, 4/7/25 indicated the left heel pressure ulcer as unstageable and had the same treatment recommendation; Wash with wound wash/cleanser. Pat dry. Apply skin prep to peri skin. Cover wound with Santyl/Ca (calcium) Alginate. Cover with ABD dressing and wrap with kerlix QD (once a day) and PRN (as needed). Review of the wound consultant follow-up note dated 4/14/25 indicated: Debridement (a removal of dead, damaged or infected tissue) performed today which patient tolerated well. There is healthy exposed muscle in wound base, making this a stage 4 pressure injury. Discussed on going treatment with nurse. Wounds: Pressure ulcer heel left stage 4, Plan: Treatment Recommendations: instruction: wash with wound wash/cleanser, pat dry, skin prep to peri skin. Apply medihoney, cover with ABD with kerlix wrap. Review of the wound consultant follow-up progress notes dated 4/21/25, 4/28/25, 5/5/25 and 5/12/25 all indicated the left heel ulcer as a stage 4 and the treatment recommendation instruction: wash with wound wash/cleanser, pat dry, skin prep to peri skin. Apply medihoney, cover with ABD with kerlix wrap. Review of the Medication Administration Record dated 4/1/25-4/30/25 did not indicate any treatment orders. Review of the Treatment Administration Record (TAR) dated 4/1/25 through 4/30/25 indicated the following treatment as administered: Pressure ulcer heel Left: Wash with wound cleanser, pat dry, apply skin prep to peri wound, apply Santyl to necrotic skin calcium alginate to wound, cover with ABD pad wrap with Kerlix daily, every day shift for wound care, start date 3/26/25. The TAR failed to indicate the wound consultant recommendation dated 4/14/25, for the Stage 4 pressure ulcer to Resident #69's left heel was provided as indicated. The TAR indicated the order to treat the unstageable pressure ulcer to Resident #69's left heel continued. Review of the Treatment Administration Record dated 5/1/25 through 5/13/25 indicated Pressure Ulcer Heel Left: wash with wound cleanser, pat dry, apply skin prep to peri wound, apply Santyl to necrotic skin calcium alginate to the wound, cover with ABD pad wrap with Kerlix daily was signed off as administered 5/1/25- 5/13/25 with the omission of 5/3/25. This treatment was for the unstageable pressure ulcer and not the treatment recommended by the wound consultant for the stage 4 pressure ulcer on Resident #69's left heel. Review of the MAR/TAR for April 2025 and May 2025 failed to indicate the treatment order for the stage 4 pressure ulcer to Resident #69's left heel was implemented until 5/14/25, resulting in 29 days without the recommended treatment by the wound consultant for Resident #69's stage 4 left heel pressure ulcer. During an interview on 6/4/25 at 9:00 A.M., Nurse #2 said Resident #69 had a pressure ulcer on his/her left heel and is seen weekly by the wound consultant. Nurse #2 said the nurse caring for the resident will do the wound rounds with the wound consultant. Nurse #2 said recommendations for treatment is made by the wound consultant and the ADON (Assistant Director of Nursing) or DON (Director of Nursing) obtain the order from the doctor or nurse practitioner (NP) and the treatment is entered as an order. Nurse #2 said the doctor and NP always agree with the recommendations made by the wound consultant, especially for Resident #69. Nurse #2 said treatments are completed as ordered and signed off on either the MAR or TAR after the treatment is done. Nurse #2 said Resident #69 does not refuse treatments but sometimes will take off the dressing and that is why she coverers it with a slipper sock. Nurse #2 said in April (2025) the wound consultant changed the treatment to Resident's #69's left heel pressure ulcer after it was debrided. Nurse #2 reviewed the TAR and MAR and said the treatment order stayed the same and was not changed in April as recommended. Nurse #2 said she knew the treatment was changed to medihoney. During an interview on 6/4/25 at 1:38 P.M., the DON said Resident #69 is followed by the wound consultant. The DON said any recommendation made by the wound consultant should be placed in the physician's orders and completed as ordered. The DON said the nurses who round with the wound consultant do not realize they are able to get an order from the doctor or NP and place the order in the medical record. The DON said the wound consultant is the person who assesses and knows how to treat a pressure ulcer and if orders are not followed or implemented there could be a potential for the wound to worsen. During an interview on 6/4/25 at 2:59 P.M. the wound consultant said she is a nurse practitioner and wound care specialist. The wound consultant said she rounds weekly on wounds and the nurse on the floor caring for the resident rounds with her most times. The wound consultant said when recommendations are made, she tells the nurse verbally, then I provide a note with who I have seen, and recommendations made and give it to the Director Nursing at the end of my rounding and the next day my full note would be uploaded in the electronic medical record. The wound consultant said she would expect the recommendations to be entered as physician's orders. The wound consultant said there are many factors on how a wound can heal and the dressing is the cherry on top. The wound consultant said off-loading, chronic conditions are factors for a wound to heal or worsen. The wound consultant said when she first met Resident #69 around the end of March 2025 or April 2025 the wound was unstageable and covered with necrotic tissue. The wound consultant said she then debrided the wound and determined the appropriate staging after the debridement of the left heel as a stage 4 pressure ulcer. The wound consultant said she changed the treatment at that time to treat the stage 4 open area on Resident #69's left heel. The wound consultant said the treatment for the unstageable pressure ulcer was Santyl which is an enzymatic to breakdown necrotic tissue and the calcium to manage any drainage from the wound. The wound consultant said once the wound was opened and clean the wound no longer needed Santyl, but the Santyl would not breakdown healthy skin. The wound consultant said she changed the treatment to medihoney as treatment for the left heel stage 4 pressure ulcer and was not aware that the treatment to the stage 4 left heel pressure ulcer was not implemented for nearly a month. During an interview on 6/4/25 at 4:22 P.M., Resident #69's nurse practitioner said the wound consultant has the expertise, not me to make recommendations for pressure ulcer treatments. The NP said she would follow the recommendations and expect the treatment to be entered as an order and provided by the nurse caring for Resident #69. During an interview on 6/5/25 at 10:57 A.M., the Medical Director, who is Resident #69's physician said orders are to be implemented after the wound provider rounds and makes recommendations. The MD said this has been identified as a problem at the facility with staff not following through. The MD said he would 100% follow the wound consultant recommendations for Resident #69's pressure ulcer on his/he left heel, as this is their area of knowledge. The MD said the risk of not implementing the wound consultant recommendations could lead to infection, worsening or neglect. The MD said the wound consultant notes are sent to him for review and that he was not aware the treatment recommendation was not implemented as an order for Resident #69's left heel stage 4 pressure ulcer. 4b. Review of Resident #69's Treatment Administration Record (TAR) dated 2/1/25 through 2/28/25 indicated the following order: Pressure Ulcer Heel left, wash with wound cleanser, pat dry, apply skin prep to peri skin, calcium alginate to wound, cover with ABD pad wrap with Kerlix daily and PRN (as needed). Further, review of the TAR indicated the treatment was not signed off as competed on 2/3/25, 2/4/25, 2/6/25, 2/17/25, 2/19/25, 2/20/25, 2/24/25, and 2/27/25. Eight pressure ulcer treatments were not documented as provided out of 28. Review of the clinical record indicated progress notes dated 2/15/25 and 2/22/25 that Resident #69 refused the treatment. These dates did not correspond with the days that were left blank on the TAR. There were no progress notes dated for the eight blank days on the TAR. During an interview on 6/4/25 at 9:00 A.M., Nurse #2 said nurses provide wound treatments, date and sign the dressing, them sign off in the TAR as completed. Nurse #2 said if for any reason the treatment is not provided then a progress note should be written. Nurse #2 said the TAR should not be left blank. Nurse #2 reviewed the February TAR and said 8 treatments were blank and not signed off as completed. During an interview on 6/4/25 at 1:38 P.M., the Director of Nursing said if the TAR is blank then there is no documentation to support the treatment was completed. 5. Resident #21 was admitted to facility in October 2018 with diagnoses including stroke, and dementia. Review of the Minimum Data Set assessment dated [DATE] indicated Resident #21 is severely cognitively impaired and totally dependent on staff for all activities of daily living. On 6/3/25 at 7:38 A.M., the surveyor observed Resident #21 resting in bed on an air mattress (a specialty mattress utilized to reduce pressure to the body.) Resident #21 appeared thin, frail and was unable to engage in the interview process. Review of the clinical record indicated Resident #21 had pressure injuries on his/her left hip and sacrum and was being followed by the Wound Consultant. Review of the Wound Consultant note dated 5/26/25 indicated: Patient laying in bed. Seen with nurse today. Patient has new DTI (deep tissue injury) to gluteal cleft (the groove between the buttocks that runs from just below the sacrum to the perineum,) and left hip pressure injury has re-occurred. Patient unable to provide history. Nurse does not recall seeing these wounds a few days ago when last caring for patient. Treatment Recommendations: Instruction: Wash with wound cleanser, cover with bordered foam dressing. Change daily and PRN. Review of Resident #21's physician orders failed to indicate any treatment order related to his/her newly developed DTI on his/her gluteal cleft. During an interview on 6/3/25 at 11:50 A.M., Nurse #3 said that Resident #21 has pressure injuries on his/her sacrum and hip. Nurse #3 did not say Resident #21 had a wound to his/her gluteal cleft. During an interview on 6/4/25 at approximately 8:15 A.M., Nurse #1 said that Resident #21 has wounds on his/her hip, sacrum and possibly on his/her heel but it may have healed at this point. During an interview on 6/4/25 at 9:54 A.M., Certified Nursing Assistant (CNA) #1 said that she is assigned to care for Resident #21 and he/she needs two staff for assistance with turning and positioning. CNA #1 said that Resident #21 has two pressure areas and pointed to the left and right hip. On 6/4/25 at 10:01 A.M., the surveyor observed Nurse #1 (with the assistance of Nurse #2) complete Resident #21's wound treatments. Nurse #1 said that Resident #21 has two areas; one on the right hip which requires skin prep and an unstageable area to his/her sacrum which required cleansing with calcium alginate with silver and to cover with a border foam dressing. At 10:04 A.M. Nurse #1 checked the orders and returned with supplies to perform the dressing changes. During the treatment, Resident #21's gluteal cleft was observed to be red, fragile, and did not have a dressing on it. Nurse #1 said that there was no treatment in place for that area and Nurse #2 said that the area had been open in the past for Resident #21, although it was not currently an open area. During an interview on 6/4/25 at 10:21 A.M., Nurse #1 said that the recommended treatment made by the Wound Consultant for Resident #21's gluteal cleft should have been implemented. Nurse #1 said she was not sure who is responsible for reviewing the wound treatment recommendations and entering them into the computer as the unit does not currently have a Unit Manager. Nurse #1 said that when treatment recommendations are not implemented, there is a risk of a wound worsening and infection. During an interview on 6/4/25 at 1:18 P.M., the Director of Nursing (DON) said that the Wound Consultant rounds weekly with the floor nurses who are then responsible for inputting the treatment recommendations into the electronic health record as orders. The DON said that the Wound Consultant notes are automatically uploaded to the resident record and she will also review them and input the treatment orders if they are missing. The DON was not aware a treatment and dressing was not in place for Resident #21 newly acquired DTI at the time of the surveyor's observation. During an interview on 6/5/25 at 10:52 A.M., the Medical Director said that he was not aware that recommendations from the wound consultant were not being implemented by the facility. He said that his expectation is that recommendations are reviewed with the attending providers and implemented as recommended. He said that he would not go against the recommendations of the wound consultant because they are the experts in wounds, and he is not. He said that not implementing treatment recommendations as ordered could result in infection, sepsis, and worsening wounds. He said wounds are a big risk factor for residents and that nurses and medical staff need to stay on top of them and ensure proper treatment. Refer to F726, F867 Based on observation, record review and interview, the facility failed to ensure five Residents (#24, #61, #30, #69 and #21) with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing, out of a total sample of 24 Residents. Specifically, 1. For Resident #24 the facility failed to implement recommendations from the Wound Consultant over a three-month period resulting in the deterioration of a pressure wound from a stage 2 pressure wound to an unstageable pressure wound. 2. For Resident #61 the facility failed to implement recommendations from the Wound Consultant for the treatment of a pressure ulcer. 3. For Resident #30 the facility failed to implement recommendations from the Wound Consultant for the treatment of a pressure ulcer. 4. For Resident #69 the facility failed to a. ensure that treatment provided to a stage 4 left heel pressure ulcer was implemented in accordance with the wound consultant recommendation, and b. failed to ensure treatment to a deep tissue injury to Resident #69's left heel was provided in accordance with the physician's orders. 5. For Resident #21 the facility failed to implement recommendations from the Wound Consultant for the treatment of a pressure ulcer. Findings include: Review of the facility policy titled Pressure Ulcers/ Skin Breakdown- Clinical Protocol, Revised October 2010, indicated the following: -The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores; for example, immobility, recent weight loss and a history of pressure ulcer(s). -The physician will authorize pertinent treatment orders related to wound treatments, including pressure reduction surfaces, wound cleaning and debridement approaches, dressings (occlusive, absorption, etc.) and application of topical agents. 1. Resident #24 was admitted to the facility in January 2023 with diagnoses that included fusion of spine, cervical region, protein calorie malnutrition and iron deficiency anemia. Review of the most recent Minimum Data Set (MDS) Assessment, dated 5/26/25, indicated a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating that the Resident is cognitively intact. The MDS further indicated that the Resident has one stage 1 pressure ulcer, and one unstageable pressure ulcer, neither of which were present on admission. The MDS dated [DATE] did not assess for behaviors, however, review of an MDS assessment dated [DATE] indicated that the behavior of rejection of care was not present. Review of the most recent Norton Assessment (an assessment to determine risk for skin breakdown), dated 5/28/25, indicated a risk score of 18, indicating low risk for skin breakdown. Review of Resident #24's active risk for skin breakdown care plan indicated the following, dated as revised 5/11/23: Skin: [Resident] has OCC. (occasional) incontinence r/t (related to) Confusion, Impaired Mobility, Physical limitations, with a goal that indicated, [Resident] will remain free from skin breakdown due to incontinence and brief use through the review date. Review of the wound consultant note, dated 2/24/25, indicated the following: -With facility-acquired pressure ulcers. PU2 (pressure ulcer) to proximal lower back and distal lower back over the vertebrae. No other areas of concern. The patient denies pain. No signs or symptoms of infection were noted. Tx (treatment) plan is added. -Treatment recommendations for both areas: #3 Pressure ulcer Lower Back proximal and #4 Pressure ulcer Lower Back distal -Measurements for Pressure ulcer to the lower back proximal were 0.8 centimeters (cm) x 0.6 cm x 0.1 cm in depth, and for the pressure ulcer to the lower back distal were indicated as 1 cm x 2.2 cm x 0.1 cm in depth. Instruction: Wash with wound cleanser. Pat dry. Skin prep to peri skin. Cover with Xeroform, Silicone bordered dressing QD (daily) and PRN (as needed). Frequent repositioning. Off Load pressure Q2hrs (every two hours). *Recommend Vitamin C 500mg, Zinc 50mg and protein supplement. Review of active and discontinued physician's orders failed to indicate that recommendations were implemented as indicated in the wound consultant note, and indicated the following orders: -Santyl (a prescription medication that removes dead tissue from wounds) Ointment 250 unit/gm (gram) (Collagenase) Apply to Proximal lower back topically every day shift related to pressure ulcer of unspecified site, stage 2, Cleanse wound with wound cleanser. Rinse wound with normal saline. Pat dry. Apply skin barrier to peri wound skin. Apply Santyl then normal saline to the wound base. Cover with Xeroform then silicone bordered dressing daily & PRN AND Apply to proximal lower back topically every 24 hours as needed for dislodgement or soiled dressing, cleanse wound with wound cleanser. Rinse wound with normal saline. Pat dry. Apply skin barrier to peri wound skin. Apply Santyl then normal saline to the wound base. Cover with Xeroform then silicone bordered dressing, dated as active from 2/26/25 through 3/21/25. [sic] -Santyl Ointment 250 unit/gm (Collagenase) Apply to distal lower back topically every day shift related to pressure ulcer of unspecified site, stage 2, cleanse wound with wound cleanser. Rinse wound with normal saline. Pat dry. Apply skin barrier to peri wound skin. Apply Santyl then normal saline to the wound base. Cover with Xeroform then then silicone bordered dressing. Change daily and PRN AND Apply to distal lower back topically every 24 hours as needed for dislodgement or soiled dressing Cleanse wound with wound cleanser. Rinse wound with normal saline. Pat dry. Apply skin barrier to peri wound skin. Apply Santyl then normal saline to the wound base. Cover with Xeroform then silicone bordered dressing, dated as active from 2/26/25 through 3/21/25. [sic] Review of the medical record failed to indicate that the recommendations for offloading the wounds, Vitamin C or Zinc were implemented. The medical record further indicated that the Resident was already receiving protein supplementation, prior to the recommendation. Review of the medical record failed to indicate that the care plan was updated to indicate actual skin breakdown and that new interventions for repositioning or offloading were implemented in the plan of care for Resident #24. Review of the wound consultant note, dated 3/20/25, indicated the following: -#4 Pressure ulcer Lower Back distal- stage 2 (stage 2 pressure ulcer) -Measurement: 2 cm x 1 cm x 0.1 cm in depth. Instruction: Wash with wound cleanser. Pat dry. Skin prep to periskin. Cover with Xeroform, Silicone bordered dressing QD and PRN. Frequent repositioning. Off Load pressure Q2hrs. *Recommend Vitamin C 500mg, Zinc 50mg and protein supplement. [sic] Review of the medical record failed to indicate that any recommendations were implemented following the Wound Consultant visit. Review of discontinued physician's orders indicated the following: -Cleanse unstageable wound lower spine with NS. Pat dry. Apply skin prep every shift May apply ABD over lower spine wound for comfort, dated 3/21/25, and active until 4/17/25, (which did not match the recommendations from the Wound Consultant). Review of the wound consultant note, dated 3/31/25, indicated the following: -PU2 to lower distal back is improving to this week. PU2 to lower proximal back has resolved. -Treatment plan is updated. Nursing aware of wound assessment and treatment plan. No new skin concerns were noted. The patient denies pain. No signs or symptoms of infection were noted. -#4 Pressure ulcer Lower Back distal- Stage 2 -Measurement: 1.7 cm x 0.5 cm x .01 cm in depth. Instruction: Wash with wound cleanser. Pat dry. Skin prep to periskin. Cover with Xeroform, Silicone bordered dressing QD and PRN. Frequent repositioning. Recommend: Vitamin C 500mg, Zinc 50mg and protein supplement. [sic] Review of discontinued physician's orders indicated the following: -Cleanse unstageable wound lower spine with NS. Pat dry. Apply skin prep every shift May apply ABD over lower spine wound for comfort, dated 3/21/25, and active until 4/17/25, (which did not match the recommendations from the Wound Consultant). Review of the wound consultant note, dated 4/28/25, indicated the following: -Patient is being seen for evaluation and treatment recommendation regarding lower back pressure injuries. -Patient was seen with nurse today. He/She denies concerns. The proximal pressure injury to his/her lower back has reopened since the last visit. He/She denies pain to the site and tells me that the wound comes and goes because the curvature of his/her spine. He/She reports that offloading helps. There are no signs or symptoms of infection. The distal pressure injury to the low back is improved. No other concerns noted. Discussed ongoing treatment plan with nurse. #3 Pressure ulcer Lower Back proximal (re opened)- stage 2 -Measurements: 1 cm x 0.5 cm x 0.2 cm in depth. Instruction: Wash with wound cleanser. Pat dry. Skin prep to intact skin. Cover with silicone foam dressing. Change QD and PRN. Frequent repositioning to offload bony prominence. Recommend: Vitamin C 500mg, Zinc 50mg and protein supplement. -#4 Pressure ulcer Lower Back distal- stage 2 measurement: 1.2 cm x 0.6 cm x 0.1 cm in depth- moderate serous drainage. Instruction: Wash with wound cleanser. Pat dry. Skin prep to intact skin. Cover with silicone foam dressing. Change QD and PRN. Frequent repositioning. Recommend: Vitamin C 500mg, Zinc 50mg and protein supplement. [sic] Review of the medical record failed to indicate that any recommendations were implemented from the Wound Consultant visit. Further review of the medical record failed to indicate that any dressing changes or wound care were provided, beginning on 4/17/25. Review of the wound consultant note, dated 5/19/25, indicated the following: -Patient is being seen for evaluation and treatment recommendation regarding lower back pressure injuries. -Patient seen sitting in WC. He/She denies pain or concerns related to wound care. Wounds are improving. No new areas of concern. Treatment plan updated and discussed with nurse. -#3 Pressure ulcer Lower Back proximal- stage 2 -Measurement: 0.5 cm x 0.5 cm x 0.1 cm in depth. Instruction: Wash with wound cleanser. Pat dry. Skin prep to intact skin. Apply single layer xeroform to wound. Cover with bordered gauze dressing. Change QD and PRN. Frequent repositioning to offload bony prominence. Recommend: Vitamin C 500mg, Zinc 50mg and protein supplement. [sic] -#4 Pressure ulcer Lower Back distal- stage 2 measurement: 1 cm x 0.5 cm x 0.1 cm in depth. Instruction: Wash with wound cleanser. Pat dry. Skin prep to intact skin. Apply single layer xeroform to wound. Cover with bordered gauze dressing. Change QD and PRN. Frequent repositioning. Recommend: Vitamin C 500mg, Zinc 50mg and protein supplement. Review of the medical record failed to indicate that any recommendations were implemented from the Wound Consultant visit. Further review of the medical record failed to indicate that any dressing changes or wound care were provided, beginning on 4/17/25. Review of the wound consultant progress note, dated, 5/26/25 indicated the following: -Pressure ulcer to distal lower back is deteriorating while pressure ulcer to proximal lower back continues to improve. Stage 2 PU to distal lower back has changed into unstageable PU. Patient denies pain. No new areas of concern or s/s (signs and symptoms) of infection. Treatment plan updated and discussed with nurse. -#3 Pressure ulcer Lower Back proximal- stage 2 -Measurement: 0.5 cm x 0.5 cm x 0.1 cm in depth. Instruction: Wash with wound cleanser. Pat dry. Skin prep to intact skin. Apply single layer xeroform to wound. Cover with bordered gauze dressing. Change QD and PRN. Frequent repositioning. Recommend: Vitamin C 500mg, Zinc 50mg and protein supplement. -#4 Pressure ulcer Lower Back distal- unstageable pressure ulcer measurement: 2 cm x 1.5 cm x 0.2 cm in depth- moderate serous drainage. 90% Slough (in wound bed). Instruction: Wash with wound cleanser. Pat dry. Skin prep to intact skin. Apply santyl to wound followed by cut-to-fit piece of moist gauze. Cover with bordered foam dressing. Change QD and PRN. Frequent repositioning to offload bony prominence with pillow behind back on wheelchair. Recommend: Vitamin C 500mg, Zinc 50mg and protein supplement. Review of the May 2025 Medication Administration Record and Treatment Administration Record failed to indicate that the treatments for either pressure ulcer were initiated and implemented as per the recommendations from the wound consultant. Further review of the medical record indicated that the Zinc 50 mg recommendation was not implemented until 5/31/25, 96 days after it was initially recommended to aid in wound healing. Review of active physician's orders as of 6/3/25 indicated the following: -Zinc 220 mg daily, dated 5/31/25, initially recommended in wound recs on 2/24/25, 96 days after it was recommended to aid in wound healing. -Cleanse wound on back with NS (Normal saline) and apply skin prep and optifoam dressing daily, dated 3/31/25. (This order was entered as ancillary and was not scheduled on any Medication or Treatment Administration Record, therefore there is no sign off to indicate that the order was completed or implemented. Review of nursing progress notes also failed to indicate that the treatment was provided). Review of active and discontinued physician's orders failed to indicate that Vitamin C, offloading of the pressure areas and frequent repositioning were ever initiated or monitored per the Wound Consultant recommendations beginning 2/24/25. Review of the medical record failed to indicate that from 4/17/25 to 6/3/25 a wound treatment order was completed or implemented as recommended by the wound consultant. Review of the medical record from 5/19/25 through 5/26/25, when the pressure ulcer to the distal lower back was documented as deteriorated and now assessed as an unstageable wound by the Wound Consultant, failed to indicate that any treatments were in place or implemented, and failed to indicate refusal of any skin wound treatments. Review of the medical record also failed to indicate that the recommendations from 5/26/25 were implemented until 6/4/25 when the surveyor brought it to the attention of the facility. During an interview and observation on 6/3/25 at 12:35 P.M., Resident #24 said he/she has a wound on his/her back, but they are no longer providing treatments to it. The surveyor requested to observe the wound, and the Resident declined for today. The surveyor asked if they could return tomorrow and re-address and the Resident said that would be fine but that at this time, he/she wants to lay down. During this observation, the resident was lying in bed, on his/her back, without any offloading measures in place. During an interview on 6/4/25 at 7:34 A.M., Nurse #5 said that she often takes care of Resident #24. She said Resident #24 has no wounds and no orders for any dressings or offloading/ repositioning measures. She said she has not completed any wound treatment or dressing changes on Resident #24 recently. She reviewed the medical record and confirmed, there are no ordered treatments on the Treatment Administration Record. During an interview on 6/4/25 at 7:45 A.M., Certified Nurse Aide #2[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to provide a safe environment free from abuse for one Resident (#41) out of a sample of 24 residents. Specifically, the facility failed to provide an environment free from physical, sexual and mental abuse. Findings include: Review of the facility policy titled 'Clinical Services, Subject: Abuse' with a revision date of March 2023 indicated the following: It is the policy of the facility that each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. It is the philosophy of the facility to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. Definitions: -Abuse-means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Willful means that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Sexual abuse means non-consensual sexual contact of any type with a resident. Sexual abuse included but is not limited to sexual harassment, sexual coercion or sexual assault. -Physical abuse includes hitting, slapping, pinching and kicking. It also included controlling behavior through corporal punishment. -Mental abuse- includes but is not limited to humiliation, harassment and threats of punishment or deprivation. Prohibited includes agitating a resident to solicit a response. Resident #41 was admitted to the facility in April 2024 with diagnoses including Hodgkin's lymphoma, anxiety, depression and pain in an unspecified shoulder. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 15 out of a possible 15 indicating intact cognition. Further review of the MDS indicated the following: -Shower/bathe self-Partial/moderate assistance. -Sit to lying-Supervision/touch assistance: helper provided verbal cues or touching/steadying assistance as resident completes activity. During an interview on 6/10/24 at 9:45 A.M., Resident #41 said that on 6/7/24, Certified Nurse's Assistant (CNA#1) ripped him/her aggressively from a sitting position and threw him/her on the bed. Resident #41 said he/she was sleeping on his/her knees while sitting on the side of the bed. He/she said this is a comfortable position for him/her to sleep in. Resident #41 said his/her shoulder hurts as a result of being thrown on the bed in a forceful manner. The Resident said approximately three weeks ago, CNA #1 bathed him/her roughly during a shower, he/she said CNA #1 forcefully spread his/her legs, scrubbed him/her aggressively between his/her legs. Resident #41 said CNA #1 did not listen to him/her when he/she told him he/she wanted to wash himself/herself with supervision. Resident #41 said he/she told the Director of Nurses (DON) about these concerns. Resident #41 said he/she also told his/her family members who also reported the concerns to the DON. During an interview on 6/10/24 at 10:03 A.M., the Assistant Director of Nurses (ADON) said they were aware of both of the concerns the Resident told to the surveyor regarding CNA #1 washing the Resident roughly and CNA #1 throwing the Resident on the bed aggressively. The ADON said they have already reached out to the Resident's family members and managed these concerns as a customer service issue. The ADON then said the facility has also provided education to staff, including CNA #1. The ADON said the only new concern that she was not aware of was the pain the Resident was reporting on his/her shoulder. The ADON provided the surveyor with a list of handwritten concerns dated 5/29/24. The list indicated showers and waking up aggressive as concerns. [sic] The ADON provided an inservice she instructed, dated 5/29/24, signed off by staff. The list of staff did not include CNA #1. Review of the 5/29/24 staff schedule indicated CNA#1 called out. The inservice's subject was Resident #41. The detailed instruction of the inservice indicated the following: -When giving Resident showers, do not touch Resident, just give Resident face cloths and allow Resident to wash himself/herself. -When helping Resident at midnight, please do not yell, talk in low voice before assisting Resident. During an observation and interview on 6/12/24 at 8:00 A.M., Resident #41 was observed sitting on his/her bed, he/she did not give any eye contact to the surveyor, he/she looked down during the whole interview. Resident #41 said he/she was in so much pain this morning, he/she rated his/her pain at an 8 out of a possible 10. The Resident said his/her body is already in pain from his/her neuropathy and cancer diagnosis. He/she said since CNA #1 threw him/her on the bed, his/her pain level has increased on his/her shoulder, he/she said he/she is in pain when he/she breathes in and out. The Resident said when CNA #1 was in the shower with him/her, he/she felt violated by him, especially after he/she offered to clean himself/herself, the CNA refused and then proceeded to forcefully spread his/her legs and began scrubbing between his/her legs, turning him/her around to reach between his/her legs. The Resident said he/she felt as if he/she was getting a private parts wash. The Resident said he/she has never been touched by a staff member in that way, he/she felt his/her boundaries were violated, he/she said both incidents keep replaying in his/her head. Resident #41 said no one in the facility has sat down to talk to him/her about the incidents. Resident #41 said he/she would like to speak to a therapist to work through both incidents with a professional. During a telephone interview on 6/11/24 at 12:17 P.M., the Resident's family members said Resident #41 told them about two concerns regarding CNA #1. The Resident's family members said the first concern happened approximately three weeks ago, they said Resident #41 told them that CNA #1 was helping him/her take a shower. Resident #41 told them that CNA #1 was washing him/her in a rough manner. Resident #41 told them that he/she told the CNA he/she could shower himself/herself. The CNA told Resident #41 that he/she was not doing a good job. The CNA then proceeded to kick the Resident's legs open and began scrubbing between his/her legs in a rough manner. Resident #41 told his/her family members that he/she felt like he/she was being sexually assaulted. Resident #41 told his/her family members that he/she had reported the concern to the DON. The Resident told the DON that he/she did not want the CNA caring for him/her again. The family members said they filed a formal complaint with the DON about this concern as well. The family members said the CNA was assigned to work with the Resident again because another incident involving CNA #1 and their father/mother occurred. They said they believed this was retaliation from the first incident. They said that on 6/7/24, Resident #41 told them that CNA #1 grabbed their father/mother, who was sleeping on his/her knees while sitting at his/her bedside, and threw him/her on the bed vigorously. The Resident's family members said their father's/mother's shoulders have been gone for years, they said staff should know not to move him/her with force. The family members said their father/mother injured his/her shoulder during this transfer. The Resident's family members said they told the facility's DON about this incident on 6/7/24. The Resident's family members said they have not heard from the facility with any follow up on how the two incidents were being addressed. A review of Resident #41's May 2024 Shower/Bathe self-tasks signed off by CNA #1 indicated the following: -Partial/Moderate Assistance, helper does less than half of the effort, helper lifts, holds or supports trunk or limbs but provides less than half of the effort. -Supervision/Touching Assistance, helper provided verbal cues and or touching, steadying or contact guard assistance. Assistance may be provided throughout or intermittently. -Evening Shift: -5/18-Supervision/Touching assistance, 5/20-Supervision/Touching assistance, 5/21-Partial/Moderate assistance, 5/24-Partial/Moderate assistance. -Night Shift: -5/4-Partial/Moderate assistance,5/6-Partial/Moderate assistance,5/7-Partial/Moderate assistance, 5/13-Partial/Moderate assistance, 5/21-Partial/Moderate assistance, 5/23-Partial/Moderate assistance, 5/28-Partial/Moderate assistance. A review of Resident #41's June 2024 Sit to Lying tasks signed off by CNA #1 indicated the following: Evening Shift: -6/1-Supervision/Touching assistance, 6/3-Supervision/Touching assistance, 6/4-Supervision/Touching assistance, 6/7-Supervision/Touching assistance. -Night Shift: 6/2-Supervision/Touching assistance, 6/5-Partial/Moderate assistance, 6/8-Supervision/Touching Assistance. During a telephone interview on 6/14/24 at 10:10 A.M., CNA #1 said he has never provided care to Resident #41 because he/she is able to provide his/her own Activities of Daily Living. CNA #1 said Resident #41 is able to shower/bathe and transfer himself/herself. During an interview on 6/11/24 at 1:11 P.M., the Administrator said he was not aware of any concerns reported by the Resident. He said he expects to be made aware of any abuse allegations made by residents. The ADON and DON said they managed the concerns as customer service with the family members so they did not report them to the Administrator. The DON and ADON said the facility expectation is, all allegations of abuse should be reported to the Administrator so an investigation can be initiated. The Administrator, ADON and DON said allegations of abuse should be thoroughly investigated. They said documentation of the investigations was not completed by initiating incident reports after Resident #41 made abuse allegations. They said they did not obtain statements from identified potential witnesses, they did not complete necessary evaluations and they did not maintain a timeline of the events. The Administrator, ADON and DON said allegations of abuse should be reported to the state agency and local law enforcement within two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to implement their abuse policy for one Resident (#41) out of a sample of 24 residents. Specifically, 1. The Director of Nurses (DON) and Assistant Director of Nurses (ADON) failed to notify the Administrator about allegations of physical, sexual and mental abuse, 2. Keep Resident #41 safe by suspending the staff member involved in the abuse allegations, 3. Failed to report and investigate the abuse allegations as required, and 4. Failed to report the allegations to the state agency (SA) and law enforcement. Findings include: Review of the facility policy titled 'Clinical Services, Subject: Abuse' with a revision date of March 2023 indicated the following: It is the policy of the facility that each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. It is the philosophy of the facility to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. Definitions: -Abuse-means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Willful means that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Sexual abuse means non-consensual sexual contact of any type with a resident. Sexual abuse included but is not limited to sexual harassment, sexual coercion or sexual assault. -Physical abuse includes hitting, slapping, pinching and kicking. It also included controlling behavior through corporal punishment. -Mental abuse- includes but is not limited to humiliation, harassment and threats of punishment or deprivation. Prohibited includes agitating a resident to solicit a response. Procedure for Abuse Investigation: Identification: -Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. Action: -Immediately protect Resident from alleged abuse. -Immediately notify your administrative staff or nursing supervisor on duty of abuse allegation. -The Administrative staff/Nursing supervisor will immediately report all allegations to the Administrator and Director of Nurses. -Immediately suspend employee pending investigation. -The facility will notify the Department of Public Health and Local law enforcement no later than two hours after abuse allegation was received. Resident #41 was admitted to the facility in April 2024 with diagnoses including Hodgkin's lymphoma, anxiety, depression and pain in an unspecified shoulder. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 15 out of a possible 15 indicating intact cognition. Further review of the MDS indicated the following: -Shower/bathe: self-Partial/moderate assistance. -Sit to lying-Supervision/touch assistance: helper provided verbal cues or touching/steadying assistance as resident completes activity. During an interview on 6/10/24 at 9:45 A.M., Resident #41 said that on 6/7/24, Certified Nurse's Assistant (CNA#1) ripped him/her aggressively from a sitting position and threw him/her on the bed. Resident #41 said he/she was sleeping on his/her knees while sitting on the side of the bed. He/she said this is a comfortable position for him/her to sleep in. Resident #41 said his/her shoulder hurt as a result of being thrown on the bed in a forceful manner. The Resident said approximately three weeks ago, CNA #1 bathed him/her roughly during a shower, he/she said CNA #1 forcefully spread his/her legs, scrubbed him/her aggressively between his/her legs. Resident #41 said CNA #1 did not listen to him/her when he/she told him he/she wanted to wash himself/herself with supervision. Resident #41 said he/she told the DON about these concerns. Resident #41 said he/she also told his/her family members who also reported the concerns to the DON. During an interview on 6/10/24 at 10:03 A.M., the ADON said they were aware of both of the concerns the Resident told to the surveyor regarding CNA #1 washing the Resident roughly and CNA #1 throwing the Resident on the bed aggressively. The ADON said they have already reached out to the Resident's family members and managed these concerns as a customer service issue. The ADON provided the surveyor with a list of handwritten concerns dated 5/29/24. The list indicated showers and waking up aggressive as concerns. [sic] During a telephone interview on 6/11/24 at 12:17 P.M., the Resident's family members said their parent told them about two concerns regarding CNA #1. The Resident's family members said the first concern happened approximately three weeks ago. They said Resident #41 told them that CNA #1 was helping them take a shower. Resident #41 told them that CNA #1 was washing him/her in a rough manner. Resident #41 told them that he/she told the CNA he/she could shower himself/herself. The CNA told Resident #41 that he/she was not doing a good job. The CNA then proceeded to kick the Resident's legs open and began scrubbing between his/her legs in a rough manner. Resident #41 told his/her family members that he/she felt like he/she was being sexually assaulted. Resident #41 told his/her family members that he/she had reported the concern to the DON. The Resident told the DON that he/she did not want the CNA caring for him/her again. The family members said they filed a formal complaint with the DON about this concern as well. The family members said the CNA was assigned to work with the Resident again because another incident involving CNA #1 and their father/mother occurred. They said they believed this was retaliation from the first incident. They said that on 6/7/24, Resident #41 told them that CNA #1 grabbed their parent, who was sleeping on his/her knees while sitting at his/her bedside and threw him/her on the bed vigorously. The Resident's family members said their parent's shoulders have been gone for years, they said staff should know not to move him/her with force. The family members said their father/mother injured his/her shoulder during this transfer. The Resident's family members said they told the facility's DON about this incident on 6/7/24. The Resident's family members said they have not heard from the facility with any follow up on how the two incidents were being addressed. During a telephone interview on 6/14/24 at 10:10 A.M., CNA #1 said he has never provided care to Resident #41 because he/she is able to provide his/her own Activities of Daily Living. CNA #1 said Resident #41 is able to shower/bathe and transfer himself/herself. A review of Resident #41's May 2024 Shower/Bathe self-tasks signed off by CNA #1 indicated the following: -Partial/Moderate Assistance, helper does less than half of the effort, helper lifts, holds or supports trunk or limbs but provides less than half of the effort. -Supervision/Touching Assistance, helper provided verbal cues and or touching, steadying or contact guard assistance. Assistance may be provided throughout or intermittently. -Evening Shift: -5/18-Supervision/Touching assistance, 5/20-Supervision/Touching assistance, 5/21-Partial/Moderate assistance, 5/24-Partial/Moderate assistance. -Night Shift: -5/4-Partial/Moderate assistance,5/6-Partial/Moderate assistance,5/7-Partial/Moderate assistance, 5/13-Partial/Moderate assistance, 5/21-Partial/Moderate assistance, 5/23-Partial/Moderate assistance, 5/28-Partial/Moderate assistance. A review of Resident #41's June 2024 Sit to Lying tasks signed off by CNA #1 indicated the following: Evening Shift: -6/1-Supervision/Touching assistance, 6/3-Supervision/Touching assistance, 6/4-Supervision/Touching assistance, 6/7-Supervision/Touching assistance. -Night Shift: 6/2-Supervision/Touching assistance, 6/5-Partial/Moderate assistance, 6/8-Supervision/Touching Assistance. During an interview on 6/13/24 at 7:21 A.M., the Unit Manager said all abuse allegations made by residents should be reported to the ADON, DON and Administrator. During an interview on 6/11/24 at 1:11 P.M., the Administrator said he was not aware of any concerns reported by the Resident. He said he expects to be made aware of any abuse allegations made by residents. The ADON and DON said they managed the concerns as customer service with the family members, so they did not report them to the Administrator. The DON and ADON said the facility expectation is, all allegations of abuse should be reported to the Administrator so an investigation can be initiated. The Administrator, ADON and DON said allegations of abuse should be thoroughly investigated. They said documentation of the investigations was not completed by initiating incident reports after Resident #41 made abuse allegations. They said they did not obtain statements from identified potential witnesses, they did not complete necessary evaluations and they did not maintain a timeline of the events. The Administrator, ADON and DON said allegations of abuse should be reported to the state agency and local law enforcement within two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to report an allegation of abuse for one Resident (#41) out of a sample of 24 residents. Specifically, the facility failed to report allegations of physical abuse, sexual abuse and mental abuse to the (SA) state agency. Findings include: A review of the facility policy titled 'Clinical Services, Subject: Abuse' with a revision date of March 2023 indicated the following: It is the policy of the facility that each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. It is the philosophy of the facility to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. Definitions: -Abuse-means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Willful means that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Sexual abuse means non-consensual sexual contact of any type with a resident. Sexual abuse included but is not limited to sexual harassment, sexual coercion or sexual assault. -Physical abuse includes hitting, slapping, pinching and kicking. It also included controlling behavior through corporal punishment. -Mental abuse- includes but is not limited to humiliation, harassment and threats of punishment or deprivation. Prohibited includes agitating a resident to solicit a response. Procedure for Abuse Investigation: Identification: -Any complaint of, observation of, or suspicion of resident abuse, mistreatment or neglect is to be thoroughly investigated and reported. Action: -Immediately protect Resident from alleged abuse. -Immediately notify your administrative staff or nursing supervisor on duty of abuse allegation. -The Administrative staff/Nursing supervisor will immediately report all allegations to the Administrator and Director of Nurses. -Immediately suspend employee pending investigation. -The facility will notify the Department of Public Health and Local law enforcement no later than two hours after abuse allegation was received. Resident #41 was admitted to the facility in April 2024 with diagnoses including Hodgkin's lymphoma, anxiety, depression and pain in an unspecified shoulder. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 15 out of a possible 15 indicating intact cognition. Further review of the MDS indicated the following: -Shower/bathe: self-Partial/moderate assistance. -Sit to lying-Supervision/touch assistance: helper provided verbal cues or touching/steadying assistance as resident completes activity. During an interview on 6/10/24 at 9:45 A.M., Resident #41 said that on 6/7/24, Certified Nurse's Assistant (CNA#1) ripped him/her aggressively from a sitting position and threw him/her on the bed. Resident #41 said he/she was sleeping on his/her knees while sitting on the side of the bed. He/she said this is a comfortable position for him/her to sleep in. Resident #41 said his/her shoulder hurts as a result of being thrown on the bed in a forceful manner. The Resident said approximately three weeks ago, CNA #1 bathed him/her roughly during a shower, he/she said CNA #1 forcefully spread his/her legs, scrubbed him/her aggressively between his/her legs. Resident #41 said CNA #1 did not listen to him/her when he/she told him he/she wanted to wash himself/herself with supervision. Resident #41 said he/she told the Director of Nurses (DON) about these concerns. Resident #41 said he/she also told his/her family members who also reported the concerns to the DON. During an interview on 6/10/24 at 10:03 A.M., the Assistant Director of Nurses (ADON) said they were aware of both of the concerns the Resident told to the surveyor regarding CNA #1 washing the Resident roughly and CNA #1 throwing the Resident on the bed aggressively. The ADON said they have already reached out to the Resident's family members and managed these concerns as a customer service issue. The ADON provided the surveyor with a list of handwritten concerns dated 5/29/24. The list indicated showers and waking up aggressive as concerns. [sic] During a telephone interview on 6/11/24 at 12:17 P.M., the Resident's family members said Resident #41 told them about two concerns regarding CNA #1. The Resident's family members said the first concern happened approximately three weeks ago, they said Resident #41 told them that CNA #1 was helping them take a shower. Resident #41 told them that CNA #1 was washing him/her in a rough manner. Resident #41 told them that he/she told the CNA he/she could shower himself/herself. The CNA told Resident #41 that he/she was not doing a good job. The CNA then proceeded to kick the Resident's legs open and began scrubbing between his/her legs in a rough manner. Resident #41 told his/her family members that he/she felt like he/she was being sexually assaulted. Resident #41 told his/her family members that he/she had reported the concern to the DON. The Resident told the DON that he/she did not want the CNA caring for him/her again. The family members said they filed a formal complaint with the DON about this concern as well. The family members said the CNA was assigned to work with the Resident again because another incident involving CNA #1 and their father/mother occurred. They said they believed this was retaliation from the first incident. They said that on 6/7/24, Resident #41 told them that CNA #1 grabbed their father/mother, who was sleeping on his/her knees while sitting at his/her bedside and threw him/her on the bed vigorously. The Resident's family members said their father's/mother's shoulders have been gone for years, they said staff should know not to move him/her with force. The family members said their father/mother injured his/her shoulder during this transfer. The Resident's family members said they told the facility's DON about this incident on 6/7/24. The Resident's family members said they have not heard from the facility with any follow up on how the two incidents were being addressed. During an interview on 6/13/24 at 7:21 A.M., the Unit manager said all allegations of abuse reported by residents should be reported to the state agency and law enforcement within two hours. During an interview on 6/11/24 at 1:11 P.M., the Administrator, ADON and DON said allegations of abuse should be reported to the state agency and local law enforcement within two hours. A review of the Health Care Facility reporting system (HCFRS) did not indicate any abuse allegations were reported in May 2024 and prior to June 10, 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to investigate allegations of abuse for one Resident (#41) out of a sample of 24 residents. Specifically, the facility failed to investigate allegations of physical, sexual and mental abuse. Findings include: Review of the facility policy titled 'Clinical Services, Subject: Abuse' with a revision date of March 2023 indicated the following: It is the policy of the facility that each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. It is the philosophy of the facility to encourage an environment that recognizes the special qualities of our residents and provides them with a safe environment. Definitions: -Abuse-means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Willful means that the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. -Sexual abuse means non-consensual sexual contact of any type with a resident. Sexual abuse included but is not limited to sexual harassment, sexual coercion or sexual assault. -Physical abuse includes hitting, slapping, pinching and kicking. It also included controlling behavior through corporal punishment. -Mental abuse- includes but is not limited to humiliation, harassment and threats of punishment or deprivation. Prohibited includes agitating a resident to solicit a response. Procedure for Abuse Investigation: -Any complaint of, or suspicion of resident abuse shall be thoroughly investigated. -Facility investigation will be completed within 72 hours of the incident, documentation of investigation to be completed by initiating an incident and accident report, obtaining statements from identified potential witnesses, completing necessary evaluations (i.e. skin/body checks, pain evaluation), and maintaining a timeline of events. Resident #41 was admitted to the facility in April 2024 with diagnoses including Hodgkin's lymphoma, anxiety, depression and pain in an unspecified shoulder. A review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] indicated a Brief Interview for Mental Status score of 15 out of a possible 15 indicating intact cognition. Further review of the MDS indicated the following: -Shower/bathe: self-Partial/moderate assistance. -Sit to lying-Supervision/touch assistance: helper provided verbal cues or touching/steadying assistance as resident completes activity. During an interview on 6/10/24 at 9:45 A.M., Resident #41 said that on 6/7/24, Certified Nurse's Assistant (CNA #1) ripped him/her aggressively from a sitting position and threw him/her on the bed. Resident #41 said he/she was sleeping on his/her knees while sitting on the side of the bed. He/she said this is a comfortable position for him/her to sleep in. Resident #41 said his/her shoulder hurts as a result of being thrown on the bed in a forceful manner. The Resident said approximately three weeks ago, CNA #1 bathed him/her roughly during a shower, he/she said CNA #1 forcefully spread his/her legs, scrubbed him/her aggressively between his/her legs. Resident #41 said CNA #1 did not listen to him/her when he/she told him he/she wanted to wash himself/herself with supervision. Resident #41 said he/she told the Director of Nurses (DON) about these concerns. Resident #41 said he/she also told his/her family members who also reported the concerns to the DON. During an interview on 6/10/24 at 10:03 A.M., the Assistant Director of Nurses (ADON) said they were aware of both of the concerns the Resident told to the surveyor regarding CNA #1 washing the Resident roughly and CNA #1 throwing the Resident on the bed aggressively. The ADON said they have already reached out to the Resident's family members and managed these concerns as a customer service issue. During a telephone interview on 6/11/24 at 12:17 P.M., the Resident's family members said Resident #41 told them about two concerns regarding CNA #1. The Resident's family members said the first concern happened approximately three weeks ago, they said Resident #41 told them that CNA #1 was helping them take a shower. Resident #41 told them that CNA #1 was washing him/her in a rough manner. Resident #41 told them that he/she told the CNA he/she could shower himself/herself. The CNA told Resident #41 that he/she was not doing a good job. The CNA then proceeded to kick the Resident's legs open and began scrubbing between his/her legs in a rough manner. Resident #41 told his/her family members that he/she felt like he/she was being sexually assaulted. Resident #41 told his/her family members that he/she had reported the concern to the DON. The Resident told the DON that he/she did not want the CNA caring for him/her again. The family members said they filed a formal complaint with the DON about this concern as well. The family members said the CNA was assigned to work with the Resident again because another incident involving CNA #1 and their father/mother occurred. They said they believed this was retaliation from the first incident. They said that on 6/7/24, Resident #41 told them that CNA #1 grabbed their father/mother, who was sleeping on his/her knees while sitting at his/her bedside and threw him/her on the bed vigorously. The Resident's family members said their father's/mother's shoulders have been gone for years, they said staff should know not to move him/her with force. The family members said their father/mother injured his/her shoulder during this transfer. The Resident's family members said they told the facility's DON about this incident on 6/7/24. The Resident's family members said they have not heard from the facility with any follow up on how the two incidents were being addressed. During an interview on 6/13/24 at 7:21 A.M., the Unit manager said she manages all the units in the facility. She said she was a part of an abuse/neglect in-service on 5/29/24 presented by the ADON. She said she was not aware of the details but was aware abuse allegations had been made by a resident on the first floor. She said all allegations of abuse made by residents should be investigated. During an interview on 6/11/24 at 1:11 P.M., the Administrator, ADON and DON said allegations of abuse should be thoroughly investigated. They said documentation of the investigations was not completed by initiating incident reports after Resident #41 made abuse allegations. They said they did not obtain statements from identified potential witnesses, they did not complete necessary evaluations and they did not maintain a timeline of the events.