**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for two of three sampled residents (Resident #2 and Resident #1), the Facility failed to ensure they were free from physical and/or verbal abuse by staff members when; 1) On 2/19/24, Resident #2, who was alert and oriented, reported to a staff member that during an 11:00 P.M. to 7:00 A.M. shift (later determined to be on 2/18/24) he/she had a fall, that Nurse #2 picked him/her up, put him/her back into bed, that Nurse #2 then put his hand over his/her mouth and verbally threatened him/her saying he (Nurse #2) would hurt his/her (Resident #2's) family if he/she told anyone. Resident #2 told staff he/she was scared of Nurse #2, and he/she became visibly upset and cried even weeks later, when interviewed regarding the incident. 2) On 03/06/24, Resident #1, who had significant cognitive impairment and was dependent on staff to meet his/her care needs, spit food out at CNA #1 and in response, CNA #1 grabbed both of Resident #1's arms, forcefully shook him/her, and then backhanded Resident #1 on the mouth. A skin assessment was conducted and Resident #1 was found to have new bruised areas on his/her left side and left arm. Although Resident#1's impaired cognition minimized his/her understanding of the incident, an unimpaired individual would have experienced physical pain and mental anguish after being treated by a caregiver in this manner. Findings include: Review of the Facility's Policy titled Resident Abuse Prevention, Investigation, and Reporting, dated as revised 03/2023, indicated the following: -it is the policy of the Facility that each resident has the right to be free from abuse, neglect, 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. 1) Resident #2 was admitted to the Facility in April 2023, diagnoses included major depressive disorder, chronic pain, spinal stenosis (narrowing of the spinal canal), and anxiety disorder. Review of Resident #2's Minimum Data Set (MDS) Assessment, dated 02/02/23 indicated he/she had intact cognition, was able to make his/her needs known and was his/her own decision maker. The MDS indicated Resident #2 required moderate assistance from one staff member to meet his/her care needs. Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 02/19/24, indicated that on 02/19/24, Resident #2 reported that after he/she had a fall, that a nurse (later identified as Nurse # 2) assisted him/her (back to bed), then the nurse placed his hand over his/her (Resident #2's) mouth and said, do not say anything about this or your family will be in trouble. During an interview on 03/19/24 at 11:10 A.M., Resident #2 said he/she could not remember the date, but that sometime late at night or early morning, he/she heard a girl yell, he/she is flat on his/her face! Resident #2 said next thing he/she knew, Nurse #2 was picking him/her up, and then threw him/her onto his/her bed. Resident #2 said then Nurse #2 put his hand over his/her mouth and told him/her not to tell anyone or he would come back and hurt his/her family. Resident #2 said he/she felt very threatened by Nurse #2. Resident #2 was observed to be visibly upset and tearful during the interview with the Surveyor, which was one month after the alleged incident occurred. Review of a Social Services Progress Note, dated 03/01/24, indicated that when Social Worker (SW) #1 asked Resident #2 about his/her abuse allegation, he/she said he/she had tried to avoid Nurse #2. The Note indicated that Resident #2 was still upset, and said he/she was trying to understand why he (Nurse #2) would do something like that to him/her, and said, I'm a good person, what did I do wrong? The Note indicated that SW #1 provided reassurance, support, and validation of his/her recent trauma. Review of a Police Report, dated 02/19/24, indicated Resident #2 said he/she had been lying in bed at night when Nurse #2 came into his/her room, grabbed him/her and assisted him/her out of bed. The Police Report indicated Nurse #2 pulled Resident #2, he/she fell and hit his/her face on the floor. The Police Report indicated that the Officer observed a bruise on Resident #2's upper lip. The Police Report indicated that Resident #2 said Nurse #2 threw him/her down onto the bed, and told him/her to be quiet or he would be back, which Resident #2 took as a threat. The Police Report further indicated that Resident #2 said Nurse #2 knew his/her family, their addresses, and that Resident #2 was clearly scared and hesitant to tell anyone because he/she was concerned for his/her family's well-being. The Police Report indicated that a few days had passed after the incident before the resident told CNA #2. The Police Report indicated that Facility Administration reported to the Officer that Resident #2 had told CNA #2 that when Nurse #2 threw him/her on the bed, he covered his/her (Resident #2's) mouth and told him/her that if he/she told anyone, he would hurt his/her family. During a telephone interview on 03/26/24 at 9:24 A.M., and review of her Written Witness Statement, dated 02/19/24, Certified Nurse Aide (CNA) #2 said she knew Resident #2 very well and had been regularly assigned to care for him/her. CNA #2 said she could not remember the exact date, but said when she went to care for Resident #2 in the morning, Resident #2 said to her, thank God you are here, because that man threw me in bed last night, put his hand over my mouth, and told me not to say anything or he would do something to my family. CNA #2 said Resident #2 was crying, shaking, and hugged her when he/she (Resident #2) told her what happened. CNA #2 said she told Nurse #1 immediately. Review of the Facility's Investigation Summary Report, undated, indicated that on 02/19/24 Resident #2 reported that Nurse #2 picked him/her up (off the floor), threw him/her in bed, and then put his hands over Resident #2's mouth and told him/her not to tell anyone or he was going to come for his/her family. The Report indicated that on 02/19/24, Nurse #1 said that staff noticed a bruise on Resident #2's upper lip and when Nurse #1 asked him/her how he/she got the bruise, Resident #2 said he/she had already had it and denied any falls. The Report indicated that Resident #2 had said to CNA #2 that, the big man (later identified as Nurse #2) picked me up, threw me onto the bed, put his hands over my mouth and told me not to tell anyone or he was going to come after my family. The Report indicated that CNA #5, who worked the night shift starting on 02/18/24 into 2/19/24 with Nurse #2 on Resident #2's unit, was interviewed on 02/19/24, and that CNA #5 said that at approximately 11:50 P.M. (sometime at the start of the shift) when she answered Resident #2's call light, and she found him/her on the floor. The Report indicated that CNA #5 told Nurse #2, and he (Nurse #2) picked Resident #2 up. The Report indicated that Nurse #2 would not comply with the Facility's investigation, and the Facility substantiated Resident #2's allegation of abuse. Review of a CNA #5's Written Witness Statement, undated, indicated that on 02/11/24, (per the Director of Clinical Operations, correct date was 02/19/24) at approximately 11:50 P.M., she went to Resident #2's room to answer his/her call light and found Resident #2 on the floor. The Statement indicated that CNA #5 told Nurse # 2 that Resident #2 was on the floor and that he (Nurse #2) picked Resident #2 up. The Surveyor was unable to interview CNA #5 as she did not respond to the Department of Public Health's telephone or letter requests for an interview. Review of Resident #2's Medical Record indicated there was no documentation to support Nurse #2 documented that Resident #2 had a fall anytime during the overnight shift from 02/18//24 into 02/19/24. Review of a Skin Assessment, dated 02/19/24, indicated Resident #2 had a bruise on the left side of his/her mouth. During a telephone interview on 3/27/24 at 10:24 A.M., and review of her Written Witness Statement, dated 02/19/24, Nurse #1 said she knew Resident #2 very well, and was assigned to him/her during 7:00 A.M. to 3:00 P.M. shifts. Nurse #1 said that on 02/19/24 in the morning, she noticed bruising on Resident #2's left upper lip, that had not been there the last time she worked with Resident #2 (2-3 days prior) and asked him/her what happened. Nurse #1 said Resident #2 initially denied anything had occurred which would have caused the bruise. Nurse #1 said that after she left Resident #2's room, CNA # 2 approached her and told her that Resident #2 had just reported to her that Resident #2 got scared when he/she heard her (CNA #2) jiggle the doorknob to enter the bathroom. Nurse #1 said CNA #2 then told her that Resident #2 had told her (CNA #2) that some night over the weekend, a large man picked him/her up, threw him/her onto his/her bed, put his hand over his/her mouth and then told him/her not to say anything or he would hurt his/her family. Nurse #1 said she went back to speak with Resident #2 again and that Resident #2 repeated to her the exact allegation that CNA #2 had just reported to her. Nurse #1 said Resident #2 apologized for lying about the bruise on his/her lip, but said he/she was afraid to say anything because Nurse #2 told him/her that he would hurt his/her family if he/she did. Nurse #1 said that when Resident #2 told her what happened, he/she was crying, shaking, and afraid. Nurse #1 said Resident #2 told her that he/she was afraid for his/her family. Nurse #1 said it took Resident #2 until last week (about one month) to return to his/her emotional baseline. Nurse #1 said she was also present during Resident #2's follow-up interview with the Police Detectives approximately two weeks after the incident occurred and said when Resident #2 had to restate his/her account of the alleged incident, he/she was crying, shaking, and told them he/she was scared. Nurse #1 said there was never any variation in Resident #2's account of the alleged incident. During an interview on 03/20/24 at 1:27 P.M., the Assistant Director of Nurses (ADON) said Nurse #1 reported Resident #2's allegation on 02/19/24 in the morning. The ADON said she went to interview Resident #2 and he/she seemed afraid to tell her any information. The ADON said Resident #2 then told her that a big dude picked him/her up from the floor, threw him/her into bed, then put his hand over his/her mouth and told him/her (Resident #2) not to say anything. The ADON said Resident #2 apologized for initially lying about his/her fall but said he/she lied because he/she was afraid for his/her family. During an in-person interview on 03/20/24 at 3:04 P.M., and a telephone interview on 03/29/24 at 9:35 A.M., the Director of Clinical Operations said that upon completion of the Facility's investigation, Nurse #2 had been terminated. The Director said she and the ADON attempted to interview Nurse #2, and although he had refused to answer any of their questions, said that Nurse #2 had acknowledged that Resident #2 had a fall, and that he refused to document it. The Director said CNA #5's Written Witness Statement had mistakenly indicated the date of the incident was 02/11/24, but said it should have been 02/19/24. The Director said based on Resident #2's allegation and interviews, CNA #5's Written Witness Statement and facility interview, the Facility substantiated an allegation of abuse and terminated Nurse #2. During a telephone interview on 03/19/24 at 1:10 P.M., Nurse #2 said he had retained an attorney and refused to participate in an interview with the Surveyor, stating he was invoking his Fifth Amendment Rights, and then began quoting his [NAME] Rights. Nurse #2 said he would always cooperate with the Department of Public Health however, he refused to participate in an interview. Although there were no witnesses to corroborate Resident #2's allegation that Nurse #2 threatened him/her and covered his/her mouth, a reasonable person would be convinced abuse occurred based on Resident #2's intact cognition and consistent statements regarding the allegation, as well as Nurse #2's failure to be forthcoming at the time of Resident #2's fall and Nurse #2's refusal to participate in investigations conducted by the Facility and the Department of Public Health. 2) Review of the Report submitted by the Facility via the Health Care Facility Reporting System (HCFRS), dated as submitted 03/06/24, indicated that Nurse #1 reported that she witnessed a Certified Nurse Aide (CNA, later identified as CNA #1) with her hand raised toward Resident #1's mouth. Resident #1 was admitted to the Facility in April 2023, diagnoses included Alzheimer's Disease, dementia, and anxiety disorder. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 01/24/24, indicated he/she had severe cognitive impairment and was dependent on staff to meet his/her care needs. Review of a Skin Assessment,dated 02/29/24, indicated Resident #1 had intact skin, with no issues noted. Review of the Facility's Investigation Summary Report, undated, indicated that on 03/06/24 at approximately 9:45 A.M., Nurse #1 reported that she observed Certified Nurse Aide (CNA) #1 with her hand raised toward Resident #1's mouth. The Summary indicated that during an interview conducted by the Assistant Director of Nurses (ADON), Nurse #1 told her that she witnessed CNA #1 slap Resident #1 on the mouth. Review of CNA #1's Written Witness Statement, dated 03/06/24, indicated that Resident #1 spit on her (CNA #1) and that she tapped Resident #1 on the mouth for spitting. During an interview on 03/20/24 at 9:24 A.M., CNA #1 said that on 03/06/24 that Resident #1 had been spitting food out and that when she tried to wash his/her face with a facecloth, Resident #1 spit in her (CNA #1's) face. CNA #1 said she then tapped Resident #1 on the lips and said, no, no, no don't do that. However, further review of the Facility's Investigation Summary Report indicated that during an interview conducted by the Assistant Director of Nurses (ADON), CNA #1 told the ADON that Resident #1 spit his/her medications at her, and that she (CNA #1) backhanded Resident #1 so he/she would stop spitting. The Summary indicated that an allegation of abuse had been substantiated. Review of a Police Report, dated 03/06/24, indicated that CNA #1 said that at approximately 9:30 A.M., Resident #1 spit ice cream at her. The Report indicated that in response to the spitting, CNA #1 admitted that she smacked Resident #1's mouth with the back of her hand and told him/her no. The Report indicated that the Police Officer had been informed that Resident #1 had a bruise on his/her arm from being grabbed and that CNA #1 said she had grabbed Resident #1's hands to assist him/her up so she could provide care, but said she was unaware if she had left any bruising. Review of a Nurse Progress Note, dated 03/06/24, indicated that at 9:30 A.M. that morning, Resident #1 had been involved in an incident involving a staff member. The Note indicated that CNA #1, with an open back hand, hit Resident #1 on the mouth. Review of a Skin Assessment, dated 03/06/24, indicated Resident #1 had scattered bruises on bilateral arms and left breast area. During an interview on 03/19/24 at 2:12 P.M. and review of her Written Witness Statement, dated 03/06/24, Nurse #1 said that on 03/06/24 during breakfast, Resident #1 had been combative and had been spitting his/her food out. Nurse #1 said she witnessed CNA #1 hit Resident #1 in the mouth with the back of her hand. Nurse #1 said that during a skin check following the incident, she noticed bruising on Resident #1's left breast area and both forearms. Nurse #1 said she works during the day Monday through Friday on Resident #1's unit, is very familiar with him/her, and said she had not seen the bruises on Resident #1's arms or left breast area prior to 3/06/24. During a telephone interview on 03/28/24 at 10:07 A.M. and review of her Written Witness Statement, dated 03/06/24, CNA #3 said at the start of her day shift (7:00 A.M. to 3:00 P.M.) on 03/06/24, CNA #1 seemed agitated. CNA #3 said during breakfast in the dining room, she saw CNA #1 trying to feed Resident #1, but he/she was resistant. CNA #3 said she was fluent in Resident #1's language and said Resident #1 kept saying he/she did not want to eat. CNA #3 said she told CNA #1 that Resident #1 was saying he/she did not want to eat and that CNA #1 told her that he/she had to eat, and that he/she did this all of the time. CNA #3 said she saw CNA #1 grab Resident #1's cheeks, force food into his/her mouth, and then Resident #1 spit the food out at CNA #1. CNA #3 said she then saw CNA #1 grab both of Resident #1's arms and shake him/her forcefully. CNA #3 said at that point, she immediately went to get Nurse #1. During an interview on 03/20/24 at 1:27 P.M., the Assistant Director of Nurses (ADON) said on 03/06/24, Nurse #1 reported to her that she had just witnessed CNA #1 backhand (smack) Resident #1 in the mouth. The ADON said she and Director of Clinical Operations interviewed CNA #1 together. The ADON said CNA #1 told them that Nurse #1 gave Resident #1 medications and then he/she started to spit them at her (CNA #1). The ADON said CNA #1 told them that she backhanded (smacked) Resident #1 and that CNA #1 then demonstrated to them, what she had done. The ADON said that on 03/06/24 CNA #3 told her that during breakfast, she saw Resident #1 hitting and spitting at CNA #1 and he/she would not stop. The ADON said CNA #3 told her that CNA #1 then shook Resident #1's arms. The ADON said she saw bruises on Resident #1's left breast area and left arm. Review of a Skin Assessment, dated 03/19/24, indicated Resident #1 had a fading yellow bruise over his/her left breast area. During an in-person interview on 03/20/24 at 3:04 P.M., and a telephone interview on 03/29/24 at 9:35 A.M., the Director of Clinical Operations said she and the ADON interviewed CNA #1 together. The Director said CNA #1 told them that when Resident #1 spit at her, she (CNA #1) backhanded him/her in the mouth, and at the same time she (CNA #1) demonstrated the backhand motion to them. The Director said that she and the ADON determined that the bruise on Resident #1's left breast area and both arms were a result of the physical abuse by CNA #1. The Director said the Facility had substantiated the abuse and CNA #1 had been terminated. Although Resident#1's impaired cognition minimized his/her understanding of the incident, an unimpaired individual would have experienced physical pain and mental anguish after being treated by a caregiver in this manner.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), who was assessed by nursing to be at an increased risk for elopement, had a history of wandering the unit, and told staff he/she wanted to go home, the Facility failed to ensure staff responded appropriately to a sounding exit door alarm, in an effort to maintain Resident #1's safety and prevent an incident/accident (elopement), resulting in an injury. On 2/23/23, sometime during the evening shift (3:00 P.M. to 11:00 P.M.), Resident #1 who was last seen in the day room on his/her unit, exited the Facility, unbeknownst to staff. The Facility received a call from someone in the community saying they heard someone outside the Facility yelling for help. Resident #1 was found outside on the Facility grounds, lying in the prone (face down) position on the ground, he/she was transported to the Hospital Emergency Department (ED) for evaluation, where he/she was diagnosed with a hematoma (bruise) above his/her left eye and a left rib fracture. Findings include: The Facility's Policy, titled Missing Person-Elopement, dated as revised June 2015, indicated the following: -it is the policy of the Facility to minimize the potential of resident elopement and to establish a process to locate a resident if they are unable to be found in the Facility or on the grounds -an elopement assessment is completed on residents upon admission, quarterly, annually, and as needed. Residents scoring 10 or greater is considered an elopement risk and will have their picture posted at the front desk and on each unit -door breach: if door alarm sounds and staff cannot identify who has triggered the alarm, residents identified as an elopement risk must be checked and located by a staff member Resident #1 was admitted to the Facility in March 2021, diagnoses included Alzheimer's disease, Dementia with behavioral disturbances, Abnormalities of gait and mobility, Anxiety, Dysthymic disorder, bilateral knee pain, and muscle weakness. Review of Resident #1's Quarterly Minimum Data Set (MDS) Assessment, dated 12/15/22, indicated that Resident #1 had severe cognitive impairments, exhibited wandering behavior, and he/she required extensive assistance of one staff person with ambulation, and locomotion on/off the unit. The MDS indicated Resident #1's balance was not steady during transitions and walking. Review of Resident #1's Behavioral Care Plan, (reviewed and renewed with the Quarterly MDS dated [DATE]), indicated that he/she had behavioral symptoms that included intrusive wandering and attempting to elope. Review of Resident #1's Fall Risk Assessment, dated 12/21/22, indicated that he/she was assessed by nursing as being a high risk for falls. Review of Resident #1's Falls Care Plan, (reviewed and renewed with the Quarterly MDS dated [DATE]), indicated that he/she required an assist of one for ambulation and was at risk for falls related to bilateral knee pain. Review of Resident #1's Certified Nurse Aide (CNA) Care Card, updated as 1/05/23, indicated that Resident #1 required assist of one with ambulation and locomotion on/off the unit, and that he/she could become angry, wanting to go home, and was an elopement risk. Review of a Nurse Progress Note, dated 2/08/23, indicated that Resident #1 was verbally and physically abusive to staff, and attempting to elope. Review of Nurse Progress Notes, dated 2/17/23, indicated that Resident #1 was combative, yelling/screaming, and trying to elope. Review of Resident #1's Activity of Daily Living (ADL's) Flow sheet, for February 2023, indicated that on 2/23/23 Resident #1 exhibited wandering behavior on the 3:00 P.M.-11:00 P.M. shift. Review of the Facility's Internal Investigation Report, dated 2/24/23, indicated that at approximately 8:50 P.M., Resident #1 became combative and was redirected by staff, he/she was brought to a common area to watch television while staff tended to other residents. The Report indicated Resident #1 eloped outside through a door and fell before staff could reach him/her and that he/she was transported to the Hospital Emergency Department. Review of a Nurse Progress Note, dated 2/24/23 at 12:19 A.M., indicated at approximately 8:50 P.M., (2/23/23) this writer (identified as Nurse #1) was notified by a CNA (identified as CNA #2) that there was a resident outside. The Note indicated Nurse #1 went outside found Resident #1 lying on his/her abdomen with another nurse present (identified as Nurse #2), he/she was assessed and sent to the Hospital Emergency Department (ED) for evaluation. During an interview on 3/09/23 at 3:00 P.M., Certified Nurse Aide (CNA) #3 said on 2/23/23, she worked the evening shift and she was assigned to provide care to Resident #1 and that he/she became combative saying I am going home. CNA #3 said that this was not unusual for Resident #1. CNA #3 said she asked CNA #4 to take Resident #1 for a walk because he/she (Resident #1) wanted nothing to do with her (CNA #3). CNA #3 said that she told CNA #4 to stay with him/her while she provided care to another resident. CNA #3 said she was going back to go look for Resident #1 when CNA #2 came running towards the nurse's station saying Resident #1 was outside on the ground. CNA #3 said she did not know how Resident #1 eloped because she did not hear a door alarm sound until she opened the exit door near the nurse's station to go outside with CNA #2 and Nurse #1 after Resident #1 was found outside. During an interview on 3/13/23 at 3:35 P.M., Certified Nurse Aide (CNA) #4 said she worked on 2/23/23 during the evening shift on Resident #1's unit. CNA #4 said that CNA #3 asked her to take Resident #1 for a walk because he/she did not want CNA#3 to care for him/her and that he/she wanted to go home. CNA #4 said she walked with Resident #1 then sat him/her in a chair in the day room by him/herself and left the room. CNA #4, at some point later in the shift (exact time unknown) CNA #2 came to the unit yelling the neighbors called, and Resident #1 is outside lying on the ground. CNA #4 said that when CNA #2 and CNA #3 opened the exit door near the nurse's station the alarm sounded and said she had not hear any door alarm sound until they opened that door. CNA #4 said she should not have left Resident #1 alone because he/she had Dementia, wandered the unit, and was at risk for eloping. During an interview on 3/13/23 at 2:45 P.M., Nurse #3 said on 2/23/23 during the evening shift, she heard a door alarm sounding and saw Nurse #2 shut the alarm off from behind the nurse's station, but said she could not recall the exact time the alarm went off. Nurse #3 said a few minutes after Nurse #2 had shut the alarm off Nurse #2 told her a neighbor called saying someone was outside the Facility yelling for help and she was going outside to check around the building. Nurse #3 said that CNA #2 stayed at the nurses station watching the camera monitors and then CNA #2 left the unit to go outside because Nurse #2 had not come back into the Facility. Nurse #3 said CNA #2 then came back into the Facility and told her (Nurse #3) to 911 because there was a resident outside, and he/she was hurt. During an interview on 3/08/23 at 3:00 P.M., Certified Nurse Aide (CNA) #2 said she worked on 2/23/23 during the evening shift on another unit. CNA #2 said that she returned from her dinner break at approximately 8:25 P.M., and about ten minutes later Nurse #2 told her that neighbors had called the Facility and informed her they heard someone outside yelling help me and said Nurse #2 told her to watch the cameras monitors at the nurse's station while she went outside to do a perimeter check of the building. CNA #2 said on the monitors she saw someone walking up the driveway and she immediately ran outside, down the driveway and said there was a man saying there is a resident on the ground and then she heard Nurse #2 yell, I need help. CNA #2 said she ran back into the Facility and yelled to Nurse #3 to call 911 immediately. CNA #2 said she then ran to the unit where Resident #1 resided to inform staff that he/she was outside on the ground and Nurse #2 needed help. CNA #2 said she did not hear any door alarms sound until she and CNA #3 opened the exit door to go outside to help. During an interview on 3/09/23 at 8:36 A.M., Nurse #1 said the last time she saw Resident #1 was around 7:45 P.M., that he/she was sitting in the main day room near his/her unit, and she (Nurse #1) left the room at that time to go pass medications to other residents. Nurse #1 said that CNA #2 came to the unit (exact time unknown) and started yelling, Nurse, Nurse your resident is outside on the ground. Nurse #1 and said that one of the CNA's (name unknown) opened the exit door near the nurse's station and the alarm sounded as she ran outside with the CNA's. Nurse #1 said she saw Resident #1 lying on his/her abdomen at the bottom of cement steps on the ground and Nurse #2 was with him/her. Nurse #1 said that she and Nurse #2 assessed Resident #1 and did not move him/her from the position he/she was in until the Emergency Medical Technicians (EMT's) arrived. Nurse #1 said that she never heard a door alarm sound until the exit door by the nurse's station was opened by a CNA (name unknown). Nurse #1 said she was not aware Resident #1 had eloped off the unit. During an interview on 3/08/23 at 12:36 P.M., the Maintenance Director said that there are alarm keypads on each unit located at the nurse's stations and said the nurses have the codes to shut off the alarm in the Facility from the nurse's station when an exit door is opened. The Maintenance Director said when a door alarm sounds the alarm keypad shows what door has been opened. Review of Nurse #2's Written Witness Statement, dated 2/23/23, indicated that she found Resident #1 lying in the prone position on the ground on the side of the building and instructed CNA #2, who was first to respond outside, to get Nurse #1 while she remained with him/her. The Statement indicated 911 was called and Resident #1 was transported to the Hospital ED. During an interview on 3/14/23 at 1:31 P.M., Nurse #2 said that she heard a door alarm sounding while she was in a resident's room and said she went to the nurse's station and shut the alarm off. Nurse #2 said she questioned why the alarm went off and quickly looked at the cameras monitors but did not see anyone exit out a door and said that she was not surprised because the alarm had been sounding for at least five minutes before she shut it off. Nurse #2 said the alarm keypad at the nurses's station shows what exit door was opened and said that she could not remember what door had been opened. Nurse #2 said she knew what the process was when an exit door is opened and the alarm goes off, that staff should investigate why an alarm went off and all residents are accounted for and safe and said that she did not follow the process. Nurse #2 said she received a phone call a few minutes later from neighbors that lived behind the Facility that told her that they were hearing someone yelling for help outside. Nurse #2 said she told CNA #2 to watch the cameras monitors and she immediately ran outside to check the perimeter of the building and found Resident #1 outside lying face down below a cement staircase on the side of the building and he/she had a large hematoma above his/her left eye. Nurse #2 said that CNA #2 came running outside and she told her to go call 911 and to go get Nurse #1. Nurse #2 said the EMT's arrived and quickly assessed Resident #1 and he/she was transported to the Hospital Emergency Department (ED). Review of Resident #1's Hospital Emergency Department Report, dated 2/23/23, indicated that Resident #1 was seen in the Emergency Department after being found outside the Facility at the bottom of concrete stairs, was status post fall with a hematoma and abrasions to the left side of his/her forehead. The Report indicated that Resident #1 sustained a closed head injury, left supraorbital (above the eye) hematoma and a nondisplaced fracture through his/her left seventh rib. Review of a Nurse Progress Notes, dated 2/24/23 at, indicated the following: -Resident #1 returned to the Facility with a closed head injury and a fractured rib -contusion over his/her left orbital and swelling/bruising noted with decreased Range of Motion (ROM) on his/her left ring and middle finger During an interview on 3/08/23 at 3:59 P.M. and 3/14/23 at 12:21 P.M., the Director of Nurses (DON) said on 2/23/23, Resident #1 got out of the building through an exit door, and he/she was found outside lying on the ground near cement stairs on the side of the building and said he/she sustained rib fractures and a hematoma above his/her left eye. The DON said that Resident #1 wandered the unit and would state he/she wanted to go home. The DON said when Resident #1's behaviors escalated he/she would start yelling and try to find a way out and said that staff needed to supervise him/her because he/she was an elopement risk. The DON said that during her investigation staff told her they had heard a door alarm sound, but they did not witness Resident #1 going out of the building and said that she could not determine what door he/she had exited from. The DON said her expectation is staff would follow the policy and process when a door alarm sounds.

Based on interview, policy review, and record review, the facility failed to notify the Resident's physician about changes in condition, to re-evaluate the potential need to alter the treatment plan for one Resident (#43), from a total sample of 17 residents. Specifically, the facility failed to notify the primary physician of: a. a change in a new pressure injury in order to alter the treatment plan to prevent deterioration, and b. a significant weight loss of over 9% in 7 weeks in order to alter the plan of care to prevent an additional weight loss of 4.96%. Findings include: Resident #43 was admitted to the facility in October 2022 with diagnoses of dementia and hypertension. a. Review of the nursing progress notes indicated on 11/20/22 Resident #43 had developed an area to the left buttock with a darkened center. A new order was implemented for normal saline wash, pat dry, followed by a dry protective dressing and to change the dressing daily and as needed. Review of the Weekly Skin Assessment, dated as occurring on 11/17/22 and recorded on 11/20/22, indicated there was a pressure ulcer to the left lower buttocks, with no measurements or additional descriptive information. Review of the November 2022 Treatment Administration Record (TAR) indicated the treatment of normal saline wash, pat dry, followed by a dry protective dressing was implemented on 11/20/22. The TAR indicated the following description on 11/27/22: wound has slough (necrotic (dead) tissue that is green, yellow, tan, or brown, and may be moist, loose, or stringy). Review of the medical record for Resident #43 failed to indicate the primary physician had been notified of the change in condition of the wound from an area with a darkened center to slough on 11/27/22 following the treatment of the wound. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 12/1/22 indicated the area to the left ischium was unstageable due to necrosis, measured 5 centimeters (cm) in length by 2.5 cm in width by a non-measurable depth. The wound had a moderate serous exudate (watery drainage), 80% thick adherent devitalized necrotic tissue and 20% skin. The wound physician recommended a treatment of Santyl, Calcium Alginate and cover with a gauze island with border dressing. During an interview on 2/23/23 at 3:05 P.M., the Director of Nurses said the physician was notified when the area developed on 11/20/22 as they had ordered the dry protective dressing. She said she could not locate any documentation to indicate the primary physician had been alerted to changes in the wound which could alter the treatment based on the wound becoming necrotic. b. Review of the facility's policy titled Weight Measurement, revised in February 2022, indicated the charge nurse will notify the physician, responsible party, and dietitian when a 5% more or less variance is noted. Review of the medical record for Resident #43 indicated the following weights: 11/3/22: 132.1 pounds (lbs.) 12/23/22: 119.0 lbs. (a loss of 9.92% in 7 weeks) 1/5/23: 120.2 lbs. (a loss of 9.02% in two months) 1/19/23: 113.1 lbs. (an additional loss of 4.96% in two weeks, for a total loss of 14.38% in less than three months) Review of the medical record for Resident #43 (including telephone orders, progress notes, and care plans) failed to indicate the physician was notified of the significant weight loss on 12/23/22 and failed to indicate any changes to the plan of care between 12/23/22 and 1/6/23. During an interview on 2/23/23 at 3:05 P.M., the Director of Nurses said she was unable to locate any documentation or recommendations to indicate the physician had been notified of the significant weight loss of 9.92% when it first occurred on 12/23/22.

Based on observation, record review, and interview, the facility failed to ensure interventions were implemented for the treatment of bilateral hand contractures for one Resident (#22) out of a sample of 17 residents. Specifically, the facility failed to ensure bilateral palmar guards were in place as ordered by the physician to maintain and prevent further contracture and increased pain with range of motion. Findings include: Resident #22 was admitted to the facility in July 2019 with diagnoses including Alzheimer's dementia and contracture of the right and left shoulder. Review of the 12/15/22 Minimum Data Set (MDS) assessment indicated Resident #22 had severely impaired cognitive skills for daily decision making, was dependent on staff for all activities of daily living and had impaired functional limitation in range of motion in both upper and lower extremities. Review of the medical record indicated the following Physician's Orders: -Bilateral palmar guards on during the daytime hours-after morning care-assess skin integrity (5/24/21) -Bilateral palmar guards to be removed with evening care-assess skin integrity on removal (5/24/21) -Occupational Therapy (OT) evaluation and treatment as indicated (12/8/22) Review of comprehensive care plans included but was not limited to: -Problem: Resident is at risk for complications related to the use of bilateral upper extremity palmar guards (9/16/21) -Approach: Assess for pain; doff (take off) bilateral palmar guards as per instructions from registered Occupational Therapist (prior to evening care); don (put on) bilateral palmar guards as per instructions from registered Occupational Therapist (after morning care); may remove palmar guards for hand hygiene; skilled Occupational Therapist to provide education to insure the staff understand placement of palmar guards and wear time; staff to observe for signs/symptoms of skin breakdown or any signs/symptoms of infection including redness/discoloration, odor, swelling, blisters, fluid, sores, pimples, skin lesions, or any non-removable foreign material (9/25/22) -Goal: Resident will utilize bilateral upper extremity palmar guards to decrease pain and for contracture prevention and will not develop any complications related to their use. Review of a 12/8/22 OT Evaluation & Plan of Treatment note indicated Resident #22 was evaluated for decreased hand function below functional baseline and demonstrates right hand pain intensity of 5/10 as evidenced by facial grimacing. Goals of treatment identified included, but were not limited to: -Decrease right hand pain from 5/10 utilizing Pain Assessment in Advanced Dementia scale (PAINAD) to 3/10 during passive range of motion; -Resident will safely wear least restrictive splinting/orthotic device during daily tasks without complaints of discomfort in order to improve passive range of motion for adequate hygiene. The Resident was discharged from OT services on 1/27/23 and noted a pain level of 4/10 on the PAINAD scale. Review of 1/30/23 and 2/1/23 Nursing Notes indicated Resident #22's left palmar guard was missing and a towel was placed in the Resident's left palm. The Nurse indicated the Rehab department was notified of the missing palmar guard. On 2/21/23 at 10:16 A.M., the surveyor observed Resident #22 in a high back wheelchair in his/her room. The Resident had a palmar guard in place in his/her right hand. The Resident's left hand was contracted and resting on his/her lap. There was no devices or towel in place in the Resident's left hand. On 2/22/23 at 8:28 A.M., the surveyor observed Resident #22 seated in a high back wheelchair in the Visitor's Lounge sleeping. The Resident had no palmar guards applied to either the left or right hand and his/her hands were contracted and resting in his/her lap. On 2/22/23 at 8:35 A.M., the surveyor observed Resident #22 seated in a high back wheelchair being fed breakfast in the unit's Visitor Lounge. The Resident had a palmar guard in place in his/her right hand. The Resident's left hand was contracted and resting on his/her lap. There was no devices or towel in place in the Resident's left hand. During an interview on 2/22/23 at 9:13 A.M., Nurse #5 said Resident #22 was supposed to have bilateral palmar guards in place but does not have the left guard in place right now. She said the left guard was missing and they were waiting on therapy for a new one. During an interview on 2/22/23 at 1:05 P.M., Rehab Staff #2 said she works per diem and last worked with Resident #22 a few weeks ago. She said the Resident has had the palmar guards for a long time and were replaced on 1/4/23 because they were worn. She said she was not aware of the missing palmar guard and wished she knew earlier so she could have replaced it immediately. She said she was going to perform a Rehab screen for Resident #22 today. On 2/22/23 at 1:21 P.M., the surveyor observed Resident #22 seated in a wheelchair in his/her room. The Resident had no palmar guards applied to either the left or right hand and his/her hands were contracted and resting in his/her lap. The right palmar guard was observed on the bureau. During an interview on 2/23/23 at 11:40 A.M., Rehab Staff #2 said she conducted a screen yesterday and was currently conducting an evaluation of Resident #22's right and left hand contractures. She said when she arrived, the Resident had a palmar guard in his/her right hand, but nothing in his/her left hand. She said the Resident demonstrated increased pain when she attempted passive range of motion of his/her left hand, and it could have been avoided if the palmar guards were applied as ordered. She said she would pick up the Resident for services due to the decline. Rehab Staff #2 said she had ordered another palmar guard and expects it to come in tonight. Review of the completed 2/22/23 Rehabilitation Screen Form and the 2/23/23 OT Evaluation and Plan of Treatment included, but was not limited to: -Resident #22 experienced an increase in pain 6/10 (pain level on 1/27/23 was 4/10) when attempted left hand and digit passive range of motion; -Resident would benefit from skilled OT services to decrease pain and prevent further contractures; -Bilateral palm protector splints have not been properly utilized for 3+ weeks; -Resident would benefit from skilled services in order to prevent skin breakdown, maintain skin integrity, promote tone reduction, and reduce further risk of contractures; -It is recommended the Resident wear a palmar guard on the right and left hands at all times except bathing, exercise, and at night, in order to prevent skin breakdown, maintain skin integrity, promote tone reduction, and reduce further contractures. During an interview on 2/23/23 at 1:47 P.M., the Assistant Director of Nursing (ADON) said staff should have notified the Rehab department immediately that Resident #22's left palmar guard was missing to prevent the Resident from experiencing increased pain during range of motion and further contracture.

Based on observations, interviews, record review, and policy review, the facility failed to monitor the nutritional status for Resident #43 with an unplanned, significant weight loss, out of a total sample of 17 residents. Specifically, the facility failed to implement nutritional interventions to prevent further weight loss. Findings include: Review of the facility's policy titled Weight Measurement, revised in February 2022, indicated the frequency of weights will be determined by the interdisciplinary team (IDT) based on the resident's individual needs. When a significant weight fluctuation of 5% more or less is noted, the resident will be weighed based on the determination of the IDT. The resident's plan of care will be updated accordingly. Resident #43 was admitted to the facility in October 2022 with diagnoses of dementia. Review of the medical record failed to include a care plan to indicate the nutritional goals and interventions for Resident #43. Review of the medical record indicated the following weights: 11/3/22: 132.1 pounds (lbs.) 12/23/22: 119.0 lbs. (a loss of 9.92% in 7 weeks) 1/5/23: 120.2 lbs. (a loss of 9.02% in two months) 1/19/23: 113.1 lbs. (an additional loss of 4.96% in two weeks, for a total loss of 14.38% in less than three months) Review of the medical record (including telephone orders, progress notes, and care plans) failed to indicate any changes to the plan of care between 12/23/22 and 1/6/23. Review of a progress note by the Registered Dietitian on 1/6/23 (14 days after the significant weight loss) included: -laboratory values and skin concerns with the Resident having an approximate total intake of 815 kcal (kilocalories) and an estimated need of 1912 kcals. -Plan to increase the nutritional frozen treat (Magic Cup) to twice per day for an additional 600 kcal for a total intake with interventions of 1415 kcals. -Continue to monitor weights. The progress note failed to mention the significant weight loss from 132.1 lbs. to 119.0 lbs (a loss of 9.92%), failed to address interventions to attain the estimated need of 1912 kcals, and failed to indicate how often weights were to be obtained. Review of the medical record indicated Magic Cup, twice per day was ordered on 1/9/23. Review of the progress note by the Registered Dietitian on 1/23/23, a quarterly review note, indicated: -The Resident triggered for a significant weight loss of 5% in 30 days with a weight of 113.1 lbs. on 1/19/23. -The Resident had an approximate total intake of 1415 kcals with an estimated need of 1912 kcals and that intake is insufficient to meet needs, putting the Resident at risk for malnutrition related to significant weight loss. -Resident #43 consumed an average of 38% of meals. -The Registered Dietitian recommended to increase the Magic Cup to three times per day and that an appetite stimulant may benefit the Resident. -Plan to continue to monitor intakes and weights. The Registered Dietitian failed to indicate the significant weight loss of 14.38% in less than three months, failed to address interventions to attain the estimated need of 1912 kcals as the increased Magic Cup would bring the approximate total intake to 1715 kcal, almost 200 kcal below the estimated need, and failed to indicate how often weights would be monitored. Review of the Physician's Orders following the Registered Dietitian review on 1/23/23, indicated the Magic Cup was increased to three times per day. Review of the medical record indicated as of 2/21/23 Resident #43 had not had their weight monitored since 1/19/23, four weeks prior. On 2/21/23 at 11:00 A.M., the surveyor observed a handwritten note at the unit nursing station indicating the family of Resident #43 would like to have the Resident fed at every meal. On 2/21/23 at 12:35 P.M., the surveyor observed Resident #43 to be in his/her room in a reclining wheelchair with an overbed table with their lunch meal on it. The meal tray contained a cup of juice, which had been knocked over and spilled on the meal tray. There was a half of peanut butter and jelly sandwich, which was half eaten, sausage chopped up in a roll, uneaten, cabbage uneaten and a chocolate Magic Cup, uneaten. There were no staff members in the room with the Resident. At 12:50 P.M., the surveyor observed Certified Nursing Assistant (CNA) #3 take the tray from Resident #43. During an interview at this time, the CNA said she did not know who helped the Resident eat, but that the Resident does not eat a lot of food. At this time two additional CNAs approached the surveyor and CNA #3. CNA #5 said she did not have Resident #43 on her assignment and did not help him/her eat. CNA #4 said she did not help the Resident eat but knew there was a note from the family indicating that someone needed to help the Resident eat. On 2/22/23 at 8:15 A.M., the surveyor observed Resident #43 with their breakfast tray including orange juice, eggs, a biscuit, coffee, oatmeal and a half of peanut butter and jelly on a small plate. There was no Magic Cup on the breakfast tray. Review of the meal ticket failed to indicate a Magic Cup should have been included. Resident #43 was observed to be able to pick up the peanut butter and jelly sandwich. At 8:28 A.M. the surveyor observed CNA #5 ask Resident #43 if they were all set and take the Resident's meal tray. Approximately 25% of the food had been eaten. During an interview on 2/22/23 at 10:18 A.M., the Health Care Proxy of Resident #43 said the Resident had a family member who came every day and wanted the Resident to have help with eating. The Health Care Proxy said Resident #43 was having difficulty eating due to their medical condition and she had spoken with one of the nurses the week prior and asked them to help the Resident eat because he/she was not eating enough. During an interview with observation on 2/23/23 at 8:22 A.M., CNA #10 said she likes to feed Resident #43 things that may be difficult, such as the oatmeal she was feeding now. She said the Resident can pick up his/her own sandwich but eats more of other items if someone helps him/her. The surveyor observed the breakfast tray to not have a Magic Cup. During an interview on 2/22/23 at 4:36 P.M., the Director of Nurses said she had placed a call to the Dietitian to see how often Resident #43 should be weighed. She said they had talked about it as an Interdisciplinary Team (IDT), but she did not know how often the Resident was to be weighed. Review of the medical record failed to indicate how often the weight of Resident #43 should be monitored and failed to indicate a plan established by the IDT for weight monitoring. During an interview on 2/23/23 at 8:24 A.M., the Director of Nurses said the weight for Resident #43 on 2/22/23 (four weeks after the last significant weight loss) was now 106.5 lbs. (a loss of 5.84% in one month, a loss of 10.5% in three months and a total loss of 19.38% in less than four months). During an interview on 2/23/23 at 12:10 P.M., the Director of Nurses said the Magic Cup should have been on the meal tray for every meal and should have been on the meal ticket for Resident #43. The DON reviewed the physician's order for Magic Cup with the surveyor and said the order was written as three times per day but entered incorrectly as a frequency of twice per day. The DON said the IDT should have had a plan following the initial significant weight loss. The surveyor attempted to contact the Registered Dietitian on 2/23/23 at 11:15 A.M. with no response.

2. Resident #34 was admitted to the facility in March 2022 with diagnoses including unspecified severe protein-calorie malnutrition and encounter for palliative care. Review of the Minimum Data Set (MDS) assessment, dated 12/15/22, indicated that Resident #34 was moderately impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 8 out of 15. The MDS also indicated the Resident was at risk for developing pressure ulcers. Review of current Physician's Orders indicated the following: -Off-load (distribute the load to other areas which are not susceptible to pressure) bilateral heels with pillow (8/17/22) -Weekly skin checks on bath day, complete under Matrix observation and notify MD/NP of new or worsening skin areas and document in progress note (3/10/22) Review of the Pressure Ulcer Care Plan, initiated 3/15/22, indicated the following: Problem: -Resident is at risk for pressure ulcers related to incontinence and dependence on staff for bed mobility and peri-hygiene Goal: -Resident's skin will remain intact Approach/Interventions: -off-load heels as tolerated -report any signs of skin breakdown (sore, tender, red, or broken areas) On 2/22/23 at 8:27 A.M., the surveyor observed Resident #34 sitting up in bed with his/her heels resting on the mattress and not off-loaded per physician's orders. During an interview on 2/23/23 at 10:36 A.M., the Director of Nursing (DON) said the expectation was for staff to implement interventions per physician's orders. Review of a nursing progress note, dated 1/30/23, indicated a new, small open area on the right great toe. Review of the medical record failed to indicate consecutive weekly Skin Assessments had been completed under the Matrix observation, per physician's order, since staff first identified the open area on 1/30/23 for continued monitoring. During an observation with interview on 2/23/23 at 11:55 A.M., the surveyor and DON assessed the Resident's feet for pressure areas. The Resident's heels were observed resting on the mattress and not off-loaded per physician's orders. A bed cradle (frame at the foot of the bed to keep sheets/blankets off legs/feet) was in place; however, blankets were observed resting on top of the Resident's feet and not over the cradle. The DON said the heels were pink but they were like that and should have been off-loaded to prevent further injury, and the blankets should not have been resting on top of the Resident's feet. Review of the medical record failed to indicate staff had reported any recent signs of skin breakdown on the Resident's heels as the DON had indicated during the assessment with the surveyor. During an interview on 2/23/23 at 2:02 P.M., the surveyor reviewed the weekly skin assessments with the DON who said they were not being consistently done. She said the expectation was for staff to complete them weekly as ordered. The DON said she did not document her earlier assessment of the Resident's heels. On 2/23/23 at 7:07 A.M., the surveyor observed Resident #34 lying in bed sleeping. His/her heels were not off-loaded in the bed. During an interview on 2/23/23 at 8:06 A.M., Nurse #6 said Resident #34 was on Hospice care and was supposed to have his/her heels elevated and the bed cradle in place. She said staff were expected to implement interventions to prevent new areas from developing.Based on observations, interviews, and record review, the facility failed to ensure three Residents (#43, #34, and #22), out of a total sample of 17 residents, received care and treatment to prevent and to promote healing of pressure injuries. Specifically, the facility failed: 1. For Resident #43, to implement treatments as ordered to a pressure injury of the left ischium (forms the lower and back region of the hip bone) that became an infected stage 4 pressure injury, and worsening bilateral heel pressure injuries; 2. For Resident #34, to ensure monitoring and pressure related interventions were consistently implemented to prevent the development of a pressure injury to the Resident's bilateral heels; and 3. For Resident #22 to ensure interventions were implemented to maintain skin integrity of a contracted hand. Findings include: Review of the facility's policy titled Pressure Ulcers/Skin Breakdown-Clinical Protocol, undated, indicated the following: -the nursing staff and physician will assess and document an individual's significant risk factors for developing pressure sores -the nurse shall describe and document the following: full assessment including location, stage, length, width, depth and presence of exudates or necrotic tissue; current treatments including support surfaces 1. Resident #43 was admitted to the facility in October 2022 with diagnoses of dementia and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 1/10/23, indicated Resident #43 needed extensive assist from one person for bed mobility and was dependent upon two staff for transferring between surfaces. Review of the medical record for Resident #43 indicated the following pressure injuries developed during the Resident's stay: A. Stage 4 pressure injury (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone) of the left ischium, B1. Stage 3 pressure injury (full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present) of the right heel, and B2. Stage 4 pressure injury of the left heel. A. Review of the nursing progress notes indicated on 11/20/22 Resident #43 had developed a pressure injury to the left buttock (ischium) with a darkened center; a new order was implemented for normal saline wash, pat dry, followed by a dry protective dressing and to change daily and as needed. Review of the Weekly Skin Assessment, dated as occurring on 11/17/22 and recorded on 11/20/22, indicated there was a pressure injury to the left lower buttocks, with no measurements or additional information. During an interview on 2/22/23 at 2:40 P.M., the Assistant Director of Nurses said when a new pressure injury develops an incident report is initiated. The surveyor requested the incident report for the pressure injury to the left ischium. On 2/23/23 at 3:05 P.M., the Director of Nurses provided an incident report which indicated a pressure injury developed to the left buttocks (ischium) on 11/20/22. The incident report did not include any measurements or descriptions. The incident report was signed as completed on 2/23/23. During an interview at this time, the Director of Nurses said the agency nurse had never completed an incident report for the wound and she was unable to find any wound descriptions in the medical record. Review of the November 2022 Treatment Administration Record (TAR) indicated the treatment of normal saline wash, pat dry, followed by dry protective dressing was implemented on 11/20/22. The TAR indicated the following descriptions: 11/27/22: wound has slough (necrotic (dead) skin tissue that is green, yellow, tan, or brown, and may be moist, loose, or stringy) 11/28/22: wound change not completed 11/29/22: left buttocks (no further information regarding the wound was documented) 11/30/22: lower left buttock (no further information regarding the wound was documented) Review of the nursing progress notes from 11/20/22 through 12/1/22 failed to indicate any description or change in the wound to the left ischium. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 12/1/22, indicated the pressure injury to the left ischium was unstageable due to necrosis (dead tissue), measured 5 centimeters (cm) in length by 2.5 cm in width by a non-measurable depth. The wound had a moderate serous exudate (watery drainage), 80% thick adherent devitalized necrotic tissue and 20% skin. The wound physician recommended a treatment of Santyl ointment (used for wound healing), Calcium Alginate (a highly absorbent dressing that interacts with the wound fluids to form a gel that provides a moist wound environment and facilitates auto debridement) and cover with a gauze island with border dressing. Review of the December 2022 TAR indicated the treatment of normal saline wash, pat dry, followed by a dry protective dressing was discontinued on 12/2/22. Review of the December 2022 TAR failed to indicate the new recommendation of Santyl, Calcium Alginate, cover with a gauze island with border dressing was implemented. The TAR indicated no treatment was provided to the pressure injury of the left ischium for 19 days (12/2/22 through 12/21/22). Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 12/15/22 indicated the pressure injury to the left ischium was a stage 4, measuring 4.5 cm in length by 2.5 cm in width by 2 cm in depth, with 60% slough and no change in the wound progress. The recommendation was to continue the treatment of Santyl, Calcium Alginate, and cover with a gauze island with border dressing. Review of a nursing progress note for Resident #43, dated 12/15/22, indicated the buttock wound (pressure injury to the ischium) appeared to be worsening and did not indicate what treatment was being provided. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 12/22/22, indicated the pressure injury to the left ischium was a stage 4, measuring 4.5 cm in length by 2 cm in width by 4 cm in depth, with 40% slough and no change in the wound progress. The wound consultant indicated a treatment plan to add crushed Flagyl (antibiotic) 500 milligrams (mg) into the wound, continue Santyl, continue Calcium Alginate, continue to use the gauze island with border dressing. Review of the medical record indicated an order was written to obtain a wound culture of the left ischium pressure injury. A specimen was collected on 12/23/22 and results returned on 12/25/22 indicating abnormal results of a moderate growth of bacteria (Proteus Mirabilis). During an interview on 02/23/23 at 1:02 P.M., the Assistant Director of Nurses said she had reviewed the medical record of Resident #43 and found the physician order for the treatment to the left ischium from 12/2/22 was not entered correctly and was not put on the administration records and the nurses do not know to do the treatments if the orders were not entered correctly. She said there was no documentation to indicate any wound treatment was provided to the stage 4 pressure injury to the left ischium from 12/2/22 through 12/21/22 (19 days). Review of the December Medication and Treatment Administration Records and the 12/29/22 Wound Evaluation and Management Summary from the wound consultant indicated the Flagyl to the wound bed was discontinued on 12/29/22. Review of the nursing progress notes indicated a new order was written to obtain a wound culture of the left ischium on 12/31/22. Review of the laboratory results collected on 12/31/22 and reported on 1/4/23 indicated abnormal results of a moderate growth of bacteria (Proteus Mirabilis). The laboratory paperwork indicated an order from the Nurse Practitioner for Bactrim DS (antibiotic) twice per day for 7 days. Review of the telephone orders and Medication Administration Record indicated the order was written for Bactrim DS one tablet once daily for 7 days. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 1/5/23 indicated the left ischium wound had deteriorated with 30% necrotic tissue and an odor. The recommendation was to add crushed Flagyl 500 mg, continue Santyl, continue Alginate Calcium, and continue gauze island with border. Review of the January 2023 Administration Records failed to indicate the Flagyl was re-ordered on 1/5/23 per the recommendations. During an interview on 2/23/23 at 11:09 A.M., the Assistant Director of Nurses said the Flagyl had not been ordered on 1/5/23 and would have needed a separate order from the wound treatment in order for the pharmacy to send the medication. She said she was not sure how this was missed. During a review of the Wound Evaluation and Management Summaries, dated 1/17/23 and 1/19/23, the Assistant Director of Nurses said the wound consultant thought the Flagyl had been in place from 1/5/23 through 1/19/23 when it was recommended to discontinue the Flagyl. Review of the nursing progress notes indicated on 2/6/23 the primary physician ordered a Foley catheter placement due to the wound on the left buttocks (ischium). The nursing progress note on 2/6/23 at 2:45 P.M. indicated Foley catheter supplies had not been brought upstairs for the catheter to be inserted. There were no further nursing progress notes regarding the Foley catheter. Review of the Administration record indicated the Foley catheter was not inserted and the order was extended until 2/7/23. During an interview on 2/22/23 at 10:18 A.M., the Health Care Proxy said Resident #43 had a wound to the buttock (ischium) and she had been told the facility staff had attempted to put in a Foley catheter and when they were unable to put it in the Assistant Director of Nurses said she would try herself. She said she was assuming Resident #43 had a Foley catheter at this time (two weeks later). During an interview on 2/22/23 at 2:40 P.M., the Assistant Director of Nurses said she did not attempt to put the Foley catheter in Resident #43, and she was unsure why the order was discontinued. During an interview on 2/23/23 at 3:05 P.M., the Director of Nurses said she had tried to insert the Foley catheter for Resident #43 but was unable to. She said there was no documentation to indicate the physician was aware to re-evaluate the interventions. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 2/9/23, indicated the wound measured 7 cm in length by 2 cm in width by 5 cm in depth with 20% necrotic tissue, 40% slough with a recommendation to start Flagyl 500 mg crushed to wound bed, continue Alginate Calcium, Collagen Sheet with silver, and Santyl, cover with gauze island with border. Review of the medical record indicated the last wound visit from the wound consultant was conducted on 2/9/23. During an interview on 2/23/23 at 11:09 A.M., the Assistant Director of Nurses reviewed the medical record and said there were no wound measurements or descriptions of the wound since the last wound consultant visit (two weeks prior). She said the expectation is that if the wound consultant is unable to visit the facility the nurses are responsible for evaluating the wound to update the physicians on any changes. B. Review of the medical record for Resident #43 indicated on 10/21/22 the Resident had developed a Deep Tissue Injury (DTI) (intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) to the bilateral heels with a new order to elevate the heels while in bed. Review of the Initial Wound Evaluation and Management Summary, from the wound consultant on 10/27/22, indicated the following areas: B1: unstageable DTI of the right heel with intact skin, measuring 2 cm in length by 3 cm in width by non-measurable depth. B2: unstageable DTI of the left heel with intact skin, measuring 2 cm in length by 2 cm in width by non-measurable depth. The recommendation for both heels was to apply skin prep and cover with gauze island with border, off-load (distribute the load to other areas which are not susceptible to pressure) the wounds and float the heels while in bed. Review of the nursing progress note indicated on 10/30/22 the Assistant Director of Nurses noted new recommendations from the wound consultant and new treatments were ordered. Review of the October and November 2022 Treatment Administration Records (TAR) for Resident #43 indicated an order was implemented from 10/20/22 through 11/20/22 to wash bilateral heels with normal saline, pat dry, apply Puracol (a highly absorbent dressing) and cover with a foam dressing. During an interview on 2/23/23 at 9:30 A.M., the Assistant Director of Nurses said she could not tell why the treatment that was ordered was different from the one recommended by the wound consultant. Review of the nursing progress notes for Resident #43 indicated on 11/8/22 bilateral heel dressings were changed with a moderate amount of yellow, foul-smelling drainage noted on the old dressing. Review of the nursing progress notes, dated 11/9/22, indicated both heels were open with a large amount of foul-smelling drainage on the old dressing. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 11/10/22 indicated the following: B1: unstageable DTI of the right heel measuring 3 cm in length by 3 cm in width by unmeasurable depth with light serous drainage B2: unstageable DTI of the left heel measuring 3.5 cm in length by 3 cm in width by unmeasurable depth with light serous drainage The recommendation for both heels was to discontinue the skin prep, start collagen sheet with silver (a sheet that maintains a moist environment at the wound surface to aid in the formation of healthy tissue, the silver is intended to reduce bacteria in the wound) and apply the gauze island with border. Review of the November TAR indicated the following treatments initiated on 11/11/22: B1. wash DTI of right heel with normal saline, pat dry, apply collagen sheet, cut to fit, cover with foam dressing B2. wash DTI of left heel with normal saline, pat dry, apply collagen sheet, cut to fit, cover with foam dressing. Neither order contained the recommended collagen sheet with silver. During an interview on 2/23/23 at 9:30 A.M., the Assistant Director of Nurses said the order on 11/11/22 should have been written for collagen sheet with silver and these were not the same treatments. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 11/17/22, indicated the following: B1: Stage 3 pressure injury to the right heel measuring 3 cm in length by 3 cm in width by unmeasurable depth with moderate serous drainage, and 30% necrotic tissue. The wound progress was noted as deteriorated. B2: Stage 3 pressure injury to the left heel measuring 4 cm in length by 3 cm in width by an unmeasurable depth with moderate serosanguinous (fluid with blood) drainage and odor and 20% necrotic tissue. The wound progress was noted as deteriorated. The recommendation for both heels was to discontinue the collagen sheet with silver, add Santyl, add Calcium Alginate, add ABD pad, gauze roll, tape, and a gauze island with border dressing. Review of the December 2022 TAR for Resident #43 indicated the following: B1: right heel treatment not completed on 12/6, 12/7, 12/10, 12/11, 12/12, 12/13, and 12/20 B2: left heel treatment not completed on 12/6, 12/7, 12/10, 12/11, 12/12, 12/13, and 12/20 Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 1/26/23, indicated the following: B1: stage 3 pressure injury to the right heel measuring 3 cm in length by 2 cm in width and an unmeasurable depth (surface area 6.0 cm); showing improvement. Treatment recommendation was to continue Calcium Alginate, collagen sheet with silver, gauze island with border, ABD pad, gauze roll and tape. B2: stage 4 pressure injury to the left heel measuring 3 cm in length by 4 cm in width and an unmeasurable depth, unchanged status. Treatment recommendation was to add Santyl, continue Calcium Alginate, collagen sheet with silver, gauze island with border, ABD pad, gauze roll, and tape. Review of the January 2023 TAR for Resident #43 indicated the following on 1/27/23: B1: the treatment to the right heel, which was to continue per the recommendations on 1/26/23 was discontinued, no further treatments to the right heel were ordered at that time. Review of the Wound Evaluation and Management Summary, from the wound consultant, dated 2/2/23, indicated the following: B1: stage 3 pressure injury to the right heel measuring 3.5 cm length by 3.5 cm in width and an unmeasurable depth (surface area 12.25 cm) with a recommendation to continue the previous order of Calcium Alginate, collagen sheet with silver, gauze island with border, ABD pad, gauze roll and tape. Review of the February 2023 TAR for Resident #43 indicated the treatment to the right heel was re-instated on 2/6/23 with 10 days of missed treatments to the right heel. During an interview on 2/23/23 at 12:08 P.M., the Assistant Director of Nurses said the order for the right heel was discontinued in error and the treatment should have continued through the days it was missed. Review of all Wound Evaluation and Management Summaries from 11/28/22 through 2/9/23 recommend the Prevalon boots (have a cushioned bottom that floats the heel off the surface, helping to reduce pressure) with the heel cut out. On 2/21/23 at 8:50 A.M., the surveyor observed Resident #43 to be seated in a Geri-Chair (reclining wheelchair), wearing blue booties to the bilateral feet. The blue booties were not observed to have a heel cut out. On 2/22/23 at 10:52 A.M., the surveyor observed the Resident in the Geri-Chair with blue booties, neither bootie had heel cut outs. On 2/23/23 at 8:03 A.M., the surveyor observed the Resident in the Geri-Chair with blue booties which did not have a heel cut out. During an interview on 2/23/23 at 12:08 P.M., the Assistant Director of Nurses said she had not seen the recommendation from the wound physician regarding the Prevalon boots with heel cut out as she had not read that section of the wound evaluation. She said no one at the facility had ordered the correct booties for the Resident. The surveyor attempted to contact the primary physician of Resident #43 on 2/23/23 at 11:46 A.M., with no return call. The surveyor contacted the answering service for the Medical Director on 2/23/23 at 2:02 P.M. and requested a call back, with no return call. 3. Resident #22 was admitted to the facility in July 2019 with diagnoses including Alzheimer's dementia and contracture of the right and left shoulder. Review of the 12/15/22 Minimum Data Set (MDS) assessment indicated Resident #22 had severely impaired cognitive skills for daily decision making, was dependent on staff for all activities of daily living and had impaired functional limitation in range of motion in both upper and lower extremities. Review of the medical record indicated the following Physician's Orders: -Bilateral palmar guards on during the daytime hours-after morning care-assess skin integrity (5/24/21) -Bilateral palmar guards to be removed with evening care-assess skin integrity on removal (5/24/21) -Occupational Therapy (OT) evaluation and treatment as indicated (12/8/22) Review of comprehensive care plans included but was not limited to: -Problem: Resident is at risk for complications related to the use of bilateral upper extremity palmar guards (9/16/21) -Approach: Assess for pain; doff (take off) bilateral palmar guards as per instructions from registered Occupational Therapist (prior to evening care); don (put on) bilateral palmar guards as per instructions from registered Occupational Therapist (after morning care); may remove palmar guards for hand hygiene; skilled Occupational Therapist to provide education to insure the staff understand placement of palmar guards and wear time; staff to observe for signs/symptoms of skin breakdown or any signs/symptoms of infection including redness/discoloration, odor, swelling, blisters, fluid, sores, pimples, skin lesions, or any non-removable foreign material (9/25/22) -Goal: Resident will utilize bilateral upper extremity palmar guards to decrease pain and for contracture prevention and will not develop any complications related to their use. On 2/21/23 at 10:16 A.M., the surveyor observed Resident #22 seated in a wheelchair in his/her room with a palmar guard in place in his/her right hand. The Resident's left hand had no device, was contracted, and resting on his/her lap. On 2/22/23 at 8:28 A.M., the surveyor observed Resident #22 seated in a wheelchair in the Visitor's Lounge sleeping. The Resident had no palmar guards in place in either the left or right hand. The Resident's hands were contracted and resting in his/her lap. On 2/22/23 at 8:35 A.M., the surveyor observed Resident #22 seated in a wheelchair being fed breakfast in the unit's Visitor Lounge. The Resident had a palmar guard in place in his/her right hand. The Resident's left hand had no device, was contracted, and resting on his/her lap. During an interview on 2/22/23 at 9:13 A.M., Nurse #5 said Resident #22 is supposed to have bilateral palmar guards in place, but it has been missing for a few weeks. Review of 1/30/23 and 2/1/23 Nursing Notes indicated Resident #22's left palmar guard was missing. During an interview on 2/22/23 at 1:05 P.M., Rehab Staff #2 said she works per diem and last worked with Resident #22 a few weeks ago. She said the Resident has used the palmar guards for a long time. She said they were replaced on 1/4/23 because they were worn. She said she was not aware of the missing palmar guard and wished she knew earlier so she could have replaced it immediately. On 2/22/23 at 1:21 P.M., the surveyor observed Resident #22 seated in a wheelchair in his/her room. The Resident had no palmar guards applied to either the left or right hand. His/her hands were contracted and resting in his/her lap. The right palmar guard was observed placed on a bureau. During an interview on 2/22/23 at 2:15 P.M., Rehab Staff #1 said she was not aware Resident #22's left palmar guard was missing and staff was not applying the guards daily as ordered. She said the purpose of the palmar guards was to prevent further contracture and maintain skin integrity. On 2/23/23 at 8:27 A.M. and 10:39 A.M., the surveyor observed Resident #22 seated in a wheelchair in the dayroom. A palmar guard in place in his/her right hand. The Resident's left hand had no device, was contracted and resting on his/her lap. On 2/23/23 at 11:40 A.M., Rehab Staff #2 was observed seated next to Resident #22. She said she conducted a screen yesterday and was currently conducting an evaluation of Resident #22's right and left-hand contractures. She said when she arrived, the Resident had a palmar guard in his/her right hand, but nothing in his/her left hand. Rehab Staff #2 said the Resident has skin breakdown on the palm of his/her left hand and redness on the palm of his/her right hand. She said it could have been avoided if the palmar guards were applied as ordered. Review of the completed 2/23/23 OT Evaluation and Plan of Treatment included, but was not limited to: -Upon arrival, resident presented with palm protector splint in right hand and no splint or hand roll in left. Facecloth was obtained and placed in left palm until facility left palm protector arrives to facility. Right palm red hardened area, and left palm open areas were noted. -It is recommended the resident wear a palmar guard on the right and left hand at all times except bathing, exercise, and at night, in order to prevent skin breakdown, maintain skin integrity, promote tone reduction, and reduce further risk of contractures.