**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake 2575924Based on interview and record review, the facility failed to protect the resident's right to be free from mental abuse and verbal abuse by a staff member. Findings Include:Review of the medical record reflected that R1 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including chronic pain syndrome, carpal tunnel syndrome, jaw pain, muscle spasms, restless legs syndrome, opioid dependence, intervertebral disc disorders (a condition that affects the disc between the vertebrae of the spine), adjustment disorder with mixed anxiety and depression, temporomandibular joint disorder (causing pain and dysfunction of the jaw), migraine, post-traumatic stress disorder, dental caries, anxiety disorder, depression, low back pain, and sciatica. The Minimum Data Set (MDS) reflected that R1 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS), a cognitive screening tool. R1 was no longer at the facility.Facility reported incident reflected on 6/30/25, RN C received a verbal order to increase R1's pain medication but did not enter it until 7/3/25. She admitted she failed to follow up with the physician in a timely manner. A physician statement dated 7/8/25 confirmed that the order for Norco was agreed upon with R1 on 6/30, but by the weekend, the changes were still not made. The Physician Assistant noted concern and intervened.Review of the facility reported incident dated 7/22/25 reflected Resident (R1) reported allegations against a staff member. R1 requested a review of a previous concern she had made that she did not feel was resolved. Upon further investigation, the NHA [covering Nursing Home Administrator] determined the need to report the allegation. A thorough investigation is being conducted. The alleged staff member will not return to work until a conclusion is made.Review of the Facility Reported Incident Report dated 7/22/25 indicated that on that date, covering NHA E reviewed two Concern Forms R1 had written on 7/5/25 along with the statements collected during the initial investigation. NHA E decided to formally report the allegations and initiate a separate investigation, as R1 continued to express unresolved concerns. R1 alleged that Registered Nurse (RN) C had threatened her life and well-being by telling her that narcotic medications would be withheld if she refused to go to the Emergency Department. R1 also alleged that RN C failed to process a physician's order dated 6/30/25 to increase her pain medication.Review of a Resident Assistance Form completed by R1 and dated 7/5/25 stated: [RN ‘C'] threatened my life and my well-being. She refused to listen to my wishes. I have a detailed EMS (Emergency Medical Service) report which backs up my claims. [RN ‘C'] also refused to put in doctor's orders on Monday. A second Resident Assistance Form contained allegations of unequal treatment from RN C. R1 again accused RN C of nearly killing her, threatening her life and well-being, and added, people like RN ‘C' do not deserve to have anyone's life in their hands. If this doesn't stop, she will definitely kill more people. The form again referenced the EMS report from a 6/25/25 hospital transfer.Review of a Nurse's Note dated 6/25/25 at 11:58 AM stated: Resident [R1] c/o (complained of) dizziness and fatigue. Pulse 45 and O2 (oxygen saturation) 70%. 2L (liters) nasal cannula applied, O2 increased to 80%. Pulse increased to 49. This writer contacted PA (Physician's Assistant) and received an order to send to ER (Emergency Department). EMT contacted and resident transferred to ER.Review of the Prehospital Care Report Summary from EMS for the 6/25/25 transfer revealed that EMS arrived at 10:33 AM. The Narrative History Text stated that EMS arrived to find R1 lying in bed. Patient (R1) was surprised they were there to transport her to the ED. Staff stated they believed her pain medication had caused her heart rate and SpO2 to drop. R1 stated she felt better and refused to go to the ED. Contact was made with the ED Physician, who confirmed that if the patient was alert and oriented (A&Ox4) and refused, she could not be forced to go. R1 continued to refuse. Staff then stated, we will not give you any kind of pain medication if you stay here. R1 responded, you will put me into DT (delirium tremors) if you do that. Staff allegedly replied, that's fine, I will make you go to the hospital when you are unconscious. Per the EMS prehospital summary, R1's vital signs were as follows on 6/25/25 at 10:41 AM (seven minutes after arrival) Blood pressure 139/75 Pulse 54 SPO2 93%. At 11:06 AM (while still at the facility) blood pressure 127/67 Pulse 77 SPO2 92%. The vitals show that R1 was hemodynamically stable.In an interview on 8/20/25 at 10:47 AM, Confidential Staff Member K described RN C as snippy and rude and reported hearing her say things like, well if you would follow what you're supposed to do, this wouldn't be happening. At 12:03 PM, LPN S stated that R1 was visibly upset over medication changes and felt she was treated differently by RN C. At 12:48 PM, LPN L stated she was present during the 6/25/25 hospital transfer. RN C reportedly said, Can you help me, [R1] is getting on my nerves and won't go to the hospital. LPN L entered the room and heard RN C tell R1, I'm not going to give you pain medication if you stay, to which R1 responded, If you withhold my medications, I'll fall over and die. RN C allegedly replied, I guess I'll send you to the hospital then and you won't be able to refuse. LPN L told RN C to stop being snippy and then exited the room.On 8/20/25 at 3:17 PM, R1 was interviewed and described feeling targeted after reporting a near-miss medication error in November 2024, which led to a nurse's termination. She said she was treated differently thereafter, especially by RN C. R1 recounted the 6/25/25 event as described in the facility reported incident and medical record.R1 became tearful, describing the experience as emotionally and verbally abusive, triggering her PTSD. She stated that RN C targeted her, labeled her a drug seeker, laughed at her, rolled her eyes, and once stood in the hallway laughing while she cried in pain. R1 stated that RN C made her feel insignificant and like her life had no value.Psychology Notes dated 4/22/25 and 5/20/25 documented R1's PTSD diagnosis and her mistrust of staff. R1 disclosed a history of childhood and domestic abuse, chronic pain, and emotional difficulties tied to her condition and environment.On 8/21/25 at 12:26 PM, LPN W confirmed that RN C was nasty to R1 and other residents. She reported being warned that R1 might get you fired, and stated RN C referred to R1 as a drug seeker who was stoned out of her [NAME]. LPN W found the comments appalling and reported them to the former NHA but was told not to worry. She also reported witnessing a conversation in which R1 asked PA T if he had discontinued her narcotics because RN C said he did. PA T denied this.On 8/20/25 at 10:18 AM, RN I stated that during the 7/1/25 meeting, RN C told R1, You're on a whole bunch of medications, you're going to die, using a condescending tone. At 3:04 PM, RN J confirmed being present during the same meeting and recalled RN C saying, You're not getting the medication list today because one doctor is trying to decrease your narcotics, but [the facility doctor] hasn't changed anything like he should have. RN J stated that RN C was a newer nurse and lacked customer service skills.Review of an Employee Corrective Action form dated 7/8/25 showed RN C was disciplined for not following through with a doctor's order. It also noted a prior written warning on 6/2/25 with no substantial improvement since. An Employee Warning Record dated 7/25/25 cited disciplinary action for the 6/25/25 incident. The summary noted that RN C communicated a verbal physician's order in a way that made the resident feel threatened, though the investigation did not find intent to threaten. It recommended better tone, body language, and communication during stressful situations. It further stated that when an order needs clarification, the provider must be contacted immediately and documentation must reflect all steps taken to process or delay a physician's order.In an interview on 8/21/25 at 10:11 AM, RN C stated that on 6/25/25, she assisted staff with addressing R1's change in condition. RN C felt that the medication that R1 was taking and her recent diagnosis of bronchitis had affected her respiratory status. RN C reported calling PA T and receiving a verbal order to hold all narcotic medication, however when asked why RN C did not document this order, RN C stated that she did not and per best standards of practice. Regarding the verbal Physician order for R1's pain medication, RN C stated that she did not put the order in timely because she felt it required provider clarification. RN C stated that she did not call back PA T after resolution of R1's symptoms and notify PA T that the acute change in condition had resolved and to inquire of holding R1's medications would still be necessary.In an interview on 8/21/25 at 10:11 AM, covering NHA E stated that after reviewing the grievances dated 7/5/25, it was clear that these concerns were allegations of abuse and should have been reported to the State Agency within the two-hour time frame. The Facility Reported Incident was not reported until 7/25/25, 20 days later.As a result of these practices, R1 stated that she experienced significant psychological distress, humiliation, and fear for her safety. She reported being targeted, made to feel insignificant, Multiple staff corroborated that RN C threatened to withhold R1's pain medications, coerced her into transferring to the hospital, told her you're going to die because of her prescriptions, and openly ridiculed her while she was crying in pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], revealed Resident #43 (R43) was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (loss of function from right side after a stroke), history of falling, type 2 diabetes without complication, vascular dementia and urge incontinence. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/5/23 revealed R43 scored 9 out of 15 (cognitively impaired) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool). The same MDS revealed that R43 utilized a walker and was independent with ambulation and toileting. In an observation and interview on 01/10/24 at 12:01 PM, R43 was seated in a recliner, facing the doorway of her room. R43 reported that she had a fall recently. When inquiring about the details of the fall, R43 stated that she did not know what happened, but she remembered falling to the floor and after, she got back up. R43 seemed pleasantly confused and could not elaborate further regarding the details of the fall. Review of an Incident Note dated 7/24/23 revealed Resident (R43) was trying to walk through the area by South hall nurses station. There was slight crowding, resident's walker either hit someone's wheelchair or someone's wheelchair backed into resident's walker. Resident fell onto her right side and bumped theright [sic] side of her head. There was a small bump to the rt [right] side of her head .there were no deficit's in strength between her hands or her legs . Review of an Incident Report dated 7/24/2023 at 4:15 PM revealed resident (R43) was trying to walk by the nurses station by activities room and she either hit someone's wheelchair with her walker or someone backed into her with their wheelchair. resident fell onto her right side and bumped her head. The Other Info section of the Incident Report stated resident (R43) was trying to walk through lobby area by activities and there was slight crowding. There was no Interdisciplinary Note explaining any further details regarding this fall. Review of an Incident Note dated 11/1/2023 revealed Resident (R43) was coming out of her room using her walker. The walker appeared to get caught on the edge of an easy stand (mechanical lift) that was in the hallway by her door. She tripped and fell face first onto the floor. Resident assessed. Nose bleeding resident rolled onto her side pressure applied to nose to stop bleeding [Local Ambulance Service] contacted for transport to hospital . R43 was transported to the hospital for treatment. Review of a Nurses Note dated 11/2/2023 revealed that R43 returned to the facility at 11:00 PM and was diagnosed with a left rib fracture. Review of an Incident Report dated 11/1/23 revealed resident (R43) was coming out of her room using her walker. The walker appeared to get caught on the edge of an easy stand that was in the hallway by her door. She tripped and fell face first onto the floor. There was no Interdisciplinary Note explaining any further details regarding this fall. On 01/10/24 at 2:26 PM, an observation was made of an easy stand parked outside of R43's. Additionally, a resident was parked in their wheelchair near the South Nurses station creating an obstruction of the entry/exit way of the hall which R43 resides in. On 01/11/24 at 7:46 AM, eight residents in wheelchairs were parked around the south nurse's station and near the activities room. The activities room door was closed, and the lights were off. On 01/11/24 at 7:47 AM, an easy stand was observed outside of R43's room on the right side and an additional mechanical lift was observed outside of R43's room on the left side. On 01/11/24 at 12:20 PM, a mechanical lift was observed directly outside of R43's room, parked along the wall. The left wheel of the mechanical lift was angled about approximately 80 degrees, impeding into the hallway. In an interview on 1/11/24 at 09:51 AM, Certified Nursing Assistant (CNA) F reported that she was familiar with R43's care needs. CNA F stated that R43 was independent with ambulation utilizing her walker at the time of the falls. In an interview on 01/11/24 at 10:33 AM, Registered Nurse (RN) G reported that she was working the day of the fall that occurred on 11/1/23. RN G confirmed that R43's fall occurred due to her walker getting caught on the easy lift. RN G stated that the wheel of the easy stand was kicked out to the side like at a 90-degree angle and the easy stand was in the doorway. RN G stated that employees received education about the easy stand and ensuring the wheels were flush with the legs, so the wheel did not protrude out into the hallway and into the walking path of residents. In an interview on 01/11/24 at 12:21 PM, Certified Nursing Assistant H confirmed she was working on 11/1/23 and confirmed R43 sustained the fall due to the easy lift being positioned right outside of R43's room and R43's walker catching the front wheel of the easy stand. CNA H stated that staff received education about ensuring the wheel of the easy stand was flush with the legs so the wheel did not protrude out into the hallway and into the walking path of residents. In an interview on 01/11/24 at 12:40 PM, Registered Nurse (RN) D stated that she was aware of the falls that R43 had experienced. Regarding the fall on 7/24/23, RN D stated that the Care Planned intervention for that fall was to acknowledge when the resident is carrying an item but was unsure why that intervention was implemented after that fall. When inquiring about the fall that occurred on 11/1/23, RN D stated that the easy stand was parked outside of R43's room and part of the leg of the easy stand was sticking out maybe 3 and a half inches into the doorway of R43's room. RN D stated that Physical Therapy was working with R43 after the fall, one of the goals being how to educate R43 on how to use a wheelchair. Review of Physical Therapy notes with a start of care date of 11/8/23 revealed reason for referral/Current Status: patient is a . long term care resident who had a fall involving catching walker leg on mechanical lift sitting alongside of hallway . In an interview on 01/11/24 at 2:25 PM, Director of Nursing (DON) B reported she was unsure why there was an absence of Interdisciplinary Team Notes for the two falls R43 had experienced. Concerning the fall that occurred on 7/24/23, DON B stated that the South Hall nurses station is near activity room and it's a large area that funnels into the doorway. R43 was in the middle of the pack when the fall occurred. When asked about the intervention, DON B thinks R43 was taking something to the activity room. When asked what the item was, DON B stated that she thinks it was a sweater or something thrown over her arm. Documentation of this was not found. Concerning the fall that occurred on 11/1/23, DON B stated apparently her walker leg hooked onto the platform of one of the lifts so Physical Therapy started working with the resident. When asked what the root cause of the fall on 11/1/23, DON B stated that R43's legs were very swollen and R43 was incapable of maintaining her balance. There was no additional documentation or Physician Notes provided regarding the edema in R43's legs or the altered gait. Review of a Nurses Note dated 1/11/2024 at 3:12 PM revealed late entry from 11/8/24 [sic] Residents bilateral lower legs assessed after therapy reported blister left lower leg has a blister, upon assessment both legs were light pink cool to touch there was a small scab area noted and and [sic] a darker pink area which could have been where blister was it appears dry and flakey not opened no drainage Doctor contacted on 11/9/24 stated would eval (evaluate) on 11/10/24. Review of a Nurses note dated 11/10/2023 at 11:50 PM revealed In house skin sweep conducted resident was found to have no abnormalities. Review of Skin Assessments dated 11/7/23 and 11/14/23 revealed no abnormalities of R43's skin. Based on observation, interview, and record review the facility failed to prevent incidents and accidents in 3 (Resident #43, #48 & #50) of 3 reviewed for incidents and accidents, resulting Resident #43 sustaining falls with a rib fracture, pain (Resident #50), and a head injury (Resident #48). Findings include: Resident #48 (R48) R48 was observed on 1/11/24 at 8:45 AM being transported from the dining room in a Broda chair (specialty wheelchair) with the footrest on chair folded up against leg rest. R48's feet were not supported. Two areas on the right side of chair were noted with white medical tape wrapped around a connection piece. R48's Minimum Data Set (MDS) assessment dated [DATE] revealed she admitted to the facility on [DATE], had a Brief Interview for Mental Status (BIMS, a performance-based cognitive screener) score of 00 (00-07 Severe Cognitive Impairment). The same MDS indicated R48 was dependent on staff for activities of daily living (ADL). In review of R48's incident and accident report dated 10/25/23 at 5:30 PM, a nurse assistant was pushing R48 in a Broda chair in the hallway when R48 took a tumble out of the chair landing face first. The same report indicated R48 sustained a hematoma (blood pooling under skin) to her forehead. The same report revealed R48's Broda chair was not used correctly when R48 was transported. R48's risk for falls care plan revised 9/10/23 revealed she was at risk for falls due to Alzheimer's dementia, depression, history of stroke, impaired mobility and weakness. The same care plan indicated R48 was receiving hospice care services. R48's ADL deficit care plan, revised 9/10/23 instructed to ensure padded footrest was attached to her wheelchair. Nurses Note dated 12/31/23 at 2:01 AM revealed 3 blisters on R48's right lower extremity were noted, and the Unit Manager was notified. Nurses note dated 1/04/24 10:28 PN revealed hospice was notified of request for cushion for chair related to marks on the back of her right leg. Nurses Note dated 1/07/24 at 5:42 PM revealed three new wounds on the posterior of the R48's right lower extremity; appeared to be caused from skin rubbing on wheelchair connection that the plastic cover was missing from. The same note indicated R48's chair taped up for the moment, until assessed by maintenance. R48's incident and accident reports were requested and did not include any skin alterations due to her Broda Chair. Licensed Practical Nurse (LPN) L was interviewed on 1/11/24 at 1:07 PM and stated she was not aware of any issues with R48's chair or any skin issues due to the Broda chair. During an observation at the same time with LPN L, three reddened areas were noted on back of R48's right calf. R48's Broda chair was observed with two taped areas on chair on right side. During an interview with Certified Nurse Assistant (CNA) M on 1/17/24 at 9:55 AM she stated R48 had bruising on her leg due to her Broda chair. CNA M did not recall how long R48's chair had been taped in two areas. CNA M stated R48 did not use the footrest, she put a pillow under her legs when she was in the chair. CNA M stated R48's footrest would not stay down when adjusted. During an interview with the Director of Nursing (DON) B on 1/17/24 at 10:10 AM, she stated she was not aware of any issues with R48's Broda Chair. DON B stated she would expect an incident accident report to be generated if there were skin alterations caused from the Broda chair. Hospice Clinical Coordinator S was interviewed on 1/17/24 at 12:10 PM and stated hospice knew nothing about R48 needing a chair until 1/17/24 when the facility called her supervisor; and R48 would receive a new chair on this same day. Resident #50 According to the clinical record including the Minimum Data Set (MDS) dated [DATE], Resident # 50 (R50) was a [AGE] year old female admitted to the facility with diagnoses that include cerebral vascular accident with right side hemiparesis and hemiplegia affecting the dominant right side. R50 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS). During an interview with R50 on 01/10/24 11:38 AM, it was reported she required assistance from 2 staff persons for transfers with the use of a gait belt. R50 stated a few months ago during a weekend the facility was short staffed and Certified Nursing Assistant (CNA) L transferred her to the toilet without the assistance of another CNA. R50 alleged the gait belt was not in the correct position and during the transfer she had severe pain in her ribs that lasted for weeks, and as a result of the pain R50 had missed some physical therapy sessions. When queried if her ribs were fractured, R50 stated she didn't know because there an x-ray was not done, when queried what the physician or nursing assessment determined, R50 said the physician or nursing staff never looked into it. On 01/11/24 09:22 AM during an interview with Physical Therapist (PT) K she reported being very familiar with R50, PT K stated R50 currently uses a lift for transfers but was a 2 person transfer with a gait belt a few months ago. PT K stated she was aware of R50's complaint that she was transferred by one staff opposed to two and that CNA L allegedly had the gait belt not positioned correctly and as a result R50 complained of pain in her ribs and declined therapy sessions due to the pain. PT K stated this was reported to Nursing staff, although she wasn't sure which person in nursing was notified. Review of the physical therapy notes dated 11/06/23 reflected R50 complained of pain in her ribs due to a transfer that occurred over the weekend. The progress note reflected R50 needed increased time for transfers due to pain and ended the physical therapy session early. Review of R50's care plan for activity of daily living dated 3/22 reflected R50 was to be transferred with the assist of 2 staff with a gait belt. A revision to the care plan was made by the physical therapy department on 11/07/23 for a one person assist using a mechanical lift. On 01/11/24 at 10:16 AM, during an interview with Nurse Unit Manager J, she reported she had no knowledge of the incident and if she would have been informed the proper protocol would have been to complete and incident and accident report, notify the physician, assess R50 , obtain an x-ray if ordered and provided education to CNA L as/if warranted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #01 (R01) Review of the medical record revealed Resident #01 (R01) was admitted to the facility on [DATE] with diagnoses that included major depression, anxiety, obesity, chronic pain syndrome, and Polyosteoarthritis. According to Resident #01 (R01)'s Minimum Data Set (MDS) dated [DATE], revealed R01 scored 15 out of 15 (cognitively intact) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R01 requires 1-2 persons for turning and repositioning, 1-2 persons for assistance with personal care and peri care due to obesity and not having the ability to reach all areas of her lower body. During an interview and observation on 11/06/23 at 12:20PM, R01 stated she had a hole in her butt. R01 then pointed to her right foot and stated she had to wear that moon boot because she has a wound there too. R01 stated the facility no longer had a wound care nurse so Registered Nurse (RN) O would come in and assess it. R01 stated they didn't have the correct dressing for the wound vac last night to put it on after her shower, so they packed the wound and covered it with a foam dressing. R01 gave writer permission to come back in and watch her wound care. During an observation and interview on 11/06/23 at 2:30PM, Registered Nurse (RN) RN O and RN P were working together on this dressing change. RN P assisted with rolling R01 toward her, so RN O could get to the wounds. Observation of a reddened are on R01's left hip the size of a sauce plate. Also observed the right gluteal was reddened and bleeding as well. R01 had red streaks across her back under the location of a bra line. R01 stated she wasn't sure if it was nail marks from scratching but unclear of the nature. RN O removed the packed dressing from the coccyx wound, washed the area with normal saline. Used a sterile Q-tip to measure the depth of the coccyx wound, while using the same q-tip to measure tunneling or underminning. RN O applied skin prep surrounding the coccyx wound and over the right gluteal wounds. As RN O continued the prep for the wound vac, she stated that R01 had an appointment at the wound clinic on 11/14/23. RN O also stated that this resident used to be down another hall, so once R01 arrived on this hall, RN O requested a wound clinic evaluation. RN O then placed green foam in the opening of the coccyx wound and across the top of the skin over the right gluteal wounds. RN O then laid a clear adhesive dressing called a drape over the coccyx and right gluteal wounds, cutting a small hole over the green foam and placed a disc/tubing over the coccyx wound, used a dressing called a bridge (connected one wound to another) attached to the wound vac. Wound vac was set at suction@ 125mmHg. RN O had to apply additional pieces of drape due to air leak in the dressing not allowing the wound vac to work properly. Once the wound vac maintained its seal, this dressing change was completed. During an interview and observation on 11/06/23 at 3:00PM, RN O stated they were doing daily dressing changes on the right heel and added the escar had come loose over the weekend, so they are now using a different dressing than what was ordered. RN O removed the dressing from the right heel using clean technique, cleaned with normal saline, a picture was taken of the wound, a dry foam dressing was put back on heel the wound bed was covered in escar tissue with bleeing coming out of the corner of it. R01 also had a red area under her right breast that was bright red and appeared to be inflamed. R01 stated it was painful when they cleaned it and put the zinc oxide on the area. The reddened area was approx 2.5 wide by 6 long. R01 had a strip of a dry wicking fabric laying between the breast and chest wall to prevent touching. Area cleaned with normal saline and the dry wicking fabric was placed back between the breast and the chest wall. RN O also stated that the wound care nurse had left in August 2023, so the unit managers were given the wound care responsibility with the DON B. During an interview on 11/07/23 at 4:40PM, RN O stated when a resident develops a new wound, she opened a new identifier in point click care (PCC) electronic record. She also stated after the wound care nurse left in august 2023, she had to go in and closed out wounds that had healed. RN O stated they had a morning meeting, and that was where she would bring up any new wounds and the orders to the whole team. RN O also stated that the DON B was certified in wound care. RN O stated that they have a product guide they used for a tool until the doctor was notified. If a wound is identified over the weekend, the nurses are instructed to call her at home, like the discovery of the skin issue under the right breast and the right heel opening. RN O stated she had not seen the doctor yet today; however, he was in the facility yesterday (11/06/23) and did not remove the dressing to the wounds to assess, reported he would look at the pictures once they were taken. When asked about the pictures that were taken of the coccyx wound, the right gluteal wound and the right heel. RN O stated some of the pictures were deleted by accident, so she had to take some new ones. RN O also stated that the picture app that they used for taking pictures on the wounds was challenging to use at times. RN O added that the nurses had this app on their personal phones and then they were given an IPad with the program on that, but also was challenging to use if you needed to get is certain places. During an interview on 11/08/23 at 07:35AM, DON B stated the wound care nurse had left in the beginning of September 2023. DON B stated she had some wound education and knew how to do what needed to be done. DON B stated she had assigned wound care to the two-unit managers. She provided wound vac training through the company itself. (name of company) came in to train on the wound care supplies and dressings. They held monthly nurses' meetings that nurses had to attend, signed in and had education provided by various vendors. Writer asked DON O what the turning and repositioning process was. DON B stated they had process called check and change, turn, and reposition. This was part of their standard of care. If a resident refused to be repositioned, the Cena was to tell the nurse and she would reapproach. DON B also stated that this was the time the cena's looked at their skin and document on a separate form all the services they provided with the skin audit. DON B stated that she met with the unit managers every morning, go over the new events, falls, new skin issues, and what needed to be followed up on. DON B also added that both doctors at the facility are engaged in the wounds but neither one touches the wounds but counts on the nurses to relay the information to them. DON B stated that the unit managers have tools to use to identify the dressing needed based on the assessment of the wounds. If the nurses need to address the wounds, then they would write an order and they have a formulary they could order from. DON B also stated that the unit managers are actively involved with the skin and wound care program, taking pictures of the wounds, treating the wounds. DON B did state that she heard that some of the pictures of the wounds were lost. Also stated she felt that was a user error. DON B stated that you should be able to reopen the previous wound identifier of a specific location and update it. It should have the same identifier as it did initially. DON B stated the minimum data set (MDS) Nurse was actively involved in the wound care program, she was present at weekly meetings to compare wounds week to week, and had to document it in the MDS documentation. She was the one who documents significant change in condition if they are getting better or worse. DON B stated they have a past noncompliance on pressure ulcers dated 10/31/23 and presented it to this writer at this time. DON B stated that she identified care plans did not match the focus, goal or interventions needed. Turn, reposition, check and change was not documented every two hours, not individualized on the care plans. During an interview on 11/08/23 at 0945AM, DON B stated that the wound identifier did not allow nurses to reopen wound assessments, so they had to identify as a new wound and was given a new wound number for identification. During an interview on 11/08/23 at 11:20 AM, RN P stated R01 was on the hall she was managing initially. Also stated that R01's skin had no issues on 09/12/23. Writer provided a picture to show skin break down, stage 2 pressure ulcer, following week R01 had aquacel with a foam dressing covering. RN P stated that within a week's time her pressure ulcers were opened up, adding that R01 refused to be repositioned and bathed. RN P also stated the nurses were using the blue dot locator correctly when they were taking pictures of these wounds. RN P stated they did not know they needed to place the blue dot in a certain position for the pictures or the measurements would be off, giving a false reading. RN P also added that wounds are not her favorite thing, but they did not have a wound care nurse. RN P stated she would ask the other unit manager for assistance with would care measurements and treatments. RN P also stated that they were educated last week on the use of zinc oxide since they had been using it on open areas, not the intended use. Record review of skin and wound assessments revealed variations in measuring and staging of the pressure ulcers. Pictures taken were not taken from the same distance from the wound, the blue dot was placed on varying locations around the pressure ulcer giving a false assessment or the picture was so blurry, you were unable to identify the body structure that was being identified. Some wounds did not have pictures attached related to pictures getting deleted. Some areas of the pressure ulcers assessment document were not filled out, leaving out important information and characteristics of the wounds. Right gluteal wounds would be marked resolved when there were visible alterations in the skin. Record review of the physician orders revealed R01 had an order for wound care for the right breast dated 10/25/23 including to cleanse under breast unilateral with wound cleaner, pat dry, apply an abd pad for excessive moisture. Complete this every day for skin management. The wound assessment on 11/06/23 stated this was a new wound, where in fact it was a previous wound with a current treatment plan in place dated 10/25/23. Record review of current orders revealed wound care to coccyx wound as follows, Coccyx wound: Remove previous dressing materials, cleanse wound with normal saline, prep peri wound with skin prep, apply drape to peri wound, fill wound cavity with green foam, secure with drape, apply bridge, apply vac head & connect to tubing. Apply continuous suction@ 125mmHg dated 10/16/23. During the observation of the wound care on 11/06/23 at 2:30PM, RN O did not perform wound care as ordered. RN O placed the green foam directly over the right gluteal wounds without a drape placed over the skin first, then the green foam should had been placed on top of this drape to protect the compromised skin. Record review of physician orders revealed R01 was ordered to wear a heel protector boot on both feet. During observations on 11/06/23 and 11/07/23 R01 was not wearing both boots, only one on the right foot. Writer could not visibly see a second boot in R01's room. During an observation on 11/08/23 R01 was wearing both heel protector boots. Resident #2 (R2): Review of the medical record reflected R2 admitted to the facility on [DATE] and readmitted [DATE], with diagnoses that included dementia, chronic obstructive pulmonary disease (COPD), neuromuscular dysfunction of bladder and retention of urine. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/8/23, reflected R2 scored seven out of 15 (severe cognitive impairment) on the Brief Interview for Mental Status (BIMS-a cognitive screening tool), did not walk and required extensive assistance of two or more people for bed mobility and transfers. According to the same MDS, R2 was coded for an indwelling catheter and was not coded for pressure ulcers. R2 did not reside in the facility at the time of the survey. According to the Discharge Return Anticipated MDS, with an ARD of 9/15/23, R2 did not have any pressure ulcers. A Progress Note for 7/14/23 at 11:57 PM reflected R2 had open skin lesions on the sacrum and the left and right buttocks. The note reflected there were existing orders for wound care, and lotion was applied to the area. A Nutritional Progress Note for 7/17/23 reflected a monthly status update related to moisture-associated skin damage (MASD/skin impairment due to prolonged moisture exposure) to the sacrum that was improving. A Progress Note for 9/15/23 at 6:00 PM reflected R2 was sent to the Emergency Department for a change in condition. The eINTERACT Transfer Form, dated 9/15/23 at 5:24 PM, reflected a Skin/Wound Care section, which revealed documentation of Several stage 2 ulcers on both buttocks (partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer). An Emergency Department Progress Note reflected R2 stated her bottom hurt. The note reflected she had .a large area of erythema [redness] over her sacrum and gluteal folds with a few 1 cm [centimeter] round ulcers proximally stage II [2] . A hospital Progress Note for 9/16/23 at 3:29 AM reflected there was a sacral wound present. There was no further descriptive information on the wound. During an interview on 11/7/23 at 4:08 PM, Registered Nurse (RN) F did not recall the documentation of R2 having several stage two ulcers on her buttocks on the transfer form dated 9/15/23. RN F reported a stage two pressure ulcer was not necessarily open, but it was reddened and broke down, deeper than just the first layer. The Skin & Wound section of R2's electronic medical record (EMR) reflected MASD was present. The last assessment on 9/12/23 reflected MASD was documented as improving. The picture on 9/12/23 had the presentation of peeling, flaking skin with underlying red/pink tissue. The picture did not appear to capture the entire area of impaired tissue, as evidenced by impaired tissue that extended to all edges of the picture. R2's Skin & Wound evaluations for 7/10/23, 7/17/23, 7/25/23, 8/1/23, 8/8/23, 8/15/23, 8/22/23, 8/29/23, 9/6/23, 9/12/23 were reflective of MASD to the sacrum, with an onset of 4/17/23. The assessments did not reflect the presence of pressure ulcers. During an interview on 11/8/23 at 10:52 AM, RN J reviewed pictures from the skin and wound section of R2's medical record for 8/1/23 to 9/12/23 and described the appearance of the skin, as seen in the pictures. Pertaining to the picture of R2's impaired skin on 8/1/23, RN J stated it looked like a stage two pressure ulcer was present, but she was not going to say it was. RN J identified excoriation and MASD and stated the wound looked worse in the pictures. She reported the larger wound in the picture looked like a stage two or stage three pressure ulcer (Full-thickness loss of skin that may have visible subcutaneous fat in the ulcer. Slough (non-viable yellow, tan, gray, green or brown tissue) and/or eschar (dead tissue that is usually black, brown or tan) may be visible but do not obscure the depth of tissue loss.). Pertaining to the 8/8/23 picture, RN J reported there were three open areas that she would probably call stage two pressure ulcers because they were open, and she could see the wound bed. She stated the larger wound appeared to have slough, but she could not be positive based on the picture. Pertaining to the 8/15/23 picture, RN J reported that because she knew what R2's skin looked like, the wound was not as deep as it looked in the picture. She stated she would call the impaired skin MASD. RN J reported the pictures were poor quality. Pertaining to the 8/22/23 picture, RN J reported two open areas appeared to be stage two pressure ulcers. Pertaining to the 8/29/23 picture, RN J stated R2's skin looked worse and awful. She stated there was no depth noted (on the assessment), but there appeared to be a stage three pressure ulcer present, as well as MASD. Pertaining to the 9/6/23 picture, RN J stated there was excoriation caused by MASD that was healing. Pertaining to the 9/12/23 picture, RN J reported there was dry, flaky tissue that was almost healed. During the same interview, RN J described a stage one pressure ulcer as being pink tissue that may or may not be blanchable. She described a stage two pressure ulcer as the top surface of the skin being open, and a wound bed being visible. RN J described a stage three pressure ulcer as wound that was deeper and could have slough. RN J described MASD as skin that was chapped, dry, excoriated and could be flaky depending on what was used for treatment. RN J stated there could be open tissue with MASD based on the appearance of R2's skin. According to the State Operations Manual, revised on 2/3/23, a stage one pressure ulcer was intact skin with an area of non-blanchable redness. A Physician's Order, with a revision date of 6/26/23, reflected R2's sacrum was to be cleansed with soap and water, patted dry, and zinc oxide was to be applied three times daily for wound care. During an interview on 11/8/23 at 12:13 PM, RN J stated she did not use zinc oxide on open areas, and it was not used on stage two pressure ulcers. This citation pertains to intakes MI110044 and MI00139379. Based on observation, interview and record review, the facility failed to prevent and treat pressure ulcers, in three of three residents reviewed for pressure ulcers (Resident #1, #2, and #3) resulting in worsening of pressure ulcers (Resident #3), facility acquired pressure ulcers, pain, and unmet needs. Findings include: Resident #3 (R3) In review of R3's admission Nurse assessment dated [DATE], she had a Stage 1 pressure ulcer (alteration of intact skin) on her coccyx (tailbone) and had an indwelling catheter. Physical Therapy Evaluation dated 6/05/23 and diagnoses list revealed R3 fell at home when walking to the bathroom with a cane and sustained a right hip fracture. R3 had the diagnoses of Dementia, diabetes, heart failure, osteoporosis, arthritis and macular degeneration (eye disease). The same evaluation revealed R3 required substantial/maximal assistance in bed mobility and weight bearing status was as tolerated. R3's admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 6/09/23, revealed she was admitted to the facility with one Stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising; may also present as an intact or open/ruptured blister). The same MDS introduced a Brief Interview for Mental Status (BIMS), a short performance-based cognitive screener, score of 08 (08-13 Moderate Impairment). R3's MDS revealed she was at risk for pressure ulcers and a turning/repositioning program (consistent program for changing the residents' position and realigning the body; organized, planned, documented, monitored, and evaluated based on an assessment of the resident's needs) was not implemented. The same MDS indicated R3 required extensive assistance for bed mobility and was frequently incontinent of urine. Braden Assessment (tool used to determine risk of pressure ulcer development) dated 6/03/23 revealed R3 was at risk for pressure ulcers. The same assessment indicated R3's ability to change and control body position was slightly limited, able to make frequent though slight changes in body or extremity position independently. R3's Occupational Therapy (OT) Evaluation dated 6/05/23 revealed her goals were to get better and go home. The same evaluation indicated R3 demonstrated good rehab potential as evidenced by ability to follow 1-step directions. R3's pressure ulcer care plan dated 6/05/23 revealed to encourage R3 to make small, frequent shifts in position; and to assist in floating her heels. The same care plan did not include to avoid positioning on back or how often to reposition when in her bed or wheelchair. Prior to admission to the facility, hospital notes dated 5/29/23 revealed nursing orders included to reposition R3 when in chair every hour. Wound Evaluation dated 6/07/23 indicated R3 had a Stage 2 pressure ulcer on her sacrum (above coccyx, triangular-shaped bone between hip bones and positioned below the last section of the spine) and the wound bed consisted of 80 percent (%) slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, soft, stringy and mucinous in texture). The same evaluation included a picture of the sacrum and coccyx, and it appeared to have 2 separate pressure ulcer wounds on the sacrum and coccyx; it appeared the sacrum ulcer (above tailbone) was measured. The sacral ulcer was 1.42 centimeters (cm) in length by 0.82 cm in width. Centers for Medicare and Medicaid Services (CMS's) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0, Version 1.18.11, October 2023, manual, instructed: Stage 2 pressure ulcers by definition have partial thickness loss of the dermis; Granulation tissue (red tissue with cobblestone or bumpy appearance; bleeds easily when injured), slough, and eschar (dead or devitalized tissue, hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) were not present in Stage 2 pressure ulcers. Total Body Skin assessment dated [DATE], indicated R3 had no new wounds. OT noted dated 6/12/23 revealed R3 was found lying on her back in bed with pressure sores located on both of her heels. Pillows were placed under R3's heels to decrease pressure on heels while in bed. The same note indicated the nurse was notified of R3's pressure ulcers. R3 was tearful throughout treatment and reported pain at a level of 9 (0 to 10 scale rating with 0 being no pain and 10 being the worst pain imaginable) and the nurse was notified of need for pain medication. The same note revealed R3 was dependent on staff for toileting hygiene, showers, lower body dressing and putting on and taking off footwear. Wound Evaluation dated 6/12/23 indicated R3's sacral pressure ulcer was a Stage 2 with 80% granulation tissue. The same evaluation revealed a picture that appeared R3 had 2 separate pressure ulcers; the bottom wound (coccyx) was measured according to the picture and was 3.27 cm in length and 1.04 cm in width. Skin and Wound Evaluation dated 6/12/23 revealed R3's right heel had a pressure ulcer that was staged as a deep tissue injury (DTI, persistent non-blanchable deep red, maroon or purple discoloration); and was 2.4 cm in length and 1.5 cm in width, was an intact blister, no edema or swelling were noted. Skin and Wound Evaluation dated 6/19/23 revealed R3 had an in-house acquired pressure ulcer on her left heel that presented as DTI and was 2.3 cm in length by 1.4 cm in width. Wound Evaluation dated 7/17/23 revealed R3's left heel was DTI that measured 3.39 cm in length by 2.77 cm in with. The same evaluation included a picture of the heel wound; the measurement sticker appeared to be on the inside of the left heel wound. Wound Evaluation dated 7/17/23 revealed R3's right heel presented as DTI and was 3.94 cm by 2.8 cm. The same evaluation included a picture of the heel wound; the measurement sticker appeared to be on the inside of the right heel wound. Wound Evaluation dated 7/17/23 revealed R3's sacrum pressure ulcer was a Stage 2 pressure ulcer, had 80% granulation tissue, and was 3.07 cm by 0.81 cm. MDS Coordinator (MC) D was interviewed on 11/07/23 at 3:00 PM and stated R3's she could not remember if she asked the wound nurse about the stage accuracy of R3's stage 2 sacral pressure ulcer due to documentation of slough, on R3's admission MDS with ARD of 6/09/23. MC D stated if a resident was admitted with a Stage 2 pressure ulcer, they had to continue coding as a Stage 2, even when the pressure ulcers worsened. Registered Nurse Unit Manager (UM) O was interviewed on 11/07/23 at 4:48 PM stated R3 wore slipper socks when sitting in her wheelchair. R3 had a stage I pressure ulcer on her sacrum when she was admitted . UM O stated R3's pressure ulcers on her heels developed due to pressure from her wheelchair foot pedals. UM O stated R3's Total Body Skin assessment dated [DATE] was not investigated for accuracy. UM O stated the wound nurse had retired and was instructed she and another unit manager would take over wound management. UM O stated before the wound nurse left, they had a weekly pressure ulcer meeting, and currently did not have a weekly meeting. Director of Nursing (DON) B was interviewed on 11/08/23 at 7:55 AM and 9:50 AM and stated she was not aware of MDS coding inaccuracies DON B stated she had identified issues with accuracy of wound measurement assessments, care plans and Braden assessment accuracy, and facility nurses were educated. DON B stated unit managers were responsible for staging pressure ulcers, and if a resident was admitted on the weekend, the nurse would describe the wound; the unit managers were on-call on weekends for nursing questions. DON B stated all residents were checked and changed every 2 hours and would increase turning as needed. Physical Therapy Discharge summary dated [DATE] revealed R3 was discharged home with her daughter due to exhausted benefits. Post Discharge Plan of Care, effective date 7/14/23, revealed R3 was discharged home on 7/17/23 with wound care instructions for both heels and sacrum. Hospital notes dated 7/30/23 revealed R3 was admitted to the hospital and the chief complaint was worsening of pressure ulcer wounds