**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake MI000132486 Based on interview and record review, the facility failed to assess, monitor, and notify the physician of new onset behavioral changes (refusing care, crying, screaming/yelling), immobility and difficulty transferring for one resident (Resident #108), resulting in a 4 day delay in care and treatment of a severe right hip fracture. Findings: Resident #108 (R108) Review of an admission Record reflected R108 originally admitted to the facility on [DATE] with diagnoses that included Down Syndrome, adjustment disorder, insomnia, edema, primary generalized osteoarthritis, dysphagia, constipation, major depressive disorder, delusional disorder, hallucinations, high blood pressure, pain and dementia. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected R108 was severely cognitively impaired as evidenced by a Brief Interview for Mental Status (BIMS) score of 3/15. Section E-Behavior indicated R108 did not exhibit behavioral symptoms and did not reject care. Section G - Functional Status reflected R108 needed supervision and one-person physical assistance for bed mobility, walking in room and in the corridor as well as for locomotion on and off the unit. R108 needed extensive assistance from one person for toilet use, personal hygiene and dressing, did not have functional limitations in Range of Motion (ROM) and did not use mobility devices (cane, walker, wheelchair). Review of a Nurse Practitioner 60 Day mandatory visit progress note dated 10/5/2022 reflected Pt (patient, R108) seen today sitting in the common room. Pt is without any acute concerns and does not appear to be in any distress. Pt is a poor historian and the bulk of this history of presenting illness was deferred to nursing staff and chart review. Nursing staff denies any concerns for the patient. They state that he has been content and easily directed by staff with a calm approach. They deny any clinical concerns for the patient at this time. In terms of ADLs (activities of daily living), pt. does require assistance with bathing and grooming. He is able to ambulate independently. He has maintained adequate intake with food and fluids and is both continent and incontinent of bowel and bladder. We will continue with this plan and follow up with him periodically. Review of a General Progress Note dated 10/24/2022 at 3:30 PM reflected 3:30 - Loud scream heard. Resident (R108) having Grand Mal seizure while sitting in recliner. Muscles became rigid, loss of consciousness, breathing was slow and labored, seizure lasted approximately 5 minutes. 4:40 - Breathing normal, VS (vital signs) 125/50 (blood pressure), 69 (heart rate), 98% (oxygen saturation). Talking with staff. DPOA (durable power of attorney) and NP (Nurse Practitioner) notified. A full physical assessment to of R108 after the seizure was not documented. On 11/29/2022 at 4:05 PM, Incident and Accident/Unusual Occurrence reports pertaining to R108 for the month of October were requested from the Director of Nursing (DON). An incident report was not completed for R108 after the seizure on 10/24/2022. Review of a Documentation Survey Report v2 (a Certified Nurse Aide (CNA) task and resident functional status documentation) for the month of October 2022 reflected that prior to 10/24/2022, R108 was typically independent with transfers and required only supervision and/or limited support to complete transfers occasionally. On 10/25/22 and 10/26/2022 R108 was coded as being totally dependent on two people for transfers. On 10/27/22 R108 needed extensive assistance from one person to transfer and was again totally dependent on two people for transfers on 10/28/2022. R108 was independent with walking in his room or in the corridor the majority of the time during the month of October until 10/24/2022 when it was documented R108 was either totally dependent of two staff members for locomotion or did not walk at all between 10/24-10/28/2022. Behavior documentation reflected that R108 exhibited yelling/screaming and rejected care on 10/25/22, had frequent crying and rejected care on 10/26/22 and had frequent crying, yelling/screaming and rejection of care on 10/27/2022. Review of a General Progress Note dated 10/28/2022 at 12:06 PM reflected Complaining of pain in Right hip. Screaming in pain when being turned. NP notified N.O. (new order) for Xray of right and left hip and abdomen. Miralax (laxative) given for constipation. Review of a General Progress Note dated 10/28/2022 at 7:12 PM reflected Xray results showing R (right) hip fx (fracture). Notified on call (name of on call provider), receiving order to send to the ED (Emergency Department) for eval and further tx (treatment). Guardians notified and will meet him there. On call manager notified. Report called to (name of local hospital), all necessary documentation sent with resident and (ambulance company). Further review of progress notes from 10/24/2022 -10/28/2022 did not reflect evidence of a nursing assessment or physician notification related to the documented change in R108's behavior, transfer or mobility status as noted in the CNA charting. Review of R108's hospital records from 10/28/2022-10/31/2022 reflected the Chief Complaint: HIP PAIN (Patient had seizure 4 days ago and has been unable to ambulate since. Xray of right hip was completed and fracture of right hip was found.) The History of Present Illness reflected [AGE] year-old male with history of Down syndrome and a seizure disorder presents (to) emergency department with hip pain after a fall. Patient had seizure 4 days ago. Since that time has been refusing to walk. X-rays obtained at the facility showed a right-sided acetabular fracture. Patient was sent to the emergency department for evaluation. Patient's cousins are here with him for his power of attorney. They are not aware of any other recent illness. They saw him last week and he was doing well. When the patient is in bed at rest, he has no complaints of pain. The final result from the CT Abdomen and Pelvis Without IV Contrast reflected 1. Complex comminuted and displaced fractures of the right acetabulum involving both the anterior and posterior columns. Extension of the anterior column fracture into the iliac wing with a displaced fracture fragment into the iliacus muscle resulting in a small volume intraperitoneal hemorrhage. Additional fracture extension into the superior pubic ramus. The hospital record indicated that R108 was not a good surgical candidate and family was planning on hospice care. Review of Progress Notes from 11/01/2022-11/14/2022 reflected that R108 readmitted to the facility and elected hospice care. R108 was treated for pain and comfort and passed away at 11:46 AM on 11/14/2022. During an interview on 12/01/2022 at 9:39 AM, NP P reported that he was likely in the facility on 10/24/2022 and would have been made aware of R108's seizure at that time. NP P said he was not made aware R108 had a change in condition after 10/24/2022 until he was told R108 had a severe hip fracture. NP P reported that the facility staff are very good at documenting when a resident is doing well or are doing very poorly but that identifying and reporting changes in condition as they occur needs improvement.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to 1.) provide care following professional standards of practice and facility policy to prevent the development/worsening of avoidable pressure ulcers, 2.) assess, monitor, and provide ordered treatment for residents with new/worsening pressure ulcers, and 3.) promptly notify the physician of a change in condition for 2 residents (Resident #21 and #9), reviewed for alterations in skin integrity/pressure ulcers, resulting in unrecognized changes and the worsening of skin impairments, a delay in treatment and the potential for prolonged wound healing, infection, and overall deterioration in health status. Findings: Review of the Quality Assessment & Assurance Committee-AD HOC MINUTES dated 10/19/22 revealed, Plan of Correction-Wound & Skin Management Program (from previous F-Tag 686 citation issued on 8/23/22) .Education *Licensed Nurses and CENAs (Certified Nursing Assistant) were educated by the DON (Director of Nursing)/designee on the policies and procedures for Skin Monitoring and Management program, specifically assessment of wounds, communication from providers, updating and implementing plans of care, turning and repositioning, and appropriate physician orders for treatments .Chief Nursing Officer will educate DON and Administrator on the IDT (Interdisciplinary Team) Skin Committee Weekly meeting. *DON and Administrator educated the IDT on the IDT Skin Committee Weekly meeting expectations. Monitoring *Audits will be completed on 5 random residents with wounds weekly x4 weeks then monthly x2 months, or until substantial compliance has been achieved, by ensuring appropriate assessment of wounds, communication from providers, updating and implementing plans of care, turning and repositioning, and appropriate physician orders for treatments. Any concerns will be corrected immediately. *The results will be present to the QAA committee for review and consideration of further corrective actions. Alleged Compliance- The Administrator will be responsible for assuring substantial compliance is attained through this plan of correction by 10/19/2022 and for sustained compliance. Resident #21 (R21) Review of an admission Record revealed R21 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's Disease. Review of a Minimum Data Set (MDS) assessment for R21, with a reference date of 9/16/22 revealed R21 was severely cognitively impaired. Review of the Functional Status revealed that R21 required extensive 1 person assist for bed mobility, toileting, and personal hygiene, and extensive 2 person assist for transferring. Review of the Skin Conditions revealed R21 did not have a pressure ulcer but was at risk for the development of pressure ulcers. Review of R21's Physician Order dated 11/10/21 revealed, Apply border foam dressing to coccyx every 3 days and prn (as needed) for protection. Review of R21's Physician Order dated 2/8/22 revealed, Desitin Paste (Zinc Oxide) Apply to buttock topically every shift for incontinence dermatitis. Review of R21's ADL (Activities of Daily Living) Care Plan revealed, Turn and reposition frquently (sic) Date Initiated: 11/02/2021 . Review of R21's Skin Observation Tool dated 11/16/22 revealed no alterations in skin integrity. Review of R21's Skin Observation Tool dated 11/22/22 revealed, .MASD (Moisture Associated Skin Damage), continue zinc as ordered .Res is turned and repositioned Q (every) 2 HRS and PRN (as needed). R21's Care Plan was not updated to reflect repositioning every 2 hours). Review of R21's Skin Observation Tool dated 11/23/22 revealed, .Resident has MASD on bilateral buttocks and her coccyx area, continuing zinc as ordered. Resident has pressure area on coccyx, continuing with treatment order for mepilex dressing. Resident is turned and repositioned Q2hrs and PRN. No other skins (sic) concerns for resident at this time . Review of R21's Progress Notes revealed no documentation that the provider was notified of R21's skin breakdown on 11/22/22 or 11/23/22. Review of R21's Progress Notes revealed no documentation that the Unit Manager or Director of Nursing were notified of R21's skin breakdown on 11/22/22 or 11/23/22. Review of the Provider Communication Book located in the Gilead (name of locked dementia unit) Unit Nursing Station revealed no documentation/communication of R21's skin breakdown on 11/22/22 or 11/23/22. Review of R21's Physician Orders revealed no new orders or order changes regarding R21's MASD or Pressure Area identified on 11/22/22 or 11/23/22. Review of R21's Care Plans revealed no new interventions were implemented and/or no changes made regarding R21's MASD or Pressure Area identified on 11/22/22 or 11/23/22. During an observation and interview on 11/30/2022 at 12:40 PM, Certified Nursing Assistant (CNA) X reported that R21's buttocks had skin breakdown that had been worsening over the week. CNA X reported that she had notified the facility nurse of the worsening of R21's skin breakdown. R21 was turned to her left side and her coccyx area had a border gauze that was heavily soiled (unable to determine if it was drainage from the wound or stool/urine) with the edges of that dressing rolled up/not secure to skin (falling off). The border gauze did not have a date to indicate when it was applied and did not have initials to indicate the facility nurse that placed the border gauze on R21. CNA C removed the dressing. R21's skin was red approximately 2-2.5 inches in diameter. Inside the area of redness there were 3 open areas, with bright pink wound beds exposed, indicating a measurable length and width. CNA C and CNA X verified that there were 3 open areas and they both reported those open areas were new for R21. There was an unused border gauze dressing with a handwritten date of 11/30 and initials of Registered Nurse (RN) I on R21's nightstand. CNA C placed zinc barrier cream on R21's coccyx area/skin breakdown and then placed the border gauze over the zinc barrier cream/skin breakdown. CNA C was not a licensed nurse and performing wound care and/or treatment administration was outside CNA C's scope of practice. (Reference 4) CNA X reported that residents were not receiving the care they required from licensed nurses or support staff because of the lack of facility staff. CNA X reported that there were many residents on the Gilead Unit that required extensive assist or 2 assist with cares. CNA X stated it's not reasonable to expect that ADL care and supervision can be completed with the number of staff available. Review of R21's Treatment Administration Record (TAR) immediately following R21's skin injury observation on 11/30/2022 at 12:40 PM revealed an order Apply border foam dressing to coccyx every 3 days .for protection and was documented as being completed by RN I. Review of R21's Progress Notes revealed no documentation of R21's skin injury or that R21's treatment had been performed by CNA C. During an interview on 11/30/2022 at 1:42 PM, RN I verified that the girls did it (R21's dressing change) and reported that CNA C and CNA X reported that there were 3 areas but not open (on R21's coccyx). RN I reported that she had not done a skin assessment on R21 but would document the pressure injury concern. Review of R21's Electronic Health Record revealed no documentation that RN I documented R21's pressure injury or that she notified the R21's provider of the pressure injury. Review of R21's Skin Observation Tool dated 11/30/22 (lock time 8:23 PM) revealed Section 1 was completed with no new skin issues identified. Section II ALTERATIONS IN SKIN INTEGRITY and Section III ADDITIONAL INFORMATION were blank. Review of the Provider Communication Book on 12/1/22, located in the Gilead Unit Nursing Station, revealed no documentation/communication of R21's pressure injury identified on 11/30/22. During an interview on 12/01/2022 at 10:15 AM, Nurse Practitioner (NP) P reported that he was not aware of any skin integrity concerns (MASD/pressure ulcer) for R21. NP P reported that the expectation is to notify the provider immediately if there are concerns with a resident's skin integrity. NP P reported that he would want to be notified of the smallest area; even redness so he could order an intervention and/or treatment to prevent the worsening of the condition. NP P reported that if a resident has MASD he would not order border gauze as a treatment because removing the border gauze could cause the fragile skin to tear and worsen the condition of the wound. NP P reported that he would assess R21's skin and modify/implement a treatment today. An interview on 12/01/2022 at 12:45 PM with Licensed Practical Nurse (LPN) K and the DON highlighted aspects of the skin/wound monitoring program's ineffectiveness. LPN K reported that he was the Unit Manager as well as the nurse responsible for wound monitoring/care. LPN K reported that he was not Wound Care Certified. DON reported that the wound care program was new and started because of the citation that the facility had recently been issued (citation issued 8/23/22 with alleged compliance date of 10/19/22). DON reported that LPN K had been responsible for the wound care program for approximately 1 month. DON reported that the IDT (Interdisciplinary Team) met weekly regarding identified skin integrity concerns for all residents in the facility. LPN K reported that he was aware of MASD that was identified and documented approximately 1 week prior on a Skin Assessment. LPN K reported that (contracted wound care agency) was providing care to R21's roommate and consulted with LPN K concerning R21's documented MASD at that time (there was no order for consultation with the contracted wound care agency). LPN K reported that (contracted wound care agency) reported that if there was MASD on R21's buttocks, zinc topical cream and border gauze was okay to treat R21 (this recommendation conflicts with the recommendation for treatment made by NP P). Review of R21's Electronic Health Record (EHR) revealed no consultative notes/documentation regarding R21's skin breakdown and/or treatment recommendations. LPN K reported that he was under the impression that R21's provider was aware of R21's skin breakdown based on R21's active treatment orders. LPN K was not aware that R21's border foam dressing (ordered for protection) and zinc oxide topical was ordered on 11/10/21 and 2/8/22 respectively, and not because of the newly documented skin breakdown on R21's 11/22/22 and 11/23/22 Skin Assessments. LPN K and DON reported that R21 was not being followed by the IDT Weekly Skin Committee (despite the Plan of Correction outlined above). DON reported that she was made aware of R21's skin breakdown this morning (more than a week after the development of actual skin breakdown) and an order for (contracted wound care agency) consult was placed. Review of R21's Physician Provider Note dated 12/1/22 at 1:40 PM revealed: .(R21) is seen today as concerns expressed by the state surveyor regarding an open wound on her coccyx area. The patient is seen with the nursing staff and the state surveyor in her room. The patient was turned on to her left lateral position and the patient's coccyx area is noted and she has a superficial thin layer of skin is eroded and there are three small open areas that are hard to measure, has a second layer eroded, in fact it could be classified as not open as the patient has not had third layer of the skin is not open as subcutaneous tissue is not exposed. The patient does have a delicate skin and occlusive dressing would be difficult to manage so we will not use occlusive dressing and we will only use a barrier cream to protect the delicate skin and I have notified the staff to not wipe and only pat dry the area and keep it clean and dry as much as possible. We will continue to monitor. She was treated with antibiotic for pneumonia recently and she does not appear toxic. We will continue to monitor. She has recovered very well from pneumonia. She is dependent on staff for all ADL. Remains incontinent of bowel and bladder. Physical Exam- SKIN: Skin over sacral/coccyx area examined with ancillary nursing staff and state surveyor. Pt is thin with no subcutaneous tissue. She has a small area of erosion of superficial layer of skin measuring approximately about 2 inches in diameter. with in (sic) that area, there are 3 small spots that is too small to measure has lost next layer of skin and still does not appear to have lost full thickness loss. It started as Started as (sic) MASD .Instructed nursing to treat with barrier cream and to avoid occlusive dressing. Assessment / Plan- 1. Open wound of sacroiliac region - erosion of superficial layer of skin with out (sic) damage to all layer of skin .Unspecified open wound of lower back and pelvis without penetration into retroperitoneum, initial encounter . (References 1-I, 2, and 3). Review of R21's Progress Note written by DON revealed, LATE ENTRY (written on 12/2/22 at 2:49 PM) Resident wound assessed/evaluated by (NP P). No concerns noted. Superficial area breakdown (3 small pinpoint areas clustered together) noted to coccyx. Orders to apply barrier cream q (every) shift and prn. Also, staff educated on not wiping with wash cloth to avoid further disruption of fragile skin. Will continue to monitor. DON's late entry note does not correlate with NP P's documented assessment and diagnosis of Open wound of sacroiliac region - erosion of superficial layer of skin without damage to all layer of skin .Unspecified open wound of lower back and pelvis without penetration into retroperitoneum . Review of R21's Progress Note dated 12/2/22 at 4:05 PM, written by DON revealed, Full head to toe assessment completed by nursing staff. No new areas of concern. There is a noted reddened area to coccyx that is blanchable. There is also a noted chronic scar to left hip. Care plan updated as needed. Orders reviewed. Indicating R21's no longer had an Open wound of sacroiliac region - erosion of superficial layer of skin without damage to all layer of skin as documented by NP P approximately 26 hours prior. (Reference 3) Review of R21's Physician Order dated 12/2/22 at 4:04 PM revealed, Desitin Paste (Zinc Oxide) Apply to buttock topically every shift for incontinence dermatitis apply every shift and with all peri care. Do not wipe with washcloth. Indicating NP P's order was not completed/processed until approximately 26 hours later. Review of R21's Physician Order dated 12/1/22 revealed, Border foam discontinued. Indicating NP P's order was not completed/processed until approximately 26 hours later. Review of R21's skin integrity Care Plan revealed, Do not wipe fragile skin on sacrum/coccyx with wash cloth until area is healed Date Initiated: 12/02/2022 . Indicating provider-initiated intervention was not immediately updated on R21's Care Plan following his assessment and recommendation. Review of R21's Care Plan revealed turning/repositioning was not updated with a turn schedule and remained unchanged from 11/02/2021. Resident #9 (R9) Review of an admission Record revealed R9 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia and kidney disease. Review of a Minimum Data Set (MDS) assessment for R9, with a reference date of 9/2/22 revealed R9 was severely cognitively impaired. Review of the Functional Status revealed that R9 required extensive 1 person assist for bed mobility and personal hygiene, and extensive 2 person assist for transferring and toileting. Review of the Skin Conditions revealed R9 did not have a pressure ulcer but was at risk for the development of pressure ulcers. During an observation on 11/30/2022 at 9:16 AM, R9 was sitting up in her broda chair leaning towards the left in the main activity/dining area on the Gilead Unit. During an observation on 11/30/2022 at 12:00 PM, R9 was sitting up in her broda chair leaning towards the left in the main activity/dining area on the Gilead Unit. During an observation on 11/30/2022 at 12:20 PM, R9 was sitting up in her broda chair leaning towards the left in the main activity/dining area on the Gilead Unit. CNA C reported that she was going to bring R9 back to her room to provide incontinence care and lay R9 down in her bed. CNA C asked another CNA to assist her with getting R9 to bed (R9 utilized a hoyer lift for transferring which required 2 staff assistance) but the CNA was assisting another resident on the unit and was unable to help at that time. CNA stated it'll (R9's incontinence care and chair to bed transfer) have to wait until I can get help. At 12:30 PM, CNA X and CNA C transferred R9 to her bed. CNA C reported that R9's routine is to be transferred to her broda chair prior to breakfast and transferred to her bed after lunch and incontinence care is provided prior to breakfast and after lunch CNA C reported that R9 required full feeding assistance and had to be sitting upright in her broda chair for all meals which was why she remained in her broda chair until after lunch. Review of the Dining Cart Order Schedule revealed breakfast on the Gilead Unit for residents that are assisted begins at 8:30 AM and lunch begins at approximately 12:30 PM with a 15-minute variable, resulting in R9 being in her broda chair for approximately 4-5 hours at a time. R9's bilateral lower extremities were contracted (inability to straighten legs due to shortening and tightening of the muscles) and her knees were rubbing together. R9 had mild redness between her knees and CNA C reported R9 should have a pressure relieving device in place to prevent a pressure injury. R9 was placed in her bed and incontinence was provided. R9's brief was saturated/heavy with urine and stool. R9 had a dressing on her right hip that did not have a date it was applied or the initials of the licensed nurse that completed the dressing change. CNA X reported that the area on R9's right hip was a new area of skin breakdown and CNA C agreed and stated that the skin breakdown was like a blister that popped. R9's sacral wound was uncovered/no dressing in place. CNA C completed pericare on R9 and covered R9's open sacral wound with skin protectant barrier cream. CNA C then placed a clean brief on R9 and repositioned her for comfort. CNA C and CNA X reported that R9 was to be repositioned at least every 2 hours to prevent skin breakdown. CNA C reported that because of the lack of facility staff, R9 would not receive timely incontinence care or repositioning because R9 required 2 staff assistance with hoyer transfers. CNA C reported that when the other CNAs were assisting other residents, there are no additional staff to assist her with transferring R9 to her bed. Review of R9's Progress Note Details from the contracted wound care agency dated 11/22/22 revealed, .Location: Sacrum .Date of Onset: Reported August 2022. Context: Pressure. Associated Signs and Symptoms: Increased pain noted .Nursing staff report patient developed a wound to her sacrum. Patient is dependent on staff for cares and repositioning .Wound Assessment .Sacral is a Stage 3 Pressure Injury Pressure Ulcer and has received a status of Not Healed .There is no change noted in the wound progression .Slightly larger SA (Surface Area) but wound clinically unchanged . Wound Orders .Cleanse wound with Normal Saline or Wound Cleanser. Wound Dressing: Apply hydrocolloid-change dressing 3 times per week; Change dressing as needed for soiling, saturation, or accidental removal. Additional orders: Pressure Relief/Offloading .turn in bed at least once every 2 hours if able-check and change every 2 hours (and PRN) with repositioning . Coordination of Care .Education provided to LPN K on offloading, repositioning, and the importance of dressing remaining in place . Review of R9's November Treatment Administration Record (TAR) revealed, Hydrocolloid dressing right hip and coccyx for protection. change every 3 days and PRN when soiled. every 72 hours for protect right hip. R9's November TAR did not include the contracted wound care agency's wound care order for Cleanse wound with Normal Saline or Wound Cleanser. Review of R9's skin impairment Care Plan revealed, The resident is at risk for impaired skin r/t Disease process dementia, Immobility, Impaired nutritional status, incontinence. Stage 2 pressure ulcer of right coccyx Date Initiated: 08/07/2022 Revision on: 10/21/2022. R9's Care Plan was not revised to reflect R9's sacral Stage III pressure injury nor the pressure injury on her right hip. R9's Care Plan did not include interventions to relieve pressure between R9's knees. (Reference 8) Review of R9's Activities of Daily Living Care Plan revealed, .Check and Change (incontinence care) with AM/HS (morning and bedtime) care and before/after meals .Revision on: 11/03/2021. R9's Care Plan did not reflect the contracted wound care agency pressure relief orders. Review of R9's Skin Care Plan revealed, .Resident on an up and down schedule. Turn frequently, Float heels. Date Initiated: 08/07/2022. R9's Care Plan did not reflect the contracted wound care agency pressure relief orders. REFERENCES: 1.Review of the facility policy Skin Monitoring and Management-Pressure Ulcer dated 7/11/18 revealed, POLICY: It is the policy of this facility that: *A resident who enters the facility without pressure ulcers does not develop pressure ulcers unless the individual's clinical condition or other factors demonstrate that a developed pressure ulcer was unavoidable; and *A resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, unavoidable sores from developing. PURPOSE: The purpose of this policy is that the resident does not develop pressure ulcers unless clinically unavoidable, and that the facility provides care and services to: *Promote the prevention of pressure ulcer development; *Promote the healing of pressure ulcers that are present (including prevention of infection to the extent possible); and *Prevent the development of additional, avoidable pressure ulcers .This policy acknowledges that, in certain circumstances, the development of pressure ulcers is an unavoidable occurrence. In accordance with the guidance issued by the National Pressure Ulcer Advisory Panel (March 2010), the facility recognizes that an unavoidable pressure ulcer is one which developed even though the provider evaluated the individual's clinical condition and pressure ulcer risk factors; defined and implemented interventions that are consistent with individual needs goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate. Facility nursing staff is expected to identify and document the resident's clinical condition and pressure ulcer risk factors related to the development of unavoidable pressure ulcers at the time of admission and thereafter as appropriate. PROCEDURE: RESIDENT ASSESSMENT The nurse responsible for assessing and evaluating the resident's condition on admission and readmission and is expected to take the following actions: A. Complete an admission assessment/evaluation and skin risk assessment to identify risk and to identify any alterations in skin integrity noted at that time . F. Assessment of wounds identified after admission: * A licensed nurse (which may be the facility Wound Nurse) must assess/evaluate a resident's skin at least weekly. All areas of breakdown, excoriation, or discoloration, or other unusual findings must be documented in the resident's clinical record. G. A licensed nurse (which can be the facility Wound Nurse) must assess/evaluate at least weekly each wound, whether present on admission or developed after admission, which exists on the resident. This assessment/evaluation should include but not be limited to: *Measuring the wound *Staging the wound *Describing the nature of the wound (e.g., pressure, stasis, surgical wound) *Describing the location of the wound *Describing the characteristics of the wound *Describing the progress with healing, and any barriers to healing which may exist *Identifying any possible complications or signs/symptoms consistent with the possibility of infection. I. Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's Order. *All wound or skin treatments should be documented in the resident's clinical record at the time they are administered. Stages/Description/Further Description . Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. Stage II: Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. o DOCUMENTATION- A. If the clinical assessment/evaluation indicates a change in condition or decline in the wound, the assessing/evaluating nurse will notify the physician and create a narrative nurse's note documenting that notification. B. Licensed Nurse should document skin evaluations in accordance with this policy in the resident's clinical record. o MONITORING- A. Daily via medication administration and treatment administration records *Ensure all orders have been implemented as ordered. B. Weekly via Weekly Skin Committee *Prepare and maintain Skin Committee review notes and recommendations in the resident's clinical record. *Document and implement recommended additions or changes to care plan in resident clinical record. C. Skin Inspection on Showering *On shower days, CNAs to observe resident skin. *Identify any areas of skin breakdown, discoloration, tears or redness. *Communicate findings to licensed nurse .*Licensed nurse to acknowledge findings, document pertinent information in resident's clinical record, and respond/obtain and implement treatment order as appropriate. D. Weekly skin check conducted by a facility licensed nurse *All residents will have a head to toe skin check performed at least weekly by a facility licensed nurse. *The licensed nurse should document the performance of the skin check in the resident's clinical record. *Any skin issues identified as a result of the weekly skin check should be documented and responded to as outlined above. F. Comprehensive skin review should occur on an as needed basis through the activity of the Interdisciplinary Team *The assessment/evaluation and recommendations of the IDT shall be documented in the resident's clinical record. o COMMUNICATION OF CHANGES A. Any changes in the condition of the resident's skin as identified daily, weekly, monthly, or otherwise, must be timely communicated to: *The resident's physician . o QUALITY ASSESSMENT AND ASSURANCE A. Incidences of skin breakdown which develop after a resident is admitted to the facility, whether the skin breakdown is avoidable or unavoidable, will be reviewed on a monthly basis, at a minimum, by the facility Quality Assurance Committee. B. Resident response to preventive measures and treatment designed to minimize skin breakdown or facilitate healing will be reviewed on a monthly basis, at a minimum, by the facility Quality Assurance Committee. C. The Quality Assurance Committee should, among other things, evaluate strategies to reduce the development and progression of pressure ulcers as well as monitoring the incidence and prevalence of skin breakdown in the facility. D. The activities and work product of the Quality Assurance Committee relative to the evaluation and assessment of skin breakdown, and the incidence and prevalence of skin breakdown in the facility, are protected from discovery or disclosure in accordance with the State Quality Assurance privilege. 2. Review of the National Pressure Injury Advisory Panel (NPIAP) Pressure Injury Stages revealed, .Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions) . Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. The National Pressure Injury Advisory Panel (NPIAP)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #: MI00130971, MI00131278, MI00132243, MI00132497, MI00132931 and MI00132481 Based on observation, interview, and record review, the facility failed to provide sufficient staffing to 1.) prevent resident to resident abuse for 7 residents (Resident #9, #107, #32, #79, #24, #36, and #1), 2.) prevent the development/worsening of facility acquired pressure injuries for 2 residents (Resident #21 and #9), 3.) provide timely incontinence care for 2 residents (Resident #74 and #32), and 4.) provide adequate supervision for residents with known behavioral needs (wandering). This deficient practice places all residents residing in the facility at risk for unmet care needs and impaired physical, mental, and psychosocial well-being. Findings: On 11/28/2022, the current annual recertification survey and a review of several Facility Reported Incidents (FRI) and complaints commenced. It was identified during the onsite survey that the facility did not ensure there was adequate direct care staffing which resulted in the following deficiencies: 1. The facility failed to prevent resident to resident physical and sexual abuse, and protect residents from continued abuse, due to widespread system failures beginning with the failure to complete an annual facility assessment to determine direct care staffing needs, resident acuity, and staff competency and education requirements to meet the needs of residents with known behaviors and protect vulnerable residents. (Refer to noncompliance cited at F600-Abuse and F838-Facility Assessment). F600 Based on interview and record review, the facility . 3.) failed to identify increased behaviors and revise a care plan and 4.) failed to ensure there was sufficient staffing to supervise residents and prevent resident to resident abuse for 7 residents (Resident #9, #107, #32, #79, #24, #36, #1), resulting in a pattern of systemic neglect leading to resident to resident abuse and the decline in mental and psychosocial well-being. F838 Based on interview and record review, the facility failed to complete a comprehensive facility-wide assessment that included an assessment of the staffing needs, resident acuity, and staff training and education requirements, resulting in insufficient staffing to meet the needs of the residents, inadequate knowledge of the facility population and inadequate resources to care for residents and the potential for unmet care needs and physical and psychosocial harm for residents residing in the facility. 2. The facility failed to provide an adequate number of staff to meet the basic needs of the residents related to pressure ulcer prevention/healing, (Refer to noncompliance cited at F686-Treatment and Services to Prevent/Heal Pressure Ulcers) F686 Based on observation, interview and record review, the facility failed to 1.) provide care following professional standards of practice and facility policy to prevent the development/worsening of avoidable pressure ulcers, 2.) assess, monitor, and provide ordered treatment for residents with new/worsening pressure ulcers, and 3.) promptly notify the physician of a change in condition for 2 residents (Resident #21 and #9), reviewed for alterations in skin integrity/pressure ulcers, resulting in unrecognized changes and the worsening of skin impairments, a delay in treatment and the potential for prolonged wound healing, infection, and overall deterioration in health status. Incontinence Care Resident #74 (R74) Review of an admission Record revealed R74 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia. Review of a Minimum Data Set (MDS) assessment for R74, with a reference date of 10/14/22 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated R74 was severely cognitively impaired. During an observation on 11/28/22 at 09:59 AM, R74 was sitting in a chair in the common area of the Gilead Unit (locked dementia unit). R74 stood up from the chair and was visibly agitated and tearful. R74's pants and shirt were saturated with urine extending from her thighs to her midback with a strong odor of urine noted. At 10:02 AM, R74 sat back down sitting at the edge of the chair, appeared restless and shifting her weight back and forth (indicating discomfort). At 10:09 AM, R74 stood up from her chair and began pulling at her saturated pants with continued tearfulness and agitation. R74 began ambulating down the hallway towards the main dining/activity room and the chair she had been using was visibly wet with urine. During an observation on 11/28/22 at 10:14 AM, CNA Y brought R74 to her bathroom and assisted R74 with incontinence care. R74's brief was bulky and excessively saturated with urine. The entirety of R74's buttocks was erythemic (bright red) from prolonged exposure to urine in a heavily saturated brief. Resident #32 (R32) Review of an admission Record revealed R32 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: alcohol use with alcohol-induced dementia, major depressive disorder, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for R32, with a reference date of 11/3/22 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated R32 was severely cognitively impaired. Review of R32's bladder Care Plan revealed, Resident has occasional bladder incontinence r/t (related to) Confusion, Dementia, Poor toileting habits Date Initiated: 05/11/2021 . Review of R32's Skilled Nursing note dated 11/17/22 revealed, Resident has been identified as having declines in dressing, toileting, and hygiene . During an observation on 11/29/22 at 08:40 AM, R32 was walking down the hall saturated with urine. Urine was observed on the buttock area of his pants and up to the lower back area of his shirt with a strong odor of urine noted. At 08:44 AM surveyor notified Licensed Practical Nurse (LPN) A that R32 was saturated with urine. LPN A walked R32 down to his room and had him sit in his cloth recliner on top of a thin blanket. LPN A then left the room without assisting R32 with incontinence care and a clothing change. LPN A returned to the medication cart to continue morning medication administration. During an observation on 11/29/22 at 08:44 AM-09:06 AM, R32 was left sitting in his recliner saturated with urine until Certified Nursing Assistant (CNA) W was finished providing care for another resident on the unit. During an interview on 11/29/22 at 09:07 AM, CNA W reported that there was not sufficient staff to meet the physical and behavioral needs of the residents. CNA W reported that 2nd shift is scheduled to have 3 CNAs on the floor and 1 support CNA to monitor residents in the main area. CNA W reported that there are times when 2nd shift only has 2 CNAs on the floor and that is not enough to control (R32) and (R24) specifically. CNA W reported that there are many residents on the Gilead Unit that wander and there is no way to manage behaviors, prevent resident to resident altercations, and/or wandering in and out of the rooms. CNA W reported that R32 and R24 have wandering tendencies that require frequent redirection. Resident Supervision During an observation and interview on 11/29/22 at 08:45 AM, a female resident in the Gilead Unit dining room ambulated down the hall to R32's room, entered his room, and used his bathroom. Shortly after the female resident entered R32's room/bathroom, LPN A and R32 entered his room so R32 could receive incontinence care. LPN A observed the female resident exit R32's bathroom and reported it was not uncommon for that female resident to wander into resident rooms to use the bathroom. LPN A stated, she gets lost, we redirect her. LPN A reported that the Gilead Unit had a lot of residents that have wandering behaviors which require supervision and a locked unit. During an observation on 11/29/2022 at 2:55 PM, R24 entered R32's room, opened R32's nightstand, removed an item of food from the nightstand and began eating it. A female resident then entered R32's room while R24 was still in there. While R24 and the female resident were in R32's room, a second female resident attempted to enter R32's room. During an interview on 11/29/2022 at 3:00 PM, LPN M reported that the Gilead Unit was staffed with 3 CNAs at that time and 1 CNA was pulled to another unit. LPN M reported that it was difficult to monitor residents that wander in and out of rooms, especially (R32) and (R24) and reported R32 and R24 were often involved in resident-to-resident altercations. LPN M reported that dinner time to bedtime was the most difficult time of the shift because the CNA's had to assist with feeding, changing, nighttime care, and getting residents to bed. LPN M reported the Gilead Unit needed additional staff to supervise residents that wander in and out of rooms and upset other residents. During an observation on 11/30/2022 at 12:01 PM, R24 was observed ambulating up and down the hallway. R24 walked past a resident in the hallway and was less than 6 inches away from the resident. There were no staff observed on the Gilead Unit at that time. R24 has been the aggressor in multiple recent FRI's regarding resident-to-resident abuse. During an observation on 11/30/2022 at 1:05 PM, R32 was ambulating up and down the hall, smiling and talking nonsensically, and stopped in front room [ROOM NUMBER] (female room). A female resident residing in room [ROOM NUMBER] observed R32 standing in her doorway facing into her room. The female resident ambulated down the hall appearing anxious and concerned that R32 would enter. The female resident (able to make needs known with a BIMS of 9/15) used hand motions (pointing and wrist flicking) to prompt/encourage R32 to step away from her doorway and then stood in her doorway to block R32 from entering her room. The female resident and R32 were within arm's reach with no staff observed on the Gilead Unit during the encounter (no physical or verbal aggression was noted during their interaction). R32's Electronic Health Record revealed documentation that R32 would become angry with redirection, agitated and combative with attempted assist, and combative with staff at times during encouragement placing residents that attempt to redirect R32 out of and/or away from their room at risk for physical/verbal abuse. R32's known behavior of wandering into resident rooms has resulted in recent FRI's regarding resident-to-resident physical and sexual abuse. During an observation on 11/30/2022 1:10 PM, R2 was in her wheelchair in the common area on the Gilead Unit. R2 reported she wanted to go to her room but was unable to self-propel herself in the wheelchair. R2 appeared agitated and frustrated, repeatedly attempted to stand, and demanded an ambulatory resident push her to her room. There were no staff observed on the Gilead Unit at that time. During an observation on 11/30/2022 at 1:24 PM, R32 walked closely past R74 in the common area on the Gilead Unit. R74 angrily shouted, get away from me you creep. Indicating residents on the Gilead Unit require close supervision to prevent resident to resident abuse. Resident and Staff Interviews During an interview on 11/28/22 from 10:31 AM-11:24 AM with R79 and R36, R36 reported that there are 2 residents that wander the units and like to go through people's rooms. R36 reported that the 2 residents that wander the halls and enter resident rooms are R32 and R24. R36 reported that both residents had recently entered his room without invitation (intake 132481). R36 reported that he raised my voice to get them to leave and R24 took a swing at me. R36 reported fear with 2 men trying to accost me. R36 reported that he pushed him away with my leg and then R32 came at me. R36 reported that he had to use his walker to protect himself and it took everything I could to get away from them. R36 reported that R24 and R32 are left unsupervised and they are dangerous together. R36 reported that residents that require supervision are not supervised. R36 reported that the facility had a couple other (residents) that were bad news. R36 reported that a few months ago R107 sexually assaulted a female resident (R36 was able to name R107 and R9-intake 132243). R36 stated the Gilead Unit is a vulnerable area. These women can't protect themselves from the residents with known behaviors. R79 reported that approximately 2 weeks prior she was in bed sound asleep and (R32) grabbed my boobs. I screamed! (intake 132931) R79 reported fear when she woke to a man standing over her and ongoing fear and anxiety that there have been no changes made to prevent another occurrence. R79 stated the facility needs to hire one person as a pair of eyes to watch the guys (R32 and R24). R79 reported that there were not enough staff to meet the needs of the residents and the staff can't keep up. R79 reported that there was recently a night shift where there was only 1 CNA for all of the residents on the Gilead Unit. R79 reported that there are 2 CNAs scheduled for 3rd shift and there's no way they can have 2 staff at night to watch those 2 guys (R24 and R32). It's not enough. They try hard but they can't do it (their jobs) with 2 guys that are extra trouble. R36 reported that they try to get R24 and R32 to stay out of other rooms by putting up stop signs (Velcro mesh across resident doorways) but R24 will remove the stop sign from the doors and enter the room. R36 reported that R32 recently went around peeing in garbage and sinks but not the toilet because of the lack of staff/supervision. R79 reported that she is fearful of R24 and if you say something (R24) doesn't like he (punching motion) and the nurses are scared of him. R79 stated, there's not enough staff to give care and attention to residents. If they could bring more staff on it would be perfect. During an interview on 11/30/2022 at 12:40 PM, CNA X reported that residents were not receiving the care they required because of the lack of staff. CNA X reported that there were many residents on the Gilead Unit that required extensive assist or 2 assist with cares and the staff were expected to monitor and supervise (R32) and (R24). CNA X reported that when a resident that requires 2 persons assist for care is being helped, it takes 2 CNAs off the floor which results in even less supervision for R32 and R24. CNA X reported that because of the lack of staff available on the Gilead Unit she has seen an increase in resident falls and resident to resident altercations. CNA X reported that if there is a call off on another unit, they pull from the Gilead Unit. CNA X reported that second shift is the most difficult because they are expected to monitor R32 and R24 while also providing care to all the residents (incontinence care, toileting, repositioning), assisting with dinner (passing trays, feeding, picking up trays), monitoring residents that are sundowning (increased behaviors that occur in the evening), and putting the residents to bed. CNA X reported that there were many residents that required 2-person assistance to get to bed because of their use of a hoyer lift. CNA X reported that it was not reasonable to expect that ADL care and supervision can be completed with the number of staff available. During an interview on 12/01/2022 at 12:45 PM, DON reported that only she and LPN K were part of the nursing management team. DON reported that LPN K was working as the Unit Manager as well as the Wound Care Program nurse. DON reported that the Infection Preventionist/Assistant Director of Nursing had abruptly quit on 11/30/22 at 7:30 PM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes #: MI00132481, MI00132243, MI00132497, and MI00132931 Based on interview and record review, the facility 1.) failed to ensure a comprehensive facility-wide assessment that included an assessment of the staffing needs, resident behaviors (wandering), resident acuity, and staff training and education requirements was complete and accurate, 2.) failed to evaluate the effectiveness of the interventions in place for residents with known behaviors, 3.) failed to identify increased behaviors and revise a care plan and 4.) failed to ensure there was sufficient staffing to supervise residents and prevent resident to resident abuse for 7 residents (Resident #9, #107, #32, #79, #24, #36, #1), resulting in a pattern of systemic neglect leading to resident to resident abuse and the decline in mental and psychosocial well-being. Findings: Resident #9 (R9) Review of an admission Record revealed R9 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: dementia and kidney disease. Review of a Minimum Data Set (MDS) assessment for R9, with a reference date of 9/2/22 revealed R9 was cognitively impaired. Resident #107 (R107) Review of an admission Record revealed R107 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: restlessness and agitation, schizophreniform disorder, major depressive disorder, and dementia. Review of a Minimum Data Set (MDS) assessment for R107, with a reference date of 7/28/22 revealed a Brief Interview for Mental Status (BIMS) score of 4, out of a total possible score of 15, which indicated R107 was severely cognitively impaired. Review of R107's Care Plan for behaviors revealed, Focus-Resident has a behavior concern r/t (related to) dementia & depression. Has the potential to wander and may be friendly toward females (asks staff if they are married or make inappropriate/vulgar comments) Resident may touch female. May ask them for sex or make inappropriate gestures toward them (fondled self). May refuse to keep clothing and brief on. Date Initiated: 08/10/2021 . Indicating inappropriate sexual behavior was known and ongoing since the time of admission (greater than 1 year). Review of R107's Care Plan for behaviors revealed, Interventions-Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Put up stop barriers on the doors of female rooms on the same hallway. Date Initiated: 10/11/2021 .Redirect/distract res. from rooms and carts and offer assistance. Date Initiated: 11/17/2021 . Review of R107's Care Plan for wandering/elopement revealed, Resident is an elopement risk and/or exhibits wandering behavior r/t dementia. Per wife, has a history of wander halls and rooms. May go into other resident rooms with or without clothing on (a sexually inappropriate behavior). Date Initiated: 08/09/2021 . Indicating behavior was known and ongoing since the time of admission (greater than 1 year). Review of R107's Progress Note dated 9/3/22 revealed, Behaviors all shift. Coming out of room and taking food from people and eating it. Unable to redirect or to stop behavior. Becomes aggressive with attempts to stop. Asking for multiple drinks, etc. Seems unable to notice when he has had sufficient food. Review of R107's Progress Note dated 9/7/22 revealed, Resident had multiple behaviors all shift. Looking for cigarettes and coffee. Became angry and striking out at staff with redirection. Resident required close supervision t/o (throughout) shift. Cena (CNA-Certified Nursing Assistant) was able to redirect resident to his bed at this time. Review of R107's Progress Note dated 9/12/22 revealed, resident very combative last night. Needed to be redirected several times. Verbally aggressive with room mate (sic). Moved to new room for the night so there was no confrontation with room mate (sic). R107's Care Plan was not updated to reflect verbal aggression with roommate/room change. Review of R107's Progress Note dated 9/14/22 revealed, Resident was up multiple times through out (sic) the night, seeking drinks and food. Very difficult to redirect, yelling and combative with staff. Required close supervision through out (sic) shift. Review of R107's Progress Note dated 9/18/22 revealed, Intrusive behavior in early morning . Review of R107's Progress Note dated 9/19/22 at 9:17 PM revealed, Resident was intrusive going into other resident rooms, looking for food and drinks. Angry and striking out at staff with redirection. Resident given food and drinks from pantry. But behaviors continues (sic). Required close supervision through night. Review of R107's Progress Note dated 9/20/22 at 2:00 PM revealed, Resident was intrusive going into other resident rooms, looking for food and drinks. Resident given food and drinks. Behaviors continue. Required close supervision throughout shift . Review of R107's Progress Note dated 9/23/22 at 1:56 AM revealed, Resident up walking in hallway since beginning of shift .Resident aggressive toward staff and making inappropriate statements, putting his fists up as if to hit staff. Demanding more drinks and snacks. Angry facial expression . Review of R107's Progress Note dated 9/23/22 at 9:37 PM revealed, Resident was walking up and down hallways and going into other residents rooms looking for food and drinks. Resident was very difficult to redirect. Angry with redirection. Striking out at staff and verbally abusive. Resident given food and drinks but behaviors continues (sic). Resident required close supervision due to intrusive behaviors . Review of R107's Progress Note dated 9/24/22 at 2:43 PM revealed, Restlessness, seeking food and drinks throughout shift. Going into other resident rooms and taking med pass, applesauce, and pudding off med carts. Continuously hungry. Redirected with activities with little effect. Review of R107's Social Service note dated 9/15/22 revealed, IDT (Interdisciplinary Team) reviewed res. (resident) in behavior/psychotropic committee meeting today 9.15.22. This is a follow up from previous meeting 9.8.22 when res. Was started on Abilify. IDT reviewed medications and behaviors. No further concerns noted, therefore no further recommendations made by IDT at this time . Review of R107's Social Service note dated 9/22/22 revealed, IDT reviewed res. in behavior/psychotropic committee meeting today 9.22.22. This is a follow up from previous meeting 9.15.22 when resident had some increased appetite. IDT reviewed medications and behaviors. No further concerns noted, therefore no further recommendations made by IDT at this time . On 9/7/22, 9/14/22, 9/19/22, and 9/20/22 nursing staff documented in R107's Progress Notes that R107 required close supervision for his behaviors and on 9/12/22 R107 was verbally aggressive with his roommate which resulted in him moving to another room. The IDT met on 9/15/22 and 9/22/22 to review R107's medications and behaviors. There were no concerns noted and no recommendations made indicating the IDT team did not identify R107's escalating behaviors now required close supervision and a room change. R107's Care Plan was not updated with interventions to keep himself and/or other residents safe from his behaviors. Review of R107's Care Plan revealed, Encourage res. (resident) to be close to staff and/or eye sight (sic) when able (or when out of room). Date Initiated: 09/27/2022 . Indicating the Care Plan for his increase in behaviors was updated after the Resident to Resident incident occurred. Review of a Witness Statement written by Activity Assistant (AA) Q revealed, At the request of nursing, this is my account of (R107) behaviors 9/24/22. (R107) was very disruptive from morning up until the incident with (R9). Stealing res (resident) beverages. Entering res rooms + startling them . Review of the Facility Reported Incident revealed that on 9/24/22 at 4:00 PM, (R107) was witnessed with his pants pulled down on top of (R9) while she was laying in her bed fully clothed (gown and brief on and not tampered with) her bed sheets were pulled up covering her body . (R107) was sent out to the hospital for evaluation . Through the investigation it was determined that prior to this event, (R107) did not display sexually inappropriate behavior toward other residents, he had historically directed his comments toward staff members and had been making comments throughout the day to staff members . Administrator spoke with (Family Member FM O), wife/guardian on 9/24/22 to inform her of the incident that occurred and his transfer to the hospital for further evaluation. At this time (FM O) stated that (R107) had no history of sexual behaviors towards other residents in the past and was surprised to hear of the incident . CONTRIBUTING FACTORS/ROOT CAUSE ANALYSIS: The primary root cause of (R107) sexually inappropriate behavior is due to his dementia and impaired ability to control impulsive behavior. In addition to the root cause, there are multiple contributing factors relating to the allegations: (R107) is diagnosed with schizophreniform disorder, dementia with behavioral disturbance, major depressive disorder, and restlessness/ agitation. (R107) had a medication change on 8/25/2022 and started on Abilify for major depressive disorder, which was a new medication for him. (R107) recently had moved rooms . Indicating the facility identified possible agitators that caused an increase in R107's behaviors and no new interventions were implemented prior to the incident. During an interview on 12/01/22 at 04:07 PM, FM O reported that the incident never should have occurred. FM O reported that the facility wasn't paying attention to this particular (dementia) unit and she could not understand how there were no staff supervising the residents, with known wandering behaviors, to prevent this type of situation. FM O stated, if they had been paying attention this wouldn't have happened. Review of the staffing schedule dated 9/24/22, the Gilead Unit had 1 support aide, 2 nurses, and 3 CNA's (Certified Nursing Assistant) scheduled at the time of the incident between R107 and R9. A 4th CNA was scheduled to work from 5-9 PM. Resident #32 (R32) Review of an admission Record revealed R32 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: alcohol use with alcohol-induced dementia, major depressive disorder, and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for R32, with a reference date of 11/3/22 revealed a Brief Interview for Mental Status (BIMS) score of 3, out of a total possible score of 15, which indicated R32 was cognitively impaired. Review of R32's behavior Care Plan revealed, Resident has a behavior concern r/t Depression, anxiety, and Dementia (memory issues). He may exhibit refusals of care (showers/clothes changes), may become combative/aggressive (grab staff arm/hand, swat at staff, chest bump, push staff out of room). Res. may have boundary issues and/or walk up to another res. and/or talk to them while tapping or placing hand on their shoulder/arm. Resident may wander into other resident's rooms touch their belongings, stand over them while they sleep, lay in empty beds. Patient wanders, and may paces and rummage in his room, and at times in his roommate's personal space, putting him at risk for intruding on the privacy of others. Date Initiated: 06/11/2021 . Resident #79 (R79) Review of an admission Record revealed R79 was an [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: lung disease, heart failure, dementia. Review of a Minimum Data Set (MDS) assessment for R79, with a reference date of 10/25/22 revealed a Brief Interview for Mental Status (BIMS) score of 9, out of a total possible score of 15, which indicated R79 was moderately cognitively impaired. Review of the Staffing Schedule dated 11/20/22 for the shift 10 PM-6 AM revealed there were 2 CNA's and 1 nurse working on the Gilead Unit at the time of the incident. Review of R79's Witness Statement dated 11/21/22 revealed, Last night around 2am-3am, I was lying down in bed on my back, he came in and said them are mine referring to my breasts. He grabbed my breasts over the top of my pajama shirt and bra. I screamed for the nurse, she came in and got him out. Then he came back about 20 min later. I yelled at him you can't touch me, and I hit him on the head. I yelled for the nurse again and they took him out again .(R32) has been here too long, he goes in/out of rooms, he could rough anyone up at any time (interview with police officer) he came into my room [ROOM NUMBER] times last night. That man. (Could not provide a name or description after prompting from the officer). He said I want to feel you up and grabbed my breasts. I yelled Nurse, Nurse. Then he came back a second time and he grabbed them again and I yelled at him to get out and called for the Nurse. He didn't say anything the second time when he grabbed me. Then he came in another time and I yelled at him to get out. Review of CNA R's Witness Statement dated 11/21/22 revealed, (R32) walked into her room [ROOM NUMBER] times last night. The first time it was around 1:30am and I was in the middle of doing my rounds actively changing someone when I heard (R79) yell Nurse, nurse. The minute I could, I went in the room and directed (R32) out of the room. It took me maybe 1-2 minutes to get there from the time (R79) yelled for help, I was in the room next door .When I entered the room (R79) was lying in bed and (R32) was standing next to the recliner which is in the middle of the room. All (R79) said was if he comes in again I am going to kick his ass. From what I could see he was at least 10' away from her and not close enough to touch her .I went to change another person and again he went to her room and she got angry again. Less than 10 minutes had passed. He barely made it through the threshold of the door the 2nd time and I caught him immediately and redirected him .(R32) has a history of wandering and there were no allegations made last night . Review of CNA S's Witness Statement dated 11/21/22 revealed, I saw CNA R redirecting (R32) in the hallway last night and she (R79) came out and told me that the next time he came in her room I will beat his ass, or something to that effect. I said (R79) you aren't going to do that, he doesn't know any better . Review of LPN T's Witness Statement dated 11/21/22 revealed, .As far as I know I thought (R32) was in bed for the majority of my shift last night. The facility investigation indicated a lack of supervision for R32 when it was known he was entering R79's room. There were no immediate interventions put in place for R32's behaviors after he entered R79's room the first time causing R79 to be fearful and threaten physical violence against R32 when he attempted to enter her room the 2nd time. The FRI did not reflect that increased supervision or other interventions were implemented that would avoid psychosocial harm or physical abuse between R32 and R79. Additionally, the facility failed to affirm R79's fearfulness resulting in mental anguish despite the nature of the allegation (unwitnessed sexual assault). Review of R79's Police Report dated 11/22/22 revealed, .(R79) stated that she wanted (R32) out of the unit because she doesn't feel safe when he wanders . Review of a Facility Reported Incident between R79 and R32 revealed, On 11/21/2022 around 3:30pm Administrator was notified of potential abuse allegation between (R79) and (R32). It was reported that (R32) entered (R79's) room and attempted to touch her. Facility to initiate investigation.(R79) was likely startled by (R32) wandering into her room and it caused her to change her story in various ways in hopes that it would cause him to be removed from the facility. · (R79) has a history of making false accusations which are a part of her preexisting mood and behavior care plans. Her decision making and impulse control are both impaired due to her dementia diagnosis. (R32) also has an impairment in decision and impulse control, with a history of wandering, this likely caused him to wander into her room at various points throughout the evening. Both residents reside on the memory care unit, and both have diagnosis of dementia and poor decision-making abilities. DETERMINATION OF FINDINGS/CONCLUSION: Based on the findings of the investigation including interviews with the residents, review of the clinical record and interviews with staff members identified above, a decisive conclusion was made the occurrence was NOT the result of abuse, neglect, misappropriation, or harm. The event is determined to not have occurred. The abuse policy was followed . The facility determined the allegation did not occur although there were no witnesses present when R32 was alone in R79's room unsupervised. Review of the Quality Assessment and Assurance Committee minutes dated 11/22/22 revealed, Review & discuss outcomes of investigation of Abuse: 11/21/2022 (R32) vs. (R79) Abuse-Root Cause-(R32) entered (R79's) room and it startled her. she changed her story numerous times throughout the day in hopes that it would cause (R32) to get kicked out of the facility after talking with her friend (R36). She also changed her story again after speaking to administration and the police. *Immediate intervention-stop sign on (R79's) door, 15 minute checks for (R32) and (R79), encourage (R79) to sleep with her bedroom door shut in the evening. The Quality Assessment and Assurance Committee minutes did not address R32's wandering behaviors, staffing (required to redirect wandering behavior that impacts other residents), or supervision to prevent further abuse and/or allegations. Review of R79's mood Care Plan revealed, .Offer support visits to assist with any upset mood/behavior. Offer stop signs for doorway and suggest door is closed to reduce other resident's entering Date Initiated: 07/23/2021 Revision on: 09/27/2022 . prior to the facility reported incident of alleged resident to resident sexual assault. Review of R79's mood Care Plan revealed, .Offer support visits to assist with any upset mood/behavior. Offer stop signs for doorway and suggest door is closed to reduce other resident's entering Date Initiated: 07/23/2021 Revision on: 11/21/2022 . Indicating R79's Care Plan was not updated with new interventions following the incident. R79's Care Plan did not have an intervention related to 15 minute checks, invalidating the facility report to the state agency claiming meaningful changes to the plan of care had been implemented. Review of R32's behavior Care Plan revealed, .15-minute checks during the night x72 hours Date Initiated: 11/21/2022 . despite the fact that CNA R reported that R32 attempted to reenter R79's room when less than 10 minutes had passed. Resident #24 (R24) Review of an admission Record revealed R24 was a [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: alcohol induced dementia, post-traumatic stress disorder, alcohol dependence, psychotic disorder with delusions due to known physiological condition, and major depressive disorder. Review of a Minimum Data Set (MDS) assessment for R24, with a reference date of 8/31/22 revealed a Brief Interview for Mental Status (BIMS) score of 2, out of a total possible score of 15, which indicated R24 was severely cognitively impaired. Review of R24's behavior Care Plan revealed, Resident has a behavior concern d/t (due to) PTSD (Post Traumatic Stress Disorder), Dementia, Psychotic disorder w/ delusions. He may push/grab staff, use abusive/vulgar language (swear/use the F word), use hand gestures, slap at staff, May be physical with staff and/or others. May also have aggressive/threatening behavior and/or reject care (incontinence). Often above behaviors occur when he is rejecting care. May use tray tables or walkers inappropriately and throw things. May swing wet floor signs at others or throw walker. May try to stab at staff with pens May go into other resident's rooms when wandering the unit. Res. may also retaliate when feeling threatened. May be affectionate with female residents Date Initiated: 08/31/2021 Revision on: 11/21/2022 . Resident #36 (R36) Review of an admission Record revealed R36 was an [AGE] year-old male, originally admitted to the facility on [DATE], with pertinent diagnoses which included: unspecified dementia, without behavioral disturbance Review of a Minimum Data Set (MDS) assessment for R36, with a reference date of 8/24/22 revealed a Brief Interview for Mental Status (BIMS) score of 10, out of a total possible score of 15, which indicated R36 was moderately cognitively impaired. Review of the Facility Reported Incident for R36, R24, and R32 revealed, .On 10/13/2022 at 4:25 PM, staff witnessed resident (R36) in his room, using a walker to push resident (R32) away from him. Another resident, (R24) was also in the room at the time. (R36) stated when staff came in to assist, that he was trying to get (R32) and (R24) out of his room. (R36) said that (R24) took a swing at him .(R32) and (R24) have a history of wandering behavior due to their dementia diagnosis .(R36) was interviewed and gave an account for what happened in his room. He stated that (R24) took a swing at me and (R32) came down too, they were both in my room. He said that when (R24) took a swing at him, he said had no choice but to defend himself. He said he told them two times that they have to get out of here, that is when (R24) took a swing at him. (R36) said that he got (R24) away from him and then grabbed the walker that was in his room to put between himself and (R32) so he would not come near him .The root cause of the incident was (R24) and (R32) entering (R36's) room. This caused (R36) to become upset with the gentlemen. When he asked (R36) to get out of his room that is what triggered (R24's) response of, reportedly swinging at him. (R24's) cognitive status caused him to respond to (R36's) request to leave his room, in the manner in which he did. When (R32) started walking toward (R36), (R36) felt as though he had to protect himself, so his immediate response was to grab the walker and place it between them. Conclusion: Based on the findings of the investigation including interviews with the residents, review of the clinical record and interviews with staff members identified above, a decisive conclusion was made the occurrence was NOT the result of abuse, neglect, misappropriation or harm. It can not be substantiated that (R24) took a swing at (R36) as (R36) does have impaired cognition and the event was not witnessed. However, it was witnessed that (R36) did use a walker to push between himself and (R32). (R36) did not take this action with intent to cause harm to others, but with an intent to encourage (R32) to leave his room and to defend himself. The event did not result in harm, pain, or mental anguish and all three residents remain at their baseline. It is not substantiated that an intent to cause harm or intent for any lasting negative impact exists . R32's Care Plan was not updated following this altercation that resulted from his wandering behavior. Resident #1 (R1) Review of an admission Record revealed R1 was a [AGE] year-old female, originally admitted to the facility on [DATE], with pertinent diagnoses which included: Unspecified dementia with behavioral disturbance and anxiety disorder. Review of a Minimum Data Set (MDS) assessment for R1, with a reference date of 8/19/22 revealed a Brief Interview for Mental Status (BIMS) score of 6, out of a total possible score of 15, which indicated R1 was cognitively impaired. Review of the Facility Reported Incident for R1 and R24 revealed, .On 10/16/2022 at 5:45 AM, facility administrator was notified of a potential resident to resident altercation. Staff witnessed (R1) yelling at (R24) to get out of her room. As he was wandering out (R1) hit (R24) .(R24) is independent with ambulation using a front wheeled walker, and frequently wanders throughout the unit . (R1) was heard yelling at (R24) to get out of her room. As he was leaving the room, she was seen hitting (R24) and losing her balance, in which point she fell . Root Cause Analysis/Contributive Factors: The investigation determined the event occurred and is likely related to (R24) wandering into (R1) room. (R24) wandered into (R1) room, this startled her and caused her to respond by yelling. As he was leaving her room, she hit him which was due to her lack of impulse control and poor decision-making abilities related her dementia diagnosis. Both residents have dementia and impairment related to decision making. DETERMINATION OF FINDINGS/CONCLUSION: Based on the findings of the investigation including interviews with the residents, review of the clinical record and interviews with staff members identified above, a decisive conclusion was made the occurrence was NOT the result of abuse, neglect, misappropriation or harm. The event is determined to have occurred but due to the residents impaired cognition, they were unable to form a willful intent to cause harm. (R1) was responding to (R24) wandering into her room, causing her to yelling and hit him. The IDT with input from frontline staff and developed new meaningful interventions for (R24). Both residents remain unchanged from baseline . R24's Care Plan was not updated following the altercation on 10/13/22 that resulted from his wandering behavior. There were no interventions implemented to prevent additional occurrences of resident to resident abuse due to R24's wandering behaviors. Review of R24's behavior Care Plan revealed, .Monitor/distract as able away from other rooms. Date Initiated: 10/16/2022 . Review of R24's behavior Care Plan revealed, .Monitor/distract as able from other rooms. Try to keep in common areas of the unit. Revision on: 10/17/2022 . During an interview on 11/28/22 from 10:31 AM-11:24 AM with R79 and R36, R36 reported that there are 2 residents that wander the units and like to go through people's rooms. R36 reported that the 2 residents that wander the halls and enter resident rooms are R32 and R24. R36 reported that both residents had recently entered his room without invitation (intake 132481). R36 reported that he raised my voice to get them to leave and R24 took a swing at me. R36 reported fear with 2 men trying to accost me. R36 reported that he pushed him away with my leg and then R32 came at me. R36 reported that he had to use his walker to protect himself and it took everything I could to get away from them. R36 reported that R24 and R32 are left unsupervised and they are dangerous together. R36 reported that residents that require supervision are not supervised. R36 reported that the facility had a couple other (residents) that were bad news. R36 reported that a few months ago R107 sexually assaulted a female resident (R36 was able to name R107 and R9-intake 132243). R36 stated the Gilead Unit is a vulnerable area. These women can't protect themselves from the residents with known behaviors. R79 reported that approximately 2 weeks prior she was in bed sound asleep and (R32) grabbed my boobs. I screamed! (intake 132931) R79 reported fear when she woke to a man standing over her and ongoing fear and anxiety that there have been no changes made to prevent another occurrence. R79 stated the facility needs to hire one person as a pair of eyes to watch the guys (R32 and R24). R79 reported that there were not enough staff to meet the needs of the residents and the staff can't keep up. R79 reported that there was recently a night shift where there was only 1 CNA for all of the residents on the Gilead Unit. R79 reported that there are 2 CNAs scheduled for 3rd shift and there's no way they can have 2 staff at night to watch those 2 guys (R24 and R32). It's not enough. They try hard but they can't do it (their jobs) with 2 guys that are extra trouble. R36 reported that they try to get R24 and R32 to stay out of other rooms by putting up stop signs (Velcro mesh across resident doorways) but R24 will remove the stop sign from the doors and enter the room. R36 reported that R32 recently went around peeing in garbage and sinks but not the toilet because of the lack of staff/supervision. R79 reported that she is fearful of R24 and if you say something (R24) doesn't like he (punching motion) and the nurses are scared of him. R79 stated, there's not enough staff to give care and attention to residents. If they could bring more staff on it would be perfect. During an interview on 11/29/22 at 08:45 AM, LPN A reported that the Gilead (name of locked dementia unit) Unit had a lot of residents that have wandering behaviors which require supervision and a locked unit. During an interview on 11/29/22 at 09:07 AM, CNA W reported that there was not sufficient staff to meet the physical and behavioral needs of the residents. CNA W reported that 2nd shift is scheduled to have 3 CNAs on the floor and 1 support CNA to monitor residents in the main area. CNA W reported that there are times when 2nd shift only has 2 CNAs on the floor and that is not enough to control (R32) and (R24) specifically. CNA W reported that there are many residents on the Gilead Unit that wander and there is no way to manage behaviors, prevent resident to resident altercations, and/or wandering in and out of the rooms. CNA W reported that R32 and R24 have wandering tendencies that need direction. During an interview on 11/29/2022 at 3:00 PM, LPN M reported that the Gilead Unit was staffed with 3 CNAs at that time and 1 CNA was pulled to another unit. LPN M reported that it was difficult to monitor residents that wander in and out of rooms, especially (R32) and (R24) and reported R32 and R24 were often involved in resident-to-resident altercations. LPN M reported that dinner time to bedtime was the most difficult time of the shift because the CNA's had to assist with feeding, changing, nighttime care, and getting residents to bed. LPN M reported the Gilead Unit needed additional staff to supervise residents that wander in and out of

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes MI00127897 and MI00128815 Based on observation, interview, and record review, the facility failed to provide quality care to 6 residents, (Resident #7, Resident #20, Resident #8, Resident #13, Resident #15, Resident #21) out of 21 resident's sampled, resulting in lack of available fluids, delays in staff response to care needs, increased risk for infection, undetected neurological changes after a fall, decreased feelings of self-worth when not provided regular bathing, and unrelieved pain. Findings: Resident #7 (R7) Review of an admission Record revealed R7 was a [AGE] year old male, most recently admitted to the facility from the hospital on [DATE], with pertinent diagnoses of a stroke, contractures of the right hand and wrist and both knees and ankles, Diabetes Mellitus type 2, Chronic Kidney Disease-stage 2, blindness in one eye and low vision in the other eye (see's only shadows), moderate protein calorie malnutrition, and retention of urine and use of a foley catheter. R7 is his own responsible person and primary language is Spanish. Review of a Kardex (a quick reference bedside care guide) for R7 reflected the following instructions for care: (1) showers on Saturday, (2) keep frequently used items within reach, (3) encourage resident to be up in wheelchair for all meals, (4) liquids in a cup with handle and lid, (5) elevate heels off bed surface while at rest in bed, and (6) long pillow against wall by knees when in bed. Review of a Care Plan for R7 (in addition to the above referenced Kardex care instructions) revealed the following directions for the residents plan of care: (1) place positioning wedge under right side of residents trunk and left arm for support at all times when resident is resting in bed, (2) encourage resident to sit on toilet to evacuate bowels if possible, (3) protective boots on while in bed to protect heels, (4) priority frequent assisted repositioning, (5) apply splint to right hand for 3 hours every day, and (6) follow established plan of care within the facility to assist resident in maintaining optimal levels of strength, function, and medical status. During an observation on 11/01/22 at 8:15 AM, R7 sat in bed, flat on his back, the head of the bed at 30 degrees, and watching tv. R7 was malodorous, with a strong smell of urine. R7 did not have protective boots on, did not have a positioning wedge under the right side of R7's trunk and arm, did not have a cup with a handle for fluids, did not have a splint on his right hand, and did not have a long pillow against the wall by his knees. The styrofoam cup of water was dated 10/31/22- 2nd shift. R7 indicated that he had moved his bowels earlier this morning and asked to be changed but was told that he would have to wait until after he had breakfast. As of this interview, staff had not been back to change him. R7 stated that staff do not attempt to get him up to the toilet to move his bowels. They tell me to use the brief. R7 also stated that staff do not get him up in the wheelchair for meals and that he just stays in bed all day. When asked when the last time R7 has a shower, R7 responded a very long time and stated that staff clean him up in bed a little when they do come and check him. During an observation on 11/01/22 at 10:49 AM, R7 sat in bed, flat on his back, the head of the bed at 30 degrees, and watching tv. R7 was malodorous, with a strong smell of urine. R7 did not have protective boots on, did not have a splint on the right hand, did not have a positioning wedge under the right side of R7's trunk and arm, did not have a cup with a handle for fluids, and did not have a long pillow against the wall by his knees. The styrofoam cup of water was dated 10/31/22- 2nd shift. R7 indicated that staff had come in and changed his brief. During an observation on 11/01/22 at 2:20 PM, R7 sat in bed, remained flat on his back, the head of the bed at 30 degrees, and watching tv. R7 was malodorous, with a strong smell of urine. R7 did not have protective boots on, did not have a splint on the right hand, did not have a positioning wedge under the right side of R7's trunk and arm, did not have a cup with a handle for fluids, and did not have a long pillow against the wall by his knees. The styrofoam cup of water was dated 10/31/22- 2nd shift. R7 indicated that staff have not repositioned him since the morning. During an observation on 11/01/22 at 4:26 PM, R7 sat in bed, remained flat on his back, the head of the bed at 30 degrees, and watching tv. R7 was malodorous, with a strong smell of urine. R7 did not have protective boots on, did not have a splint on the right hand, did not have a positioning wedge under the right side of R7's trunk and arm, did not have a cup with a handle for fluids, and did not have a long pillow against the wall by his knees. R7 indicated that staff have not repositioned him since the morning. During an observation on 11/02/22 at 1:21 PM, R7 sat in bed, remained flat on his back, the head of the bed at 30 degrees, and watching tv. R7 was malodorous, with a strong smell of urine. R7 did not have protective boots on, did not have a splint on the right hand, did not have a positioning wedge under the right side of R7's trunk and arm, did not have a cup with a handle for fluids, and did not have a long pillow against the wall by his knees. R7 indicated that his brief had not been checked or changed since last night. During an observation on 11/03/22 at 8:32 AM, R7 sat in bed, remained flat on his back, the head of the bed at 30 degrees, and watching tv. R7 was malodorous, with a strong smell of urine. R7 did not have protective boots on, did not have a splint on the right hand, did not have a positioning wedge under the right side of R7's trunk and arm, did not have a cup with a handle for fluids, and did not have a long pillow against the wall by his knees. The styrofoam cup of fluids sat on the over bed table out of reach of R7, still had the paper covering the end of the straw, and was dated 11/02/22- 3rd shift. Resident #20 (R20) Review of an admission Record revealed R20 was a [AGE] year old female, last admitted to the facility from the hospital on [DATE], after receiving care for an acute GI (gastrointestinal) bleed. R20 had pertinent diagnoses of left sided paralysis and weakness following a stroke, seizure disorder, low back pain, other chronic pain issues, and a history of migraine headaches. R20 was dependent on staff for activities of daily living. During an observation on 11/03/22 at 8:20 AM, R20 sat up in bed with glasses on and the tube feed pump was empty and beeping. R20's left arm was contracted and in a splint. The call light touch pad sat on top of the blanket between R20's legs. When asked if R20 could reach the call light where it was sat, R20 responded no. R20 stated that she had no use of the left arm. R20's bed was positioned in the room in such a manner that R20's dominant and useable arm and hand ( the right side) were closest to the wall and not toward the room where fluids and personal items were kept on the over bed table. R20 had a styrofoam cup of fluids on the bedside table, out of reach, and dated 11/02/22-3rd shift. The cup of fluids had a paper covering on the end of the straw. R20 reported terrible pain this morning, facial grimacing observed, and reported the pain to be at 10/10 and located in the stomach and left arm. During an observation on 11/03/22 at 10:15 AM, R20 again reported I have terrible pain and was not sure if she received any pain medications recently. A styrofoam cup of fluids sat on the over the bed table out of reach of the resident. During an interview on 11/03/22 at 10:25 AM, Licensed Practical Nurse (LPN) G indicated that at the time R20 received pain medication around 8 AM, R20 had reported pain at 10/10. At the time of this interview, LPN G indicated that she had not gone back to check on R20 or re-assess R20's pain. Review of a Physician Order Summary for R20 reflected an order for Lisinopril ( a medication used to treat high blood pressure) one tab daily via PEG tube ( the tube feed) and to hold the medication if R20's systolic (top number) blood pressure was less than 120. During the above interview with LPN G on 11/03/22 at 10:25 AM, LPN G reported giving R20 a dose of Lisinopril this morning without having a blood pressure. Review of blood pressures for R20 in the EHR (electronic health record) reflected: that only 1 blood pressure on 9/4/22 had been checked for the month of [DATE], that only one blood pressure on 10/10/22 had been checked for the month of [DATE], and that no blood pressures had been obtained for R20 thus far during the month of [DATE]. The Emar (electronic medication administration record) for R20 in the months of Sept, Oct, and [DATE] revealed R20 was given the ordered dose of Lisinopril daily without blood pressure monitoring. Review of a Physician Progress Note dated 09/13/22, indicated that lab work for R20 would be ordered. Review of a Physician Order reflected that labs for R20 had been ordered on 09/13/22. Review of the EHR for R20 did not reflect any lab results since 09/13/22. During an interview on 11/03/22 at 11:58 AM, the Administrator stated that the labs ordered on 09/13/22 for R20 had not yet been completed. Resident #8 (R8) Review of an admission Record revealed R8 was a [AGE] year old female in a persistent vegetative state from an anoxic (no oxygen) brain injury requiring a tracheostomy and use of a tube feed for all nutrition and hydration intake. R8 had contractures of both hands and wrists and both knees and feet. R8 is completely dependent on staff for all activities of daily living. During an observation on 11/01/22 at 8:53 AM, R8's outer cannula of the trach was coated in a thick brownish-yellow substance and the trach was not properly secured as it was protruding out of the stoma (the opening in the skin on the neck where the plastic trach is inserted into the trachea) one inch. There were multiple 4x4 dressings tucked under the collar. The bedside 3 tier plastic tower, which held supplies for staff to access easily and quickly, had only 3 oral sponges (used to swab the mouth) in the bottom drawer. No oral swabs were located in the bedside table (which held other supplies) nor on R8's side of the room. During an observation on 11/01/22 at 4:40 PM, R8's outer cannula of the trach was coated in a thick brownish-yellow substance. During an observation on 11/02/22 at 1:25 PM, the bedside plastic 3 tier tower near R8's bed contained only 3 oral sponges in the bottom drawer. No oral sponges were located in the bedside table nor on R8's side of the room. During an interview on 11/03/22 at 10:04 AM, Unit Manager (UM) M indicated that the oral swabs used for R8 were kept in the plastic 3 tier supply tower located next to R8's bed. Upon checking, the only oral swabs located in the tower or anywhere in R8's room, were the 3 oral swabs in the bottom drawer of the plastic tower. Review of a Care Plan intervention for R8 reflected .oral care twice daily and swab mouth frequently. Resident #13 (R13) Review of an admission Record reflected R13 was an [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses of diabetes mellitus, chronic kidney disease, high blood pressure, and dementia. Review of a Brief Interview for Mental Status (BIMS) dated 10/21/22, revealed a score of 11 out of 15, indicating R13 had slight cognitive impairment. During an observation on 11/01/22 at 8:41 AM, R13 sat in a recliner, recently finished breakfast, and was watching tv. R13 indicated not getting enough to eat for breakfast and was still hungry. When it was suggested that R13 could ask for more food, R13 recoiled, upper body stiffened, eyes opened wide and R13 stated no you can't they will get mad. R13's hair is greasy and R13 cannot recall when her last shower was. A styrofoam water cup dated 10/31/22- 3rd shift, sat empty on the over the bed table. During an observation on 11/01/22 at 10:59 AM, R13 sat in the recliner resting with eyes closed. The styrofoam cup dated 10/31/22- 3rd shift, sat empty on the over the bed table. During an observation on 11/01/22 at 1:01 PM, R13 sat in the recliner resting with eyes closed. The styrofoam cup dated 10/31/22- 3rd shift, sat empty on the over the bed table. During an observation on 11/01/22 at 2:26 PM, R13 sat in the recliner resting with eyes closed. The styrofoam cup dated 10/31/22- 3rd shift, sat empty on the over the bed table. During an observation on 11/02/22 at 1:16 PM, R13 sat in the recliner, awake, and watching TV. Her hair was very greasy and actually looked wet. When asked if she had been given a shower today, R13 responded no shower today, no shower yesterday. Review of a Kardex for R13 revealed showers were scheduled to be given on Thursdays. Review of a task monitor for documenting showers reflected that as of 11/1/22, R13 had one bed bath in the past 30 days. Review of an Emar for R13, dated October 1 2022 through October 31st 2022, revealed an order for Humolog insulin, inject 1 unit in the evening and hold is blood sugar is less than 100. Review of the same Emar for R13 reflected that R13 received the injection of insulin on 10/04/22 despite having a blood sugar of 92 and on 10/17/22 despite a blood sugar reading of 90. Resident #15 (R15) Review of an admission Record reflected R15 was a [AGE] year old male, admitted to the facility on [DATE], with pertinent diagnoses of dementia, high blood pressure, unsteadiness on feet, weakness, and disorientation. Review of facility Incident/Accident reports revealed R15 sustained 2 unwitnessed falls during his admission. Review of a facility Policy/Procedure-Falls reflected the following .initiate neurological checks for any fall where a resident hit their head or for any unwitnessed falls. During an interview on 11/03/22 at 1:35 PM, the Administrator indicated that neurological checks for R15's two unwitnessed falls, could not be located. Resident #21 (R21) Review of an admission Record revealed R21 was an [AGE] year old female, last admitted to the facility on [DATE], with pertinent diagnoses of dementia, high blood pressure, and over active bladder. During an observation on 11/03/22 at 8:39 AM, R21 asked the surveyor, can you help me, I'm moving my bowels and I need help. R21's call light was out of reach. The surveyor handed R21 the call light and it was activated. Staff entered R21's room within 2 minutes after the call light was activated and asked R21 what she needed. R21 told staff she needed to be changed, staff turned off the call light and told R21 that (the staff person) would find someone to get her changed. During an observation on 11/03/22 at 10:12 AM, staff were in R21's room getting her changed. During an interview on 11/03/22 at 10:46 AM, the Administrator, after hearing about the above incident involving R21, stated that an hour and a half was too long for someone to have to wait to get cleaned up after having a bowel movement. The Administrator went on to say that the call light should have been left on until R21's needs were met.