Deficiency Text Not Available

Based on observation, interview and record review, the facility failed to ensure two out of 17 sampled residents were free from abuse. Certified Nurse Aide (CNA) N yelled at Resident #6 in the dining room and pulled on the resident's arm- telling the resident he/she needed to leave and eat in their room, causing the resident to cry and be afraid. CNA G scolded Resident #7 when he/she yelled for assistance with continence care, due to not having a call light within reach. CNA G told the resident it was the last time he/she was going to care for the resident in bed, causing him/her to feel hurt and disrespected. During a later event, CNA G spoke disrespectfully towards the resident while walking past them. The census was 86. Review of the abuse prevention policy, dated 9/16/24, showed: -Prevention and reporting: Suspected resident/patient abuse, neglect and/or misappropriation of property; -The facility prohibits the mistreatment, neglect, and abuse of residents/patients and misappropriation of resident/patient property by anyone including staff, family, friends, etc; -The Administrator has the primary responsibility in the facility for the implementation of the abuse/neglect program: -The facility will follow all state and federal guidelines on preventing abuse, neglect, mistreatment, exploitation and misappropriation of property; -The facility encourages and supports all resident, staff and families in feeling free to report any suspected acts of abuse, neglect, misappropriation or injury. The facility takes all measures possible to ensure the resident, staff and families are free from fear of retribution if reports or incidents are filed with the facility; Allegations of abuse will be promptly reported and thoroughly investigated. The facility should immediately report all such allegations to the Administrator and to the Department of Health and Senior Services; -The administrator and Director of Nursing (DON) are responsible for investigation and reporting. They are also ultimately responsible for the following as they relate to abuse, neglect: -Implementation and ongoing monitoring consist of the following: screening, training, prevention, identification, protection, investigation and reporting; -Definitions: -Abuse: -Willful infliction of an injury; -Unreasonable confinement; -Intimidation with resulting physical harm, pain or mental anguish; -Instances of abuse includes verbal, sexual abuse, physical and mental abuse; -Verbal abuse: oral, written or gestured language that includes disparaging and derogatory terms to the resident or their families with within their hearing distance; -Physical abuse: includes hitting, slapping, pinching, scratching, spitting, holding roughly, etc; -Mental/emotional abuse: includes, but not limited to humiliation, harassment, and threats of punishment or deprivation; -Training: -Provide training for new employees and volunteers through new hire orientation and annually with ongoing training programs on abuse and neglect and the handling of abuse, and neglect. Training will include, but not limited to: -Definitions of abuse, neglect and mistreatment; -Identification and reporting of abuse, neglect and mistreatment; -Utilization of appropriate interventions to deal with aggressive and/or catastrophic (detrimental) reactions for resident; -How to provide protection for residents; -Investigation of abuse, neglect and mistreatment; -Document staff training and maintain with educational records in the facility; -Resident rights- how the residents are to be treated, including the right to be free from abuse and what to do if an employee/volunteer suspect that a resident has been violated; -Prevention: -Ensure that prevention techniques are implemented in the facility including, but not limited to an ongoing supervision of employees through visual observation or care delivery and recognition of signs of burnout, stress and frustration. It is the responsibility of the staff to promote a safe environment for the residents; -Identify, correct and intervene in situations where abuse, neglect and/or mistreatment are more likely to occur: sufficient staffing on each shift to meet needs of the residents, residents with needs and behaviors which might lead to conflict and supervision of staff to identify inappropriate behavior, such as rising derogatory language, rough handling and ignoring residents while giving care; -Instruct staff that they are required to report concerns and incidents; -Protection: -Provide for the immediate safety of the resident upon identification of the suspected abuse, including but not limited to: moving the resident to another room or unit, provide 1:1 monitoring as appropriate, immediate suspension of the suspected staff pending outcome of the investigation; -Initiate behavior crisis management interventions as applicable. -Reporting: -Any person witnessing or having knowledge of alleged violation involving abuse, neglect or misappropriation are to notify the Administrator and DON immediately. 1. Review of Resident #6's medical record, showed the following: -Moderately impaired cognitive skills for daily decision making. -Diagnoses include traumatic brain dysfunction, depression, and psychotic disorder. Review of the resident's care plan, in use during the survey, showed the resident has periods of crying and mood changes. Interventions included to provide active listening and support when needed, and to encourage the resident to express feelings. Observation of video footage, dated 3/8/25, showed the resident entered the dining room and walked towards a table. He/She pulled out the chair. Another resident approached the resident and spoke to him/her. Certified Nurse Aide (CNA) F approached the residents and motioned with his/her arms, then walked around both residents. CNA F pulled on the resident's left arm. Licensed Practical Nurse (LPN) G intervened and CNA F left the dining room. During an interview on 3/11/25 at 9:53 A.M., the resident said he/she was in his/her room and experienced an episode of urinary incontinence. A CNA entered the room, and helped him/her change clothes. The resident said his/her shoes were wet and the CNA said he/she could not go to lunch because his/her shoes were wet and he/she had to eat in his/her room. The resident walked to the dining room. While at his/her dining room table, the CNA began to yell at him/her and said you can not be in here without shoes, you have to eat in the room. The CNA pulled on his/her right arm. The resident said he/she cried and was very upset and felt terrible. It was just terrible, he/she is afraid of the CNA now, and didn't want the CNA working with him/her. During an interview on 3/12/25 at 1:13 P.M., Resident #20 said he/she sat at the table during lunch on 3/8/25. The resident saw a staff person push on Resident #6. It made Resident #20 scream, Stop that. Resident #6 was crying. Resident #20 was so scared because he/she couldn't do a damn thing. It scared Resident #20 because someone could also hurt him/her. During an interview on 3/12/25 at 1:40 P.M., Visitor H said he/she was in the dining room during lunch with Resident #20 on 3/8/25. Visitor H saw Resident #6 at the dining room doorway, and staff telling the resident he/she couldn't come into the dining room without shoes on, and pushed the resident out. Other residents go to the dining room wearing socks without shoes. Resident #6 was crying. Staff grabbed and pulled at the resident, who yelled, Get your hands off me. Visitor H told the staff not to put his/her hands on people. The staff person said do what you want and left. Other staff were present but did not intervene. Visitor H said it was physical abuse. It could have made the resident fall, it wasn't safe and could be frightening to other residents. Resident #6 was crying and this upset Resident #20. Visitor H told another staff person, in the office across from the chapel, that staff pushed Resident #6. This staff person said he/she would report it but could not nothing about nursing. Visitor H said he/she expected the staff person to report it and for someone to stick up for Resident #6. During an interview on 3/12/25 at 12:52 P.M., the Social Worker said she didn't see the CNA pull the resident's arm, but she went to the resident's table because she heard the resident crying. The Social Worker called the Administrator about 1:00 P.M. on 3/8/25, to report the resident and CNA were arguing and the resident was crying. The Administrator instructed her to tell the DON, which she did on 3/10/25 between 7:30 and 8:00 A.M. During an interview on 3/10/25 at 2:27 P.M., the DON said the incident occurred over the weekend. She found out about it on 3/10/24 before lunch, when the resident's grandparent reported to her that staff snatched his/her arm on Saturday 3/8/25, before lunch. During an interview on 3/10/25 at 3:38 P.M., the Administrator viewed the footage and suspended the CNA. Review of CNA F's timecard, showed he/she worked on 3/8/25 until 2:31 P.M. Observation on 3/10/25 during the day shift, showed CNA F worked directly with the residents. 2. Review of Resident #7's medical record, showed the following: -Intact cognitive response; -Diagnoses include muscle weakness, functional quadriplegia, acquired absence of left leg below the knee and end stage kidney disease. Review of the resident's care plan, updated on 10/24/24, showed: -The resident was at risk for psychosocial well-being; -Interventions included: Allow the resident time to answer questions and to verbalize feeling, perceptions and fears; Inform DON/Administrator of alleged abuse/neglect. During an interview on 3/12/25 at 9:52 A.M., the resident said: -CNA G worked the night shift on his/her hall; -He/She did not have a call light within reach and needed help with incontinence care; -He/She had to holler for help; -CNA G came into the room and told the resident he/she was too big for the CNA to move by him/herself; -CNA G scolded the resident, telling him/her not to holler because he/she would wake the other residents; -He/She tried to explain that he/she only hollered because the call light was not in reach; -CNA g left and came back with another CNA and provided care; -CNA G told the resident it was the last time he/she was going to care for the resident in bed before leaving the resident's room; -The resident was mad because he/she had to holler for the longest time and no one came to help him/her; -The resident's feelings were hurt and he/she felt disrespected; -He/She returned to the facility on Sunday around 7:40 P.M., after a birthday party; -He/She was waiting at the nurses station in his/her wheelchair to go back to his/her room; -CNA G came down the hall and passed the resident saying I'm not going to work with (him/her)! and called the resident a bad name, which he/she could not recall; -It made the resident feel mad and he/she did not want to tell anyone because he/she felt like all of the staff were up against him/her at that point and that they would not help the resident; -He/She did not want CNA G to provide care to him/her anymore. During an interview on 3/10/25 at 4:10 P.M., CNA G said: -Violation of resident rights was when a staff member used a threatening voice, refused to care for residents or refused to listen to residents' needs and/or wants; -He/She would notify the charge nurse or administrative staff of any violation of resident rights so they could investigate the incident; -He/She worked on 3/8/25 from approximately 2:45 P.M. until 8:59 P.M.; -He/She did not have any complaints from the resident regarding care; -He/She had a good relationship with the resident. During an interview on 3/12/25 at 7:50 A.M., the DON said: -The resident reported to her on 3/11/25 that a CNA was talking badly about him/her on Sunday, after the resident had returned from a birthday party; -The CNA said I am not going to put (his/her) fat ass into the bed while he/she was pushing another resident in a wheelchair past the resident at the nurses' station; -The DON looked at the video that was taken around the time described by the resident and determined the CNA in question was CNA G; -The video shows CNA G pushing another resident in a wheelchair past the resident and CNA F was seen speaking to resident. There was no audio to the video; -She had not begun her investigation yet but would try to find out determine what happened and then make the determination of what was best for the residents in regards to psycho-social care; -She expected staff to report any verbal abuse to residents; -She was going to terminate CNA G after the investigation due to other allegations of resident rights violations; -She was educating staff on resident rights; -The resident did not report any incidents of staff rudeness to her.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to notify the Primary Care Physician and obtain orders for pressure ulcers (ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) when they were first identified for two residents (Resident #2 and #5) out of three sampled residents. The facility also failed to administer treatments as ordered and failed to have consistent documentation of the wounds. The census was 84. Review of the National Pressure Ulcer Advisory Panel (NPUAP), prevention and treatment of pressure ulcers: quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel 2014 showed the following: -Assess the pressure ulcer initially and re-assess it at least weekly; -With each dressing change, observed the pressure ulcer for signs that indicate a change in treatments as required (e.g., Wound improvement, wound deterioration, more or less exudate, signs of infection, or other complications); -Address the signs of deterioration immediately. Review of the Long Term Care Facility Resident Assessment Instrument User's Manual, Version 3.0, Chapter 3, Section M, defines the different stages of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) as follows: -Stage I: an observable, pressure related alteration of intact skin, whose indicators as compared to an adjacent or opposite area on the body may include changes in skin temperature, tissue consistency, sensation, and/or a defined area of persistent redness; -Stage II: Partial thickness loss of dermis (the inner layer that makes up skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue). May also present as an intact or open/ruptured 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 (destruction of tissue or ulceration extending under the skin edges) or tunneling (a passage way of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound); -Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color) may be present on some parts of the wound bed. Often includes undermining and tunneling; -Unstageable pressure ulcers (known but unstageable due to coverage the wound bed by slough (necrotic/avascular tissue in the process of separating from the viable portion of the body, usually light colored, soft, moist and stringy) and or eschar (thick leathery, frequently black or brown in color, necrotic tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined; -Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue damage. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue; -Slough: necrotic/avascular tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and stringy; -Eschar: thick, leathery, frequently black or brown in color, necrotic (dead) or devitalized tissue that has lost its usual physical properties and biological activity. Eschar may be loose or firmly adhered to the wound. Review of the National Pressure Ulcer Advisory Panel (NPUAP), Prevention and Treatment of Pressure Ulcers; quick reference guide, Washington DC: National Pressure Ulcer Advisory Panel: 2009, showed ongoing assessment of the skin is necessary to detect early signs of pressure. Review of the facility's Pressure Ulcer/Skin Breakdown Policy, revised April 2018, showed: -The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers: for example, immobility, recent weight loss, and a history of pressure ulcer(s); -The nurse shall describe and document/report full assessment of the pressure ulcer and current treatments; -The physician will assist the staff to identify the type of ulcer; -The physician will order pertinent wound treatments; -The physician will evaluate and document the progress of wound healing. During an interview on 2/3/25 at 4:05 P.M., the Director of Nursing (DON) said the facility did not have a policy to Follow Physician Orders. 1. Review of Resident #2's annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 10/22/24, showed: -Severe cognitive impairment; -Impairment on one side of upper body; -No mobility devices were used; -Total dependence on staff for all activities of daily living (ADLs) including bed mobility, transfers, and eating; -Received hospice care; -At risk for pressure ulcers; -No unhealed pressure ulcers present; -Pressure reducing device for chair and bed were present; -Diagnoses included heart failure, diabetes mellitus, dementia, chronic kidney disease, dysphagia (difficulty swallowing), cognitive communication deficit and contracture of left and right hands. Review of the resident's care plan, undated, showed: -Problem: The resident was incontinent of bowel and bladder related to confusion and was at risk of skin break down. The resident had a Stage II Pressure Ulcer noted to his/her coccyx (a small triangular bone at the base of the spinal column) on 12/28/24. Interventions included: Resident to wear bilateral heel protectors; Assess skin weekly and as needed and inform resident's responsible party (RRP) and Primary Care Physician (PCP) of changes in skin integrity; Treat right foot and ankle as ordered; Treat calluses (hard, thickened skin) as ordered; Treat coccyx as ordered. Review of the hospice handwritten care notes, dated 11/06/24 through 12/3/24, showed there was no documentation found showing the resident had wounds. Review of the facility weekly wound report, dated Week One of December 2024, showed: -The resident had a wound (not specified) at his/her coccyx, measuring 4.5 centimeters (cm) by 3.5 cm by 0.1 cm deep, with a treatment of Dakin's (an antiseptic cleanser) moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her right ankle, measuring 3.0 cm by 3.0 cm by 0.2 cm, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her left ankle, measuring 1.0 cm by 1.0 cm with no depth, with a treatment of Dakin's moist with gauze border dressing daily and as needed. Does the not specified statements above refer to the staff not documenting a stage for the wound? Who completes the weekly wound report? is it a designated wound nurse working at the facility? a nurse from a wound management co? I see the interview with the wound nurse below but couldn't tell if he/she was a facility employee. Review of resident's shower sheets, dated 12/3/24 through 12/15/24, showed there was no documentation found of any open areas or skin issues. Review of the hospice handwritten care notes, dated 12/3/24 through 12/15/24, showed there was no documentation found showing the resident had wounds. Review of the facility weekly wound report, dated Week Two of December 2024, showed: -The resident had a wound (not specified) at his/her coccyx, measuring 4.5 cm by 3.5 cm by 0.1 cm deep, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her right ankle, measuring 3.0 cm by 3.0 cm by 0.2 cm, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her left ankle, measuring 1.0 cm by 1.0 cm with no depth, with a treatment of Dakin's moist with gauze border dressing daily and as needed. Review of the resident's weekly skin assessment, dated 12/16/24 at 2:14 P.M., showed the resident's skin was intact with no open areas noted. Review of the facility weekly wound report, dated Week Three of December 2024, showed: -The resident had a wound (not specified) at his/her coccyx, measuring 4.5 cm by 3.5 cm by 0.1 cm deep, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her right ankle, measuring 3.0 cm by 3.0 cm by 0.2 cm, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her left ankle, measuring 1.0 cm by 1.0 cm with no depth, with a treatment of Dakin's moist with gauze border dressing daily and as needed. Review of the hospice handwritten care notes, dated 12/16/24 through 12/24/24, showed there was no documentation found showing the resident had wounds. Review of the resident's shower sheet, dated 12/24/24 with no time notes, showed the coccyx area was circled with a note saying new open area. Review of the facility weekly wound report, dated Week Four of December 2024, showed: -The resident had a wound (not specified) at his/her coccyx, measuring 4.5 cm by 3.5 cm by 0.1 cm deep, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her right ankle, measuring 3.0 cm by 3.0 cm by 0.2 cm, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her left ankle, measuring 1.0 cm by 1.0 cm with no depth, with a treatment of Dakin's moist with gauze border dressing daily and as needed. Review of the resident's weekly skin assessment, dated 12/26/24 at 9:46 A.M., showed: -A pressure ulcer at the resident's coccyx was present, measuring 4.5 cm by 3.5 cm by 0.1 cm deep; -A pressure ulcer at the resident's right ankle was present, measuring 3.0 cm by 3.0 cm by 0.2 cm deep; -A pressure ulcer at the resident's left ankle was present, measuring 1.0 cm by 1.0 cm with no depth noted. Review of the resident's progress notes, showed: -On 12/28/24 at 6:09 P.M., a family member reported the resident had an open area to his/her coccyx and an open area to his/her right ankle with multiple calloused areas on both heels and foot. A call was placed to the PCP for treatment orders for both pressure areas to cleanse the wounds with wound cleanser, apply Medihoney (antimicrobial to treat burns and wounds) and cover with bordered dressing (bandage) once a day and to apply skin prep (liquid film-forming dressing that forms a protective film over skin). There was no documentation found showing where to apply the skin prep; -On 12/28/24 at 6:49 P.M., showed the RRP was made aware of the new orders for the resident's wounds at his/her coccyx and right ankle; -There was no documentation found the facility notified the PCP or RRP of any wounds from 12/1/24 through 12/27/24. Review of the resident's Treatment Administration Record (TAR), dated December 2024, showed: -An order, dated 5/17/24, to apply skin prep to the medial (inner edge that runs from the heel to the big toe) right foot once a day. Documentation showed the facility completed the treatment as ordered 15 out of 31 opportunities; -An order, dated 12/29/24 for Stage II pressure ulcer at right ankle, cleanse with wound cleanser, apply Medihoney and cover with bordered gauze dressing every day shift for wound healing. Documentation showed the facility completed the treatment as ordered two out of three opportunities; -An order, dated 12/29/24, for Stage II pressure injury at coccyx, cleanse with wound cleanser, apply Medihoney and cover with bordered gauze dressing every day shift for wound healing. Documentation showed the facility completed the treatment as ordered two out of three opportunities; Review of the resident's weekly skin assessment, dated 12/30/24 at 11:04 A.M., showed: -A pressure ulcer at the resident's coccyx was present, measuring 4.5 cm by 3.5 cm by 0.1 cm deep; -A pressure ulcer at the resident's right ankle was present, measuring 3.0 cm by 3.0 cm by 0.2 cm deep; -A pressure ulcer at the resident's left ankle was present, measuring 1.0 cm by 1.0 cm with no depth noted. Review of the resident's physician order sheets, dated December 2024, showed there was no order for a treatment to the resident's left ankle. Review of the hospice handwritten care notes, dated 12/26/24 through 1/2/25, showed there was no documentation the resident had wounds. Review of the facility's weekly wound report, dated Week One of January 2025, showed: -The resident had a wound (not specified) at his/her coccyx, measuring 4.5 cm by 3.5 cm by 0.1 cm deep, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her right ankle, measuring 3.0 cm by 3.0 cm by 0.2 cm, with a treatment of Dakin's moist with gauze border dressing daily and as needed; -The resident had a wound (not specified) at his/her left ankle, measuring 1.0 cm by 1.0 cm with no depth, with a treatment of Dakin's moist with gauze border dressing daily and as needed. Review of the resident's weekly skin assessment, dated 1/2/25 at 2:16 P.M., showed: -A pressure ulcer, unstageable, at the resident's coccyx was present, measuring 4.5 cm by 3.5 cm by 0.1 cm deep; -A Stage II pressure ulcer at the resident's right ankle was present, measuring 3.0 cm by 3.0 cm by 0.2 cm deep; -A Stage II pressure ulcer at the resident's left ankle was present, measuring 1.0 cm by 1.0 cm with no depth noted. Review of the resident's weekly wound assessment, dated 1/2/25 at 4:32 P.M., showed: -A callous (hard thickened skin) located at the right ankle, acquired on 12/26/24, wound bed described as necrotic and dry, with no exudate, measuring 3 millimeters (mm) by 3 mm by .02 mm deep. Apply skin prep daily, with off-loading boot. Waiting on hospice measurements; -A Stage II pressure ulcer located at the coccyx, found on 12/26/24, wound bed described as necrotic and dry, measuring 45 mm by 35 mm by .01 mm deep. Apply border gauze daily; -A callous located at the left ankle, acquired on 12/26/24, wound bed described as necrotic and dry, measuring 1 mm by 1 mm by 0 mm deep. Apply skin prep daily, with off-loading boot. Waiting on hospice measurements. Review of the hospice handwritten care notes, dated 1/3/25, no time noted, showed the resident had wounds to his/her coccyx and right lateral ankle. Review of the facility's weekly wound report, dated Week Two of January 2025, showed there was no documentation on the resident's wounds. Review of the resident's progress note, dated 1/10/25 at 11:24 A.M., showed the RRP was called to confirm and educated the family on the resident's declining status and wound care. Review of the resident's weekly skin assessment, dated 1/9/25 at 2:16 P.M., showed: -A pressure ulcer, unstageable, at the resident's coccyx was present, measuring 3.5 cm by 3.0 cm by 0.1 cm deep; -A Stage II pressure ulcer at the resident's right ankle was present, measuring 1.0 cm by 1.0 cm with no depth noted; -A Stage II pressure ulcer at the resident's left ankle was present, measuring 1.0 cm by 1.0 cm with no depth noted. Review of the resident's weekly wound assessment, dated 1/9/25 at 4:38 P.M., showed: -A callous located at the right ankle, acquired on 12/26/24, wound bed described as necrotic and dry, with no exudate, measuring 1 mm by 1 mm by 0 mm deep. Apply skin prep daily, with off-loading boot. Waiting on hospice measurements; -A Stage II pressure ulcer located at the coccyx, found on 12/26/24, wound bed described as necrotic and dry, measuring 35 mm by 30 mm by .01 mm deep. Apply border gauze daily; -A callous located at the left ankle, acquired on 12/26/24, wound bed described as necrotic and dry, measuring 1 mm by 1 mm by 0 mm deep Apply skin prep daily, with off-loading boot. Waiting on hospice measurements. Review of the Hospice Nurse Wound assessment, dated 1/10/25 at 9:24 A.M., showed: -Hospice assessed and treated the resident's wounds; This is the first time hospice assessed the wound? -A Stage II pressure ulcer at the right buttock, first assessed on 1/10/25, wound bed 50% granulation, 25% slough and 25% eschar, with small amount of serosanguineous, foul-smelling exudate (drainage) measuring 3.5 centimeters (cm) by 2.5 cm; -A Stage III pressure ulcer at the right ankle, first assessed on 1/10/25, wound bed of 100% slough, with moderate amount of serosanguineous exudate, measuring 2 cm by 2 cm by 0.1 cm deep. Review of the facility's weekly wound report, dated Week Three of January 2025, showed there was no documentation on the resident's wounds. Review of the Hospice Nurse Wound Assessment, dated 1/15/25 at 12:17 A.M., showed: -Hospice assessed and treated the resident's wounds; -A Stage III pressure ulcer at the right buttock, first assessed on 1/10/25, wound bed described as fragile, moist, necrotic and pink, with a small amount of tan exudate with a musty odor, no measurements found, wound status described as deteriorating. -A Stage III pressure ulcer at the right ankle, first assessed on 1/10/25, wound bed described as necrotic and pink with a small amount of exudate, no odor, no measurements found, wound status described as evolving; -A Stage III pressure ulcer at the left ankle, first assessed left blank, wound bed described as dry pink, with no exudate or odor, no documentation found regarding wound status. Review of the resident's weekly skin assessment, dated 1/16/25 at 10:18 A.M., showed: -A pressure ulcer, unstageable, at the resident's coccyx was present, measuring 8.5 cm by 3.5 cm by 0.1 cm deep; -A Stage II pressure ulcer at the resident's right ankle was present, measuring 2.0 cm by 2.0 cm by 0.2 cm deep; -A Stage II pressure ulcer at the resident's left ankle was present, measuring 1.5 cm by 1.5 cm with no depth noted Review of the resident's weekly wound assessment, dated 1/16/25 at 4:44 P.M., showed: -A callous located at the right ankle, acquired on 12/26/24, wound bed described as necrotic and dry, with no exudate, measuring 2 millimeters (MM) by 2 mm by .02 mm deep. Apply skin prep daily, with off-loading boot and border gauze (bandage) as needed. Waiting on hospice measurements; -A Stage II pressure ulcer located at the coccyx, found on 12/26/24, wound bed described as necrotic and dry, measuring 52 mm by 35 mm by .02 mm deep. Apply border gauze daily; -A callous located at the left ankle, acquired on 12/26/24, wound bed described as necrotic and dry, measuring 15 mm by 15 mm by .02 mm deep. Apply skin prep daily, with off-loading boot and border gauze (bandage) as needed. Waiting on hospice measurements. Review of the resident's progress note, dated 1/17/25 at 3:50 P.M., showed social services called the hospice four times to obtain their wound report and measurements for the wound nurse. The calls were not answered. Review of the resident's progress notes, showed there was no documentation found the RRP or PCP were notified of the Stage II pressure ulcer found on the resident's left ankle. Review of the resident's TAR, dated January 2025, showed: -An order, dated 5/17/24, to apply skin prep to the medial right foot once a day. Documentation showed the facility completed the treatment as ordered nine out of twenty one opportunities; -An order, dated 12/29/24, discontinue on 1/16/25, for Stage II pressure ulcer at right ankle, cleanse with wound cleanser, apply Medihoney and cover with bordered gauze dressing every day shift for wound healing. Documentation showed the facility completed the treatment as ordered seven out of sixteen opportunities; -An order, dated 1/17/25, for Stage II pressure ulcer at right ankle, cleanse with wound cleanser, apply Medihoney and cover with bordered gauze dressing every day shift for wound healing. Documentation showed the facility completed the treatment as ordered two out of five opportunities; -An order, dated 12/29/24, for Stage II pressure injury at coccyx, cleanse with wound cleanser, apply Medihoney and cover with bordered gauze dressing every day shift for wound healing. Documentation showed the facility completed the treatment as ordered ten out of twenty one opportunities; -There was no treatment order for the resident's left ankle. Review of the resident's electronic medical record (EMR), showed there was no documentation of the resident's Braden score (test that scores resident's risk of pressure ulcers). Observations on 1/22/25 at 12:47 P.M. and at 1:22 P.M., showed: -The resident asleep in his/her bed, laying on his/her right side, on a low air loss mattress, covered with a blanket; -The resident's bed was in a lowered position and the bed had bilateral side rails in the raised position; -The resident had a cup of liquid on his/her bedside table, out of reach of the resident; -The resident was not able to answer any questions, blinked and opened and closed his/her mouth when spoken to; -The resident's skin on his/her arms appeared dry with visible superficial cracks and the resident's lips appeared dry with flaky skin; -There was a stack of wound supplies at bedside. During an interview on 1/22/25, at 1:27 P.M. the Wound Nurse said: -She was responsible for all wound reports, all weekly skin assessments, all wound treatments (unless they were for non open areas or skin tears) and to round with the Wound Doctor once a week; -She was also responsible for completing treatments on any hospice residents unless the hospice nurse completed them; -She expected hospice nurses to document when they completed treatments on residents and to give report to the nurse so they could track the wound's healing status; -She expected nurses who got report from the hospice nurse to write a progress note documenting what was done, by whom, when and the status of the wound during treatment; -She expected nursing staff to alert her when there was a new skin issue by telling her verbally or by putting a note in the wound nurse binder at the nurses station; -She was responsible for assessing resident's skin when she was alerted to a new skin issue, to document her findings on a skin assessment in the resident's EMR, then write a progress note what skin issue was found, the notification of the PCP for treatment orders and notification of the RRP. -She was responsible for putting the physician orders into the resident's physician order sheets in the EMR; -She completed the resident's treatments to his/her right and left ankles and to his/her coccyx before the day shift nurse arrived; -Hospice nurses were responsible for completing weekly assessments on the hospice residents; -She expected hospice nurses to give their wound assessments on the day they were completed; -She was responsible for putting all wound assessments from both the Wound Physician and the hospice nurse into the residents' EMR and on the facility weekly wound report; Observation on 1/22/25 at 1:33 P.M., showed: -The Wound Nurse performed a skin assessment on the resident while the resident was in his/her bed; -The resident wore protective boots on both of his/her feet, had a pillow in between his/her knees and a pillow tucked under his/her right upper body as he/she lay on his/her right side; -The Wound Nurse exposed the resident's right ankle, showing a bandage which had exudate showing through to the surface of the bandage. The bandage was not dated or signed; -The Wound Nurse exposed the resident's left ankle, showing a bandage, which was not dated or signed; -The Wound Nurse exposed the resident's coccyx, showing a bandage was present, which was not dated or signed; -The Wound Nurse was not sure who changed the resident's bandages after she had completed the treatments earlier that morning and had dated and signed each bandage with the day's date and her initials. During an interview on 1/22/24 at 1:45 P.M., Registered Nurse (RN) C, said: -He/She did not administer any treatments to the resident that day; -He/She thought maybe a hospice nurse came and changed them after breakfast; -He/She expected the hospice nurse to document in the hospice binder when they visited, showing what they did during the visit; -He/She did not get a report from the hospice nurse today and would not document if he/she did get a report from hospice staff; -He/She was called to the resident's room a few weeks ago by the RRP; -The RRP was upset because the resident had a wound at his/her coccyx for at least a week and a half and still staff had not done anything about it; -RN C assessed the resident's coccyx and found a new wound was present. He/She called the PCP, got an order, put in the resident's EMR and applied the treatment to the resident; -It was the first time the nurse was alerted to any wound located on the resident's coccyx; -If a Certified Nursing Assistant (CNA) told the nurse of a new skin issue, or if the nurse found a new skin issue, he/she would assess the wound, notify the PCP and RRP, obtain new treatment orders, put the treatment order in the resident EMR and apply the treatment, documenting all in a progress note; -He/She would also alert the Wound Nurse either verbally or by writing a note in the Wound Nurse binder found at the nurses station. Review of the handwritten Hospice Care notes, showed: -A note, dated 1/21/25, no time noted, showed the hospice nurse completed wound treatments on the resident; -There was no documentation they visited the resident on 1/22/24. During an interview on 1/28/25 at 12:20 P.M., the Director of Nursing (DON) said: -If a resident received hospice care, hospice nurses were responsible for changing the wound treatments when they are there and if they are not there, the Wound Nurse was responsible; -Hospice was also responsible for weekly wound assessments and if they didn't do it, the Wound Nurse was responsible or charge nurse in her absence; -If hospice changed a wound treatment and/or completed weekly wound assessments, the charge nurse or Wound Nurse would document that it was complete in the resident's progress notes and in the TAR with a note, saying hospice completed. 2. Review of Resident #5's annual MDS, dated [DATE], showed: -Severe cognitive impairment; -Dependent on staff for toileting, showering, personal hygiene, bed mobility and transfers; -Wheelchair used for locomotion; -Always incontinent of bladder and bowel; -Diagnoses included kidney disease, diabetes mellitus, stroke, dementia and Parkinson's disease (disorder of central nervous system that affects movement). Review of the resident's current care plan, showed: -Problem: The resident was at risk for open areas related to decreased mobility and incontinence; -Interventions included: follow up with wound specialist as needed; Inform PCP and RRP of changes in skin integrity; Assess skin weekly and as needed and inform PCP and RRP of changes in skin integrity. Review of the resident's weekly skin assessment, dated 12/3/24 at 1:50 P.M., showed the resident had intact skin, no open areas, area to sacrum (was red), ointment applied. Review of the resident's shower sheet, dated 12/3/24, showed there were no areas circled or skin issues noted. Review of the resident's weekly wound assessment, dated 12/3/24, showed, Stage I pressure ulcer at the resident's coccyx, acquired on 12/3/24, wound bed had pink, moist tissue with no drainage, measuring at 5 mm by 5 mm with no depth, current treatment of collagen (used to absorb exudate) and border gauze daily. Review of the resident's weekly wound assessment, dated 12/5/24, showed: -The resident had a callus at his/her right heel, acquired on 12/3/24, with necrotic tissue present with no exudate, measuring 0 mm by 0 mm by 0 mm deep, with a treatment order to apply skin prep daily and as needed. Review of the facility's wound report, dated Week One of December 2024, showed: -The resident had an unspecified wound on his/her coccyx, measuring 1.5 cm by 0.5 cm by 0.1 cm with a treatment order of collagen and border gauze daily and as needed. Review of the resident's weekly skin assessment, dated 12/9/24, showed: -A pressure ulcer (stage not applicable) at the resident's right heel, with no measurements noted; -A Stage I pressure ulcer at the resident's sacrum, measuring 1.5 cm by 0.5 cm by 0.1 depth. Review of the resident's shower sheet, dated 12/10/24, showed there were no areas circled or skin issues listed. Review of the resident's weekly wound report, dated 12/12/24, showed: -The resident had a callus at his/her right heel, acquired on 12/3/24, with necrotic tissue present with no exudate, measuring 10 mm by 10 mm by 0 mm deep, with a treatment order to apply skin prep daily and as needed; -There was no documentation on the resident's coccyx. Review of the facility's wound report, dated Week Two of December 2024, showed: -The resident had an unspecified wound on his/her coccyx, measuring 1.5 cm by 0.5 cm by 0.1 cm with a treatment order of collagen and border gauze daily and as needed. Review of the resident's weekly skin assessment, dated 12/16/24, showed: -A suspected deep tissue injury at the resident's right heel, measuring 1.0 cm by 1.0 cm by 0.1 depth; -A Stage I pressure ulcer at the resident's sacrum, measuring 0.5 cm by 0.5 cm by 0.1 cm deep. Review of the resident's shower sheet, dated 12/17/24, showed the resident's left buttock was circled with a note showing there was an open area present with a treatment in place. There was also a circle around both the right and left heels with a note saying skin prep to heels. Review of the resident's weekly wound report, dated 12/19/24, showed: -The resident had a callus at his/her right heel, acquired on 12/3/24, with necrotic tissue present with no exudate, measuring 10 mm by 10 mm by 0 mm deep, with a treatment order to apply skin prep daily and as needed; -There was no documentation on the resident's coccyx. Review of the facility's wound report, dated Week Three of December 2024, showed: -The resident had an unspecified wound on his/her coccyx, measuring 0.5 cm by 0.5 cm by 0.1 cm with a treatment order of collagen and border gauze daily and as needed; -The resident had an unspecified wound at his/her right heel, measuring 1.0 cm by 1.0 cm with no depth, with a treatment to apply skin prep daily and wear offloading boots. Review of the resident's weekly skin assessment, dated 12/23/24, showed: -A suspected deep tissue injury at the resident's right heel, measuring 1.0 cm by 1.0 cm by 0 depth; -A Stage I pressure ulcer at the resident's sacrum, measuring 0.5 cm by 0.5 cm by 0.1 cm deep. Review of the resident's shower sheet, dated 12/24/24, showed the resident's left buttock was circled with a note showing there was an open area present with a treatment in place. There was also a circle around both the right and left heels with a note saying skin prep to heels. Review of the resident's weekly wound report, dated 12/28/24, showed: -The resident had a callus at his/her right heel, acquired on 12/26/24, with necrotic tissue present with no exudate, measuring 10 mm by 10 mm by 0 mm deep, with a treatment order to apply skin prep daily and as needed; -There was no documentation found on the resident's coccyx. Review of the facility's wound report, dated Week Four of December 2024, showed: -The re

Based on interview and record review, the facility failed to address an order of increased fluids from the Primary Care Physician (PCP) on 9/10/24 and again on 11/22/24 from the Registered Dietitian (RD) for a resident with diagnoses of severe malnutrition, renal (kidney) disease and abnormal lab values, for one out of three sampled residents (Resident #3). This resulted in the resident's hospitalization with the admitting diagnoses of renal failure, hypernatremia (high sodium levels in the blood) and altered mental status. The census was 84. Review of the facility's Nutrition and Hydration to Maintain Skin Integrity policy, revised October 2010, showed: -Purpose: The purpose of this procedure is to provide guidelines for the assessment of resident nutritional needs, to aid in the development of an individualized care plan for nutritional interventions, and to help support the integrity of the skin through nutrition and hydration; -When there is a decline in a resident's appetite, nutritional intake, weight, or overall condition, caregivers should first attempt to discover the factors compromising nutritional status and offer support with eating; -If intake continues to be inadequate, impractical or impossible, nutritional support must be implemented according to the plan of care; -Ensure that the resident's intake of fluid is sufficient. Sufficient fluid'' means the amount of fluid needed to prevent dehydration and maintain health; -The Dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that places the resident at risk for impaired nutrition; -The specific amount of hydration needed is specific for each resident, and fluctuates as the resident's condition fluctuates; -Risk factors for dehydration include: fluid loss and increased fluid needs (e.g. uncontrolled diabetes), functional impairments that make it difficult to drink, reach fluids, or communicate fluid needs, or dementia in which a resident forgets to drink or forgets how to drink; -Review supportive ancillary documentation that impacts the nutritional assessment, including, but not limited to, the food and fluid consumption record (Appetite Sheet), weight and height records, laboratory results, and nursing notes; -Implement nutritional support and interventions according to the plan or care. Review of Resident #3's Physician Order Sheet (POS), dated August 2024, showed: -An order, dated 6/14/24, for regular diet, mechanical soft texture, regular/thin consistency, a snack at night and Boost (a nutritional supplement for diabetics) three times a day. Use a divided plate; -An order, dated 8/21/24, for labs, including a complete metabolic panel (CMP, measures 14 substances in the blood to assess metabolism, kidney and liver function and electrolyte and fluid balance). Review of resident's lab report, dated 8/30/24, showed: -On 8/30/24 at 2:30 A.M., the blood sample was collected; -On 8/30/24 at 9:34 A.M., the blood sample was received by the lab; -On 8/30/24 at 11:35 A.M., the final report for the CMP was completed; -Sodium (measures the amount of sodium in the blood. Normal ranges are between 136 milliequivalents per liter (mEq/L) and 145 mEq/L) measured within normal range at 142 mEq/L; -Creatine (measures how well kidneys are functioning, normal levels are between 0.7 milligrams per deciliter (mg/dL) and 1.3 mg/dL. High levels of creatine can show kidney disease or dehydration) measured high at 1.4 mg/dL; -Blood urea nitrogen (BUN, measures the amount of urea nitrogen in blood, showing how well kidneys are functioning. Normal levels are between 10 mg/dL to 22 mg/dL. High BUN could indicate kidney problems) measured high at 30 mg/dL; -BUN to Creatine ratio (blood test that measures the levels of urea nitrogen and creatinine. Normal levels are between 8.6 to 16.7. A high BUN to creatinine ratio could indicate kidney problems or dehydration) measured high at 21.4286; -An order, dated 9/10/24, was handwritten by the PCP on the lab report to push fluids. Review of the resident's POS, dated September 2024, showed: -There was no order found to push fluids. Review of the PCP progress note, dated 11/11/24, showed: -The resident had generalized muscle weakness, was not well-looking, chronically ill and appeared poorly nourished; -The resident reported confusion, disorientation, memory lapse or loss, gait abnormality, difficulty with balance and poor coordination; -Plan of Care included to follow up with weight management; add Remeron (an appetite stimulant) 7.5 milligrams (mg) at night due to severe malnutrition. Review of the resident's Medication Administration Record (MAR), dated November 2024, showed: -An order, dated 11/11/24, discontinued on 11/19/24, for Remeron 7.5 mg, give once at bedtime for weight loss; -Documentation showed the facility administered the medication as ordered seven out of the eight opportunities. Review of the resident's progress notes, from 11/11/24 through 11/19/24, showed: -No documentation was found showing an order was given to discontinue the Remeron on 11/19/24. Review of the resident's Nutrition/Dietary Note, dated 11/22/24 at 12:23 P.M., showed: -The resident had a significant weight gain from 10/10/24 weight of 103.4 pounds (lbs) to 124.4 lbs on 11/8/24; -The resident height was 68 inches and current Body Mass Index (BMI, measured body fat based on height and weight) was 18.9, which was low for his/her age; -The RD believed the resident's October weight was inaccurate as there were no diagnoses or medications noted that could to contribute to weight fluctuation; -The resident was prescribed a mechanical soft diet with thin liquids, with special instructions to use a divided plate; -Supplements included Ensure (nutritional shake) three times a day (TID) and a snack at night; -Most recent labs from 8/30/24, showed creatine high at 1.4 mg/dL and BUN high at 30 mg/dL; -The PCP noted on the lab results to push fluids; -The RD recommended to update diet order to state push fluids 500 milliliters (ml)/2 cups at meals and 250 ml/1 cup in between; -The RD will continue to monitor weight, by mouth (PO) intake and labs as available; -The goal was to improve nutrition related labs and maintain weight plus four percent. Review of the resident's MAR, dated November 2024, showed there was no order to push fluids 500 ml at meals and 250 ml/1 cup between meals. Review of the resident's care plan, undated, showed: -Problem: The resident was at risk for unplanned/unexpected weight loss due to diagnosis of severe protein calorie malnutrition; -Interventions included: give supplements as ordered; give diet as ordered; push fluids 500 ml/2 cups at meals and 250 ml/1 cup in between meals, initiated on 11/22/24. Review of the resident's POS, dated December 2024, showed: -An order, dated 12/10/24, to push fluids 500 ml at meals and one cup in between meals, five times a day for hydration. Review of the resident's MAR, dated December 2024, showed: -An order, undated, to push fluids 500 ml at meals and 1 cup in between meals five times a day for hydration; -Documentation showed from 12/10/24 at 11:00 A.M. through 12/23/24 at 8:00 A.M., the facility documented they followed the order as written 15 times out of 65 opportunities; -Documentation showed the facility failed to follow the order three out of five opportunities on 12/19/24, 12/20/24 and on 12/21/24; -Documentation showed the facility failed to follow the order once out of five opportunities on 12/22/24. Review of the resident's progress note, showed: -A note, dated 12/16/24 at 2:34 P.M., an order was received from the PCP to obtain labs, including a CMP; -A note, dated 12/16/24 at 4:44 P.M., the nurse was informed by the RRP that while the resident was out having a computed tomography (CT scan, combines a series of x-ray images taken from different angles around the body), the office informed him/her that the resident's creatine level was high. The nurse reported the information to the PCP. Review of the resident's POS, dated December 2024, showed: -An order, dated 12/17/24, for labs, including CMP, one time only for creatinine level. Review of the resident's lab report, dated 12/18/24, showed: -On 12/18/24 at 4:26 A.M., the blood sample was collected; -On 12/18/24 at 11:11 A.M., the blood sample was received by the lab; -On 12/18/24 at 1:55 P.M., the final report for the CMP was completed; -Sodium measured high at 156 mEq/L; -Creatine measured high at 1.76 mg/dL; -BUN measured high at 43 mg/dL; -BUN to creatine ratio measured high at 24.4; -A handwritten note, unsigned and undated, showed a call was placed to the PCP to ensure orders were verified, to encourage fluids and repeat CBC and CMP labs in one month. Review of the resident's POS, dated December 2024, showed: -There was no documentation found to repeat CBC and CMP labs in one month; Review of the resident's progress notes, showed: -A note, dated 12/18/24 at 2:41 P.M., the resident's lab results were still pending and the nurse will pass the information on in report; -A note, dated 12/19/24 at 4:59 P.M., the resident's responsible part (RRP) called concerned the resident was getting fluids, stating he/she put a sports drink and water in the resident's personal fridge. The RRP stated the resident had a CT scan on Monday (12/16/24) and iodinate will need to get flushed out. The writer informed the RRP the resident was offered fluids. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/21/24, showed: -Severe cognitive impairment; -Required moderate assistance with eating; -Height of 68 inches; -Weight of 120 pounds; -Risk for pressure ulcers (a localized area of damaged skin or tissue that occurs when pressure is applied to the skin for a prolonged period of time); -No pressure ulcers present; -Diagnoses included non-traumatic brain dysfunction, hypertension (high blood pressure), kidney disease, Diabetes Mellitus, Alzheimer's disease, stroke, dementia and severe protein-calorie malnutrition. Review of the resident's progress notes, showed: -A note, dated 12/23/24 at 9:45 A.M., the resident was leaving the building with a family member for a doctor appointment; -A note, dated 12/23/24 at 11:47 P.M., a call was made to the RRP asked when the resident would return to the facility. The RRP stated the resident was sent to the hospital emergency department for evaluation on an order from the doctor during their appointment; -A note, dated 12/24/24 at 12:09 A.M., the nurse called the hospital emergency department and was informed the resident was admitted to the hospital. Admitting diagnoses were hyponatremia (low sodium in the blood), dehydration and altered mental status. During an interview on 1/28/25 at 12:20 P.M., the Director of Nursing (DON) said: -She expected nursing staff to have knowledge of and to follow facility policies; -She expected staff to be aware of and to follow resident's care plans; -It was the charge nurses' responsibility to take physician written orders off of lab results and put them into the resident's physician order sheet in the electronic medical record (EMR); -The DON read the RD's nutritional recommendations after his/her visit to residents and was responsible for putting the RD's orders into the residents' physician order sheet in the EMR; -If the DON was not present on the days the RD came in to assess residents, the RD would email his/her report and the DON was responsible for putting the RD's orders into the residents' physician order sheet in the EMR; -She expected all written, verbal or telephone orders entered into residents' physician order sheet in the EMR within 48 hours; -Residents' health could decline if orders were not put into the EMR in a timely manner; -She expected nurses to document in a progress note when an order was discontinued; -Both she and the Assistant Director of Nursing (ADON) were responsible monthly for reviewing EMRs to review if orders were put in correctly; -Both she and the ADON would review MARs occasionally, especially if a resident complained they were not getting medications; -She was not aware of any issues regarding orders not implemented or followed per the plan of care or PCP; -When there was a blank in the documentation on a MAR, it meant the order was not done; -She expected staff to follow orders and offer fluids to dependent residents; -She expected nurses to follow up with Certified Nursing Assistants (CNA) to ensure the residents were given fluids as ordered; -The residents were at risk of complications to their health related to possible dehydration and/or malnutrition if nursing staff did not administer fluids as ordered. During an interview on 1/30/25 at 2:58 P.M., the hospital charge nurse said: -He/She was the charge nurse on the floor where the resident was admitted to on 12/23/24; -The emergency room (ER) Physician notes, on 12/23/24, said the resident was significant for renal failure, altered mental status and hyponatremia; -The resident's labs taken on 12/23/24 while he/she was in the ER, showed estimated glomerular filtration rate (eGFR, measures how well kidneys filter waste. Normal range is 90 or higher) was 35, showing moderate to severe decreased kidney function, sodium was high at 154 mEq/L, BUN was high at 48 mg/dL and creatine level was high at 1.87 mg/dL; -The ER physicians often dictate their notes and do not review them after they were scribed into the medical record for accuracy; -Given the resident's lab result of sodium at 154, the resident had hypernatremia (high sodium levels in the blood), not hyponatremia. MO00247413

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, record review, and facility policy review, the facility failed to ensure two of three residents (Resident (R)54 and R45) reviewed for abuse out of a total sample of 24 did not engage in verbal threats that escalated to physical abuse of kicking and slapping each other. R45 suffered psychosocial harm following the incidents as evidenced by her fearful comments to her psychiatric Nurse Practitioner and to other staff members. Findings include: Review of the facility's policy titled Abuse Prevention Program revised December 2016, revealed .Our residents have the right to be free from abuse, neglect, misappropriation and exploitation. This includes freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse .As part of the abuse prevention the administration will: 1. Protect our residents from abuse by anyone including, but not limited to: facility staff, other residents, consultants, vendors, visitors, family members, or any other individual . Review of the facility's reportable incidents with a look back period of January 2023 to May 2024 revealed both verbal and physical altercations occurred between R54 and R45. Once on 11/21/23 and again on 03/24/24, with both residents cursing, kicking and hitting each other. 1. R54 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia and history of a traumatic brain injury sustained during an arrest several years ago. Review of R54's Minimum Data Set (MDS) assessments with an Assessment Reference Dates (ARD) of 10/13/23, 01/13/24, and 04/14/24 revealed Brief Interview for Mental Status (BIMS) scores of 10, nine, and 10, respectively which indicated moderate cognitive impairment. During the survey, R54 did not participate meaningfully in interviews when attempted, but he was observed each day of the survey exhibiting disruptive and verbally abusive behavior directed at staff and other residents. R54 was ambulatory via wheelchair and was rarely found in his room. Throughout the five-day survey, R54 was observed yelling and shouting vulgarities towards other residents and staff. Most of his behaviors were focused on his desire to go outside to smoke. Interviews with direct care staff (Certified Nurse Aide (CNA) 1 and Certified Medication Technician (CMT) 1 on 04/30/24 at 11:30 A.M. revealed they were unable to predict and/or prevent R54's behaviors. One intervention on his care plan was to have R54 on 15 minute checks but that intervention usually lasted 48-72 hours, situationally, and in response to his abusive behaviors, not as a deterrent. CNA1 stated .I try to keep him in sight all the time - but I can't watch him if I'm helping another resident that needs to go to the bathroom or whatever they need . Review of a facility investigation revealed on 11/21/23, R54 propelled himself to R45's room and stated, Suck my dick. R45 hit R54 on the head with her reacher/grabber tool and then R54 kicked R45. Next R45 kicked R54 back and threw water on R54. The kicking went back and forth until the two were separated by staff. After the separation, R54 continued to yell and threaten R45 and stated he will shoot everybody in this building. Cross Reference: F609 Reporting and F610 Investigation of allegations of abuse. Immediately after this incident, the facility transferred R54 to the hospital for a Geri-psychiatric evaluation. He returned the same night with no new orders to manage his behaviors. R54 was moved to a different room and placed on 15-minute checks for 72 hours. The next incident occurred on 03/24/24, when R54 propelled himself to the end of the hall near R45's room. Staff did not hear if any words were exchanged but saw R54 standing over R45 and hitting her on her head. R45 returned blows by hitting R54 with her reacher/grabber tool. Staff separated the residents. When asked by staff why he (R54) was near R45's room, R54 stated that he was looking for his room and then stated, I saw that bitch who threw water on me. She thinks I forgot. I don't forget shit and I hit her . Both residents were assessed and neither had any physical injuries from the incident. 2. R45 was admitted to the facility on [DATE] with diagnosis of vascular dementia and osteoarthritis and a BIMS score of 15 which indicated R45 was cognitively intact. She was ambulatory via specialty wheelchair. R45 was interviewed on 04/30/24 at 12:45 PM and confirmed the incident with R54 as described. She stated .nobody [sic] going to talk to me that way - if he does it again, I'll take care of it again - I take up for myself. R45 stated that her room is on the other side of the building now, but she occasionally sees R54 in the dining room and she stays away from him. When asked directly about the incident she remembered it and stated that she doesn't sleep well now .due to keeping watch on her door -so that man doesn't come in and do something to her . She stated she does feel more secure since her move off the hall where R54 resides, but she still sleeps with an eye on the door . Medical record review revealed that R45 was seen by psychiatry once monthly. Review of a Psychiatric Nurse Practitioner's progress note dated 04/09/24 and found in the Progress Note tab of the EMR revealed .Psych Impression: [R45 name] is an [AGE] year old resident at [facility name]. She complains of not sleeping at night because she has to watch for strange men coming in her room. Staff report she curses at them from time to time. This seems to be her personality and not necessarily a behavior issue addressed with medication . In the prior psychiatric visits, R45 mentioned that she slept well except for one time she complained of pain in her knees when trying to sleep. An interview with the Director of Nursing (DON) on 04/30/24 at 3:15 PM revealed the facility had sought alternate placement for R54 due to his aggressive behaviors, . and no-one will take him [R54] because of his behaviors. He has a sister that can't care for him in her home so he is here, and we have to play it by ear and try to stay between him and trouble .but it's not fair for the other residents to see him get his way every time he wants something by being loud, vulgar, and stubborn - he won't stop until he gets his way . In an interview with the Medical Director (MD) on 05/03/24 at 12:15 PM by phone, the MD stated he has intermittently provided situational or one-time orders to manage R54's behaviors when he was out of control until he could be re-evaluated by psych. He did not have specific information about the two incidents identified above.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, interview, and observations, the facility failed to implement pressure ulcer interventions after surgery for left hip repair and failed to follow physician's treatment orders for one of four residents (Resident (R) 63) reviewed for pressure ulcers out of a total sample of 24 residents. This failure caused actual harm when R63 acquired unstageable pressure ulcers on the left foot. Findings include: Review of the Census tab located in the electronic medical record (EMR) revealed R63 was initially admitted on [DATE] and readmitted to the facility on [DATE]. Review of the Med Diag [Medical Diagnoses] tab located in the EMR revealed R63 was readmitted with diagnoses including surgical repair of the left hip. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/25/23 revealed R63 had a Brief Interview for Mental Status (BIMS) score of three out of 15 indicating severe cognitive decline. Review of a Braden Scale for Predicting Pressure Ulcer Risk form located in the EMR and dated 12/15/23 revealed a score of 16/18 indicating R63 was at risk for pressure ulcers. Review of a Skin Observation Tool assessment form located in the EMR and dated 12/23/23 revealed R63 had a left thigh surgical incision with a note stating the, resident has some swelling and a vertical surgical incision to left leg. There was no indication of any other wounds on R63. Review of a Braden Scale for Predicting Pressure Ulcer Risk form located in the EMR and dated 12/23/23 revealed a score of 17/18 indicating R63 was at risk for pressure ulcers. Review of a Braden Scale for Predicting Pressure Ulcer Risk form located in the EMR and dated 01/01/24 revealed a score of 10/18 indicating R63 was now at high risk for pressure ulcers. Review of the Care Plan located in the EMR revealed a concern/intervention related to left heel pressure sores initiated on 01/06/24 including bilateral heel protectors, promoting good nutrition and hydration, and monitoring skin and reporting to the physician. There were no previous interventions initiated after returning from the hospital post-surgery on 12/15/23. No off-loading of extremities or other pressure ulcer preventions/treatments noted before 01/06/24 after the two unstageable pressure ulcers developed. Review of a Skin Observation Tool assessment form located in the EMR and dated 01/06/24 revealed the first documentation of a left heel and left anterior foot scab area with a note stating the, resident has new area to left heel and anterior right side of foot, both areas are closed and have scabbed over. Areas are unstageable at this time. Treatment in place. Review of a Skin Observation Tool assessment form located in the EMR and dated 01/08/24 revealed R63 had a left heel pressure ulcer measuring 2.0 X 3.0 X 0.2 cm (centimeters) with a note stating the, resident w/o [without] skin issues to remaining body surface. Heel protectors placed bilaterally, tolerated assessment well. Review of an Encounter note located in the EMR dated 01/17/24 revealed a Stage 2, left foot wound with a 4.0 X 4.5 X 0.2 cm size and deteriorating status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, and elevating extremities. Review of an Encounter note located in the EMR dated 01/31/24 revealed an unstageable, left foot wound with a 4.0 X 3.0 X unable to determine (UTD) cm size and deteriorating status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of the January 2024 electronic medication administration record (eMAR) revealed an order to apply skin prep to the scabbed area on the left foot twice a day that was not documented as completed on 01/07, 01/17, and 01/31/24. Review of an Encounter note located in the EMR dated 02/16/24 revealed an unstageable, left foot wound with a 3.0 X 3.0 X 0.2 cm size and stable status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of an Encounter note located in the EMR dated 02/21/24 revealed an unstageable, left foot wound with a 3.0 X 3.0 X 0.2 cm size and stable status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of the February 2024 eMAR revealed an order to apply skin prep to the scabbed area on left foot twice a day was not documented as followed on 02/02, 02/02, 02/11, 02/13, 02/22, 02/25, and 02/26/24. Another order to cleanse the left heel opening and apply Medi-honey and a foam dressing once daily was not documented as completed on 02/01, 02/03, 02/10, 02/11, 02/13, 02/17, 02/18/, 02/21, 02/23, 02/25, 02/27, 02/28, and 02/29/24. Review of an Encounter note located in the EMR dated 03/01/24 revealed an unstageable, left foot wound with a 2.5 X 2.0 X 0.2 cm size and improving status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of an Encounter note located in the EMR dated 03/06/24 revealed an unstageable, left foot wound with a 3.0 X 2.5 X 0.4 cm size and deteriorating status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of an Encounter note located in the EMR dated 03/13/24 revealed a Stage 4, left foot wound with a 2.0 X 2.5 X 0.5 cm size and improving status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of an Encounter note located in the EMR dated 03/21/24 revealed a Stage 4, left foot wound with a 2.2 X 2.3 X 0.4 cm size and stable status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of the March 2024 eMAR revealed an order to apply skin prep to the scabbed area on left foot twice a day was not documented as completed on 03/08, 03/12, 03/17, 03/22, 03/25, 03/26, and 03/27/24. Another order (discontinued on 03/26/24) to cleanse the left heel opening and apply Medi-honey and a foam dressing was not documented as completed on 03/01, 03/02, 03/12, 03/14, 03/15, 03/16, 03/17, 03/18, 03/19, 03/22, and 03/23/23. Another order (initiated on 03/28) to cleanse the area with normal saline, apply collagen, and cover with a dry dressing once daily was not documented as completed on 03/29/24. Review of an Encounter note located in the EMR dated 04/03/24 revealed a Stage 4, left foot wound with a 1.6 X 1.0 X 0.2 cm size and improving status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of an Encounter note located in the EMR dated 04/10/24 revealed a Stage 4, left foot wound with a 2.0 X 1.5 X 0.1 cm size and improving status. Orders noted by the physician include applying off-loading boot, off-loading pressure areas, repositioning per facility turning schedule, elevating extremities, and a low-air-loss mattress. Review of a Wound - Weekly Observation Tool located in the EMR and dated 04/24/24 revealed the left heel wound with a size of 1.0 X 3.0 X 0.1 cm, with defined edges and stable progress. Review of the April 2024 eMAR revealed an order to cleanse the area with normal saline, apply collagen, and cover with a dry dressing once daily was not documented as completed on 04/03, 04/04, 04/05, 04/12, 04/13, 04/14, 04/20, 04/21, 04/23, 04/26, and 04/28/24. Review of a Skin Observation Tool assessment form located in the EMR and dated 04/29/24 revealed R63 had a left heel pressure sore measuring 1.0 X 0.3 X 0.1 cm with a note stating, no other skin openings noted. An observation on 04/30/24 at 5:26 PM revealed R63 to be in Geri-chair in common area. R63 had bilateral heel boots on. Observation of R63's room revealed a regular mattress on bed. Observation on 05/03/24 at 12:10 PM revealed the bed of R63 did not have a low-air-loss mattress. In an interview on 05/01/24 at 2:45 PM, the Director of Nursing (DON) stated the low air loss mattress was not ordered for R63 because the administration did not want to pay for it. The DON stated the physician orders should always be followed. In an interview on 05/03/24 at 11:45 AM the Director of Nursing (DON) stated the CP should have been updated after hip surgery and interventions should have been implemented. MO00233924 MO00234710