**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy review, the facility failed to ensure residents were free from abuse, for seven of nine sampled residents (Resident (R) 4, R77, R84, R30, R62, R350, and R83) reviewed. Examples include: R4 struck R77 in the mouth, resulting in a cut to the inner right lip where the resident's tooth hit it, a contusion to the upper lip and a transfer to the hospital for assessment. In a second incident, R4 pulled up the shirt of one resident with impaired decision making and cognition related to intellectual disability (R84), reaching underneath R84's shirt and touching his/her chest. In a third incident, staff entered the hallway and observed R4 being punched in the face by R30 after R4 spit on R30 and threw a cup of juice on him/her. R30 hit R4 in the face several times, resulting in a laceration under the right eye and a transfer to the hospital for a medical evaluation. A fourth incident showed R4 in the hallway sitting in his/her wheelchair, when R62 ran towards the resident. R4 ducked, however, R62 hit R4 in the back of the head, and falling out of his/her wheelchair. R4 and R350 had at least two altercations that included F350 grabbing R4 by the hair and hitting him/her in the face and then the next day getting into another fight. Last, R30 hit R83 in the leg while R30 was exhibiting sexually aggressive and verbal behaviors. The facility failed to make any changes to the residents' plans of care following the incidents. The census was 118. Findings include: Review of the facility's undated policy titled, ''Abuse, Neglect and Exploitation'' revealed, ''. each resident has the right to be free from verbal, sexual, physical, mental abuse, corporal punishment, and involuntary seclusion. The resident has the right to be free from mistreatment, neglect, and misappropriation of property. Residents must not be subject to abuse by anyone, including but not limited to; facility staff, other residents' consultants or volunteers, staff or other agencies serving the resident .'' 1. Review of R4's ''admission Record,'' located in the ''Profile'' tab of the electronic medical record (EMR), revealed he/she was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including cognitive communication deficit, schizophrenia, bipolar disorder, major depressive disorder, generalized anxiety disorder, altered mental status, high risk bisexual behavior, traumatic brain injury, and schizoaffective disorder. Review of R4's annual ''Minimum Data Set (MDS),'' located under the ''MDS'' tab of the EMR, with an Assessment Reference Date (ARD) of 12/08/23, revealed he/she scored 15 out of 15 on the ''Brief Interview for Mental Status (BIMS),'' indicating no cognitive impairment. Review of R4's care plan,' located under the ''Care Plan'' tab of the EMR and dated 02/11/23, revealed, ''The resident has behaviors as evidenced by poor interpersonal skills. R4 is manipulative and has had verbal and physical altercations with other residents.'' Review of R77's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed he/she was initially admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, cognitive communication deficit, altered mental status, bipolar disorder, anxiety disorder, and difficulty in walking. Review of R77's quarterly ''MDS,'' located under the ''MDS'' tab of the EMR, with an ARD of 06/01/23, revealed he/she scored 15 out of 15 on the ''BIMS,'' indicating no cognitive impairment. Review of R77's care plan, located under the ''Care Plan'' tab of the EMR and dated 11/16/23, revealed, ''The resident has impaired cognitive function due to a diagnosis of schizophrenia.'' Review of a ''Nurse's Note,'' located under the ''Notes'' tab of the EMR written by the Director of Nursing (DON) and dated 07/20/23 at 1:02 PM, indicated, ''[R4] was in the dining area with peers when he/she struck [R77] in the mouth. [R4] stated he/she was upset because his/her sodas were being stolen, and the person he/she struck did not know how to shut up, so he/she hit [R77] in the mouth. [R4] also stated, 'I was going to punch another resident for stealing too.'. [R4] was transported to hospital due to aggressive behaviors. Physician and guardian were notified.'' Review of a ''Health Status Note,'' located under the ''Notes'' tab of the EMR dated 07/20/23 at 8:46 PM indicated that R77 returned from the hospital and was diagnosed with a facial contusion. Review of a ''Physician encounter,'' located under the ''Notes'' tab of the EMR and dated 07/20/23 at 12:00 AM, indicated, ''physician followed up with [R77] post emergency room [ER] visit and observed that [R77] had a cut to the inner right lip where the resident's tooth hit it and a contusion to the upper lip. [R77] reported it was still painful but was getting better. During an interview on 01/17/24 at 11:52 AM, the DON stated she did not remember the specifics of the incident but what was documented in the nurses' notes was what occurred. She said both residents were separated, and she thought R4 may have been given a ''PRN (as needed)'' and sent out to the hospital. The DON stated there were no updates made to the resident's care plan or plan of care after the incident. During an interview on 01/18/24 at 6:22 PM, R77 said R4 accused him/her of calling R4 a punk and the R4 ''sucker punched'' R77. R77 said he/she was not afraid of R4 but was leery of him/her because R4 could hit him/her again. 2. Review of R84's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed he/she was initially admitted to the facility on [DATE] with diagnoses including major depressive disorder, intellectual disabilities, drug induced subacute dyskinesia, and unspecified mood disorder. Review of R84's quarterly ''MDS,'' located under the ''MDS'' tab of the EMR, with an ARD of 10/05/23, revealed he/she scored 99 out of 15 on the ''BIMS,'' indicating he/she was unable to complete the assessment. Review of R84's care plan, located under the ''Care Plan'' tab of the EMR and dated 07/12/23, revealed, ''The resident has impaired decision making and cognition due to the resident having intellectual disabilities.'' Review of a ''Nurse's Note,'' located under the ''Notes'' tab of the EMR written by Licensed Practical Nurse (LPN) 7 and dated 07/31/23 at 2:23 PM, indicated, ''[R4] was observed by staff to have [R84]'s shirt pulled up and touching the other resident's nipple. The two were separated and are on 15-minute checks. Staff educated [R4] on consent and inappropriate behaviors. Physician and Responsible party were made aware.'' During an interview on 01/16/24 at 11:16 AM, Certified Nurse Aide (CNA) 44 said he/she was in the C unit dining room putting trays away when he/she observed R4 reaching back to R84 and pulling up R84's shirt and R4 reached underneath R84 shirt touching his/her chest and he/she told R4 to stop. He/She said R84 finished eating and then he/she walked R84 down to his/her room to wash the resident's hands and face. He/She said R4 denied the incident and remained in the dining room at that time. He/She said he/she reported the incident to LPN7. He/she said he/she was not instructed to do anything different about supervising either resident after the incident occurred. During an interview on 01/16/23 at 11:58 AM, LPN7 said staff reported to him/her that R4 was in the dining room when he/she raised R84's shirt up and touched R84's nipple and staff separated both residents. LPN7 said when he/she spoke with R4, he/she stated he/she was playing with the other resident. He/She said he/she attempted to talk to R84, but he/she did not say anything. LPN7 said he/she was not aware of any changes made to R4's care other than 15-minute checks but that was standard for all the residents on C unit. LPN7 said he/she reported this incident to the MDS coordinator. 3. Review of R30's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed he/she was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses of auditory hallucinations, antisocial personality, paranoid schizophrenia, bipolar disorder, and personality disorder. Review of R30's quarterly ''MDS,'' located under the ''MDS'' tab of the EMR, with an ARD of 10/24/23, revealed he/she scored 03 out of 15 on the ''BIMS,'' indicating severe cognitive impairment. Review of R30's care plan, located under the ''Care Plan'' tab of the EMR and dated 10/11/23, revealed, ''The resident has behaviors as evidenced by aggression towards family, argues with himself/herself loudly, resident to resident altercation and requires a secured unit.'' Review of a ''Nurse's Note,'' located under the ''Notes'' tab of the EMR written by agency nurse dated 10/11/23 at 2:45 AM, indicated, ''Staff was made aware that [R4] and [R30] were in the hallway fighting. Staff entered the hallway and observed [R4] being punched in the face by [R30]. [R4] said he/she spit on [R30] resident and threw a cup of juice on him/her and then [R30] hit him/her in the face several times. Both residents were immediately separated. [R4] was taken into the activity room on the unit. 911 was called and requested EMTs [Emergency Medical Technician] with police assistance. [R4] was transferred to the hospital for a medical evaluation. All parties were notified via telephone.'' It was noted that R4 had a laceration under the right eye. During an interview on 01/18/24 at 10:44 AM, the Assistant Director of Nursing (ADON) revealed she was in the office when she heard a loud commotion and looked up and saw R30 and R4 in the hall. R30 was cursing and accused R4 of throwing juice on him/her. The ADON said R30 was difficult to redirect and suddenly jumped out his/her wheelchair and punched R4 in the face. The ADON stated she immediately grabbed R4 and pushed him/her into the dining room and closed the door. The ADON stated she went outside the door and that was when the police arrived and spoke with R30 who was still cussing. The ADON stated she left after that. 4. Review of R62's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed he/she was initially admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including schizoaffective disorder, bipolar disorder, and intellectual disabilities. Review of R62's annual ''MDS,'' located under the ''MDS'' tab of the EMR, with an ARD of 12/08/23, revealed he/she scored 15 out of 15 on the ''BIMS,'' indicating no cognitive impairment. Review of R62's care plan, located under the ''Care Plan'' tab of the EMR and dated 05/16/23, revealed, ''The resident has behaviors as evidenced by resistive to care, susceptible to being manipulated, and makes false allegations.'' Review of an ''Incident/Accident note,'' located under the ''Notes'' tab of the EMR dated 12/25/23 at 4:30 PM, revealed R4 was approached by R62. R4 was struck by R62 and fell to the floor. R4 said he/she was okay, and he/she wasn't struck that hard. R4 was assisted up by staff and separated from R62. There were no injuries noted. The residents' guardian and physician were notified. During an interview on 01/16/24 at 11:27 AM, CNA24 said R62 was upset after coming back from a visit with family. He/She said R4 was in the hallway sitting in his/her wheelchair when R62 ran towards him/her and R4 ducked, but R62 hit R4 in the back of the head. Staff ran over and grabbed R62 while he/she and another staff helped R4 up off the floor and back into his/her wheelchair. R62 was still aggressive after he/she hit R4, and staff called police. He/She said that R62 has had these types of behaviors before, and staff only gave him/her a PRN or would send him/her out to the hospital. He/She said staff would just move the more aggressive residents to another locked unit and that staff kept an eye on them, but there was really nothing done to address the aggressive behaviors. During an interview on 01/17/204 at 5:48 AM, LPN6 said R62 was upset on 12/25/23 about a recent visit with his/her family and was threatening staff and yelling. LPN6 said he/she walked off the unit briefly to call 911 and while he/she was on the phone, he/she could see R62 running down the hall. LPN6 stated he/she hung up the phone and went back onto unit and saw staff helping R4 up and back into his/her wheelchair. He/She said staff told him/her that R62 ran at R4 and hit him/her. R62 was changed to another unit but there was no change in either of the residents' care. 5. Review of R350's ''admission Record,'' located in the ''Profile'' tab of the EMR, revealed he/she was initially admitted to the facility on [DATE] with diagnoses including cognitive communication deficit, moderate intellectual disabilities, bipolar disorder, major depressive disorder, disruptive mood disorder, anxiety disorder, and disorder of adult personality and behavior. Review of R350's annual ''MDS,'' located under the ''MDS'' tab of the EMR, with an ARD of 12/08/23, revealed he/she scored 15 out of 15 on the ''BIMS,'' indicating no cognitive impairment. Review of R350's care plan, located under the ''Care Plan'' tab of the EMR and dated 12/08/23, revealed ''The resident has behaviors as evidenced by making false allegations, and has been involved in a resident-to-resident altercation.'' Review of a ''Behavior Note,'' located under the ''Notes'' tab of the EMR dated 01/10/24 at 10:30 AM, revealed, ''at about 9:30 AM [R4] said [R350] grabbed [R4] by the hair and hit him/her in the face and then [R4] hit [R350] back in the face. This writer informed [R4] that if he/she has a problem with another resident to report it to staff and not to be fighting. [R4] said that he/she was only defending himself/herself.'' During an interview on 01/15/24 at 11:13 AM, R350 said that R4 and himself/herself were roommates and R4 had stolen some of his/her personal belongings. He/She said that R4 got smart and that he/she beat him up. R350 did not explain what ''beat him up'' meant. During an interview on 01/15/24 at 11:51 AM, R4 said R350 was his/her roommate but he/she kept accusing R4 of stealing his/her stuff. He/She said there was several altercations between the two of them. R4 said on one occasion R350 was blocking the doorway to room, so he/she kicked the wheel on R350's wheelchair to get his/her attention. R350 started kicking R4 in the leg and they both ended up in the hallway and staff intervened and broke up the fight. About a week later R350 was sitting in his/her wheelchair in the middle of the hallway, blocking R4 from getting past. He tapped R350 on the shoulder, but he/she ignored him/her so R4 kicked R350's wheelchair. R4 said R350 told him/her if he/she did it again, R350 would kick his/her ass, but staff separated them again and they stayed away from one another the rest of the day. The next day R4 wheeled past R350 in the hallway and R350 grabbed him/her by the hair and hit him/her in the face and bit his/her arm so R4 said he/she slapped R350 in the face and staff came and broke it up. R350 was moved downstairs, and there had not been any more issues. During an interview on 01/16/24 at 11:27 AM, R4 told staff that he/she and R350 had got into a fight and R350 was moved to another floor. He/She said R4 told him/her that R350 bit and scratched R4's arm. He/She said they were roommates but that R350 was moved off the unit after the fight occurred. He/She said there was no change in their plan of care or any increase in supervision for either resident after the incident occurred. During an interview on 01/17/24 at 11:30 AM, the ADON said that on 01/10/24, staff came and got her and told her there was an incident between R4 and R350. The ADON stated she spoke with both residents who stated R350 pulled R4's hair and hit him/her and that R350 admitted to doing this because R4 was taunting him/her about his/her sexual orientation. The ADON stated both residents were separated and R350 was transferred downstairs. The ADON stated there were no injuries and that R4 reported that R350 ''hit like a girl,'' but there were no changes to either residents' plan of care. During an interview on 01/17/24 at 11:52 AM, the DON stated due to the resident population and all the behaviors, they had started an outside therapy group. The DON stated she was unsure of the specifics but stated it would be run by the Social Services (SS) department. The DON confirmed that services in the facility were not being integrated together, and that the nursing department was not aware of what services SS was doing to address residents' behaviors. The DON said R4 had become increasingly difficult to manage behaviorally, but he/she did get along with some peers and some staff. The DON stated that R4 was medication seeking and had a substance abuse issue, but the facility had no drug and alcohol services to provide. The DON confirmed there was a need for services related to drug and alcohol abuse. The DON stated they have spoken about the need for therapy services for residents during IDT (interdisciplinary team) meetings and stated the facility should be doing more for residents with behaviors. During an interview on 01/17/24 at 10:40 AM, the Social Services Director (SSD) said there are two behavior techs that assist residents with activities, provide encouragement, support, talking to them, and de-escalation, but they do not have specialized training to do their job and they were not hired for a particular unit. The SSD said they also have aides that help monitor on the halls and report concerns but they are not trained to intervene or prevent incidents from occurring. She said the facility had just gotten one counselor that started in December 2023, but the facility did not have any providers prior to December 2023 to provide any mental health services to any of the residents to address their behaviors. 6. R30's ''admission Record,'' dated 01/20/24 and found in the EMR under the ''Admissions'' tab, indicated the resident was admitted to the facility on [DATE] with diagnoses including antisocial personality disorder, bipolar disorder, and paranoid schizophrenia. R30's quarterly ''MDS,'' with an ARD of 10/24/23 and found in the EMR under the ''MDS'' tab, indicated a ''BIMS'' score of 3 out of 15 (severely cognitively impaired). The assessment indicated R30 experienced hallucinations and delusions during the assessment reference period and exhibited verbal behavioral symptoms toward others on 4 to 6 of the days during the assessment reference period. R30's ''Oder Summary Report,'' dated 01/11/24 and found in the EMR under the ''Orders'' Tab, indicated an order for medroxyprogesterone (a hormone) 10 MG (milligrams) one time daily for hypersexuality. R30's ''Behavior Progress Note,'' dated 01/07/24 and found in the EMR under the ''Notes'' Tab, read ''Resident [R30] up in w/c [wheelchair] on D-hall unit. Agitation with aggressive behavior. A/H & V/H [auditory hallucinations and visual hallucinations]. Delusion [s]. Yelling and cussing at other residents. Staff attempted to redirect. No success. Resident propelled self toward staff making threats. Resident took off clothes in hallway, started masturbating stating, 'I'm going to rape one of these [expletive].' Resident [R83] walked passed [sic] this resident [R30] who proceeded to punch the other resident [R83] in his leg. Staff separated residents. This resident's [R30's] behaviors continued to escalate. MD [Medical Doctor] aware. New order received. 911 notified. Police and EMT's [Emergency Medical Technicians] arrived to [sic] facility. Resident [R30] transported to [Local Emergency Department] for eval/tx [evaluation and treatment]. Call placed to [R30's Legal Guardian], left a message [sic] to contact facility ASAP [As Soon As Possible] for an update. Call placed to [R30's Family Member], left a message to contact facility. On call nurse [ADON] notified. ADM [Administrator] made aware of situation.'' R30's care plan was reviewed and indicated no care plan related to the resident exhibiting any type of abusive behavior toward others. No documentation was found to show the resident's plan of care had been updated related to the 01/07/24 incident of potential sexual and physical abuse. R30 was not able to be interviewed by the survey team due to his cognitive/mental health status (BIMS of 3). Review of R30's record indicated R30 was sent to the local emergency department on 01/07/24 (the afternoon of the above incident) and remained hospitalized for one night (through 01/08/24). R30's ''24 Hour-15 Minute Checks'' documentation was requested on 01/17/24; however, the facility was unable to provide any documentation of 15-minute checks for the resident as the resident had not been receiving the monitoring at any time during the month of January 2024. Comprehensive review of the facility's ''Reportable Occurrences and Incident Log'' on 01/16/24 and 01/17/24 revealed an incident of potential physical/sexual abuse occurred involving R30 on 01/07/24. Review of the facility's investigation of the 01/07/24 incident involving R30 indicated a summary of the above referenced progress note dated 01/07/234. Nothing could be found in the record to indicate that either R30 or R83 were ever assessed by a licensed nurse related to the incident. The investigation documentation indicated the investigation was complete on 01/10/24 and indicated that neither sexual nor physical abuse had been substantiated for either resident related to this incident. During an interview on 01/16/24 at 2:17 PM, LPN8 confirmed he/she was present at the time of the 01/07/24 incident, confirmed he/she was the author of the above referenced progress note, and stated, ''About two weeks ago [R30] was having psychotic events [audio and visual hallucinations]. He/She was yelling and cussing out other residents. He/She stripped his/her clothes off in the hallway and was masturbating and saying he/she was going to rape everyone back there [on the secured D Unit]. I was present and did witness most of it. We [staff] tried to get [R30] to go in his/her room but there was no redirecting him/her. We tried. It actually made [the situation] worse. At first there were other residents in the hall, but we had them go in their rooms or in the dining room. I was there and two aides [CNA6 and CNA7] were there [during the incident]. I did call our psych doctor at the beginning [of the incident] and he either gave me an order or [R30] had an order for a Haldol [an anti-psychotic medication] injection. I drew it up but was unable to give it. We don't have an in-house response team so have to call the police [when an incident occurs]. It took them [the police] 5 to 7 minutes to get here. At the beginning of [the incident] a resident [R83] walked past [R30] and [R30] hit [R83] in the leg and then [R83] turned around and hit [R30] twice in the face.'' LPN8 indicated R30 was placed back in his original room (in close proximity to R30) upon his/her return from the hospital on [DATE]. He/She stated no changes had been made to R30's plan of care since the incident occurred to ensure his/her safety or the safety of any of the other residents residing on the unit (including R83). During an interview on 01/16/24 at 3:02 PM, CNA6 confirmed he/she was present at the time of the incident on 01/07/24 and stated R30 could get kind of aggressive and angry. He/She stated, ''That day [the day of the incident] I think he/she [R30] was a little off and he/she acted out and it was a bad day for him/her. I came into hall and he/she exploded and he/she was yelling and cursing and smacked [R83] on his/her butt and [R83] did turn around and hit [R30] back and I had to go get the other staff working with me [CNA7] because when they [residents on the unit] get started [with behaviors] it can be a chain reaction and then we got [LPN8] and we had to get him/her [R30] sent out [to the ED].'' CNA6 stated, ''[R30] stood up and was playing with himself/herself [masturbating] and other residents were in the hallway.'' CNA6 stated R30 was still residing on the same secured unit, and he/she was not aware of any changes to his/her plan of care after the incident occurred. During an interview on 01/17/24 at 12:14 PM, the Administrator stated she had not been able to substantiate any abuse related to the incident; however, she confirmed she was unaware of the physical altercation that occurred between R30 and R83 and stated had she known the physical altercation occurred, she would have substantiated physical abuse related to the incident, and one or both of the residents involved would have been moved to a different location in the building to ensure both residents' safety. MO000230064

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to identify a resident's heel pressure ulcer and failed to provide daily treatments to the wound as ordered. Weekly skin assessments were not routinely completed in accordance with the facility's policy. The facility failed to develop an individualized care plan to address the resident's pressure ulcer. Additionally, upon wound deterioration, the facility failed to notify the resident's physician. Four residents were sampled and problems were identified with one (Resident #1). The census was 105. Review of the facility Pressure Ulcer Prevention and Management policy, revised 10/16/22, showed: -The facility is committed to the prevention of avoidable pressure ulcers and the promotion of healing of existing pressure ulcer(s); -The facility shall utilize a systematic approach for pressure ulcer prevention and management, starting with prompt assessment and treatment, including efforts to identify risk, stabilize, reduce, or remove underlying risk factors, monitor the impact of the interventions, and modify the interventions as appropriate; -Licensed nurses will conduct a Braden Scale (an assessment tool used to determine a resident's risk for developing pressure ulcers) on all residents upon admission/re-admission weekly for four weeks; -Licensed nurses will conduct a full body skin assessment on all residents upon admission, readmission, and weekly; -Assessments of pressure ulcers will be performed by a licensed nurse or physician and documented on daily with treatments and weekly wound report; -The Certified Nurse Assistants (CNA) will follow the Skin Care Protocol and report any concerns to the resident's nurse immediately; -Training in the completion of the pressure ulcer risk assessment, full body skin assessment, and pressure ulcer assessment will be provided as needed; -Interventions will be based on specific factors identified on the skin assessment and any pressure ulcer assessments; -Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure ulcer present; -Evidence-based treatments will be provided for all residents who have a pressure ulcer present; -Pressure ulcers will be differentiated from non-pressure ulcers; -Monitoring will be done by the Director of Nursing (DON), Assistant Director of Nursing (ADON), Wound Nurse or designee who will review all relevant documentation regarding skin assessment, pressure ulcer risks, progression towards healing, and compliance at least weekly and discussed at the weekly interdisciplinary team (IDT) meeting; -The physician will be notified of the presence, progressions toward healing or lack of healing, of any pressure ulcers upon identification of the ulcers; -An incident review will be performed on each pressure ulcer that develops in the facility and findings will be reported at the weekly IDT meeting. Review of the facility Skin Care Protocol policy, revised 1/12/21, showed: -CNA will perform a visual assessment of a resident's skin when giving the resident a shower and immediately report any abnormal looking skin to the Charge Nurse; -CNA will document findings on the Shower Sheet and turn form into Charge Nurse; -Charge Nurse will place their signature on the Shower Sheet after assessing the resident's skin issues; -Charge Nurse will notify Primary Care Physician (PCP) with changes and document any new orders and interventions; -Charge Nurse will forward any problems to the DON/designee for review and will notify DON/designee immediately if he/she on duty when skin issues found; -Areas of concern will be added to the care plan; -Charge Nurse will perform weekly skin assessments and document in point click care (PCC-electronic medical record); -Wounds will be measured on a weekly basis and documented; -All wounds will be discusses at weekly IDT meetings; -The facility will work in collaboration with the residents PCP for wound care management. Review of Resident #1's physician orders, dated 4/26/23, showed: -8/17/22-Weekly skin assessments and document assessment under Skin Only, every Wednesday for skin health. Start date 8/17/22 and no stop date; -10/12/22-Cleanse left lateral foot with wound cleanser, apply skin prep, leave open to air, every day. Start date 10/12/22 and no stop date. (No further documentation on what was treated.); -12/9/22-Apply skin prep to left heel and top of first left toe every day for two weeks or longer, as needed, until healed. Start date 12/9/22 and no stop date. (No further documentation on what was treated.); -12/9/22-Apply ammonium lactate 12% lotion (cream used to treat dry scaly skin conditions, and can help relieve itching from these conditions) to both lower extremities daily for dry skin. Start date 12/9/22 and no stop date. Review of the resident's licensed nurse weekly Skin Only Evaluations, showed: -1/4/23-No current skin issues; -1/11/23-No current skin issues; -1/18/23-No skin evaluation; -1/25/23- No current skin issues, treatment in place for skin prep on right/left foot and ammonium lactate to both lower legs; -2/1/23- No current skin issues. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated 2/1/23, showed no skin issues identified, CNA signature, no Charge Nurse signature. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 2/2/23, showed no current skin issues, coccyx (tailbone area) is scarred over, dry skin on feet. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed: -2/3/23-No skin issues identified, CNA signature, Charge Nurse initials; -2/8/23-No skin issues identified, CNA signature, Charge Nurse initials. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 2/8/23, showed no skin evaluation. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed: -2/10/23-No skin issues identified, CNA initials, Charge Nurse initials; -2/15/23-No skin issues identified, CNA signature, Charge Nurse initials. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 2/15/23, showed no current skin issues. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed: -2/17/23-No skin issues identified, CNA signature, Charge Nurse signature; -2/22/23-No skin issues identified, CNA signature, Charge Nurse initials. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 2/22/23, showed no skin evaluation. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated 2/24/23, showed no skin issues identified, CNA signature, Charge Nurse initials. Review of the resident's progress notes, dated 2/27/23 at 8:19 P.M., showed the primary care physician's (PCP's) skin assessment: no new rashes. Review of the resident's progress notes, dated 3/1/23 at 11:06 A.M., showed a nursing skin evaluation: No current skin issues noted at this time. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 3/1/23 at 11:06 A.M., showed no current skin issues. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed: -3/1/23-Right heel circled and middle of anterior (situated in the front) right arm circled, no information given for purpose of circles, CNA signature, Charge Nurse initials; -3/5/23-No skin issues identified, CNA signature, Charge Nurse signature; -3/7/23-Complete bed bath written, anterior upper left arm circled with bandages written, both heels circled with Dry heels, but okay written in, CNA signature, Charge Nurse signature. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 3/8/23, showed no skin evaluation. Review of the resident's progress notes, dated 3/12/23 at 4:10 P.M., showed the resident reported shortness of breath (SOB), missed dialysis 3/10/23 due to diarrhea, Nurse Practitioner agreed to send resident to hospital. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed: -3/10/23-No skin issues identified, no CNA signature, Charge Nurse initials; -3/15/23-Hospital written, CNA signature, Charge Nurse initials. Review of the resident's progress notes, dated 3/16/23 at 1:05 A.M., showed the resident returned from hospital with discharge diagnosis of fluid overload and no pain, discomfort, distress, SOB, or new orders received. No note regarding skin condition or assessment completed. Review of the resident's re-admit skin integrity screen, dated 3/16/23 at 1:58 A.M., showed skin color normal, warm and dry, turgor normal. No wounds identified. Review of the resident's Braden Scale assessment, dated 3/16/23, showed a re-admission showed a score of 15. A score of 15-18 is considered at risk. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed the following: -3/17/23-No skin issues identified, CNA signature, Charge Nurse signature; -3/21/23-Both heels circled with no explanation, inner side of left foot circled with old scab written in, arrow to outer side of left foot with old scab written in, forwarded to DON: boxes for yes or no left blank, CNA signature, Charge Nurse signature. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 3/22/23, showed no skin evaluation. Review of the resident's five day Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 3/23/23, showed: -Diagnoses of stroke, hemiplegia, high blood pressure, end stage renal disease (on hemodialysis), diabetes, depression, and schizophrenia (chronic mental disorder with symptoms of emotional instability, detachment from reality, and withdrawal into the self); -No cognitive impairment; -Unable to walk; -Required extensive assistance of one person for transfers, bed mobility, dressing, toileting and personal hygiene; -Range of motion impairment on one side of both upper and lower extremity; -Incontinent of bowel and bladder; -Required one person physical assistance of wheelchair for locomotion; -At risk for pressure ulcers: Yes; -Unhealed pressure ulcers: No; -Diabetic foot ulcer with medication and dressing to foot. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed the following: -3/24/23-Refused written, no skin issues identified, CNA signature, Charge Nurse initials; -3/28/23-Arrow to right heel identified as a blister, arrow to middle part of bottom of right foot identified as abnormal color, forwarded to DON: boxes for yes or no left blank, CNA signature, no Charge Nurse signature. Review of the resident's Treatment Administration Record (TAR), dated 3/1/23 through 3/28/23, showed no treatment order for a diabetic foot ulcer or a right heel pressure ulcer. Review of the resident's hospital Wound Center Note, dated 3/28/23 at 11:07 A.M., showed the following:-The resident presented for evaluation of his/her right heel pressure ulcer, Stage II (Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater). The resident said the wound was present for a couple of weeks and he/she was referred to the wound clinic after pointing the ulcer out to the nurse during his/her fistulagram (an x-ray of an individual's dialysis fistula to check blood flow and look for blood clots/other blockages) a week ago; -The wound measured 2.5 centimeters (cm) in length by 1.5 cm in diameter, with a depth of 0.1 cm. The wound base was clean appearing with a small area of central necrosis (necrotic tissue is a condition where living skin dies as a result of blood and oxygen deprivation to its cells) surrounding erythema (redness of the skin), no drainage, and no odor; -The Stage II pressure ulcer on the resident's right heel was stable and the wound was expected to heal with proper treatment; -The Wound Physician placed SilvaSorb (a micro-lattice synthetic hydrogel matrix that contains silver chloride used to protect and hydrate dry wounds utilizing microscopic particles of controlled-release ionic silver and claims to maintain a moist environment and hold a significant amount of exudate due to its hydrogel matrix; used to treat pressure ulcers, burns, incisions, and abrasions) on the wound base and covered with a dry dressing; -The resident will need off-loading boots (special medical boots to prevent of mitigate pressure on the heels) on both heels to prevent further pressure injury and to return in one month; -The Wound Clinic Nurse noted the Wound Physician ordered SilvaSorb and silicone dressing to the right heel and float heels with heel boots. The resident's caregiver (transportation employee) was given the SilvaSorb and instructions for the facility to follow. The facility would need to provide the heel boots. Review of the resident's physician orders, dated 4/26/23, showed the following: -3/28/23-Float right heel with boot and follow up with Wound Clinic on 4/25/23. Start date 3/28/23 and no stop date. (The order did not say to float both heels as recommended by the wound clinic); -3/28/23- Apply SilvaSorb Gel to right heel topically at bedtime, after cleansing with soap and water, and cover with a dry dressing daily. Start date 3/29/23 and discontinued 4/2/23. Review of the facility's Weekly Wound Tracking report, dated 3/27/23 to 3/31/23, showed: -Date of measurement: 3/28/23; -Wound type: Pressure ulcer (PU); -PU present on admit date : Box left blank; -PU acquired at facility date: Box left blank; -Location: Right heel; -PU stage: Stage II; -Size (length x width x depth): 2.5 cm x 1.5 cm x 1.0 cm; -Worst tissue type present: Box left blank; -Treatment (include date initiated or changed): SilvaSorb, border gauze, off-loading boots; -Completed by and date: Lines left blank/no signature and no date. Review of the resident's progress notes, showed: -3/28/23 at 1:12 P.M.-Nurse's note, resident had a wound visit today with new orders and follow-up visit; -3/29/23 at 2:34 P.M.-Nurse's skin/wound note: Wound to resident's right heel has a treatment; -The progress notes did not show wound location, type, description, or measurements and did not show documentation of physician and family notification. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 3/29/23, showed no skin evaluation. Review of the resident's TAR, dated 3/29/23 to 3/30/23, for SilvaSorb to right heel, after cleaning with soap and water, cover with a dry dressing daily at bedtime, showed: -3/29/23-No nurse initials in box (indicating not done). -3/30/23-No nurse initials in box. Review of the resident's TAR, dated 3/28 through 3/31/23, showed no order to float both heels with pressure relief boots. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated 3/31/23, showed Refused written, no skin issues identified, no CNA signature, Charge Nurse initials. Review of the resident's physician orders, showed: -4/2/23-Order for SilvaSorb Gel to right heel, after cleansing with soap and water and covering with a dry dressing daily, changed to every morning (was every evening). Start date 4/3/23 and no stop date. Review of the resident's TAR, dated 4/5/23, for SilvaSorb to right heel, after cleaning with soap and water, cover with a dry dressing daily at bedtime, showed: -4/5/23-Nurse initials in box with number 9 (9: other, see progress note-not done). Review of the resident's progress notes, showed no notes dated 4/5/23. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated 4/5/23, showed Refused written, no skin issues identified, no CNA signature, Charge Nurse initials. Review of the resident's licensed nurse weekly Skin Only Evaluations, dated 4/5/23, showed no skin evaluation. Review of the whole facility's Weekly Wound Tracking reports, showed no wound report for the week of 4/3/23 to 4/7/23. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated, 4/7/23, showed the right heel circled and middle of anterior right arm circled, no information given for purpose of circles, forwarded to DON: boxes for yes or no left blank, CNA signature, Charge Nurse signature; Review of the resident's PCP skin assessment in the progress notes, dated 4/10/23 at 12:00 A.M., showed a pressure ulcer of the right heel; no stage, appearance, or measurements. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated 4/12/23, showed the right heel circled and middle of anterior right arm circled, no information given for purpose of circles, forwarded to DON: boxes for yes or no left blank, no CNA signature, Charge Nurse initials. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 4/12/23, showed no skin evaluation. Review of the Hospital Wound Center's telephone conversation/call log, showed the following: -4/12/23 at 11:01 A.M., resident called stating his/her heel wound was turning black and would like to see the wound doctor sooner than his/her scheduled follow-up appointment. The resident was told to have a facility nurse call to arrange the appointment and if no call from them, then the wound nurse will call the facility; -4/12/23 at 4:09 P.M.,.the Wound Nurse called the facility and was told there are only agency nurses available, please call back tomorrow. Review of the resident's Nurse Practitioner (NP) skin assessment in the progress notes, dated 4/13/23 at 12:00 A.M., showed right foot pain. Review of the facility's Weekly Wound Tracking reports, for the week of 4/10/23 to 4/14/23, showed no wound information for the resident. Review of the resident's Braden Scale assessment, dated 4/14/23, showed a score of 15. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheets, showed: -4/14/23-Both heels circled and middle of anterior right arm circled, no information given for purpose of circles, forwarded to DON: boxes for yes or no left blank, no CNA signature, Charge Nurse initials; -4/18/23-Both heels circled with Rashes healing on left and upper anterior right arm circles with rash on arm a little red but healing, forwarded to DON: boxes for yes or no left blank, no CNA signature, Charge Nurse initials. Review of the Hospital Wound Center's telephone conversation/call log, showed the following: -4/18/23 at 11:42 A.M., the wound nurse contacted Nurse A; -4/18/23 at 12:17 P.M., Nurse A called back and said he/she and the DON assessed the resident's wound and there was no black discoloration. Nurse A was informed the resident has a follow up appointment on 4/25/23. During an interview on 5/2/23 at 1:00 P.M., the DON said she started work at the facility on 3/22/23. She recalled Nurse A saying something to her about the resident having an appointment with the wound clinic but she did not look at the resident's wound and could not recall when this conversation had occurred. She recalled an agency aide telling her, one day, the resident had a heel wound. She told ADON C, who also functioned as their Wound Nurse, to look at it. ADON C arranged for their Medical Director, who was also a Wound Physician, to see the resident on a day when he/she would not be out of the building for dialysis. However, she recalled Nurse A saying the resident already had an appointment with the Hospital Wound Clinic. Their Medical Director did come to see the resident, on a Thursday, but the resident went out with his/her family that day, or went somewhere. It was 4/24/23, because Social Services made a note about it. She did not know why ADON C did not document seeing the wound and scheduling an appointment with their Medical Director/Wound Doctor. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 4/19/23, showed no skin evaluation. Review of the facility's Weekly Wound Tracking reports, dated 4/16/23 through 4/22/23, showed the following: -Date of measurement: 4/19/23; -Wound type: PU and diabetic ulcer; -PU present on admit date : [DATE]; -PU acquired at facility date: Box lined through; -Location: Right heel; -PU stage: unstageable; -Size (length x width x depth): 2 cm x 4.7 cm x 4 cm; -Worst tissue type present: Necrotic tissue; -Treatment (include date initiated or changed): SilvaSorb, gauze, Kerlix, change daily. -Completed by and date: Lines left blank/no signature & no date. Review of the resident's progress notes, showed no note, dated 4/19/23, documenting the decline of the right heel wound and notification of the resident's physician. During an interview on 5/5/23 at 12:03 P.M., Social Service (SS) F said the wound physician made a special arrangement to see the resident's wound on Thursday, 4/20/23. The resident had agreed to the visit, knew the date and time of the visit, yet he/she still left the building that day. SS F was not in that day and did not hear about it until the ADON, who was very upset about it, told him/her on Monday, 4/24/23, which is when he/she wrote the progress note. The resident was young, alert, and oriented times four (cognitively alert and aware of person, place, time and situation), had a history of making his/her own appointments, arranging his/her own transportation, and not sharing the information with the staff. When he/she asked the resident what happened, why he/she left without letting anyone know prior to, the resident said he/she was aware of the appointment, but had business at the social security office. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated 4/21/23, showed bruising, dryness, and scratches circled, upper anterior right arm circled, both heels circled, back of right thigh and right fifth finger circled. No identifying information given for purpose of circles. Forwarded to DON: boxes for yes or no left blank, CNA signature, Charge Nurse signature. Review of the resident's TAR, dated 4/21/23 through 4/24/23, for SilvaSorb to right heel, after cleaning with soap and water, cover with a dry dressing daily every morning, showed: -4/21/23-Treatment initialed by Agency Nurse B; -4/22/23-Treatment initialed by Nurse A; -4/23/23-Treatment initialed by Nurse A; -4/24/23-Treatment initialed by ADON C. Review of the resident's Social Service progress note, dated 4/24/23 at 5:17 P.M., showed the resident was to see the facility's Medical Director/Wound Physician, however the resident chose to go out. The resident was aware of the Wound Doctor's appointment, prior to the resident making plans to leave, but the resident still went out. The resident was educated on the importance of compliance with wound care and the risks involved in not allowing the doctor to see/treat the wound. Review of the resident's hospital Wound Center Note, dated 4/25/23 at 10:44 A.M., showed the following: -The resident said the wound is much worse, there is a foul smell from the wound, and the nursing home was not doing the dressing changes as instructed; -Unstageable right heel pressure ulcer with thick, adherent eschar (a collection of leathery black or brown dead tissue within the wound, reflecting deep damage to tissues, and is flush with the skin surface) coverage and a foul smell. The skin surrounding the eschar was beginning to slough off; -Overall the wound is much worse since last seen; -Measurements were 4.5 cm by 6.0 cm by 0.1, unstageable right heel pressure ulcer with moderate slough (white or yellow dead tissue), moderate foul odor, moderate purulent exudate (fluid or semisolid that has exuded out of a tissue or its capillaries, more specifically because of injury or inflammation), with boggy, red, and edematous peri-wound area (skin surrounding the wound); -The resident requires the operating room for surgical debridement; -The Wound Clinic Nurse's note showed the facility dressing on the wound was soiled, with a foul smell, and moderate drainage; -The resident said the nursing home had not changed his/her wound dressing since 4/21/23 and he/she was concerned the wound was unable to heal due to the lack of care by the nursing home staff; -The Wound Physician was unable to do a bedside debridement due to the amount of eschar coverage of the wound; -The nursing home's Assistant Administrator was called and notified of the wound findings and was sent new wound care instructions and the surgery date. During an interview on 4/28/23 at 2:23 P.M., the hospital Wound Clinic Nurse said surgical debridement in the operating room was necessary because the wound, on 4/25/23, had a foul smell and the eschar was not stable. When the eschar was pressed on, it moved and felt boggy because it was soft underneath, and fluid came out around it. The resident was crying about needing the surgery and about the poor nursing home care he/she received. During an interview on 4/27/23 at 4:08 P.M., the Assistant Administrator D said the hospital Wound Clinic nurse called her on 4/25/23 and wanted to speak with the DON. The DON could not be reached. The hospital Wound Nurse told her the resident's dressing had a date of 4/21/23, he/she was going to need wound surgery, and they would be faxing something over about it. Review of the resident's progress notes, dated 4/25/23 at 1:54 P.M.,, showed the resident returned from an endocrinology (the study of hormones and endocrine glands and organs) appointment, has a surgical appointment on 4/27/23 at the hospital and transportation has been made aware. Review of the resident's physician orders, showed: -4/25/23-Cleanse right heel with wound cleanser, pat dry, apply a nickel size layer of Santyl ointment (an enzymatic ointment that removes dead tissue from wounds at the microscopic level) to the base of the wound and cover with a silicone border dressing (a self-adhering silicone dressing, with an additional bordered edge, a self-adherent silicone contact layer, and a high capacity fluid lock-away core for use on moderate to medium-high levels of wound exudate) daily in the evening. Review of the facility's Weekly Wound Tracking reports for the week of 4/24/23 through 4/28/23, showed: -Date of measurement: 4/25/23; -Wound type: PU; -PU present on admit date : Box left blank; -PU acquired at facility date: Box left blank; -Location: Right heel; -PU stage: unstageable; -Size (length x width x depth): 4.5 cm x 6.0 cm x 0.1 cm; -Worst tissue type present: Unstageable; -Treatment (include date initiated or changed): Santyl, border gauze, change daily; -Completed by and date: Lines left blank/no signature & no date. Review of the resident's licensed nurse weekly Skin Only Evaluation, dated 4/26/23, showed no skin evaluation. Review of the resident's Skin Monitoring Comprehensive CNA Shower Sheet, dated 4/26/23, showed Refused written, no skin issues identified, no CNA signature, Charge Nurse initials. Review of the resident's undated care plan, received from the facility on 4/27/23, showed no plan of care for any type of skin issues or pressure ulcer prevention, assessment, interventions, and monitoring of the right heel pressure ulcer. During an interview on 4/26/23 at 4:00 P.M., the resident said Agency Nurse B always did his/her right heel wound treatments when he/she worked. Agency Nurse B also took a picture of it for him/her. It was turning black so the resident called the hospital wound clinic twice. The first time he/she called, they called the facility nurse because the facility nurses have to arrange the appointments. He/She called again and the wound clinic said the same thing. The resident thought the first floor ADON (ADON C) made the appointment. The resident said Nurse B was the only one who did his/her wound treatments, until now. When the Wound Physician saw him/her on 4/25/23, the date on the dressing was 4/21/23. The Wound Doctor said he could not debride the wound chair side because it was too far gone. He/She now needed surgery, with anesthesia involved, because the wound was so bad. He/She assumed the missing 3 days of treatments, could have made a difference. The resident started crying when the Wound Doctor told him/her he/she needed surgery on the wound. Observation on 4/27/23 at 9:30 A.M., showed a large area of intact black eschar, approximately 5 cm by 6 cm, on the resident's right heel. The peri-wound area appeared moist, red to pink in color, with whitish/yellowish streaks. The resident wore blue pressure relief boots prior to the wound treatment. There was no low air loss mattress on the bed. During an interview on 5/5/23 at 11:19 A.M., Agency Nurse B said he/she did not recall finding instances of no dressing to the resident's right heel and did not recall finding old dressings on his/her heel, but the resident did tell him/her the other nurses were not doing the treatment. It was possible he/she may not have paid that much attention to the dates on the dressings, but there was always a dressing in place and they did not look old. He/She also took a picture of the resident's heel every week, to show to the resident, because the resident could not see his/her heel wound. The last time he/she took a picture of the heel, which could have been one and a half weeks ago, the wound had turned black. Agency Nurse B showed the resident and told him/her that was not good. The resident said he/she was going to call the wound clinic. Agency Nurse B also showed the wound picture to ADON C and told him/her it did not look good. ADON C said he/she would call their facility wound physician. Agency Nurse B said he/she did not document the findings or call the resident's primary care physician because he/she told ADON C, who follows up on the wounds. ADON C set up a visit with the facility wound physician and the resident agreed to it the day before and the day of the appointment, but when the Wound Doctor came to find him/her, he/she was gone from the building. Agency Nurse B asked the resident why he/she left the building and the resident said it was none of his/her business. During an interview on 5/5/23 at 10:40 A.M., ADON C said he/she started at the facility on 2/2/23 as a floor nurse and was promoted to the ADON/Wound Nurse position the beginning of March, 2023. He/ She is the wound nurse for the whole building, which is okay because they only have around seven wounds in the whole building. He/She had no prior experience, education, or training as a wound nurse, and the facility was aware of that. The facility did not give him/her a wound nurse job description. He/She recalled the DON asking him/her to check on the wound. It was a Wednesday, because the resident had returned from dialysis and had just returned from the shower room and there was no dressing on the wound. He/She talked with the resident and he/she looked at the wound. ADON C thought this was the facility's first encounter with the wound and did not know the resident had already been to the wound clinic and had a treatment order for the wound. The resident did not give him/her that information either. ADON C put a wet to dry dressing on it and knew their Medical Director/Wound MD was going to be at the Quality Assurance (QA) meeting the next day, Thursday, and he/she would have him look at it after the meeting. This was discussed with the resident and he/she agreed. The next day, after the QA meeting, they went to look for the resident and were told he/she had left the building with family or someone. ADON C said he/she is new to the Wound Nurse role and did not know the PCP should have been called immediately. When asked why he/she did not do the resident's treatment on 4/24/23, but did initial the TAR, signifying it was completed, he/she said there were two residents on the same hall with right heel wounds and

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the resident's right to be free from physical and verbal abuse, when two residents had a physical altercation (Residents #3 and #4). In addition, the Behavior Health Manager (BHM) punched a resident (Resident #4) in his/her right shoulder, resulting in the resident crying out in pain, followed by the BHM's verbal threat of additional physical harm. The sample size was 10. The census was 112. Review of the facility's Abuse Prevention policy, undated, showed: -Each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Resident must not be subject to abuse by anyone, including, but not limited to facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members, legal guardians, friends or other individuals; -Policy Explanation and Compliance Guidelines: -The Abuse Coordinator in the facility is the Administrator or facility appointed designee. Report allegations or suspected abuse, neglect, or exploitation immediately to: -Administrator; -Other Officials in accordance with State Law; -State Survey and Certification agency through established procedures; -Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the depravation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain, physical, mental and psychosocial well-being; -Verbal Abuse means the use of oral, written or gestured language that willfully includes derogatory and disparaging terms towards residents or their families, or within their hearing regardless of their age, ability to understand, or disability; -Physical Abuse includes, but not limited to hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment; -Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment, or deprivation; -Neglect means failure to provide goods and services necessary to avoid physical harm mental anguish, or mental illness; -Facility Abuse Prevention Plan: -Employee Screening: Background, reference and credentials' checks should be conducted on employees prior to or at the time of employment, by facility administration/business office managers, in accordance with applicable state and federal regulations. Any person having knowledge that an employee's license or certification is in question should report such information to the Administrator and Leadership Team; -Employee Training: New employees should be educated on abuse, neglect and exploitation during initial orientation. Annual education and training is provided to all existing employees. Front line supervisors or other department heads should provide education as situation arise; -Prevention of Abuse, Neglect, and Exploitation; -The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: -Train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents; -Observe resident behavior and their reaction to other residents, roommates, and/or tablemates. Place residents in accommodations and environments that keep them calm; -Provide education on what constitutes abuse, neglect and misappropriation of property; -React to all allegations or questions of abuse by residents, family members, employees or visitors; -Take appropriate actions when abuse, neglect or exploitation is suspected; -Supervise staff to identify inappropriate behaviors, such as using derogatory language, rough handling, ignoring resident while providing care, directing residents that require toileting assistance to relieve their bowels or bladder in their beds; -Assess, monitor and develop appropriate plans of care for residents with needs and behaviors which might lead to conflict or neglect. Utilize facility's abuse/neglect risk assessment and develop care needs according to findings; -Identification of Abuse, Neglect, and Exploitation: The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following factors: -Resident, staff or family report of abuse; -Verbal abuse of a resident overheard; -Physical abuse of a resident witnessed; -Psychological abuse of a resident observed; -Investigation of Alleged Abuse, Neglect, and Exploitation: When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, it must be communicated to the facility's Administrator, Department Head, or Supervisor and the Administrator and/or designee must initiate an investigation. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of the investigation may include: -Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses; -Resident Protection after Alleged Abuse, Neglect and Exploitation: The facility will make efforts to protect any and all residents after alleged abuse, neglect and/or exploitation; -Response and Reporting of Abuse, Neglect and Exploitation: Anyone in the facility can report suspected abuse to the abuse agency hotline; When abuse, neglect or exploitation is suspected, the Licensed Nurse should: -Respond to the needs of the resident and protect them from further incident (document); -Notify the Administrator and Director of Nursing (DON), document; -Initiate an investigation immediately; -Notify the attending physician, resident's family/legal representative and Medical Director; -Obtain witness statements, following appropriate policies. Suspend the accused employee pending completion of the investigation. Remove the employee from resident care areas immediately; -Contact the State Agency to report the alleged abuse; -Monitor and document the resident's condition, including the response to medical treatment or nursing interventions; -Document actions taken in steps above in the medical record; -The Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies. Facility administration should report to the state nurse aide registry or nursing board, any knowledge it has of any actions by a court of law which should indicate an employee is unfit for service. Review of the facility Incidents and Occurrences log, dated January 8, 2023, 7:00-3:00 P.M., showed a Resident to Resident altercation between Resident #1 and Resident #4. Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 11/4/22, showed: -admission date of 7/20/22; -Diagnoses included anxiety and bipolar syndrome (a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression)). Review of Resident #1's undated care plan, showed: -Problem: Has a potential for self-care decline related to intellectual disability (ID, a neurodevelopmental disorder, is characterized by deficits in intellectual and adaptive functioning), Asperger's Syndrome (repetitive patterns of behavior, preoccupation with restricted interests, and difficulties with social interaction), borderline personality disorder (a mental illness that severely impacts a person's ability to regulate their emotions) and Adult Attention-Deficit/Hyperactivity Disorder, (ADHD, a neurodevelopmental disorder, may have trouble paying attention, and controlling impulsive behaviors); -Interventions: Monitor/document/report as needed, any changes, any potential for improvement, reasons for self-care deficit, expected course and declines in function; -Problem: Has a behavior problem due to wandering into other's rooms and taking things; -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. If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. Review of Resident #1's nurse's progress notes, dated 1/7/2023 at 3:19 P.M., showed: the Infection Note, Note Text: Notified the nurse, LPN that this resident was involved in a verbal altercation with Resident #4 that resulted in this resident being punched in his/her left eye. During the assessment the nurse noted his/her eye to be slightly red and tender to touch. Review of Resident #4's undated care plan, showed: -Problem: Has the potential for mood problems due to diagnoses of schizophrenia (a serious mental disorder in which people interpret reality abnormally), depression and anxiety; -Interventions: Monitor/record/report to physician as needed, risk for harming others: increased anger, [NAME] (rapid, often exaggerated changes in mood, where strong emotions or feelings, uncontrollable laughing or crying, or heightened irritability or temper occur) mood or agitation, feels threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons; -Problem: Has potential to be physically/verbally aggressive due to ineffective coping and poor impulse control. He/She has an extensive and recent history of yelling, cursing, and fighting others when she becomes angry. He/She is also disruptive at times as evidenced by banging on doors and throwing items. He/She also has a history of high-risk heterosexual behavior when he/she lived in the community; -Interventions: When the resident becomes agitated: Intervene before agitation escalates; Guide away from source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away, and approach later; -Problem: Has a communication problem due to soft mumbling speech and cognitive impairment. At times, he/she has difficulty finding words to articulate him/herself. He/She is usually able to make his/her needs known and usually able to follow commands; -Interventions: Allow adequate time to respond, Repeat as necessary, Do not rush, Request clarification from the resident to ensure understanding, Face when speaking, make eye contact, Turn off TV/radio to reduce environmental noise, Ask yes/no questions if appropriate, Use simple, brief, consistent words/cues, Use alternative communication tools as needed. Review of Resident #4's nurse's progress notes, showed: -On 1/7/23 at 3:05 P.M., Behavior Note, Note Text: Notified Nurse A that the resident was being combative towards staff and other residents. Staff reported that this resident punched resident (Resident #1) during a verbal altercation. Staff immediately isolated all residents involved in their rooms. Later staff notified the nurse again due to this resident punching the certified medication technician (CMT) B; -On 1/7/23 at 5:28 P.M., Behavior Note, Note Text: Physician updated on resident's behavior. New order received to send the resident to the hospital to evaluate and treat. Director of Nursing (DON) updated. Spoke with ambulance service, estimated time of arrival (ETA) 30-45 minutes. During an interview on 1/24/23 at 9:49 A.M., Resident #1 said Resident #4 hit him/her and he/she hit him/her back. Resident #1 said the area under his/her eye turned red. He/She said the BHM came to the unit, but he/she didn't know if the BHM hit Resident #4. He/she said he/she didn't see it happen. During an interview on 1/25/23 at 11:48 A.M., Resident #4 said the BHM hit him/her in his/her shoulder. The BHM hit him/her with his/her fist. The BHM works security. The resident said after the BHM hit him/her, he/she started crying, because it hurt his/her feelings. The BHM told him/her he/she was sorry, but the resident is afraid of him/her. During an interview on 1/24/23 at 9:29 A.M., on the secured D hall unit, Resident #3 said he/she witnessed Resident #4 hit Resident #1. Resident #3 said he/she saw the BHM hit Resident #4 on his/her arm, and he/she felt uncomfortable seeing that happen. He/She said this happened about three to four weeks ago, the BHM hit him/her with a closed fist. Resident #3 said the BHM said to Resident #4 after he/she hit him/her, How does that feel when someone hits you? After it happened, Resident #4 didn't say anything, but it made him/her stop hitting. During an interview on 1/24/22 at 11:37 A.M., the BHM said his/her position is a supervisory position over all the certified nursing assistants (CNAs). He/She ensures they have no problems with the residents and everything goes smoothly. He/she is called if staff need help to diffuse situations. He/She worked in the mental health field for over 10 years and is trained in Crisis Prevention Intervention (CPI, management of disruptive and assaultive behavior) and he/she knows how to restrain people without hurting anyone. He/She was familiar with Resident #4. The resident gets bored and starts hurting other residents. The last time he/she thought that happened was on a Saturday, date unknown. He/She thought the staff present were agency and could not recall their names. Resident #4 was hitting people and he/she believed he/she blocked the resident with his/her hand. He/She never hit Resident #4. He/She does not hit people. During an interview on 1/24/23 at 2:04 P.M., Nurse A said he/she recalled an altercation regarding Resident #4. He/She struck Resident #1 under the eye. Nurse A assessed the area under Resident #1's eye and there was no redness. He/She didn't remember the names of the staff present and never heard a resident complain about the BHM being rough or hitting them. Nurse A said he/she went onto the secured D unit, and the BHM and Resident #4 were seated across from each other in the hallway. CMT B was walking on the hall ahead of him/her, and when CMT B passed Resident #4, Resident #4 hit CMT B on the leg. The BHM got up from his/her chair, walked across the hall and hit Resident #4 on the right shoulder. Resident #4 said, Ow, that hurts! The BHM then said to Resident #4, If you keep hitting residents, the next hit will be harder! This was the first and only time he/she saw the BHM do something like that. The BHM has been on the schedule since the incident. Nurse A said when he/she saw the BHM hit Resident #4, he/she left the secured D unit and went to the medication room to call the Administrator. The Administrator told the BHM to clock out and leave. He/She said he/she assessed Resident #4 for injury and there was no redness or swelling on his/her arm. About 15-20 minutes later, he/she saw the BHM again and told him/her, weren't you supposed to be leaving? The BHM said he/she was collecting statements, and asked Nurse A, Why did he/she report him/her? Now he/she is going to get fired. About an hour later, the BHM was still in the building. The DON arrived to send a report to state, because of the two hour window for reporting. The BHM was still there and they were standing by the DON's office talking. Nurse A left a witness statement underneath the Administrator's door. Nurse A said the BHM worked this weekend, and he/she saw him/her numerous times since the incident. When Resident #4 returned from the hospital, he/she said he/she didn't want to be here because he/she didn't want the BHM hitting him/her. During an interview on 1/25/23 at 3:53 P.M., CMT B said he/she was on the secured D hall passing medication on the date of the incident. When he/she walked past Resident #4, he/she thought Resident #4 had bumped him/her. When he/she turned around, he/she saw Resident #4 with his/her fist balled up, and the BHM walked over to Resident #4 and punched the resident in his/her right upper arm/shoulder area. CMT B said Resident #4 and the BHM were sitting across from each other in the hallway. CMT B said the BHM said to Resident #4, something like, It would be harder next time. CMT B said both he/she and Nurse A exited the D unit at the same time. CMT B didn't think the BHM knew the charge nurse was on the hall when it happened. The BHM stayed with the resident for a little while. CMT B said he/she believed the charge nurse contacted the Administrator about the incident. CMT B said no one had talked to him/her regarding the incident or collected a statement. During an interview on 1/26/23 at 12:24 P.M., CNA C said he/she was the only CNA on the secured D Hall on the date of the incident. He/She said Resident #4 was hitting Resident #1 and he/she hit CMT B. Resident #4 was sitting in a chair across from the BHM, and the BHM punched Resident #4 in the arm after Resident #4 hit CMT B. The BHM told Resident #4, The next time it will be harder. The DON came on the D hall and he/she informed the DON the BHM hit the resident. The DON said you'll have to talk to the Administrator about that. The DON only asked him/her what happened on the hall regarding the resident to resident altercation. The BHM was trying to get him/her to lie. The BHM told CNA C to write a statement which needed to say Resident #4 was aggressive to him/her, however the resident was not aggressive to him/her. Neither the DON or the Administrator have asked him/her about this incident or asked for a statement. CNA C said when it happened, Resident #4 said, Ow, and held his/her right arm. He/She asked him/her later, where did the BHM hit him/her, and Resident #4 pointed at his/her right arm. CNA C said he/she walked out of the D Hall, right behind Nurse A. Nurse A went into the medication room and the BHM got on his/her phone and called the Administrator, then handed Nurse A his/her phone. CNA C said the BHM came back on his/her hall twice, trying to pressure CNA C into writing a statement and lie about what happened. During an interview on 1/27/23 at 9:15 A.M., the Administrator said when the BHM called her on the date of the incident, he/she did not mention there was an allegation against him/her. She said she had the BHM write a statement about the altercation between the two residents. The BHM had been trying to deescalate the behaviors. The BHM told her Resident #4 hit Resident #1 in his/her eye and also hit a CMT. The DON and she contacted the nurses, and reported the resident-to-resident altercation to DHSS. She said Nurse A was downstairs and was not aware of an allegation the BHM hitting Resident #4. (Nurse A said she told her and placed his/her statement under the administrators door, the administrator denied knowledge or a statement by Nurse A) No one was aware, the DON was not aware, the only information they received was regarding Resident #4. She said they were only aware of a resident-to-resident altercation. She said they did not talk to CMT C, they asked the BHM to collect statements regarding the resident to resident altercation, and nothing in the statements mentioned the BHM hitting anyone. No staff person called and told her the BHM hit the resident. The administrator said she told the BHM and Nurse A she needed statements regarding Resident #4's behaviors. She said she was never told anything else had happened. If she was made aware, she would have told the BHM to leave, and would have started an investigation. Not a resident or staff person told her about the incident. She did ask the charge nurse for a statement, but never received anything. Review of the facility investigation, dated 1/24/23, and signed by the Administrator on 1/31/23, showed the Administrator was unaware of the allegation of the BHM striking Resident #4 and was only made aware when the surveyor brought this to her attention on 1/24/23. An investigation was started on 1/24/23, and the BHM suspended. A witness statement obtained from Resident #3, stated he/she witnessed the BHM hit Resident #4 on the left arm. No witness statement was obtained from Resident #4, as he/she was out of the facility at the time of interview. Resident #4 is now back in the facility and is currently residing on the secured B hall unit. The witness statements included the following: -The BHM's handwritten witness statement, signed and dated, 1/7/23 at 3:45 P.M., On this day he/she was called to the second floor to redirect Resident #4 because of his/her aggressive behaviors towards other residents and staff members. When the nurse on duty attempted to administer an as needed (PRN) medication, Resident #4 became aggressive and struck the nurse, causing the BHM to administer CPI to the resident in order to get the situation under control; -Resident #3's witness statement, signed and dated 1/26/23, showed the resident witnessed Resident #4 hit CMT C. Resident #3 saw the BHM hit Resident #4 and asked if that hurt or something like that. Resident #3 said Resident #4 was hit in the lower arm; -No witness statements were provided by Nurse A, CMT B, CNA C or Resident #4. During an interview on 2/2/23 at 4:45 P.M., the DON said she was not aware of an incident involving the BHM and a resident. She said she had arrived to the facility to submit a report to DHSS regarding the resident-to-resident altercation. She was made aware Resident #4 was hitting other residents, but nothing regarding the BHM hitting a resident. He/she said was made aware by the state surveyor on 1/24/23, and the administrator was investigating the allegation. MO00212957