**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident's right to be free from abuse was not violated, when residents were involved in physical resident to resident altercations. Staff witnessed Resident #6 engage in a verbal altercation with Resident #5. Resident #5 then choked the neck of Resident #6, which caused bruising to the resident's neck and a sore throat. The sample was 8. The census was 87. Review of the facility's Abuse Prevention and Prohibition Program, revised 10/24/22, showed: -Purpose: To ensure the facility establishes, operationalizes, and maintains an abuse prevention and prohibition program designed to screen and train employees, protect residents, and to ensure a standardized methodology for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, misappropriation of property, and crime in accordance with federal and state requirements; -Policy: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. The facility has zero-tolerance for abuse, neglect, mistreatment, and/or misappropriation of resident property. Staff must not permit anyone to engage in verbal, mental, sexual, or physical abuse, neglect, mistreatment, or misappropriation of resident property; -The facility is committed to protecting residents from abuse by anyone, including but not limited to facility staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors; -The Administrator is responsible for coordinating and implementing the facility's abuse prevention policies, procedures, training programs, and systems; -Procedure: The Administrator may delegate coordination and implementation of components of the abuse prevention program to other staff within the facility; -Prevention: Staff, residents and families will be able to report concerns, incidents and grievances without fear of retribution or retaliation; -Identification: The facility provides covered individuals with training to enable the identification of the following signs and symptoms of potential resident abuse and neglect: Physical Abuse: Welts or bruises; -Investigation: The facility promptly and thoroughly investigates reports of resident abuse. The investigation may take some or all of the following steps: An employee who knowingly makes a false report may be subject to disciplinary action, up to and including termination; -Protection: Resident-resident altercations will only be investigated as an incident of abuse if the incident meets the criteria of the definition of abuse (no definition provided); -Residents and facility staff will not be retaliated against for reporting abuse. Review of the Resident #6's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 12/2/24, showed: -Cognitively intact; -No impairment upper or lower extremity; -Walker; -Depression (other than bipolar disorder). Review of the resident's care plan, in use at the time of the investigation, showed: -Focus: Resident has the potential to demonstrate physical behaviors related to anger and poor impulse control toward staff and other residents; -Goal: Resident will verbalize understanding of need to control physically aggressive behavior; -Interventions: - Analyze key times, places, circumstances, triggers and what de-escalate behavior and document; -Provide physical and verbal cues to alleviate anxiety, positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; -Give the resident choices about care and activities to help de-escalate the situation; -When the resident becomes agitated, intervene before agitation escalates. Guide away from the source of distress, engage calmly in conversation. If response is aggressive, staff to walk calmly away, and approach later; -Focus: Resident has potential to demonstrate verbally abusive behaviors related to ineffective coping skills and poor impulse control; -Goal: Resident will verbalize understanding of need to control verbally abusive behavior; -Interventions included: -Assess resident's understanding of the situation. Allow time for the resident to express self and feelings toward the situation; -Give choices of care and activities to de-escalate the situation; -When the resident becomes agitated, intervene before agitation escalates. Guide away from the source of distress. Engage calmly in conversation. If response is aggressive, staff to walk calmly away and approach later. Review of Resident #8's admission MDS, dated [DATE], showed: -Severe cognitive impairment; -Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abuses others, sexually): Behavior of this type occurs daily; -Wheelchair; -Diagnoses included stroke. Review of the resident's care plan in use at the time of the investigation, showed: -Focus: Resident has potential to be physically aggressive related to poor impulse control, throwing things at staff and attempting to trip staff and other residents by putting his/her feet out; -Goal: Resident will verbalize understanding of need to control physically aggressive behavior through the review date; -Interventions/Tasks: Maintain and keep resident safe and prevent harm to other residents. Monitor and document observed behavior and attempted interventions in behavior log. Monitor/document/report as need any signs/symptoms of resident posing danger to self and others. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Cognitively intact; -Physical behavioral symptoms directed toward others (e.g., hitting, kicking, pushing, scratching, grabbing, abuses others, sexually): Behavior not exhibited; -No impairments upper/lower extremity; -Walker; -Diagnoses included: Hypertension and Alzheimer's Disease. Review of the resident's care plan in use at the time of the investigation, showed: -Focus: The resident has potential to demonstrate physical behaviors related to Dementia; -Goal: The resident will verbalize understanding of need to control physically aggressive behavior through the review date; -Interventions included: -Analyze of key times, places, circumstances, triggers, and what de-escalated behavior and document; -Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated; -When the resident becomes agitated: Intervene before agitation escalates; Guide away from the source of distress; Engage calmly in conversation; If response is aggressive, staff to walk calmly away and approach later. Review of Resident #6's alert note, showed: -2/25/25 at 12:59 P.M., the resident was yelling at everyone about the food issues but he/she was not combative at that moment. Staff stated the resident walked up to another resident (Resident #8) and made contact with his/her leg. This nurse call 911 and paramedics to assist with calming resident down and to prevent him/her from fighting other residents. Police arrived, stated that they could not take him/her since he/she had calmed and refused to go; -2/25/25 at 2:26 P.M., resident placed on 1:1 immediately after for his/her and other residents safety. Review of the facility's investigation summary, dated 2/25/25, signed by Regional Nurse Consultant (RNC), showed: Resident # 8 and Resident #6; -Incident description: During breakfast on 2/25/25, Resident #6 expressed his/her discontent about the meal and stood up, gesturing with his/her arms. In doing so, he/she inadvertently made contact with Resident #8's anterior (outer) thigh; -Immediate actions taken: -Staff promptly intervened and separated the two residents to ensure their safety; -Both residents were assessed for injuries by a licensed nurse (none noted); -Notifications were made to the Administrator, Director of Nursing (DON), RNC, Regional Director of Operations (RDO), PCP, Responsible party (RPs); -Interviews were conducted with both residents and staff; -Trauma-informed screenings were performed for Resident #8, Resident #6, and all other residents in the dining room; -Safe surveys were conducted with all residents on the unit with a Brief Interview for Mental Status (BIMS ) score above 8 (moderate cognitive impairment); -Both residents' plan of care, care plans and progress notes were reviewed; -Both residents' PCPs were seen onsite, and orders were obtained; -Both residents were placed under direct close supervision; -Follow-up action: On 2/25/25, the DON and Administrator interviewed both residents. Resident #8 could not recall the event. Resident #6 adamantly denied any willful intent to strike Resident #8, explaining that he/she was merely expressing his/her discontent with the meal and accidentally made contact while gesturing. He/She emphasized that he/she did not intend to cause any harm, injury, or pain to Resident #8. Resident #8 was unable to recall the event. Resident #6 remained 1:1 supervision, but it was lowered at this time due to the investigation deeming it was not abuse. However, he/she continued to be monitored to ensure safety. During a telephone interview on 3/3/25 at 12:36 P.M., the Social Worker Manager said she didn't hear about the event between Resident #8 and Resident #6 until after the incident between Resident #6 and Resident #5. She asked nursing staff who were present what happened. She was told Resident #6 kicked Resident #8's wheelchair, not the resident. She wasn't there. She was dependent upon information given to her by the staff. It was difficult to ask Resident #8 questions. He/She may understand most of the questions, but he/she could be aggressive too. Staff stopped Resident #6 from making things worse. She would consider the ideal thing to do was to keep Resident #6 away from Resident #8, so that's what happened. She expected staff to be proactive. If staff saw Resident #6 was screaming, agitated, acting erratic, the staff should intervene then. She said the staff actions/interventions with Resident #6 should have happened prior to the altercation with Resident #8. Review of Resident #6's alert note on 2/25/25 at 12:59 P.M., written by the ADON, showed the resident was yelling at everyone about the food issues, but he/she was not combative at that moment. He/She went outside, exchanged words with another resident (Resident #5), who then wrapped his/her hands around the resident's neck and choked him/her, leaving visible marks. Review of Resident #6's general progress note, effective on 2/25/25 at 8:45 P.M. and created on 2/26/25 at 7:58 P.M. by Registered Nurse (RN) K, showed resident agreed to go to hospital for psych evaluation. Resident alert and oriented times four. Respirations even and nonlabored. No complaints of pain. [NAME] noted to neck area. Review of resident's Resident #6's social service note dated 2/25/25 at 3:00 P.M., showed at 10:00 A.M., the resident appeared agitated and displayed signs of distress, leading to a verbal altercation with another resident. Nursing staff and aides promptly intervened to de-escalated the situation, providing verbal redirection and emotional support. The resident was encouraged to take deep breaths and step away from the situation to regain composure. Review of Resident #5's alert note, showed on 2/25/25 at 2:27 P.M., the resident was placed on 1:1 for choking another resident (Resident #6). Review of Resident #5's social service note, showed on 2/25/25 at 4:23 P.M., at 10 A.M., Resident #5 was engaged in an altercation with another resident. Nursing staff and aides promptly intervened to de-escalate the situation, providing verbal redirection and emotional support. This afternoon, the Social Worker met with the resident to discuss the physical altercation that occurred earlier on 2/25/25. The resident was given the opportunity to share his/her perspective on the incident. The Social Worker reviewed the importance of personal boundaries and discussed the impact of physical aggression on others and the overall community. He/She was encouraged to seek staff assistance or remove himself/herself from escalating situations to prevent further conflicts. The Social Worker provided education on the facility's behavioral expectations and the consequences of physical aggression. Review of Resident #5's general progress note, showed on 2/25/25 at 4:28 P.M., PCP on rounds and resident assessed. New orders received for psychiatric evaluation for patient-to-patient altercation for safety evaluation. Review of the facility's investigation summary provided by RNC, dated 2/26/25, showed: -It was alleged that during a smoke break on 2/25/25, Resident #6 and Resident #5, who know each other well from the facility and are friends, were conversing. Suddenly, without provocation, Resident #5, who was sitting across from Resident #6, extended his/her arms and placed his/her hands around Resident #6's neck. Staff immediately took the following actions: -Staff immediately intervened and separated the two residents to ensure safety; -A licensed nurse assessed both residents, and no injuries were noted; -Resident #6 stated he/she was unsure what provoked this behavior, as they are friends and it happened without apparent cause; -When interviewing Resident #5, he/she did not recall what occurred; -Resident #5 is cognitively intact. During an interview on 2/26/25 at 11:23 A.M., Resident #5 said he/she knew Resident #6 and they were friends. He/She said Resident #6 cussed him/her out yesterday. He/She said Resident #6 came into his/her room and started cussing him/her out. Resident #6 wanted everything his/her way. He/She didn't get hurt but did push Resident #6 back because he/she was in his/her face talking about people's mama and stuff. Resident #6 cussed people out bad and staff let him/her get away with a lot of stuff. He/She said Resident #6 thinks he/she can say anything to people. During an interview on 3/4/25 at 9:53 A.M., Resident #6 said Resident #5 liked him/her but they were just friends. He/She wanted to stay just friends, nothing else. Resident #5 saw him/her talking to a new resident. He/She said Resident #5 called the new resident a honky. He/She said Resident #5 choked him/her because Resident #5 was jealous. That was the only time Resident #5 choked him/her. Resident #6 and Resident #5 were arguing in the hallway as he/she was going outside to smoke a cigarette. He/She said Resident #5 didn't choke him/her until they got outside. There were aides in the hallway when they were arguing but only one of them said hey hey, what's the arguing about? No one came over to where he/she and Resident #5 were. He/She said Resident #5 told him/her to keep talking smart and if talking smart when they got outside, See what happens. He/She told Resident #5 he/she was going outside to smoke. He/She said there was bruising on his/her neck and his/her throat was sore after Resident #5 choked him/her. He/She demonstrated the choking by placing his/her thumb on one side of his/her neck, near his/her throat and his/her fingers around the neck on the other side. He/She said some residents and staff pushed Resident #5 off him/her. He/She left the patio and went to his/her room. Staff said he/she had to go to the hospital. He/She told staff Resident #5 choked him/her so why did he/she have to go? He/She said staff told him/her that was protocol. The aides kept asking him/her if he/she was ok. He/She thought there was only one other resident outside when Resident #5 choked him/her, but staff ran outside to help get Resident #5 off him/her. He/She saw the doctor at the facility. He asked if he/she was ok and didn't say anything else. He/She went to the hospital. The resident felt safe because they moved Resident #5 farther down the hall. He/She was not worried about Resident #5. He/She kept his/her distance from Resident #5 and Resident #5 has kept his/her distance from him/her. He/She said Resident #5 was his/her friend, but not now. He/She doesn't look Resident # 5's way and doesn't talk to him/her anymore. He/She doesn't trust Resident #5 anymore because he/she did him/her like that, grabbing him/her by his/her throat. He/She said Resident #5 grabbed him/her like he/she was trying to kill him/her or something. He/She said as little as he/she was, Resident #5 would grab him/her by the throat. That let him/her know where he/she was coming from. He/She said their friendship was a done deal (not friends). He/She was friendly. It made him/her upset when people got up in his/her face. Resident #6 left with his/her family because that's how upset he/she was. He/She couldn't fight. He/She was too old for that. He/She couldn't tussle and Resident #5 was big compared to him/her. During an interview on 2/25/25 at 2:15 P.M., the Social Service Manager said Resident #6 and Resident #5 didn't have a history of resident-to-resident abuse with each other or other residents. She said the residents had arguments with each other before but nothing like this. During an interview on 2/26/25 at 1:09 P.M., the Social Service Manager said she had just learned of the information about yesterday when she took Resident #6 to his/her room. The resident said Resident #5 put his/her hands on him/her. She talked with Resident #5 in his/her room. She said Resident #5 said he/she never touched Resident #6. The information Resident #5 told her was different than what everyone else said. Resident #5 told her he/she just pushed Resident #6 but didn't touch his/her neck. She informed the Administrator. During an interview on 2/26/25 at 11:59 A.M., Nursing Assistant (NA) C said he/she was at work yesterday and was assigned to Resident #6. Resident #5 lived on the same hall . The Resident #6 was outside on the patio. He/She started cussing and swung on Resident #5. Resident #5 tried to stop the resident from hitting him/her. NA C and another staff separated Resident #6 and Resident #5. They told the DON what happened and wrote statements. Resident #6 was fussing at Resident #5 and getting all up in his/her face. Then, the resident Resident #6 hit Resident #5. Resident #5 put his/her hands up. It looked like he/she hit the resident Resident #6. Resident #5 put his/her hands up to stop Resident #6 from hitting him/her. It wasn't a fight or anything like that. During an interview on 3/4/25 at 11:30 A.M., NA C said he/she didn't hear any argument between Resident #6 and Resident #5. Resident #6 was out on the patio first, then Resident #5 came out. Both were smoking. He/She didn't think there were other residents out there besides those two residents, but there could have been one other resident. He/She wasn't sure. He/She didn't know Resident #6 and Resident #5 were coupled up or dating. He/She just knew they were friends. He/She saw Resident #5 hit Resident #6 but not choke. At first, they were arguing outside. Then it escalated. Resident #6 hit Resident #5, then Resident #5 hit Resident #6 back. Resident #5 told Resident #6, you suck other people's dick. Resident #5 said other things to Resident #6 but he/she didn't hear it all. He/She just tried to keep them separated. He/She didn't know anything about Resident #6 and Resident #8's altercation. During a telephone interview on 3/3/25 at 12:36 P.M., the Social Worker Manager thought nursing staff took Resident #6 to the patio to calm down and that's where the altercation with Resident #5 happened. Resident #6 and staff told her the altercation happened on the patio but Resident #5 said it happened in his/her room. She wasn't completely dependent upon what Resident #5 said but it was false based on what everyone else said. Based on what she saw, there were two staff with Resident #6 and Resident #5 was taken back to his/her room. The door was closed. She said Resident #5 said Resident #6 tried to ask him/her for money and he/she said no. Resident #6 said he/she and Resident #5 were friends, but he/she didn't want it to be more than that. From what she understands, Resident #6 was in a heightened state that morning due to something else. She thinks the staff did their job related to the incident between Resident #6 and Resident #8. She didn't think the staff thought Resident #6 would escalate so fast. What happened that day, she didn't think anybody was used to Resident #6 getting escalated to that point. She said the resident was a calm, strict, and firm person. During a telephone interview on 3/3/25 at 3:39 P.M., the PCP said he was aware of the choking incident between Resident #5 and Resident #6. He was told the residents were girlfriend/boyfriend but he wasn't sure. During an interview on 3/4/25 at 11:53 A.M., the ADON said the Resident #6 had bruises on his/her neck. Resident #5 snatched (grabbing someone fast and with force) him/her up. He/She said Resident #6 was already upset from the night before. He/She said the resident said he/she had been upset all night and woke up this morning still upset. Resident #6 went out on the patio. He/She was cussing at Resident #5. Resident #5 picked Resident #6 up by the neck. The ADON said you can't agitate these residents because it takes a long time to calm them down. During a telephone interview on 3/3/25 at 1:45 P.M., the DON said staff could have not let Resident #5 and Resident #6 go out on the patio to smoke at the same time, if Resident #6 was still upset. She didn't think Resident #6 was still upset with Resident #5. There was nothing to indicate Resident #5 would have choked Resident #6. No words were passed between them. She said no one saw that coming because of their friendship. It happened so fast. Staff separated them immediately.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure appropriate care and services were provided to residents with pressure ulcers (injury to the skin and underlying tissue usually over a bony prominence, as a result of pressure or friction). The facility failed to document weekly wound assessments, failed to notify the physician of new wound development delaying the resident's treatment and failed to identify a newly acquired Deep Tissue Pressure Injury (DTPI). Facility staff also failed to consistently ensure pressure ulcer treatments and interventions were performed according to the wound specialist's recommendations or as ordered and failed to ensure prevention interventions were completed as ordered. This resulted in a delay of 11 days in obtaining orders and treating a pressure ulcer for one resident (Resident #15). When the wound was first staged, it was identified as unstageable (an ulcer that has full thickness tissue loss but is covered by extensive necrotic (dead) tissue). The facility identified three residents as having pressure ulcers. The survey team identified four residents as having pressures. Issues were found with three out of four residents sampled with pressure ulcers (Resident #15, #32 and #30). The sample was 12. The census was 44. Review of the facility's Resident Census and Condition of Residents, dated 12/2/21, showed: -Total residents 44; -Indicate the number of residents with pressure ulcers: Three; -Of the total of residents with pressure ulcers, how many residents had pressure ulcers on admission: Zero. Review of the facility's Resident Matrix Centers for Medicare and Medicaid Services (CMS) form, showed: -Resident #15 identified as having a stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough (moist dead tissue) or eschar (dry dead tissue) may be present on some parts of the wound bed) pressure ulcer; -Resident #32 identified as having a stage IV pressure ulcer; -Resident #30 not identified as having any pressure ulcers. Review of the facility's Wound Care Policy, revised October 2010, showed: -Purpose: To provide guidelines for the care of wounds to promote healing; -Procedure: Verify that there is a physician's order for this procedure. Review the resident's care plan to assess for any special needs of the resident. Assemble the equipment and supplies as needed; -Documentation: The type of wound care given. The date and time the wound care was given. The name and title of the individual performing the wound care. Any change in the resident's conditions. All assessment data (wound bed color, size, drainage) obtained when inspection the wound. If the resident refused the treatment and the reason why; -Reporting: Report other information in accordance with facility policy and professional standards of practice. Notify the supervisor if the resident refuses the wound care. 1. Review of Resident #15's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/9/21, showed the following: -admission date 8/6/09; -Severe cognitive impairment; -Dependence on staff for eating, dressing, toileting, and bed mobility; -Unable to ambulate; -One stage IV pressure ulcer; -Is resident at risk for developing pressure ulcers: Yes; -Diagnosis included heart failure, high blood pressure, diabetes, seizure disorder, depression and hemiplegia (paralysis of one side of the body). Review of the resident's care plan in use at time of survey, showed; -Problem: Resident is at risk for pressure ulcers related to incontinence, immobility and right sided hemiplegia; -Interventions: Administer treatments as ordered and monitor for effectiveness. Conduct a systematic skin inspection per protocol on shower days. Pay particular attention to boney prominences. Follow facility policies and protocol for the prevention and treatment of skin breakdown. Follow treatment orders given by physician daily. Monitor dressing during care to ensure it is intact and adhering. Monitor, document and report as needed any changes in skin status, appearance, color, wound healing, signs and symptoms of infection, wound size (length, width, depth), and stage. Needs assistance to turn and reposition at least every 2 hours. Report any signs of skin breakdown. Resident requires cushion in chair and pressure reliving mattress. Weekly treatment documentation to include measurement of each area of skin breakdown, width/length/depth, type of tissue and exudate (drainage). Review of the resident's skin observation tools, showed: -Dated 10/6/21, showed a new open area on coccyx (tailbone area). Treatment orders needed; -Site: Coccyx: Type: Pressure; Measurements: 1 centimeter (cm) length by 1 cm width; -Site: Right gluteal fold (buttocks); Measurements: 0.5 cm length by 0.5 cm width; -No documentation the physician was notified; -No other skin observation tools were completed in October 2021. Review of the resident's progress notes, showed: -On 10/17/21, open area noted to coccyx 1.9 cm by 0.8 cm wound bed red with macerated (soft or wet) edges, no drainage slough or odor noted. Physician notified of new area to coccyx. New order cleanse coccyx with normal saline apply foam dressing daily; -No documentation the physician was notified of the wound prior to 10/17/21. Review of the resident's electronic physician order sheet (ePOS), showed: -An order with a start date of 4/6/21, for weekly skin assessments every Tuesday; -An order dated 10/17/21, to cleanse the coccyx with normal saline, apply foam dressing daily. Discontinued 10/26/21; -No treatment order for the coccyx wound prior to 10/17/21. Review of the resident's wound provider's note dated, 10/19/21, showed: -Location: Coccyx; -Type: Pressure ulcer/injury: Unstageable; -Wound bed description: 10% granulation (new tissue growth) and 90 % necrosis and slough; -Measurements: Length 2.1 cm by width 1.4 cm, depth unable to determine (utd) cm; -Peri-wound (surrounding tissues): Normal; -Exudate: Small; -Color: Serosanguineous (clear blood tinged); -Plan: Cleanse with normal saline apply, apply nickel thick Santyl (used to remove dead tissue from wounds so they can start to heal) and cover with border gauze daily and as needed. Review of the resident's medial record, showed the resident sent to the hospital on [DATE] for a change in condition and returned to the facility on [DATE]. Further review of the resident's progress notes, dated 10/26/21, showed: -Multiple wounds, coccyx wound 4 cm is clean. No redness or drainage. Dry dressing intact. Three additional patches to buttock and old wounds not open 1 cm by 1 cm; -No further description of the wounds, staging, drainage, or clarification of the location of the multiple wounds. Further review of the resident's ePOS, showed: -No treatment order from 10/26/21 through 10/28/21; -An order dated 10/28/21, to cleanse the buttock and coccyx wounds with normal saline, apply nickel thick Santyl and cover with border gauze daily. Review of the resident's October 2021 electronic Treatment Administration Record (eTAR), showed: -No treatment documented as ordered or applied to the resident's coccyx from 10/26/21 through 10/28/21; -An order dated 10/28/21, to cleanse buttock and coccyx wounds with normal saline, apply nickel thick Santyl and cover with border gauze daily; -Not documented as completed on 10/28, 10/29 and 10/30/21. Review of the resident's wound provider note, dated 11/2/21, showed: -Location: Coccyx: -Type: Pressure ulcer/injury: Unstageable; -Wound bed description: 10% granulation and 90% necrosis and slough; -Measurements: Length 1.8 cm by width 1.2 cm by depth utd cm; -Peri-wound: Normal; -Exudate: Small; -Color: Serosanguineous; -Plan: Cleanse with normal saline apply, apply nickel thick Santyl and cover with border gauze daily and as needed; -Location: Right buttock: -Type: Pressure ulcer/injury: Unstageable; -Wound bed description: 10 % granulation and 90% necrotic and slough; -Measurements: Distal (lowest part of the wound) 1.5 cm by 0.5 cm and depth utd, Medial (middle) 4 cm by 0.5 cm; -Peri-wound: Excoriated (reddened); -Exudate: Small; -Color: Serosanguineous; -Plan: Cleanse with normal saline apply nickel thick Santyl and cover with border gauze daily and as needed. Further review of the resident's ePOS, showed: -The order to cleanse buttock and coccyx wounds with normal saline, apply nickel thick Santyl and cover with border gauze daily, discontinued on 11/2/21; -An order dated 11/3/21, for Gentamycin Sulfate Ointment 1% (antibiotic ointment); Apply to buttocks and sacral (tailbone area) wounds once daily. Cleanse right buttock and sacral wounds with normal saline. Apply nickel thick Santyl and Gentamycin 1% cover with border gauze and dressing daily; -An order dated 11/13/21 and discontinued 11/16/21, for Santyl ointment 250 unit/gram. Apply to right buttocks wound topically every day shift for wound care. Cleanse right buttocks with normal saline. Apply nickel thick Santyl and cover with boarder gauze daily and as needed. Review of the resident's November 2021 eTAR, showed the following: -An order dated 11/2/21, for weekly skin assessments every Tuesday; -An order dated 11/3/21, for Gentamycin Sulfate Ointment 1%; Apply to buttocks and sacral wounds once daily. Cleanse right buttock and sacral wounds with normal saline. Apply nickel thick Santyl and Gentamycin 1% cover with border gauze and dressing daily; -Not documented as administered on 11/3 through 11/6, 11/18 through 11/19, 11/21, 11/23, and 11/25 through 11/26/21. Review of the resident's wound provider note, dated 11/9/21, showed: -Location: Coccyx: -Type: Pressure ulcer/injury: Unstageable; -Wound bed description: 20% granulation and 80 % slough; -Measurements: Length 2.5 cm by width 1.5 cm by depth utd cm; -Peri-wound: Normal; -Exudate: Small; -Color: Serosanguineous; -Plan: Cleanse with normal saline apply, apply nickel thick Santyl and cover with border gauze daily and prn; -Location: Right buttock: -Type: Pressure ulcer/injury: Unstageable; -Wound bed description: 10 % granulation and 90% necrotic and slough; -Measurements: 4 cm by 0.5 and depth utd; -Peri-wound: excoriated; -Exudate: small; -Color: Serosanguineous; -Plan: Cleanse with normal saline apply nickel thick Santyl and cover with border gauze daily and prn. Further review of the resident's ePOS, showed: -An order dated 11/13/21 and discontinued 11/16/21, for Santyl ointment 250 unit/gram. Apply to right buttocks typically every day shift. Cleanse right buttocks with normal saline. Apply nickel thick Santyl and cover with border gauze daily and as needed; -No order to discontinue the Gentamycin Sulfate. Review of the resident's wound provider's note, dated 11/16/21 showed: -Location: Coccyx: -Type: Pressure ulcer/injury: Unstageable; -Wound bed description: 20% granulation and 80% slough; -Measurements: Length 2.2 cm by width 2.0 cm by depth utd cm; -Peri-wound: Normal; -Exudate: Small; -Color: Serosanguineous; -Plan: Cleanse with normal saline apply, apply nickel thick Santyl and cover with border gauze daily and as needed; -Location: Right buttock: -Type: Pressure ulcer/injury: Stage III (full thickness tissue loss, subcutaneous (under the skin) fat may be visible but the bone, tendon or muscle is not exposed); -Additional notes: Closed. Review of the resident's wound provider's note, dated 11/30/21, showed: -Location: Coccyx: -Type: Pressure ulcer/injury: Unstageable; -Wound bed description: 90% slough, dark tan, malodorous (foul odor) and 10% non-granular (no granulation tissue); -Measurements: Length 3.0 cm by width 3.0 cm by depth 2.5 cm; -Undermining (when significant erosion occurs underneath the outer wound edges resulting in more extensive damage beneath the skin surface): 2.5 cm circumference; -Peri-wound: 2 cm induration (hardening of the skin due to inflammation); -Exudate: Moderate; -Color: Serosanguineous; -Plan: Cleanse with normal saline apply, apply nickel thick Santyl and cover with border gauze daily and prn; -Additional notes: tissue culture (lab test to check for infection) ordered; -Location: Left heel: -Type: Pressure ulcer/injury, Deep tissue pressure injury (DTPI) Intact skin; -Wound bed description: 100% stable eschar; -Measurements: Length 4 cm by width 5cm, depth DTPI; -Exudate: None; -Interventions: Float heels with booties; -Plan: Cleanse with normal saline and apply skin prep (skin protectant) daily and as needed. Further review of the resident's medical record, showed no skin observation tools completed in November 2021. Further review of the resident's progress notes, showed no documentation of the resident's left heel DTPI. Observation on 12/1/21 at 12:22 P.M. showed the resident in his/her wheelchair and a foul odor noted in the room. CNA/Staffing Coordinator, Restorative Aide C and Certified Nursing Assistant (CNA) S placed the resident into his/her specialty bed per Hoyer lift and provided peri-care (cleansing of genitals and buttocks). Staff assisted the resident to his/her left side and the foul odor became stronger when the resident lay on his/her side. A dressing to the resident's coccyx saturated with brown drainage. The administrator, who was also working as the floor charge nurse, entered the room and removed the dressing to the coccyx. The coccyx wound had a large amount of brown drainage and string-like brown tissue to the wound bed. The administrator cleansed the wound with normal saline applied Gentamycin 1% ointment onto a piece of gauze and then packed the dressing into the resident's coccyx wound. He/she then covered it with a Collagen Alginate (specialty wound dressing that contained collagen and calcium alginate) and secured it with paper tape. No border gauze used. Further review of the resident's ePOS, showed: -An order start date 12/3/21, cleanse coccyx with normal saline, apply nickel thick Santyl ointment daily; -An order start date 12/3/21, cleanse left heel with normal saline and apply skin prep daily and as needed; -No order for a Collagen Alginate dressing; -No order for heel protector booties; -No order for wound culture. Observation and interview on 12/2/21 at 7:20 A.M., showed the resident lay in bed with no protective heel booties on his/her feet. The protective heel booties observed in the corner of the room. At 7:30 A.M., CNA M provided peri-care and then turned the resident on his/her left side. No dressing to the coccyx observed. CNA M said the wound was looking very bad and probably the worse he/she had ever seen it. He/she said the odor was awful. The coccyx wound drained a large amount of brown drainage and the drainage noted on the resident's incontinence pad on the bed. The resident's left heel observed with large, intact, blackened area. CNA M left the room to tell the nurse that there was no dressing on the resident's coccyx. Licensed Practical Nurse (LPN) B entered the room, cleansed the resident's coccyx wound with normal saline, applied Gentamycin 1% ointment to the wound base and covered it with a gauze and secured it with tape. Observation on 12/3/21 at 7:30 A.M., showed the resident's heel booties not on his/her feet. CNA M stood in the resident's room and sprayed odor neutralizer. During an interview on 12/8/21 at 8:20 A.M., Restorative Aide C said when the aide completes a bed bath or shower, a shower sheet is filled out to indicate a new area and the shower sheet is signed off by the charge nurse. Review of the resident's shower sheets, requested from the facility, showed one shower sheet provided, dated 12/3/21 and it did not indicate the resident's DTPI to the left heel. CNA signature and charge nurse signature observed on the sheet. During an interview on 12/7/21 at 9:44 A.M., Wound Provider Nurse R, said he/she identified the resident's left heel DTPI on 11/30/21. The facility did not. He/she verified that the orders for the resident's coccyx wound was only to be Santyl and not Gentamycin after the 11/9/21 visit. He/she expects staff to pack the wound if there is a depth to the wound. That would be common nursing practice for wound care. The wound culture was not obtained by the facility as ordered. He/she expects the treatments to be completed as ordered. He/she expects orders to be followed through within 24 hours. 2. Review of Resident #32's quarterly MDS, dated [DATE], showed: -Cognitively intact; -No evidence of acute change in mental status from the resident's baseline; -Total dependence in bed mobility, transfer, toilet use and dressing; -Impairment in range of motion on both lower extremities; -Diagnoses included high blood pressure, kidney disease, and diabetes; -Has a stage IV pressure ulcer. Review of the resident's care plan, in use at the time of survey, showed: -Has a stage IV pressure ulcer to the buttock; -Administer medications as ordered; -Administer treatments as ordered and monitor effectiveness; -Follow the facility policies and protocols for the prevention and treatment of skin breakdown; -Monitor dressing during shift to ensure it is intact and adhering; -Monitor nutritional status; -Encouraged good nutrition and hydration in order to promote healthier skin. Review of the resident's wound provider's note, dated 9/21/21, showed: -Location: Left buttocks; -Type: Pressure ulcer/injury: Stage IV; -Wound bed description: 70% granulation, 10% hyper-granulation (new tissue growth that forms beyond the surface of the wound) and 10% slough; -Measurements: length 16.3 cm by width 6 cm by depth 0.1 cm; -Peri-wound: Normal; -Exudate: Moderate; -Color: Serosanguineous; -Plan: Normal Saline cleanse, apply nickel thick Santyl and cover with Silver Alginate (antimicrobial dressing) and super absorbent dressing two times a day and as needed; -Additional notes: Wound bed is improving. Review of the resident's ePOS, showed: -An order dated 9/26/21, for Santyl ointment 250 unit/gram, to be applied to the left buttock topically two times a day for wound care. Cleanse area with normal saline and cover with Silver Alginate, and super absorbent dressing. The order discontinued on 11/10/21; -An order dated 11/10/21, for Santyl ointment 250 unit/gram, to be applied to left buttock topically tow times a day and as needed for wound care. Cleanse area with normal saline and cover with Silver Alginate and super absorbent dressing. The order discontinued on 12/2/21. Review of the resident's eTAR, reviewed on 12/6/21 at 8:10 A.M., showed the following dates the wound treatments not documented as administered: -On 9/27/21, 9/29/21, and 9/30/21, both day and evening shifts; -On 9/28/21, evening shift; -On 10/1/21 through 10/4/21, 10/8/21, 10/20/21 and 10/28/21, both day and evening shifts; -On 10/5/21, 10/9/21, 10/19/21, 10/23/21 to 10/25/21, 10/27/21, 10/29/21, and 10/31/21, day shifts; -On 10/10/21, 10/13/21, 10/14/21, 10/17/21, and 10/18/21, evening shifts; -On 11/3/21, 11/5/21, 11/8/21, 11/16/21, 11/18/21, 11/20/21, 11/23/21 to 11/26/21, day shifts; -On 11/21/21 and 11/25/21, both day and evening shifts. Review of the resident's wound provider note, dated 11/30/21, showed: -Location: Left buttocks; -Type: Pressure ulcer/injury: Stage IV; -Wound bed description: 90% hyper-granulation and 10% slough; -Measurements: length 14.5 cm by width 5 cm by depth hyper-granulation friable tissue; -Peri-wound: Normal; -Exudate: Moderate; -Color: Serosanguineous and yellow/dark tan; -Plan: Normal Saline cleanse, apply nickel thick Santyl and Gentamicin 0.1% and cover with Silver Alginate (antimicrobial dressing) and super absorbent dressing two times a day and as needed; -Additional notes: Wound culture ordered. Further review of the resident's ePOS, showed an order dated 12/2/21, for Gentamicin Sulfate ointment 0.1% and Santyl, to be applied to left buttock topically two times a day and as needed for wound care. Cleanse area with normal saline and cover with Silver Alginate and super absorbent dressing. During an interview on 12/1/21 at 8:09 A.M., the resident said the nurses provide wound treatments sometimes only once a day, as opposed to two times a day. He/she said it may be due to the facility's shortage of staff. 3. Review of Resident #30's quarterly MDS, dated [DATE], showed: -Moderate cognitive impairment; -Required extensive assistance from staff for mobility, dressing and personal hygiene. Total dependence on staff for showers and toileting; -Always incontinent of bowel and bladder; -Diagnoses included high blood pressure, stroke, dementia and depression; -At risk for pressure ulcers; -Number of unhealed pressure ulcers: One unhealed Stage 3. Review of the resident's care plan, in use during the survey, showed staff failed to address the wound to the resident's knee or include any preventative interventions. Review of the resident's wound management provider note, dated 10/26/21, showed: -Location: Left medial knee; -Pressure ulcer/injury: Stage III; -Wound bed description: 90% granulation and 10% slough; -Measurements: Length 2.5 cm by width 1.2 cm by depth 0.1 cm; -Exudate: None; -Interventions: Other place wedge/pillow between knees to off load pressure; -Plan: Normal saline cleanse, apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed. Review of the resident's ePOS, showed: -An order dated 10/27/21, for Santyl ointment 250 milligrams (mg), apply to left medial knee topically every day shift for wound care. Cleanse left medial knee with normal saline. Apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed; -An order dated 10/27/21, to place pillow/wedge between knees to off load pressure. Review of the resident's October 2021 TAR, showed: -An order dated 10/27/21, for Santyl Ointment 250 mg, apply to left medial knee topically every day shift for wound care. Cleanse left medial knee with normal saline. Apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed; -Start date: 10/28/21; -Staff documented completing the treatment for one out of four opportunities; -No other documentation; -No order for a pillow/wedge. Review of the resident's wound management provider note, dated 11/2/21, showed: -Location: Left medial knee; -Pressure ulcer/injury: Stage III; -Wound bed description: 95% granulation and 5% slough; -Measurements: Length 2 cm by width 1 cm by depth 0.1 cm; -Exudate: Moderate; -Color: Serosanguineous; -Interventions: Other place wedge/pillow between knees to off load pressure; -Plan: Normal saline cleanse, apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed. Review of the resident's 11/9/21 wound management provider note, showed: -Location: Left medial knee; -Pressure ulcer/injury: Stage III; -Wound bed description: 95% granulation and 5% slough; -Measurements: Length 1.8 cm by width 0.8 cm by depth 0.1 cm; -Exudate: Moderate; -Color: Serosanguineous; -Interventions: Other place wedge/pillow between knees to off load pressure; -Plan: Normal saline cleanse, apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed. Review of the resident's 11/16/21, wound management provider note, showed: -Location: Left medial knee; -Pressure ulcer/injury: Stage III; -Wound bed description: 95% granulation and 5% slough; -Measurements: Length 0.9 cm by width 0.6 cm by depth 0.1 cm; -Exudate: Moderate; -Color: Serosanguineous; -Interventions: Other place wedge/pillow between knees to off load pressure; -Plan: Normal saline cleanse, apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed. Review of the resident's 11/30/21 wound management provider note, showed: -Location: Left medial knee; -Pressure ulcer/injury: Stage III; -Wound bed description: 95% granulation and 5% slough; -Measurements: Length 1.3 cm by width 0.5 cm by depth 0.1 cm; -Exudate: Moderate; -Color: Serosanguineous; -Interventions: Other place wedge/pillow between knees to off load pressure; -Plan: Normal saline cleanse, apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed. Review of the resident's November 2021 eTAR, showed: -Staff documented administering the treatment 18 out of 30 opportunities; -No other documentation; -No order for a pillow/wedge. Review of the resident's 12/1/21 wound management provider note, showed: -Location: Left medial knee; -Pressure ulcer/injury: Stage III; -Wound bed description: 95% granulation and 5% slough; -Measurements: Length 1.3 cm by width 0.5 cm by depth 0.1 cm; -Exudate: Moderate; -Color: Serosanguineous; -Interventions: Other place wedge/pillow between knees to off load pressure; -Plan: Normal saline cleanse, apply Santyl and Calcium Alginate, cover with a dry dressing daily and as needed. Observation on 12/2/21 at 7:39 A.M., showed the resident lay in bed on his/her back. The resident had a treatment on his/her left knee dated 11/30/21 and signed by the wound management provider. A wedge/pillow was not in place between his/her knees. Observation on 12/3/21 at 7:30 A.M., showed the resident lay in bed on his/her back. The resident had a treatment on his/her left knee dated 12/2/21 and signed by the wound management provider. A wedge/pillow was not in place between his/her knees. Observation on 12/6/21 at 1:04 P.M., showed the resident lay in bed on his/her back. The resident had a treatment on his/her left knee dated 12/5/21 and initialed by facility staff. A wedge/pillow was not in place between his/her knees. Review of the resident's December 2021 eTAR reviewed on 12/6/21 at 5:25 P.M., showed: -Staff documented administering the treatment 5 out of 6 opportunities; -No other documentation; -No order for a pillow/wedge. During an interview on 12/8/21 at 8:19 A.M., CMT D said he/she was familiar with the resident. The resident used to have a wedge that staff placed on his/her side, but he/she was not aware of a wedge or pillow that needed to go between the resident's knees. 4. During an interview on 12/7/21 at 11:25 A.M., the administrator said she expected staff to follow physician orders. If the eTAR is blank, staff should document as to why it was not completed. If it is blank, either the treatment was not completed or staff failed to document completing it. There should be documentation the physician was notified after three missed treatments. 5. During an interview on 12/8/21 at 8:25 A.M., LPN L said once a wound is newly identified he/she will measure the wound, describe the wound bed and drainage if any is noted. The physician needs to be notified before the nurses shifts ends to obtain new orders. In the meantime, he/she would place a dry dressing over the wound until orders are received. He/she did not know when skin assessments are done because he/she was agency staff. He/she thought they would pop up on the computer to be completed and was not sure where they are documented. 6. During an interview with the administrator and the consultant administrator on 12/8/21 at 12:04 P.M., they said staff is expected to notify the physician before their shift ends if a new wound or a change in a wound status is observed to obtain orders so there is no delay in treatment. The weekly wound assessments are expected to be signed off on the eTAR and a skin observation tool is expected to be used weekly for the documentation of the specifics of the wound, such as if the wound is new, changes in the wound, measurements, location, and if drainage is noted. New orders from the wound nurse is expected to be in place within 24 hours. Staff is expected to complete treatments and assessments accurately and as ordered. MO00187410