**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to keep residents free from abuse for 4 (R #27, R #28, R #56 and R #134) of 5 (R #20, R #27, R # 28, R #54 and R #134) residents reviewed for abuse when staff failed to: 1. Prevent emotional trauma as a result of not immediately removing the deceased body of R #27's roommate or moving R #27 from the room while waiting for the funeral home. 2. Physical abuse by the same Certified Nurse Aide (CNA) for R #27, 38, 56, and 134. The findings are: Findings for R #27 A. Record review of R #27's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] for multiple diagnoses including but not limited to: - Need for assistance with personal care. - Lack of coordination. - Morbid obesity (severe) due to excess calories (imbalance between the number of calories consumed and the number of calories burned). B. Record review of R #27's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS; a screening for cognitive impairment. Scores range from 00 to 15) score of 15, cognitively intact. C. On [DATE] at 1:55 pm during an interview, R #27 stated she was R #136's roommate since [DATE]. She stated her roommate (R #136) passed away on [DATE], and staff left her in the room with the body. R #27 stated she asked staff to move the body, but they did not. She stated an unknown CNA stood behind the privacy curtain, told her Rest in peace, [Name of R #27], turned off the light, walked out of the room, and shut the door. She stated since that day she had panic attacks and did not want another roommate. She stated she was scared and had anxiety about being in a room with another deceased roommate. R #27 revealed she told the Assistant Director of Nursing (ADON) about the incident, but she did not receive a response from the ADON. D. Record review of a nursing progress note for R #136, dated [DATE], revealed R #136 passed away on [DATE] at 1:24 am, and the body was removed from the room at 3:00 am. E. On [DATE] at 11:49 am, during an interview, the Assistant Director of Nursing (ADON) confirmed R #136 was deceased and left in R #27's room from 1:24 am to 3:00 am. The ADON stated she did not believe it to be best practice to leave a resident in the room with a deceased roommate. Findings related to CNA #4 R #134 F. Record review of R #134 face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with multiple diagnoses including, but not limited to: - Malignant neoplasm of unspecified site of unspecified female breast (breast cancer). - Type 2 diabetes with diabetic neuropathy (nerve damage that develops gradually and caused by long-term high blood sugar levels). - Muscle weakness. - Unsteadiness on feet. - Need for assistance with personal care. - Dependence on dialysis (a blood purifying treatment given when kidney function is not optimum). - Lack of coordination. G. Record review of the facility incident report, dated [DATE], revealed R #134 reported CNA #4 entered her room, kicked her on her lower leg, and hit her kidney to wake her up on [DATE] around 8:30 pm. R #134 stated she was unsure if she wanted to report it. There were no injuries noted. H. On [DATE] at 11:49 am, during an interview with the ADON, she stated CNA #4 was suspended pending investigation on [DATE] with a return date of [DATE]. I. Record review of Corrective Action Memo for CNA #4, dated [DATE], revealed CNA #4 reported she attempted to wake R #134 several times, but R #134 did not wake up. CNA #4 reported she tapped the resident on the shoulder, and it startled the resident. J. Record review of the facility's In-Service Training for Abuse/Neglect training, dated [DATE], and the facility's Customer Service/Care Interaction training, dated [DATE], revealed CNA #4 was in attendance. R #28 K. Record review for R #28's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with multiple diagnoses including but not limited to: - Parkinson, unspecified (not a single disease, but a term for a group of conditions that affect movement and mimics Parkinson disease). - Chronic respiratory failure with hypoxia (an ongoing condition that affects your ability to breathe and process oxygen). - Need for assistance with personal care. - Other dysphasia (trouble swallowing). - Unsteadiness on feet. - Morbid obesity due to excess calories (imbalance between the number of calories consumed and the number of calories burned). - Rheumatoid arthritis, unspecified (chronic inflammatory disease that affects the joints). - Depression (feeling of sadness). L. Record review of a grievance report for R #28, dated [DATE], revealed the resident stated the night before [[DATE] thru [DATE]] was the worst night she ever had. R #28 reported CNA #4 yelled at her and told her to stay off the call light. R #28 stated CNA #4 said she would return to help her. R #28 stated CNA #4 shoved her, was very aggressive, and hurt her when she (CNA #4) changed her. M. On [DATE] at 1:17 pm, during an interview, R #28 stated a female staff was rough with her during care, but she was unable to recall the CNA's name. She stated the CNA worked nights. R #28 stated she had bruises from the CNA. She stated the police came and took a report from her. She stated she knew the CNA was fired. R #28 stated she felt like the call light was there so she could get help, not to make her feel like a problem. N. Record review of the staff schedule, dated [DATE], showed CNA #4 worked on R #28's unit on [DATE] during the 7:00 pm to 7:00 am shift. O. Record review of timecard for CNA #4 revealed the last shift she worked at the facility was the evening shift on [DATE] at 6:02 pm until morning of [DATE] at 6:01 am. P. Record review of the Police Department Field Case Report, dated [DATE], revealed the following: - Name of CNA #4. - Name victim: R #28. - Officer received a report from R #28, She advised she was resting in bed. She stated the CNA (her name) told her to keep off her call light. When the CNA #4 came to turn her, she shoved her over to the side very roughly. - During an interview, R #28 told the Officer, [Name of CNA #4] was in a bad mood. She yelled at me for using the call light. R #28 told the Officer that CNA #4 was very aggressive and rough with her when she (CNA #4) came to turn her (R #28). The resident stated the CNA shoved her to the point it caused bruising and pain. Q. Record review of the Police Department Field Case Supplement, dated [DATE] revealed the following: - R #28 stated she pressed her call light throughout the shift, and it upset CNA #4. The resident stated CNA #4 started to yell and scream at her and told her not to press her call light button. R #28 told the Officer CNA #4 shoved her when she (CNA #4) changed her (R #28). The resident showed the Officer how it occurred with her hand, in a palm strike type manner. R #28 stated CNA #4 hit/shoved R #28's right leg, and it was so hard it caused her leg to hit her other leg. - R #28 showed the officer her right outer thigh, and a large amount of bruising was noted on her leg. It covered approximately seven inches in length, along with multiple inches wide. - R #28 showed the officer her left inner leg, and the officer observed a lot of bruising. - R #28 stated CNA #4 caused the bruising. - There were two photographs of the right leg bruising and left leg bruising. R. Record review of the Police Department Field Case, Supplemental Narrative, dated [DATE], revealed an arrest warrant was obtained for CNA #4 for one count of battery (the unlawful application of physical force to another person without their consent). S. On [DATE] at 11:49 am, during an interview with the ADON, she stated they suspended CNA #4 pending investigation when the incident was reported on [DATE], and they terminated CNA #4's employment at the facility on [DATE]. T. On [DATE] at 11:31 am, during an interview with Director of Nursing (DON), she stated CNA #4 came back to work on [DATE] and was placed on the 200 hall. She stated, that after CNA #4 returned, a staff member reported to her (the DON) that R #28 voiced concerns about the CNA. The DON stated she spoke with R #28, and the resident told her about the terrible night she had with CNA #4. She stated R #28 reported CNA #4 scolded her for using her call light too many times, and when CNA #4 turned her, she (CNA #4) shoved her (R #28) on her hip area. The DON stated staff assessed R #28 and filed a grievance form. She stated during R #28's assessment, staff noted slight bruising on the resident's right side hip area. The DON stated she immediately suspended CNA #4 again, and staff did a skin sweep on the hall that CNA #4 worked. The DON stated that was when they found the bruising on R #56. R # 56 U. Record review of R #56's face sheet, dated [DATE], revealed she was admitted to the facility on [DATE] with multiple diagnoses that including but not limited to: - Fracture of the neck right femur (broken hip). - Adult failure to thrive (a condition that affects appetite, weight, and activity). - Need for assistance with personal care. - Unspecified dementia, unspecified severity, with psychotic disturbance (caused by damage to or loss of nerve cells and their connections in the brain). - Muscle wasting and atrophy, not elsewhere classified, multiple sites (loss of muscle leading to its shrinking and weakening). - Other symptoms and signs involving cognitive functions and awareness (difficulty in understanding or making sense of one's surroundings). V. Record review of a Shower Sheet for R #56, dated [DATE], did not identify any skin injury. W. Record review of Change in Condition Evaluation for R #56, dated [DATE], revealed resident had swelling with purple/black discoloration to her right lower arm. X. Record review of nursing progress notes for R #56, dated [DATE], revealed the resident was sent out for a right arm x-ray due to suspicion of a fracture. Y. Record review of the Diagnostic Radiology Report for R #56, dated [DATE], revealed the following: - Reason for exam: bruising and swelling of right forearm. - No fractures or dislocation. Z. Record review of the Police Department Case Report, dated [DATE], revealed: - R #56 had major bruising and trauma to her right forearm, on or around [DATE] [sic]. R #56 did not have any injuries prior to receiving care from CNA #4, and CNA #4 was the only staff who cared for the resident on [DATE] [sic]. Additionally, there was not an obvious medical cause for the injury, no blood drawn, and R #56 did not have any clotting disorders or medical conditions which would cause her to bruise spontaneously. - Pictures were part of the file and showed bruising of the resident's right forearm, with a visible bump to the right forearm. - According to the detective, the injuries on R #56 appeared to be consistent with her arm having been grabbed aggressively. AA. On [DATE] at 10:24 am during interview with the Regional Nurse Consultant (RNC), she confirmed the last time CNA #4 worked at the building was the evening of [DATE] thru the morning of [DATE]. The RNC stated R #56 had skin discoloration on [DATE], and the Physician felt the injury was latent (existing but not yet developed) in showing bruising. She also stated CNA #4 worked with R #56 independently on the evening shift of [DATE]. She stated the CNAs worked in pairs the evening of [DATE], and they did not report any incident of falls or other concerns, as it related to the bruising on R #56's arm. The RNC stated they felt that it was very likely that CNA #4 also hurt R #56, due to the other allegations/injury identified with R #28.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that residents received necessary treatment and service to prevent development and promote healing of pressure wounds (damaged skin caused by pressure, shear or friction) for 1 (R #19) of 3 ( R #11, 19, and 125) residents reviewed for pressure ulcers. This deficient practice likely resulted in a facility acquired pressure wound becoming necrotic (death of living tissue) before treatment was initiated. The findings are: A. Record review of R# 19's medical record revealed that resident was admitted to the facility on [DATE] and diagnoses indicated the following: Hypertension (high blood pressure), Benign Prostatic Hyperplasia (the prostate is enlarged), Altered Mental Status (brain malfunction that affects behavior and awareness), Malignant Neoplasm of Prostate (prostate cancer), Parkinson's disease (is a condition that affects the brain and causes problems with movement, balance, and coordination), Depression (persistent sadness and a lack of interest or pleasure in previously rewarding or enjoyable activities), Dysphagia (condition with difficulty in swallowing food or liquid), Dementia (condition that affect the brain's ability to think, remember, and function normally). This is not an all inclusive list. B. Record review of the Braden Scale for predicting pressure sore risk dated 02/09/23 indicated that R #19 scored a 12 which is a high risk for developing a pressure sore. Section 1 indicated that sensory perception was very limited and this would hinder is ability to respond to stimuli, 2. Moisture and R #19 scored very moist which means his skin is moist. 3. Indicated that R #19 is chairfast which means his ability to walk is severely limited or non-existent. He is unable to bear weight and must be assisted into chair or wheelchair. 4 Indicated that for mobility R #19 is very limited. He is limited in his ability to change and control body position independently and make frequent or significant changes. Section 5 Nutrition is adequate which indicated that he eats over half his meals. Section 6 indicated that for friction and shear R #19 has a problem in this area and requires moderate to maximum assistance in moving. He frequently slides down in bed or chair and requires frequent repositioning with maximum assist. C. On 02/08/23 at 8:43 am, during an interview with Wound Care Nurse, she stated that wounds for R #19 were brought to her attention last week on 02/03/23. She stated that she was asked to look at the wounds after a dressing had fallen off. She stated that when she saw the wounds they were on the Ischium (forms the lower and back region of the hip bone) and one of them was necrotic (death of living tissue) unstageable (refers to an ulcer that has full thickness tissue loss but is either covered by extensive necrotic tissue or by an eschar) and the other was a stage II (partial thickness loss of the first two layers of the skin, the epidermis and dermis). She stated that someone had been treating it because there was a dressing on it. She stated that she had not been made aware of any wound on R #19 prior to 02/03/23. She stated that she can assume that the wounds had been identified before 02/03/23 and they (nursing staff) were just treating them. Before 02/03/23 there were no orders for treatment, no change in condition completed and she didn't think the family was notified. Wound Care Nurse confirmed that R #19 was not being treated for any wounds to her knowledge prior to 02/03/23. D. Record review of skin assessments indicated weekly skin assessments completed by nurses on 01/13/23, 01/20/23 and 01/27/23 no skin impairments (nothing on the skin) were noted. E. Record review of the Certified Nursing Assistant (CNA) documentation to monitor the skin revealed that on the following dates it was noted that R #19 had an open area to his skin: 01/28/23, 01/29/23, 01/30/23, 02/02/23, 02/04/23, 02/06/23, 02/07/23 and on 02/08/23. No indication on this documentation if the nurse was notified. F. Record review of the nursing progress notes dated 02/03/23 indicated that R #19 had a wound care assessment on 02/03/23, physician informed, and orders obtained. Teaching to nurse and CNAs on repositioning q (every) 2 hours with incontinent care if needed, skin checks, wound care. G. Record review of the wound care assessment dated [DATE] indicated that there are two wounds. Left Ischium (forms the lower and back region of the hip bone) with minimal thin, tan exudate (a mass of cells and fluid that has seeped out of blood vessels) with no odor. The wound appearance is black, necrotic tissue 70% necrotic and 30% granulation (the primary type of tissue that will fill in a wound that is healing). Surrounding tissue is bright red and macerated (happens when your skin is broken down by moisture). Length is 4.3 cm (centimeters) width is 3.5 cm and no depth is noted. The right Ischium wound was noted as having no exudate, no odor, the wound appearance is red granulation tissue 80% granulation and 20% slough (necrotic tissue that needs to be removed from the wound for healing to take place) and the surrounding tissue is pink. The wound size is Length 3.0 cm width 3.2 cm and the depth is 0.3 cm. H. Record review dated 02/03/23 of a Change In Condition (CIC) progress note indicated the following: Reported on this CIC Evaluation are/were: Skin wound or ulcer Nursing observations, evaluation, and recommendations are: Resident observed to have skin breakdown near gluteal fold (fold of the buttock or horizontal gluteal crease) on left side. Pressure ulcer unstageable due to necrosis noted. Area cleansed and dressings placed. Right side same area has stage II ulcer. Wound care completed. I. Record review of the nursing progress notes for R #19 did not reveal any wound care for the pressure wounds on the Ischium prior to 02/03/23. J. Record review of the physician orders indicated the following: -Stage 2 Right Ischium pressure ulcer: Cleanse with wound cleanser, pat dry with gauze, apply thera honey to wound bed (treatment for wounds), cover with alginate (maintains a moist microenvironment, minimize bacterial infection at the wound site, and facilitate wound healing) then with foam dressing (foam dressings are used to provide a moist wound environment, most commonly in wounds with moderate-to-heavy exudate) of choice qod (every other day) and prn (as needed) for loose or soiled dressing every day shift every other day for wound care on 02/03/23. -Wound care to Left Ischium: Cleanse with wound Vashe (cleansing, irrigating, moistening, debridement and removal of foreign material), pat dry with gauze, apply derm/syn (donates moisture to dry or minimally exudating wounds for an optimal moist environment) to necrotic area, apply (sic) honey (for dry to moderately exuding wounds) to nonnecrotic area, cover with calcium alginate (highly absorptive) and foam dry dressing of choice qod and prn for loose or soiled dressing every day shift every other day for wound care on 02/03/23. K. On 02/10/23 at 9:20 am, during an interview with Registered Nurse (RN) #2, stated that they do weekly skin assessments on shower days and they have to lay their eyes on the residents skin to do the assessment. She stated that last week was when she became aware of R #19's wounds. When asked if the wound was present before last week she stated she couldn't recall. She stated that on 02/03/23 a CNA (doesn't remember who) called her into see the wound and asked if she was aware of it. She stated that there were no physician orders to treat the wound prior to 02/03/23. On 02/03/23 she did notify the DON, physician and the family. RN #2 stated that wound had necrosis (death of tissue cells) and redness on the wound when she saw it on 02/03/23. L. On 02/08/23 at 1:43 pm, during an interview with Director of Nursing (DON) she stated that she was first notified of the wound Friday afternoon which was 02/03/23. She was notified by the nurse working him (R #19) that day. The DON stated that the nurses that had been working with him did not indicate a problem and the skin check's reflect this. She stated that the CNA's had not brought up any skin issues either. M. On 02/08/23 at 2:18 pm, during an interview with the Physician he stated that R #19 has unavoidable wounds and they are unlikely to heal. He stated that he doesn't recall exactly when he was notified about the wound but stated he has known about it for awhile maybe two weeks. Physician confirmed that he did not provide wound orders until 02/03/23. N. On 02/09/23 at 1:43 pm, during an interview with CNA #8, she stated that the last time (didn't remember when that was) that she worked with R #19 he had some redness. She stated that if she had seen any redness on the resident, she would have noted that on the skin monitoring sheet and wound inform the nurse about it. CNA #8 could not recall if she had notified the nurse about any wounds or redness for R #19.