**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure each resident was free from abuse for 1 of 6 residents (Resident #1) reviewed for abuse. CNA A was physically abusive to Resident #1 on 1/28/2025 when he slapped her on the left cheek with an open hand and pointed at her twice aggressively. The noncompliance was identified as past noncompliance (PNC). The IJ (immediate jeopardy) began on 1/28/2025 and ended on 4/22/2025. The facility corrected the noncompliance before the survey began. Resident #2 was physically abusive to Resident #1 on 4/21/2025 when she punched her in the arm with a closed fist three times. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 4/21/25 and ended on 4/22/2025. The facility corrected the noncompliance before the survey began. These failures placed residents, who resided in the facility, at risk of abuse, and mental anguish caused by fear. The findings included: Resident #1 Record review of Resident #1's undated admission Record revealed she admitted to the facility on [DATE] with diagnoses of colon cancer, hemiplegia (partial paralysis on one side of body), vascular dementia and adjustment disorder with depressed mood. She was [AGE] years of age. Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 3, indicating severe cognitive impairment. She was dependent on staff for activities of daily living, including oral hygiene, toileting, bathing, and required substantial/maximum assistance for transfers. Record review of Resident #1's Care Plan Report, undated, revealed the following focuses, goals and interventions: - Focus: (Resident #1) had impaired cognitive function and impaired thought processes. Initiated on 12/6/24. Goal: The resident would maintain at current level of cognitive function through the review date. Target date 3/16/25. Interventions: Administer medications as ordered, ask yes/no questions to determine resident's needs, communicate with the resident regarding resident's capabilities and needs, and identify yourself at each interaction, face the resident when speaking and make eye contact. - Focus: (Resident #1) had unwanted behaviors related to yelling, combative with staff, refuses care, medications and meals and transfers independently without assistance. Initiated on 12/6/24. Goal: The resident would have fewer episodes of behavior by review date. Target date 3/16/25. Interventions: Caregivers to provide opportunity for positive interaction and attention, explain all procedures to the resident before starting, give 1:1 assistance (individualized attention provided by one person to the resident) to try and calm resident down, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, remove from situation and take to alternate location as needed and re-direct resident when combative, explaining this is inappropriate behavior. Record review of Resident #1's Incident/Accident Investigation Worksheet dated 1/29/2025 at 8:45am revealed an incident of abuse occurred. There were no witnesses listed. The pain assessment revealed she complained of a headache, Tylenol (a medication for pain management) was offered but refused. The conclusion/root cause was described as possible physical abuse .recommendations/interventions: Ask (family member) to check camera footage. Record review of an Abuse-Investigation Statement dated 1/29/25 revealed CNA A made the statement: (Resident #1) called asking to be changed around 9:00pm, after letter her know that I was in the middle of my round & that I would be assisting her afterward, (Resident #1) continued to call out. When I changed her/provided pericare, she asked for Tylenol & for the lights to be turned off. Approximately 5 min later (Resident #1) called out again, but she was not making any sense. In a continuance of the statement, CNA A reported that he entered Resident #1's room and asked what was wrong. I placed my hand down near her head on her bed, due to her bed being so low to the ground. (Resident #1) began to start jostling & throwing her head around. She hit her head against my hand. After that she shouted that I hit her & I moved my hand away & walked out of the room . Record review of a provider investigation report dated 2/5/2025 described an allegation of abuse in that CNA A hit Resident #1. A video from the incident shows a timestamp of 1/28/25 at 9:48pm and revealed CNA A hit Resident #1 on her left cheek. The police were notified, and CNA A was terminated on 1/30/25. The resident was assessed with no new injuries noted. An assessment was completed, and Resident #1 complained that her head hurt from the fall. The resident had a fall on 1/26/25 that resulted in a contusion (a bruise) to her right eye/cheek area. The provider investigation report was signed by the Former Administrator. The allegation of abuse was confirmed. Surveyor attempted interviews with Resident #1 on 5/13/25 at 11:11am and 5/14/2025 at 10:50 am with no success as she refused to be interviewed. Observation of the video footage sent by the Administrator to the surveyor by email on 5/14/2025 at 11:29am revealed the following: CNA A approached Resident #1 pointing at her face and talking, then hit her on her left cheek with his open right hand, then pointed at her face again, aggressively. After the slap, Resident #1 was yelling and pointing at CNA A. Conversation can be heard in the video, but it was difficult to determine what was said. In an interview on 5/14/25 at 1:48pm with CNA A, he said he recalled the incident with Resident #1. He said it was near the end of his shift, and she was the last person he cared for before charting and going home. He said Resident #1 never used her call light and she called out when she needed to be changed. He said he walked out, then walked back in and asked, I just changed you, are you sure you need to be changed. He said he then hit Resident #1 on the side of the face. When asked to describe how he hit her, he said he smacked her on the side of her cheek. He said she was screaming and irate. He said he slapped her to get her attention, but said it was not malicious. He said what he did to Resident #1 was physical abuse. In an interview on 5/13/2025 at 11:22pm, LVN C stated she was working the night of the incident between CNA A and Resident #1. She said CNA B reported to her that CNA A hit Resident #1. She said she approached the nurse who was caring for Resident #1 and shared with her what CNA B said. She said she noticed that the LVN was on her phone making notifications. She said she did not follow-up afterwards. She said she could not remember the other LVN's name. In an interview with CNA B on 5/14/2025 at 11:34am, she said she was at the facility at the time of the incident. She said CNA A approached her and told her that Resident #1 said he hit her. She looked into Resident #1's room and Resident #1 said, he hit me, he hit me! She said she was terrified, scared, yelling, crying, and asking for help. She said she and CNA A went to the break room to find Resident #1's nurse, then reported what happened. She said she stayed with CNA A until he went home. In a telephone interview on 5/15/25 at 9:15am, LVN D said she was assigned to Resident #1 when there was an allegation of abuse. She said she was on a lunch break, and LVN C came in and told her about the abuse allegation between CNA A and Resident #1. She said she assessed Resident #1, but did not see that she was fearful or upset. She said the incident occured at the end of CNA A's shift, and he completed charting, then went home. She said he did not care for other residents. In an interview on 5/14/25 at 1:28pm, MD A stated she was not aware that Resident #1 was distressed after the abuse incident. She stated residents who are abused could be fearful of caregivers and hesitant to receive care. In an interview on 5/14/25 at 3:20pm, The DON said she was aware of the incident regarding CNA A and Resident #1. She said the administrator watched video footage of CNA A slapping Resident #1 in the face. She said they suspended him the day after the incident and he was terminated after the investigation. She said they completed an assessment of Resident #1, notified police, ombudsman, HHSC, completed safety surveys with residents, took statements and in-serviced on abuse and neglect policies and procedures. She said CNA A worked from 2:30pm-10:30pm that evening, and the incident occured at 9:45pm. She said after the incident occured and notifications were made, it was time for him to go home. Resident #1 and Resident #2 Record review of Resident #2's admission Record (undated) revealed she admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbance, diabetes, major depressive disorder with psychotic symptoms, cerebral aneurysm (a bulge in a blood vessel in the brain), adjustment disorder and history of transient ischemic attack (temporary blockage of blood flow to the brain). She was [AGE] years of age. Record review of Resident #2's quarterly MDS assessment dated [DATE] revealed she had a BIMS score of 3, indicating she had severe cognitive impairment. She did not exhibit behavior symptoms during the review period. She used a wheelchair and required supervision to wheel 50 feet with two turns. Record review of Resident #2's care plan report (undated) revealed the following focuses, goals and interventions: - Focus: Resident #2 was a risk for delirium and reports of hallucinations. Initiated on 6/6/23. Goal: Cause of delirium will be resolved through the next review. Target date: 5/23/25. Interventions: Approach in calm manner, assess vital signs, medications, document changes noted. - Focus: Resident #2 had impaired cognitive function and impaired thought processes related to dementia. Initiated on 5/13/22. Goal: Resident will maintain current level of cognitive function through review dated. The resident would be able to communicate basic needs on a daily basis through the review date. Target date: 5/23/25. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Cue, reorient and supervise as needed. Monitor as needed for changes in cognitive function, specifically changes in decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness and mental status. - Focus: Resident #2 had unwanted behaviors related to delusions and hallucinations. Initiated on 9/5/24 and revised on 4/23/25. Goal: Behavior episodes would be reduced to less than daily until the next review. Target date: 5/23/25. Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Give 1:1 assistance to try to calm resident down as needed. Record review of Resident #2's progress note dated 4/21/25 at 7:00pm revealed Resident #2 was at the nurse's station with another resident, and the other resident was mumbling to herself. At 6:30pm, Resident #2 struck the other resident with a closed fist three times. Record review of Resident #1's progress note dated 4/21/25 at 7:10pm revealed Resident #1 was involved in a physical altercation with a resident at the nurse's station. Resident sustained 3 hits to the (L) arm from the other individual. The resident attempted to retaliate, however made no physical contact. No visible injuries noted upon assessment . Record review of Resident #2's Incident/Accident Investigation Worksheet dated 4/21/25 at 6:30pm revealed Resident #2 reported that another resident was talking to her in a different language, and she asked her to stop. Resident #2 said whenthe other resident refused, she said she tried to get away from her, but did not hit her. LVN E was listed as a witness. LVN E reported seeing Resident #2 strike another resident with a closed fist three times. Further review of the worksheet revealed Resident #2 was separated from the other resident, was placed on 1:1 supervision, MD ordered a urinalysis and ammonia levels, and notifications were made to psychiatric nurse practitioner, DON, Administrator, and resident's responsible party. Record review of Resident #1's Incident/Accident Investigation Worksheet dated 4/21/25 revealed on 4/21/25 at 6:45pm, Resident #1 received verbal aggression. The incident was witnessed by LVN E who saw that Resident #1 was hit by another resident. In the section for What did the resident say happened, it stated, I don't know .I don't argue. There were no injuries or recent medical changes reported. Recommendations/Interventions included the following: Resident redirected and monitored closely for any changes in behavior or physical condition .safety precautions reinforced to prevent further occurrences. Record review of Resident #1's Behavioral Health Progress Note dated 4/22/25 revealed Resident #1 had a short attention span and had neurological symptoms such as cognitive deficits and memory problems. The progress note revealed she was being assessed after an altercation with another resident. No distress was noted during the assessment. Record review of Resident #2's Med Management Clinical Note dated 4/21/25 revealed the Psychological Services NP assessed the resident after she attempted to strike another resident. It was determined that the behavior was not repeated, and the behavioral disturbance was likely related to elevated Ammonia levels. In an interview on 5/13/2025 at 3:39pm, the Social Worker stated on the day that Resident #2 hit Resident #1, Resident #2 stole her phone. She said a family member called her phone and she heard it ring near Resident #2. She said after she retrieved her phone, she left Resident #2 near the nurse's station because she said she wanted to stay out in the halls. She said moments later she heard a commotion and found out that Resident #2 hit Resident #1. She said the nurse witnessed the interaction. She said that Resident #2 had occasional agitation, but not physical aggression. She said both incidents were outside of her baseline. She said the facility determined she had a urinary tract infection. In an observation and attempted interview on 5/13/2025 at 10:12pm, Resident #2 was in bed watching television. She was unable to answer surveyor's questions. When asked a question, she would talk about her past and her family. In an interview on 5/15/25 at 1:50pm, the DON said she was notified of the incident between Resident #2 and Resident #1 by phone. She said she believed they were too close together and Resident #2 hit Resident #1 in the arm. She said neither resident remembered the incident. She said the behavior was outside of Resident #2's baseline, and stated she was not aggressive. She said it was determined that she had a urinary tract infection at the time. She said Resident #2 as placed on 1:1 supervision until a staff member of the psychology services company visited and determined she was not a threat to others. In an interview on 5/15/25 at 4:02pm, LVN E said she witnessed the incident between Resident #1 and Resident #2. She said she had just retrieved Resident #2 from the 300 hall when she let her stay near the nurse's station. She said Resident #1 was yelling and saying something, then Resident #2 started talking back and hit Resident #1 three times in the arm with a closed fist. She said it was outside of Resident #2's baseline to hit someone. She said she had not experienced a situation like this before. She said to prevent something like this from occurring, staff need to stay vigilant, be aware of changes of condition and keep lines of communication open. In an interview on 5/15/25 at 4:10pm, the Administrator said Resident #2 struck Resident #1 in the arm a few times. She said in response to the altercation, the facility separated the residents, placed Resident #2 on 1:1 supervision, completed assessments of both residents, asked psychological services to assess both residents, completed an ad hoc QAPI IDT meeting, completed in-services with staff on abuse and behaviors, contacted the police department. She said she trained staff on how to monitor for aggressive behaviors and take appropriate actions before it leads to abuse. She said even with Resident #2's cognitive impairment, it was a willful act at the time of the incident according to the Appendix PP (The State Operations Manual provided by CMS that provides guidance to surveyors for Long Term Care Facilities). The facility took the following action to correct the non-compliance between 1/28/2025 and 4/23/2025: Record review of the Provider Investigation Report dated 2/5/25 revealed facility staff completed a skin, pain and psychological assessment for Resident #1 on 1/29/25. CNA A was suspended on 1/29/25 pending an investigation and terminated on 1/30/25. The police were notified and the facility changed their external access codes. Record review of multiple Resident Interviews dated 1/29/25 revealed facility staff interviewed residents .to determine their awareness of their rights and their experience at the facility. Some residents reported they wre unaware of their reports or knowledge on how to report abuse. They were educated during the interview. All residents reported no knowledge or evidence of abuse. Record review of a facility list of residents titled, 300's Hall Skin Sweep, 1/29/25 revealed skin assessments were completed for residents who resided on the 300 hall. Record review of a facility list of residents titled, 2/3/25 Skin Sweep revealed skin assessments were completed for residents who resided on the 100 hall. The findings indicated that no new or suspicious skin issues were observed. Record review of an email from the Former Administrator dated 1/31/25 revealed the Former Administrator notified the Long-Term Care Ombudsman of the allegation of abuse. Record review of a Resident Council Minutes dated 2/3/25 revealed the Former Administrator discussed the following topics with the residents in attendance: resident rights, identifying the abuse coordinator (Former Administrator) and how to report problems. Record review of In-Services dated 1/29/25-2/3/25 revealed all staff were educated on abuse and neglect identification and abuse and neglect policies and procedures. Staff completed an abuse quiz after completion of the in-service. It was noted that after completion of the quiz, the answers were reviewed with the group and corrections were made following the discussion. Record review of Resident #1's care plan (updated) revealed it was updated on 3/13/25 to reflect that she was physically aggressive toward staff related to poor impulse control and agitation. Interventions included analyzing circumstances, triggers of behavior, assess and address for contributing sensory deficits, assess and anticipate resident's needs, 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, give the resident as many choices as possible about care and activities, when the resident becomes agitated, intervene before agitation escalates, guide away from source of distress, engage calmly in conversation, and if response is aggressive, staff were to walk away calmly and approach later. Record review of the Provider Investigation Report dated 4/28/25 revealed the allegation of resident-to-resident abuse between Resident #2 and Resident #1 was confirmed. Resident #1 was assessed after the incident on 4/21/25 at 6:30pm by LVN E. The police were notified. Record review of an attachment to the Provider Investigation Report that included a detailed summary of the facility's response (undated) revealed Resident #2 was placed on 1:1 supervision pending a psychology evaluation. The physician ordered labs that indicated Resident #2 had elevated ammonia levels, which could have contributed to Resident #2's behaviors. The psychologist cleared the resident to remove 1;1 supervision. Record review of Behavioral Health Progress Note dated 4/22/25 revealed Resident #1 was assessed by a nurse practitioner. The nurse practitioner noted she was not in distress and did not sustain any injuries. Record review of Inservice Attendance Records dated 4/22/25 revealed staff were educated regarding caring for residents with aggressive behaviors, resident rights and abuse, neglect and exploitation. Record review of Resident #2's care plan revealed it was revised on 4/22/25 to include additional interventions for aggressive behaviors, including administer medications as ordered, analyze times of day, place and circumstances to determine what de-escalates behavior, assess and anticipate resident needs, provide physical and verbal cues to alleviate anxiety, give positive feedback, give the resident as many choices as possible, place resident on one-to-one monitoring following aggressive behaviors until resident can be assessed by the physician. Observations between 5/13/25 and 5/15/25 revealed interactions between residents were pleasant, with no signs of abuse. Interviews with facility staff between 5/13/25 and 5/15/25, including CNA B, LVN A, LVN B, Unit Manager A, LVN C, LVN E, CNA K, CNA E, CNA S, CNA T and CNA L revealed they were aware of the types of abuse and what to do if they were aware of abuse in the facility. They reported how they would monitor and care for residents with behaviors that may lead to abusive actions. Interviews with facility staff on 5/29/25, including LVN S, Social Worker, CNA B, CNA R, LVN I and CNA O revealed they could state how to intervene when Resident #1 had behaviors that was consistent with her care plan. Observations between 5/13/25 and 5/15/25 revealed interactions between staff and residents were pleasant, with no signs of abuse. Interviews with 15 residents between 5/13/25 and 5/15/25 revealed no reports of abuse. Record review of the facility's Abuse, Neglect and Exploitation policy revised on 1/8/2023 read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing writing policies and procedures that prohibit and prevent abuse, neglect .'physical abuse' includes, but is not limited to hitting, slapping, punching, biting and kicking . The facility administrator is the Abuse Prevention Coordinator in the facility and is responsible for reporting allegations or suspected abuse, neglect or exploitation to the state survey agency and other officials in accordance with state law .the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves . identifying, correcting and intervening in situations in which abuse, neglect, exploitation and/or misappropriation of resident property is more likely to occur with the deployment of training and qualified, registered, licensed and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for six of 9 residents (Resident #31, #66, #90, #37, #72 and #11) reviewed for pressure sores. -The facility failed to ensure Resident #31 received wound care treatment for 38 days, did not evaluate, and obtain orders for wound care upon admission when the resident was noted to have an open wound to the buttocks. The right heel had a pressure ulcer that was not identified for further preventative treatment by the discharging hospital, and deteriated after admission - this wound was unavoidable per Wound Care MD. -The facility failed to ensure Residents #66's re-opened sacrum ulcer, #90's stage 4 ulcer to the foot, #37's stage 3 (full thickness tissue loss, open area) sacrum ulcer, #72's DTI (pressure ulcer as a [NAME] area with intack skin) to the left heel, and #11's DTI to the left heel were assessed, monitored, and treated. An Immediate Jeopardy (IJ) situation was identified on 03/01/2024 at 3:00 PM. While the IJ was removed on 03/06/2024 at 3:25 PM, the facility remained out of compliance at a scope of pattern with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for a delay in treatment, pain, a decline in health, hospitalization or a significant decline in health. Findings include: Resident #31 Record review of Resident #31's face sheet, dated 2/29/2024, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included diabetes mellitus (condition results from insufficient production of insulin, causing high blood sugar), hypertension (elevated blood pressure), malnutrition (condition that results from lack of sufficient nutrients in the body), dementia (group of symptoms that affects memory, thinking and interferes with daily life), thyroid disease (a medical condition that keeps the thyroid from making the right amount of hormones), need for assistance with personal care, sepsis (infection of the blood stream), obesity (condition characterized by abnormal or excessive fat accumulation) due to excess calories, Alzheimer's Disease (type of brain disorder that causes problems with memory, thinking and behavior), chronic kidney disease stage 3 (condition characterized by a gradual loss of kidney function) and osteoarthritis (long term degenerative joint condition). Record review of Resident #31's admission MDS, dated [DATE], with an ARD of 1/24/2024, reflected a BIMS score of 5, which indicated significant cognitive impairment. She had no impairment of either her upper or lower extremities, and she used a wheelchair for mobility. Resident #31 required assistance or was totally dependent on staff for all ADL's except eating. She was always incontinent of bowel and bladder. Section M of the MDS revealed she had no pressure injuries but was at risk of developing pressure injuries. She utilized a pressure reducing device for her bed and received application of ointments and/or medications other than to feet. Resident #31 was administered anticoagulant, antiplatelet, and hypoglycemic medications during the assessment period. She received OT, PT and ST services. Record review of Resident #31's care plan, dated 1/29/2024, reflected a focus on her ADL self-care deficit with interventions which included OT, PT, and ST services as ordered, use of task segmentation, assistance with PODUS boots to both lower extremities, and assistance with all ADL's except eating. The note related to the PODUS (soft boot to relieve heel pressure) boots to BLE as tolerated for elevating the heels, was added on 2/29/2024. A focus on her incontinence with interventions which included assisting with dressing and hygiene during the toileting process, frequent checking for incontinence care and perineal care, use of a barrier cream and weekly skin check with showers and PRN. The resident was at risk for skin breakdown r/t decreased mobility, incontinent care and diabetes. The interventions included assist with turning and repositioning during rounds as needed and notify MD for ulcers that are deteriorating as needed. A focus on Resident #31's unstageable pressure injury (severe damage of the heel) of the right heel with interventions which included a dietary consultation, monitoring for signs of infection, use of a nutritional supplement, treatment and wound care per physician's orders, and turning and repositioning every two hours. The focus on Resident #31's heel injury was dated 2/28/2024. A focus on her type 2 diabetes mellitus with interventions which included medication administration and monitoring for skin changes. Focus: The resident was at risk for pain and discomfort r/t generalized discomfort, diabetes and osteoarthritis. The interventions included administer pain medication as ordered. The focus did not include pain associated with pressure ulcers. Focus: The resident was diabetic and at risk for pressure/venous/stasis ulcers. The interventions included monitor skin for changes-redness, circulatory problems, breakdown and report to MD/RP. Focus: the resident had impaired immunity r/t recent osteomyelitis, history of COVID-19, sepsis and flu. The interventions included the resident was at risk for infection and keep environment clean. Further review of the care plan did not include resident refusal of care or refusal of repositioning. Record review of Resident #31 2023 TAR revealed an order for weekly skin assessments every Saturday day shift. The skin assessments were completed on 2/3/2024, 2/10/2024, 2/17/2024, and 2/24/2024. Resident #31 received an order related to an unstageable DTI of the right heel, and the heel was to be cleansed with normal saline, patted dry, have betadine applied, and covered with an antibacterial pad and Kerlix gauze roll. The order was written on 2/26/2024 An order for Resident #31 had an unstageable DTI of the right heel to be cleansed with saline, patted dry, betadine applied, and covered with an antibacterial pad and a Kerlix gauze roll written on 2/29/2024. Record review of resident #31's nurses notes dated 1/17/2024 at 7:23 PM, written by LVN EE, reflected the resident had an open wound to the right buttocks region, the size pencil eraser and an opening to the right heel. The note read in part .MD was notified with orders verified. Record review of Resident #31's baseline care plan, dated 01/18/2024, indicated the resident had no wounds. Record review of Resident #31's skin observation tool, dated 1/25/2024, written by LVN C, indicated the skin was intact and no new issues noted. Record review of Resident #31's skin observation tool, dated 2/14/2024, written by LVN HH, indicated there were no new skin issues noted. Record review of Resident #31's skin observation tool, dated 2/21/2024, written by LVN HH, indicated the skin was intact and no new skin issues were noted. Record review of Resident #31's skin observation tool, dated 2/26/2024, written by the TN indicated the right heel had unstageable DTI measuring 8cm x 7cm and the RP and MD were aware of the current treatment plan. Record review of Resident #31's notes revealed a clinically unavoidable skin condition pressure ulcer to the right heel, dated 2/28/2024, and signed by TN, and the physician. Record review of Resident #31's active physician's orders report, dated 2/29/2024, reflected an order, dated 2/26/2024, related to an unstageable DTI of the right heel. The order called for the wound base to be cleansed with normal saline, patted dry, betadine applied, and covered with an antibacterial pad and Kerlix gauze roll. Record review of Resident #31's active physician's orders report, dated 2/29/2024, reflected an order, dated 2/29/2024, related to an unstageable DTI of the left heel. The order called for the wound base to be cleansed with normal saline, patted dry, betadine applied, and covered with an antibacterial pad and Kerlix gauze roll Record review of Resident #31's initial wound evaluation and management summary reflected the resident was seen by the WCD on 3/1/2024. The resident had arterial wounds of the right and left heel. Interview on 2/28/2024 at 9:10 AM, the TN said she was first notified of Resident #31's right heel wound on 2/26/2024 and that was when wound care treatment began. During wound care observation and interview on 2/29/2024 at 11:00 AM, Resident #31 had soft boots to both feet and both feet were propped with pillows. The TN removed the boots. The right heel had a dressing wrapped with gauze. The TN removed the dressing. The heel had thick, dark, black, dry scab, approximately 2-3 inches in length covering the entire right heel. When the betadine-soaked dressing was removed there was a foul odor. There was no drainage noted. The surrounding skin was pink with large patches of dry flaky skin. The TN completed wound care to the right heel. The resident winced during wound care. The TN re-applied the soft boots and did not inspect the left heel until the State Surveyor questioned the discoloration to the outer edge of the left heel. The left heel had thick dry flaky skin and large dark purple areas. The skin to the left heel was intact. Resident #31 said she did not like to be turned d/t fear of falling and the staff would turn her slightly as much as she could tolerate then she stayed in the same position on her back most of the time. The TN said the left heel was clear on 2/26/24 and on 2/28/24. The TN stated Resident #31 was up in the wheelchair yesterday (2/28/2024) which could contribute to the discoloration. The TN said the pressure ulcer would have happened d/t not repositioning and offloading the feet. The TN said she would notify the MD to get a doppler study (non-invasive test to measure blood flow). The TN said the wound could develop rapidly for diabetic residents' d/t poor blood flow. Observation on 3/4/2024 at 10:57 AM revealed Resident #31 was admitted to a local hospital and was receiving care. Interview on 2/29/2024 at 12:15 PM, LVN HH said she only recently learned of Resident #31's wounds and when she did the skin assessment on 2/21/2024 there were no skin wounds. LVN HH assumed the wounds to Resident #31 were not new and the treatment nurse was taking care of it. Attempted interview on 2/29/2024 at 12:35 PM with Resident #31's RP was unsuccessful. No call back was received by the end of the Survey. Interview on 03/01/2024 at 9:53 AM, CNA L said she was aware Resident #31 would be receiving wound care on 2/29/2024 so she left her in bed and the resident had skin irritation to the buttocks d/t runny stools. CNA L said she applied skin barrier to the redness on the buttocks but there were no open wounds. CNA L said she rounded on Resident #31 by 10:30 AM on 2/29/24 and the resident was sitting up in bed on her bottom, she then changed her brief and left her sitting up in bed with a wedge under the left arm. CNA said after lunch she changed her brief and sat her back up on her bottom in bed. CNA L said the reason for repositioning was to prevent bedsores and stiffness would be a risk to the resident. CNA L said the resident refused repositioning off her back. Interview on 03/01/2024 at 12:35 PM, the WCD said this was the first time he had been to the facility to see any of the residents. The WCD said eschar (a collection of dry, dead tissue within a wound, commonly seen with pressure ulcers) could develop in 24 hours depending on the resident's status. The WCD said it first began as an open wound, then drainage occurred, then slough (yellow tissue) and scarred over just like a regular cut would scab over. The WCD said Resident #31's whole foot was in jeopardy and it might be an arterial injury d/t her pain and was more of a circulatory type of wound. The WCD said failure to reposition the resident may not have contributed to the wound development. The WCD said she may need to go to the ER and he would be speaking with the NP. The WCD said it would be hard to say how fast the wound could get worse and once an arterial wound clotted it could be rapid. The WCD said the left foot was also in jeopardy. Interview on 03/01/24 at 2:30 PM, LVN C said he may have assessed Resident #31's skin when she first admitted but could not recall what the skin looked like. LVN C said he worked regularly on the 100 Hall and Resident #31 lived in the 200 Hall. LVN C said when he performed skin assessments, he would first ask the CNAs on shower days if a resident had any changes to the skin. He said he would follow up after the shower and conduct a head-to-toe assessment. He said he looked at the back of the head, back of the body, stomach, under female breasts, groin, legs, checked toes and heels. LVN C said it was important to catch skin changes early, unfortunately changes could be missed and when that happened the facility would be proactive and address appropriately. LVN C said it was good to have extra eyes on any changes and communication was important. In a telephone interview on 03/05/24 at 1:00 PM, LVN EE saidshe was the admitting nurse and did not notify the MD of Resident #31's open wound to the buttocks and open wound to the right heel. LVN EE said normally she would make a note of it and report to Tx nurse, but it was on the 24-hour report. LVN EE said she thought the wound care nurse would see the 24-hour report and would follow up with all new Admissions and their wounds. LVN EE said she communicated the report to the oncoming shift but could not remember who the report was given to. LVN EE said she probably should have verified her observations of the wounds with another nurse d/t she cannot stage wounds. Interview on 3/4/2024 at 11:09 AM the Hospital RN P said Resident #31 was admitted to the hospital for a pressure injury of the right heel skin. Hospital RN P stated Resident #31 received wound care, had blood labs drawn, was receiving electrolyte replacement therapy and the nephrology department was consulted d/t the resident's low potassium levels. Hospital RN P said the podiatry department reported the resident would need surgical care of the pressure wound. Hospital RN P said the pressure wound to the right heel was unstageable as it was covered with necrotic (dead) tissue. Hospital RN P said Resident #31 had a small sacral pressure wound as well. Hospital RN P said the heel wound could have occurred quickly if it was due to arterial injury, but in her opinion the injury was likely present for between one and two months if there was no arterial injury. Hospital RN P said Resident #31's heel wound did not have any infection which would lead to an amputation, but lab results were still pending. Hospital RN P said if the labs indicated a serious infection it could lead to an amputation of the foot. Interview on 03/05/2024 at 1:23 PM, the TN said the 24-hour report was not too familiar with it and was not something she reviewed daily. The TN said new admits were discussed with her during daily nurse meetings and when stop and watch tools (an early warning communication tool) were used for change in condition. The TN said if she was in the building, she would do the skin assessments for the new admits and if the skin assessments were already completed, she would trust the nurse would tell her if there were any areas of concern. The TN ssaid during evening admits the charge nurse would do the skin assessments. The TN said on 2/26/2024 the Agency Nurse notified her of Resident #31's right heel, she did not remember the name of the nurse. The TN stated the resident's left heel was pink and soft and she conducted a focused assessment on the heels only. The TN said no one notified her of any skin issues to the sacral or buttocks. The TN stated, had she been notified upon Resident #31's admission of the skin issues to the right heel she would have assessed it, notified the MD and RP then put a treatment plan in place. The TN said if there were skin issues the nursing staff should have made her aware. The TN said ultimately, she was responsible to address the wounds. Interview on 03/05/2024 at 3:00 PM, the DON said she was not the DON when Resident #31 was admitted on [DATE] and therefore was not aware of the wounds if they were on the 24-hour report. The DON said the 24-hour report would be reviewed during morning meetings and admissions, readmissions and discharges would be reviewed. The DON said she began as acting DON on 01/18/2024 and was in and out of the building periodically. The DON said when a wound was identified she expected the nurse would call the doctor, document, notify the treatment nurse and the RP. The DON expected it would be written on the 24-hour report and reviewed by the treatment nurse. The DON said she probably did attend the morning meeting but did not recall hearing about Resident #31's wounds. The DON said the expectation would be to address the wounds at the time of the meeting and if the nurse was unsure of the presentation of the skin that another nurse would be consulted. Interview on 03/06/2024 at 11:10 AM, the MD said she was notified of Resident #31's wounds to the heels by TN on 2/26/2024 and not before that date. Record review of Resident #31's hospital clinical records reflected she was admitted on [DATE] and the chief complaint was for wound check at the request of the physician for concern about venous ulcers to bilateral heels. The clinical records included pressure injury limited to skin breakdown on the left lower buttocks and on the right lower buttocks and based on clinical presentation Resident #31 was at risk for PAD (peripheral artery disease), pressure wounds, osteomyelitis (infection of the bone,) and nutritional deficits. The clinical records read in part: .External Record Review .inpatient record from another hospital admission on [DATE]. It appears the patient was discharged with pressure wound to right heel. It appears this has worsened and become bilateral since discharge to rehabilitation facility . The Emergency Department Clinical Summary indicated the final diagnoses was: pressure injury of skin of right heel, pressure injury of skin of left heel, skin ulcer of buttock. The pressure injury to the dorsal right of the foot was purple, with moderate serous drainage, blistered and the patient stated both of my feet are bothering me the patient was complaining of pain to both feet and there was blood filled blister present on the left heel. Resident #66 Record review of Resident #66's face sheet, dated 02/28/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included dementia (a group of symptoms that affect memory, thinking and interferes with daily life), Chronic Obstructive Pulmonary Disease (persistent respiratory symptoms such as breathlessness and cough), bipolar disorder (a mental condition, with extreme mood swings), osteochondropathies of the left ankle and foot (disease of the bone and cartilage), HTN (elevated blood pressures), osteoarthritis, depression, cachexia (unintentional weight loss) and contractures to both hands. Record review of Resident #66's annual MDS, dated [DATE], reflected a BIMS score of 14 out of 15, which indicated intact cognition. She was dependent on staff for toileting, bathing, lower body dressing. She required substantial assistance with upper body dressing and personal hygiene. She required partial assistance from staff when rolling side to side in bed, sitting to lying and lying to sitting on side of bed. She required substantial assistance from staff when sitting to standing and transfers. She was always incontinent of bowel and bladder. She had progressive neurologic conditions. She was at risk of pressure ulcers/injuries and had no unhealed pressure ulcers/injuries. She required pressure reducing device for the bed and applications of ointments/medications other than to feet. She was administered high-risk drug classes: antipsychotic, antidepressant and anticoagulant during the assessment period. She was receiving physical therapy. Record review of Resident #66's, undated, care plan reflected: Focus - Resident #66 had ADL self-care performance deficit, dated 02/21/2024. Interventions included: the resident was bedfast all or most of the time; the resident required skin inspections, observe for redness, open areas, cuts, bruises and report changes to the Nurse, dated 12/08/2022. Focus - Resident #66 was resistive to care, revision date 2/15/2024. Interventions included: if resident resists, leave and return 5-10 minutes later and try again, dated initiated 07/06/2023. Focus - Resident #66 at risk for skin breakdown d/t decreased mobility, incontinence and malnutrition. Interventions included: assist resident with turning and repositioning during rounds and as needed. Weekly skin assessment, notify MD for ulcers that were deteriorating as needed. Focus - Resident #66 had skin impairment (damage/pressure ulcers) and at risk for further skin breakdown, date initiated 03/01/2024 (after Survey entrance). Interventions included: assess skin and record findings in clinical records, notify MD and RP, perform treatments per order, notify MD/RP if no improvement. Record review of Resident #66's active orders, as of 2/28/2024, reflected an order for weekly skin assessment, complete head to toe. Start date 6/30/2023. An order for Zinc Oxide, external paste 25%, apply to sacrum topically every shift for redness. Start date 06/23/2023. Record review of Resident #66's skin assessment, dated 2/29/2024, by TN, reflected an open pink area to the sacrum and white on the inside, wound measurements were 0.7cm x 0.4cm x 0.1cm. The resident was complaining of pain, denied having anything for pain, repositioned on her side for offloading. Record review of Resident #66's active physician orders, as of 03/01/2024, reflected an order, dated 2/29/2024, to cleanse the sacrum wound bed with NS, pat dry and apply alginate calcium and cover with foam dressing. Record review of Resident #66's weekly skin assessments, dated 12/29/23, reflected the previous wound to sacrum was healed and skin barrier cream was applied. Skin assessment, dated 1/5/24, 1/12/24, 1/19/24, 1/26/24, 2/2/24, reflected intact skin. Skin assessment, dated 2/14/24, reflected healed sacrum wound. Skin assessment, dated 2/21/24, reflected redness to sacrum was present. Skin assessment, dated 2/23/24, noted redness to the sacrum and treatment was in place. Observation and interview on 2/27/2024 at 10:05 AM revealed Resident #66 was in bed lying on her back with the HOB elevated. She stated she preferred to stay in her room. Observation on 2/28/2024 at 3:15 PM revealed Resident #66 was in bed lying on her back with the HOB elevated. Observation and interview on 2/28/2024 at 3:30 PM revealed Resident #66 was in bed sitting up with the HOB elevated. She stated she did not want to get up today. Observation on 2/28/2024 at 4:04 PM revealed Resident #66 was lying in bed on her back. Observation on 03/01/2024 at 8:42 AM revealed Resident #66 was lying on her right side propped with a pillow with the HOB slightly elevated. Observation and interview on 2/29/2024 at 1:45 PM during skin assessment rounds with the TN revealed Resident #66 was lying in bed on her back with the HOB elevated, there were no pillows under her back. Resident #66 had a small open area on the sacrum. There was no redness or drainage noted. The TN cleansed the area and applied Alginate and a dry dressing. Resident #66 stated she was not turned throughout the day then she said sometimes they did turn her onto her sides. The TN stated this was the first time she saw the sacral wound and it was open. The TN stated it was time to in-service the CNAs on reporting skin changes. The TN stated the nursing staff should have reported this to her. The TN left the room, returned, and stated she spoke with CNA L. The TN stated CNA L told her she was aware of the sacral wound and did not report it to TN d/t she was putting zinc ointment on it. Interview on 2/29/2024 at 2:20 PM, CNA L said Resident #66 had the spot on her bottom for a while, since last week maybe. CNA L saidshe would apply cream from the zinc packets to the area. When asked who gave her the zinc packets and whether she applied it to the open wound, CNA L stated she put it on the open wound to heal the wound. When asked why she did not report the wound to the nurse, she stated the resident would tell her to just put the cream on it. Interview on 2/29/2024 at 4:07 PM, the DON said Resident #66 would refuse to turn. When asked why a CNA would apply cream onto an open wound, the DON stated that was the best they knew, and they were instructed to check for redness and to use skin barrier cream. The DON said she did not know why CNA L did not notify the nurse. The DON said if the cream was not appropriate for the wound, then it would not heal or help the open area depending on the state and nature of the resident. The DON said CNAs were responsible to notify the charge nurse as soon as possible when they noticed skin changes and the opportunities for CNAs to assess skin were: during peri care, bathing or showering three times per week and during dressing and undressing the residents. The DON said the skin changes could be communicated by verbal means or the use of stop and watch forms. The DON expected the CNAs to report open areas and obvious changes that may not have been on the resident the day before. The DON said skin changes should be reported because they could get bad or worse and open wounds could get infected, deeper or worse. She said the charge nurse, unit manager and treatment nurses continued to communicate well and she conducted staff in-services regarding notifying the treatment nurse no matter what the issue may be. The DON said she did not know why there was a wound to Resident #66's toe and did not know if the CNA would have recognized it as an issue to report. The DON said the admitting nurse was responsible for the skin assessments upon admit and the next day the treatment nurse would be responsible as well. The DON said she expected the nurse conducting the skin assessment to make sure it was complete and some nurses were not so good with making immediate decisions. She said the skin assessment should be a head-to-toe evaluation and more detailed if needed to better identify any skin issues. She said the unit managers and ADON were responsible to ensure the skin assessments were complete and accurate. The DON said skin issues would be communicated during morning meetings or during one-on-one nurse reporting. The DON said if skin issues were identified a day before then it would be brought to the IDT meetings for discussion, the MD and wound care physician would be notified. She said it would also be discussed during care plan meetings, QAPI meetings along with weekly weight meetings. The DON said she would want to make sure the facility had what was needed to heal the skin issues. Interview on 03/01/2024 at 8:59 AM, LVN S said she expected CNAs to reposition residents every 2 hours to prevent sores and to apply barrier cream during incontinent care. LVN S said it was the CNAs and nurses responsibility to do skin assessments and CNAs had the opportunity to see skin during showers/baths and brief changes. LVN S said she expects the CNAs to notify the nurse of any skin changes. Interview on 3/01/2024 at 9:53AM, CNA L said Resident #66 stays in bed by her choice, and sometimes she would scream. CNA L said she changed the resident's position about 3 times during her shift and said she did this for Resident #66 yesterday (2/29/2024). CNA L said she left Resident #66 sitting up in bed at the resident's request. CNA L said when the red spot on Resident #66's sacrum started to look open about one week ago, she reported it to evening CNA F. CNA L said she thought CNA F reported it to the nurse, but she did not. CNA L said she now realized she reported it to the wrong person. Observation and interview on 03/01/2024 at 11:44 AM, with the TN and the WCD, revealed Resident #66 had a PU to her coccyx. There was a lot of redness surrounding the open area, but there was only a small open area. Per the WCD, it was a stage 3 PU (full thickness, open wound) to her coccyx that was 1cm x0.5cm x0.1cm and due to it having some drainage he was going to treat it with collagen and alginate. He said she had a PU there before and it re-opened. Interview on 03/01/2024 at 12:35 PM, the WCD said the zinc cream would not have damaged Resident #66's wound but it would not have helped it either. The WCD said not repositioning and not turning the resident could cause pressure ulcers to the sacrum. Interview on 03/03/2024 at 9:38 AM, LVN U saidshe started orientation on 2/27/2024 and was assigned to residents which included Resident #66. LVN U said she was still getting familiar with the residents and did not know all the details about Resident #66's wound. LVN U said the areas on the body that were more susceptible to pressure injures included the heels and buttocks. LVN U said residents who were at higher risk of developing pressure injuries were residents who were immobile and any time a resident had a history of wounds. LVN U said closed wounds could be treated and if not identified then the risk to the residents would be worsening of wounds. LVN U said, in general, wound prevention would include off loading and repositioning. LVN U said all nursing staff were responsible to help prevent pressure injuries. LVN U said she received in-services which included wound care, repositioning, reporting and neglect on 03/02/2024 and in-services were ongoing for her since 2/27/2024. LVN U said she was responsible to ensure the aides repositioned the residents and notified the nurses about any changes to the resident. LVN U said the aides could use barrier creams and the nurses were responsible to administer treatments as ordered by the physician. LVN U said communication took place typically during morning clinicals, reports and walking rounds with the night nurse. Interview on 03/03/2024 at 11:45 AM, CNA V said Resident #66 did not have skin issues or wounds weeks ago. CNA V said the CNAs were responsible to report skin changes to the nurse as they were the ones who would see the skin especially during bathing. CNA V said some people just had different work ethics and all aides went to the same CNA school. CNA V said some aides just didn't do what they were supposed to do. Interview on 03/03/2024 at 10:20 AM, CNA W, was assigned to Resident #66 and stated the resident had a dressing over the sacrum today. CNA W said not reporting wounds to the nurse or the treatment nurse was probably d/t nursing not paying attention. CNA W said wounds could occur from not turning, or repositioning, from not getting up out of bed or not using pillows for propping. Interview on 03/03/2024 at 2:42 PM, CNA F said she did work with Resident #66 sometime last week but did not remember the exact date. CNA F stated Resident #66 had the red area to the sacrum from the time she was first admitted . CNA F said sometime during the week of 2/19/2024 to 2/23/2024, she noticed a small area on the sacrum that was not too open and reported it to an Agency Nurse. CNA F said she did not remember the Agency Nurse's name. CNA F said she recalled talking to CNA L about different things but could not recall if they discussed the sacral wound. Resident #90 Record review of Resident #90's face sheet, dated 02/28/2024, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included urinary tract infection, dementia (group of symptoms that affects memory, thinking and interferes with daily life) diabetes (a long-lasting health condition that affects how your body turns food into energy), osteoarthritis (a type of joint disease), resistance to beta lactam antibiotics (infection becoming less affected by a group of commonly pres[TRUNCATED]