**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure one (1) of two (2) residents reivewed for pressure ulcers were not neglected. Resident #1 entered the facility without a pressure ulcer. He was discharged to another facility (nursing home). An assessment completed within 40 minutes after his discharge from the facility revealed a deep foul smelling wound to the coccyx. Resident #1 sustained actual harm. Resident identifier: #1. Facility Census: 118 Findings Include: a) Resident #1 Resident #1 was admitted to the facility on [DATE] from a critical illness recovery hospital. He had been at that facility from 01/22/25 - 02/18/25. He had previously been at another acute care hospital from [DATE] - 01/22/25. He was sent to the acute care hospital on [DATE] after his percutaneous endoscopic gastrostomy tube malfunctioned. While hospitalized he had two (2) surgeries and left the hospital on [DATE] with a surgical wound to the left and right abdomen. Due to postoperative complications a wound vac was placed for healing purposes. Upon admission to Facility #1, there was an admission progress note, and skin check performed. Documentation shows the resident arrived on 02/18/25 at 10:30 PM. Observation of the skin assessment was documented as (absent of any related wounds to coccyx). New skin Issue. Location: Left Lower Quadrant Midline. Issue type: Surgical wound. Wound was present on admission. Length (cm): 3.5 Width (cm): 0.6 Depth (cm): 0.1#002: New skin Issue. Location: Right Lower Quadrant Midline. Issue type: Surgical wound. Wound was present on admission. Length (cm): 9.8 Width (cm): 4.8 Depth (cm): 0.2#003: New skin Issue. Location: Left heel. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Unstagable pressure injuries presenting as deep tissue injury. Wound was present on admission. Length (cm): 5.6 Width (cm): 4.4 Depth (cm): 0#004: New skin Issue. Location: Right heel. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Unstagable pressure injuries presenting as deep tissue injury. Wound was present on admission. Length (cm): 1.9 Width (cm): 1.3 Depth (cm): 0 Additional skin checks were performed weekly on 02/25/25, 03/05/25, 03/12/25, 03/19/25, 03/26/25, 04/02/25 and 04/09/25. Random dated copies were provided for review for the following dates: 02/18/25 (admission), 02/26/25, 03/19/25, 04/02/25, 04/09/25. (absent of any related wounds to coccyx). In addition, the facility provided the latest skin and wound evaluations. 04/02/25 documented surgical wound to left lower quadrant abdomen 04/02/25 documented surgical wound to right lower quadrant abdomen 04/02/25 documented surgical wound, dehiscence to right lower quadrant abdomen 04/02/25 documented pressure deep tissue injury to left heel 04/02/25 documented pressure deep tissue injury to left heel On 05/12/25 Residents #1s medical records were reviewed. A Braden scale for predicting pressure risk was completed on the following days resulting in the following scores: 02/29/25 - 10 which indicated the resident was at a high risk of developing pressure ulcers. 02/25/25 - 10 which indicated the resident was at a high risk of developing pressure ulcers 03/05/25 - 11 which indicated the resident was at a high risk of developing pressure ulcers 03/12/25 -11 which indicated the resident was at a high risk of developing pressure ulcers Resident #1's care plan was reviewed and showed a focus area for the resident being at risk for skin breakdown due to decreased activity, frail fragile skin, impaired condition, incontinence, limited mobility, recent surgery and pressure areas to the left and right heel, a surgical site to the left and right lower abdomen. The goal associated with this focus area was for the pressure areas and surgical sites to heal upon review and for the resident's wound/skin impairment to heal as evidenced by a decrease in size, absence of erythema and drainage and/or pressure ulcer: Interventions related to his goal included: - Enhanced Barrier Precautions - Heels up device while in bed as resident will allow - Low air loss mattress to bed, weekly hand checks to monitor settings - Negative pressure wound therapy to right lower ABD per orders - pro mattress to bed - Pad side rails/wheelchair or other equipment as necessary - Pat (do not rub) skin when drying - Provide patient and/healthcare decision maker education regarding risk factors and interventions - Provide preventative skin care i.e. lotions, barrier creams as ordered. - Observe skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanch easily. - Evaluate for any localized skin problems, i.e. dryness, redness, pustules, inflammation. - Observe skin condition daily with ADL care and report abnormalities. - Observe for verbal and nonverbal signs of pain related to wound or wound treatment and medication as ordered. - Obtain dietitian consult as needed/ordered - Obtain skilled PT/OT evaluation to improve functional mobility. - Provide wound treatment as ordered - Provide supplements as ordered. - Weekly skin check by license nurse - Weekly wound assessment to include measurements and description of wound status. The care plan also indicated the following related to Activities of Daily Living (ADL) assistance required by Resident #1. Resident requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, - dressing, eating, bed mobility, transfer, locomotion, toileting related to hx (history) of Cerebrovascular Accident (CVA) VA with paraplegia affecting both sides. Resident is incontinent of bladder and bowel and is unable to cognitively and physically participate in a retaining program due to total lift status, neurocognitive disorder. During an interview on 05/13/25 with the Director of Nursing, she stated Nurse Aides do not document each time they turn the residents, they only document if they turn the resident during that shift. Medical Record documentation on the following days showed the resident was not turned for each of the three (3) shifts. 03/11/25, 03/16/25, 03/18/25, 03/25/25, 03/30/25, 04/08/25. When asked why all three shifts were not documented, she could not provide an answer. A review of the physician's orders for Resident #1 from the time of admission until the time discharged found no orders related to pressure ulcer treatment and/or prevention for his coccyx. A review of Resident #1s discharge progress note completed by Licensed Practical Nurse #8 states a skin check was completed, however there is no skin check or skin, and wound evaluations documented for 04/10/25 (discharge date ). There was no written discharge skin and wound evaluation documentation noted. Treatment Administration Records (TAR) for February, March and April 2025 found no wound treatments were missing. (absent of any related wounds to coccyx) On 05/12/25 at 1 PM during an interview with Licensed Practical Nurse (LPN) #6 she states she does 99% of all wound care. She said she was responsible for weekly skin checks and skin and wound evaluations. LPN #6 said if there is a new wound identified by an LPN or Nurse Aid, she also assessed that wound if she was in the facility. If not, the LPN assesses it, and LPN #6 follows up when LPN #6 returned. When asked to identify wounds that Resident #1 had upon discharge, she stated He had two abdominal surgical wounds, one on each side, bilateral DTI's (deep tissue injuries) to his heels. She denied any knowledge of a wound to his coccyx. When asked if there was ever a time when a dressing would be in place without a physicians order, she stated no. On 05/13/25 at 12:55 PM during a telephone interview with the Medical Director for the facility, he said he did not perform skin checks on residents. He said he depended on documentation from the staff. On 05/12/25 at 4:20 PM the surveyor went to the facility where the resident was discharged to. LPN #3 took report from the facility on 04/10/25. She stated the report consisted of when his last bowel movement was, his vital signs, his tube feeding details. She states the only report obtained concerning skin status, was that there were no new issues. LPN #4 was the nurse on duty on 04/10/25 at 5:45 PM when the resident arrived at the facility. She stated Resident #1 arrived at 5:45 PM via stretcher by ambulance. She stated she performed a body audit at 6:00 PM and documented it at that time on paper. She described the wound on the coccyx as deep, maybe bone exposed, foul odor, dressing in tack dated 4/10/25, there were initials on the dressing, but she did not remember what they were. Once she removed the dressing, which was a Mepilex, was removed, there was a blue foam dressing in place, it was not packed in the wound, only laid across it. LPN #4 said, Our facility calls it hydrofera blue. It smelled terrible. The body audit drawing showed the following: dated 04/10/25 6:00 PM 160.8 weight, vital signs, BP (blood pressure) 106/74 P (pulse) 76, T (temperature) 97.7, R (respirations) 20, 02 Sat 99% on 2 liters of oxygen. Front view: Head: dry, flaky skin. Feet: dry, flaky skin. Right arm: scab. Bilateral lower extremities: dry, flaky skin. Right abdominal wound, left abdominal healing scar. lower left abdomen: feeding tube. Rear view: Back: redness. Bilateral heels: redness. Wound on coccyx. Note on the back of the body audit stated: Resident has dry skin on his head and face. Small scab on right upper arm. Large abdominal wound middle of upper abdomen cover by Allevyn. Healing scar on the left side of mid abdomen. Feeding tube site on left lower abdomen. Bilateral lower legs and feet are dry and flaky. Redness on middle of back towards right side. Wound on coccyx covered with a dressing. Both heels are red. LPN #4 also documented an electronical assessment once the resident was admitted , comfortable in bed and time allowed. The electronic documentation on 04/10/25 at 8:40 PM identifies vital signs as noted above. Integumentary assessment: Deficits noted: Color: normal flesh tone appropriate to complexion Moisture: Dry Temperature: Warm Turgor: Fair Skin intact: No Comments: Abdominal wound to middle of abdomen, wound on coccyx, feeding tube on left lower abdomen, redness on heels, dry skin, scab on right arm. On 04/11/25 at 9:40 AM a wound and ulcer assessment was completed and documented by the RN as follows: Wound #1 Wound type: Pressure Ulcer Wound location: Coccyx Dressing present: Yes Dressing intact: yes Dressing changed Yes Incision present: no Sutures/staples present: No Size length 2.5 width 1.5 depth: 05 Has wound be staged by Registered Nurse? Yes Unstagable, necrotic slough/eschar tissues obscure base of ulcer, unable to determine whether ulcer is III or IV. Odor: Yes extensive malodorous purulent smell to wound Drainage: Yes Drainage color: black. Drainage amount: moderate Signs of infection: Hot, reddened Additional comments: black drainage coming from wound tissue and soaking removed dressing, gray necrotic tissues surrounding wound bed with tunneling noted at the left upper side of wound measuring 0.5 cm Are there significant changes in would or signs of infection since last assessment? Yes. Physician notified. Photos taken of the wound: Yes Wound #2 Wound type: surgical wound Wound location: Abdomen Dressing present: Yes Dressing intact: yes Dressing changed: yes Incision present: no Sutures/staples present: no Size: length: 6/9 width 3.3 depth 0 cm Not staged, no odor, no drainage Signs of infection: reddened Additional comments: healing surgical wound to left abdomen with scab formation, no drainage Physician notified Wound #3 Wound type: pressure ulcer Wound location: right heel Dressing present: yes Dressing intact: yes Dressing changed: yes Incision present: no Sutures/staples present: no Size length 3 width 3 depth 0 cm No odor, no drainage, Signs of infection: swollen, hot and reddened Physician notified Wound #4 Wound type: pressure ulcer Wound location: left heel Dressing present: yes Dressing intact: yes Dressing changed: yes Incision present: no Sutures/staples present: no Size length 3 width 3 depth 0 cm No odor, no drainage, Signs of infection: reddened Additional comments: 2 small areas of dry flaking skin beginning to peel with new tissue. Physician notified A registered nursing note stated, Resident returned 4/10/25 in late evening, wounds present with dressings intact completed on 4/10/25 at (name of facility) Wounds reviewed today per this Registered Nurse (RN) and Unit Manager for staging. Resident noted to be 100.3 degrees temp., with pain noted to turning and touch of coccyx. Coccyx wound is infected, necrotic, unstagable and requires debridement and support not available in house. No treatment orders or notification received on this wound condition; Wound not included on PASR preadmission screening and resident review). Resident condition reported to Family Nurse Practitioner (FNP) and Medical Director with orders to send to ER for further treatment. Social Services informed of wound findings to coccyx. DON/Administrator informed. Health care surrogate (HCS) informed of findings per RN unit manager and gave preference of (local hospital name) for hospital. According to the discharge summary from the local hospital with admission date of 4/11/25, the resident was admitted with the following admitting diagnosis: Decubitus ulcer State 3 present on admission. Infected with osteomyelitis. Post obstructive pneumonia. Mucus plugging. General surgery and infectious disease was consulted for care. While inpatient a debridement of the wound on his coccyx was complete with discharge orders to pack wound daily with normal saline moistened kerlix gauze. Cover with 4 X 4 and ABD (abdominal pad). Clean wound daily with wound cleanser. Per the surgical team the resident was transferred to another local hospital for a course of intravenous antibiotics. On 4/22/25 the resident was transferred to another skilled nursing facility where he was admitted because of a decubitus ulcer, sacral region, State III. He received a ten (10) day course of Daptomycin in 0.9% sodium chloride 500mg/50 ml piggyback, give 400 mg daily per IV and Piperacillin-Tazobactam 3.375 gram reconstituted solution IV every 6 hours. On 05/12/25 at 2:10 PM the Resident #1's wound was observed by this surveyor accompanied by the floor nurse and unit manager. There was a dressing in place. The wound was clean and dressed. The necrotic tissue had been removed. The RN Unit Manager states he had an appointment on 05/13/25 with the wound center to see if he is a candidate for a wound vacuum to his coccyx. . During an interview on 05/13/25 at 9:00 AM the Administrator, wound nurse and DON, said they were aware of the DON from the facility he was discharged to coming into their facility however they did not accompany her to the resident's room and are unaware if she did a skin assessment. It was their understanding that she was only there to confirm that the wound vac had been removed prior to him being sent to her facility. During this interview the wound nurse was asked for a list of wound care supplies they typically use in their facility, the list consisted of blue classic foam. On 5/13/25 at 9:10 AM the Administrator, wound nurse and DON at Facility #1 were shown the body audit, skin assessment and pictures of Resident #1 upon returning to the facility. The discussion included that the resident left their facility at 5:20 PM and arrived at the other facility at 5:45 PM. They were informed Resident #1 had a dressing to his coccyx dated 4/10/25. They all agreed. When asked how they think the dressing got applied at their facility, they had no explanation. They expressed their shock and concern for Resident #1 but denied knowing anything about the Stage III pressure ulcer to Resident #1's coccyx.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure one (1) of two (2) residents reivewed for pressure ulcers received the apprpirate care to treat a wound to the coccyx. Resident #1 entered the facility without a pressure ulcer to the coccyx . He was discharged to another facility (nursing home). An assessment completed within 40 minutes after his discharge from the facility revealed a deep foul smelling wound to the coccyx. Resident #1 sustained actual harm. Resident identifier: #1. Facility Census: 118 Findings Include: a) Resident #1 Resident #1 was admitted to the facility on [DATE] from a critical illness recovery hospital. He had been at that facility from 01/22/25 - 02/18/25. He had previously been at another acute care hospital from [DATE] - 01/22/25. He was sent to the acute care hospital on [DATE] after his percutaneous endoscopic gastrostomy tube malfunctioned. While hospitalized he had two (2) surgeries and left the hospital on [DATE] with a surgical wound to the left and right abdomen. Due to postoperative complications a wound vac was placed for healing purposes. Upon admission to Facility #1, there was an admission progress note, and skin check performed. Documentation shows the resident arrived on 02/18/25 at 10:30 PM. Observation of the skin assessment was documented as (absent of any related wounds to coccyx). New skin Issue. Location: Left Lower Quadrant Midline. Issue type: Surgical wound. Wound was present on admission. Length (cm): 3.5 Width (cm): 0.6 Depth (cm): 0.1#002: New skin Issue. Location: Right Lower Quadrant Midline. Issue type: Surgical wound. Wound was present on admission. Length (cm): 9.8 Width (cm): 4.8 Depth (cm): 0.2#003: New skin Issue. Location: Left heel. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Unstagable pressure injuries presenting as deep tissue injury. Wound was present on admission. Length (cm): 5.6 Width (cm): 4.4 Depth (cm): 0#004: New skin Issue. Location: Right heel. Issue type: Pressure ulcer / injury. Pressure ulcer staging: Unstagable pressure injuries presenting as deep tissue injury. Wound was present on admission. Length (cm): 1.9 Width (cm): 1.3 Depth (cm): 0 Additional skin checks were performed weekly on 02/25/25, 03/05/25, 03/12/25, 03/19/25, 03/26/25, 04/02/25 and 04/09/25. Random dated copies were provided for review for the following dates: 02/18/25 (admission), 02/26/25, 03/19/25, 04/02/25, 04/09/25. (absent of any related wounds to coccyx). In addition, the facility provided the latest skin and wound evaluations. 04/02/25 documented surgical wound to left lower quadrant abdomen 04/02/25 documented surgical wound to right lower quadrant abdomen 04/02/25 documented surgical wound, dehiscence to right lower quadrant abdomen 04/02/25 documented pressure deep tissue injury to left heel 04/02/25 documented pressure deep tissue injury to left heel On 05/12/25 Residents #1s medical records were reviewed. A Braden scale for predicting pressure risk was completed on the following days resulting in the following scores: 02/29/25 - 10 which indicated the resident was at a high risk of developing pressure ulcers. 02/25/25 - 10 which indicated the resident was at a high risk of developing pressure ulcers 03/05/25 - 11 which indicated the resident was at a high risk of developing pressure ulcers 03/12/25 -11 which indicated the resident was at a high risk of developing pressure ulcers Resident #1's care plan was reviewed and showed a focus area for the resident being at risk for skin breakdown due to decreased activity, frail fragile skin, impaired condition, incontinence, limited mobility, recent surgery and pressure areas to the left and right heel, a surgical site to the left and right lower abdomen. The goal associated with this focus area was for the pressure areas and surgical sites to heal upon review and for the resident's wound/skin impairment to heal as evidenced by a decrease in size, absence of erythema and drainage and/or pressure ulcer: Interventions related to his goal included: - Enhanced Barrier Precautions - Heels up device while in bed as resident will allow - Low air loss mattress to bed, weekly hand checks to monitor settings - Negative pressure wound therapy to right lower ABD per orders - pro mattress to bed - Pad side rails/wheelchair or other equipment as necessary - Pat (do not rub) skin when drying - Provide patient and/healthcare decision maker education regarding risk factors and interventions - Provide preventative skin care i.e. lotions, barrier creams as ordered. - Observe skin for signs/symptoms of skin breakdown i.e. redness, cracking, blistering, decrease sensation, and skin that does not blanch easily. - Evaluate for any localized skin problems, i.e. dryness, redness, pustules, inflammation. - Observe skin condition daily with ADL care and report abnormalities. - Observe for verbal and nonverbal signs of pain related to wound or wound treatment and medication as ordered. - Obtain dietitian consult as needed/ordered - Obtain skilled PT/OT evaluation to improve functional mobility. - Provide wound treatment as ordered - Provide supplements as ordered. - Weekly skin check by license nurse - Weekly wound assessment to include measurements and description of wound status. The care plan also indicated the following related to Activities of Daily Living (ADL) assistance required by Resident #1. Resident requires assistance/is dependent for ADL care in bathing, grooming, personal hygiene, - dressing, eating, bed mobility, transfer, locomotion, toileting related to hx (history) of Cerebrovascular Accident (CVA) VA with paraplegia affecting both sides. Resident is incontinent of bladder and bowel and is unable to cognitively and physically participate in a retaining program due to total lift status, neurocognitive disorder. During an interview on 05/13/25 with the Director of Nursing, she stated Nurse Aides do not document each time they turn the residents, they only document if they turn the resident during that shift. Medical Record documentation on the following days showed the resident was not turned for each of the three (3) shifts. 03/11/25, 03/16/25, 03/18/25, 03/25/25, 03/30/25, 04/08/25. When asked why all three shifts were not documented, she could not provide an answer. A review of the physician's orders for Resident #1 from the time of admission until the time discharged found no orders related to pressure ulcer treatment and/or prevention for his coccyx. A review of Resident #1s discharge progress note completed by Licensed Practical Nurse #8 states a skin check was completed, however there is no skin check or skin, and wound evaluations documented for 04/10/25 (discharge date ). There was no written discharge skin and wound evaluation documentation noted. Treatment Administration Records (TAR) for February, March and April 2025 found no wound treatments were missing. (absent of any related wounds to coccyx) On 05/12/25 at 1 PM during an interview with Licensed Practical Nurse (LPN) #6 she states she does 99% of all wound care. She said she was responsible for weekly skin checks and skin and wound evaluations. LPN #6 said if there is a new wound identified by an LPN or Nurse Aid, she also assessed that wound if she was in the facility. If not, the LPN assesses it, and LPN #6 follows up when LPN #6 returned. When asked to identify wounds that Resident #1 had upon discharge, she stated He had two abdominal surgical wounds, one on each side, bilateral DTI's (deep tissue injuries) to his heels. She denied any knowledge of a wound to his coccyx. When asked if there was ever a time when a dressing would be in place without a physicians order, she stated no. On 05/13/25 at 12:55 PM during a telephone interview with the Medical Director for the facility, he said he did not perform skin checks on residents. He said he depended on documentation from the staff. On 05/12/25 at 4:20 PM the surveyor went to the facility where the resident was discharged to. LPN #3 took report from the facility on 04/10/25. She stated the report consisted of when his last bowel movement was, his vital signs, his tube feeding details. She states the only report obtained concerning skin status, was that there were no new issues. LPN #4 was the nurse on duty on 04/10/25 at 5:45 PM when the resident arrived at the facility. She stated Resident #1 arrived at 5:45 PM via stretcher by ambulance. She stated she performed a body audit at 6:00 PM and documented it at that time on paper. She described the wound on the coccyx as deep, maybe bone exposed, foul odor, dressing in tack dated 4/10/25, there were initials on the dressing, but she did not remember what they were. Once she removed the dressing, which was a Mepilex, was removed, there was a blue foam dressing in place, it was not packed in the wound, only laid across it. LPN #4 said, Our facility calls it hydrofera blue. It smelled terrible. The body audit drawing showed the following: dated 04/10/25 6:00 PM 160.8 weight, vital signs, BP (blood pressure) 106/74 P (pulse) 76, T (temperature) 97.7, R (respirations) 20, 02 Sat 99% on 2 liters of oxygen. Front view: Head: dry, flaky skin. Feet: dry, flaky skin. Right arm: scab. Bilateral lower extremities: dry, flaky skin. Right abdominal wound, left abdominal healing scar. lower left abdomen: feeding tube. Rear view: Back: redness. Bilateral heels: redness. Wound on coccyx. Note on the back of the body audit stated: Resident has dry skin on his head and face. Small scab on right upper arm. Large abdominal wound middle of upper abdomen cover by Allevyn. Healing scar on the left side of mid abdomen. Feeding tube site on left lower abdomen. Bilateral lower legs and feet are dry and flaky. Redness on middle of back towards right side. Wound on coccyx covered with a dressing. Both heels are red. LPN #4 also documented an electronical assessment once the resident was admitted , comfortable in bed and time allowed. The electronic documentation on 04/10/25 at 8:40 PM identifies vital signs as noted above. Integumentary assessment: Deficits noted: Color: normal flesh tone appropriate to complexion Moisture: Dry Temperature: Warm Turgor: Fair Skin intact: No Comments: Abdominal wound to middle of abdomen, wound on coccyx, feeding tube on left lower abdomen, redness on heels, dry skin, scab on right arm. On 04/11/25 at 9:40 AM a wound and ulcer assessment was completed and documented by the RN as follows: Wound #1 Wound type: Pressure Ulcer Wound location: Coccyx Dressing present: Yes Dressing intact: yes Dressing changed Yes Incision present: no Sutures/staples present: No Size length 2.5 width 1.5 depth: 05 Has wound be staged by Registered Nurse? Yes Unstagable, necrotic slough/eschar tissues obscure base of ulcer, unable to determine whether ulcer is III or IV. Odor: Yes extensive malodorous purulent smell to wound Drainage: Yes Drainage color: black. Drainage amount: moderate Signs of infection: Hot, reddened Additional comments: black drainage coming from wound tissue and soaking removed dressing, gray necrotic tissues surrounding wound bed with tunneling noted at the left upper side of wound measuring 0.5 cm Are there significant changes in would or signs of infection since last assessment? Yes. Physician notified. Photos taken of the wound: Yes Wound #2 Wound type: surgical wound Wound location: Abdomen Dressing present: Yes Dressing intact: yes Dressing changed: yes Incision present: no Sutures/staples present: no Size: length: 6/9 width 3.3 depth 0 cm Not staged, no odor, no drainage Signs of infection: reddened Additional comments: healing surgical wound to left abdomen with scab formation, no drainage Physician notified Wound #3 Wound type: pressure ulcer Wound location: right heel Dressing present: yes Dressing intact: yes Dressing changed: yes Incision present: no Sutures/staples present: no Size length 3 width 3 depth 0 cm No odor, no drainage, Signs of infection: swollen, hot and reddened Physician notified Wound #4 Wound type: pressure ulcer Wound location: left heel Dressing present: yes Dressing intact: yes Dressing changed: yes Incision present: no Sutures/staples present: no Size length 3 width 3 depth 0 cm No odor, no drainage, Signs of infection: reddened Additional comments: 2 small areas of dry flaking skin beginning to peel with new tissue. Physician notified A registered nursing note stated, Resident returned 4/10/25 in late evening, wounds present with dressings intact completed on 4/10/25 at (name of facility) Wounds reviewed today per this Registered Nurse (RN) and Unit Manager for staging. Resident noted to be 100.3 degrees temp., with pain noted to turning and touch of coccyx. Coccyx wound is infected, necrotic, unstagable and requires debridement and support not available in house. No treatment orders or notification received on this wound condition; Wound not included on PASR preadmission screening and resident review). Resident condition reported to Family Nurse Practitioner (FNP) and Medical Director with orders to send to ER for further treatment. Social Services informed of wound findings to coccyx. DON/Administrator informed. Health care surrogate (HCS) informed of findings per RN unit manager and gave preference of (local hospital name) for hospital. According to the discharge summary from the local hospital with admission date of 4/11/25, the resident was admitted with the following admitting diagnosis: Decubitus ulcer State 3 present on admission. Infected with osteomyelitis. Post obstructive pneumonia. Mucus plugging. General surgery and infectious disease was consulted for care. While inpatient a debridement of the wound on his coccyx was complete with discharge orders to pack wound daily with normal saline moistened kerlix gauze. Cover with 4 X 4 and ABD (abdominal pad). Clean wound daily with wound cleanser. Per the surgical team the resident was transferred to another local hospital for a course of intravenous antibiotics. On 4/22/25 the resident was transferred to another skilled nursing facility where he was admitted because of a decubitus ulcer, sacral region, State III. He received a ten (10) day course of Daptomycin in 0.9% sodium chloride 500mg/50 ml piggyback, give 400 mg daily per IV and Piperacillin-Tazobactam 3.375 gram reconstituted solution IV every 6 hours. On 05/12/25 at 2:10 PM the Resident #1's wound was observed by this surveyor accompanied by the floor nurse and unit manager. There was a dressing in place. The wound was clean and dressed. The necrotic tissue had been removed. The RN Unit Manager states he had an appointment on 05/13/25 with the wound center to see if he is a candidate for a wound vacuum to his coccyx. . During an interview on 05/13/25 at 9:00 AM the Administrator, wound nurse and DON, said they were aware of the DON from the facility he was discharged to coming into their facility however they did not accompany her to the resident's room and are unaware if she did a skin assessment. It was their understanding that she was only there to confirm that the wound vac had been removed prior to him being sent to her facility. During this interview the wound nurse was asked for a list of wound care supplies they typically use in their facility, the list consisted of blue classic foam. On 5/13/25 at 9:10 AM the Administrator, wound nurse and DON at Facility #1 were shown the body audit, skin assessment and pictures of Resident #1 upon returning to the facility. The discussion included that the resident left their facility at 5:20 PM and arrived at the other facility at 5:45 PM. They were informed Resident #1 had a dressing to his coccyx dated 4/10/25. They all agreed. When asked how they think the dressing got applied at their facility, they had no explanation. They expressed their shock and concern for Resident #1 but denied knowing anything about the Stage III pressure ulcer to Resident #1's coccyx.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, and staff interviews the facility failed to ensure all residents were free from abuse and neglect for Resident #96, #2, and #212. Resident #96 was verbally abuse during an ongoing investigation involving Resident #96 and LPN #83. This verbal abuse occurred on 06/10/22 when LPN #83 as was supposed to be suspended from the facility. She entered the facility and verbally abused Resident #96 in regard to the allegations previously made against her by Resident #96. Based on Resident #96's interview it was determined he suffered psychological harm as a result of this incident of verbal abuse from LPN #83. Resident #2 indicated to the survey team they had been abused by LPN #83 on an ongoing basis by having to cry in order to receive her medications. For Resident #212 the facility failed to ensure she was free from neglect by failing to provide her medication in a timely manner. This was true for three (3) of Four (4) residents reviewed for the care area of abuse during the Long Term Care Survey. Resident Identifiers: #96, #2, and #212. Facility Census: 116. Findings included: a) Resident #96 On 06/07/22 at 8:50 am Resident #96 reported to the state surveyor that Licensed Practical Nurse (LPN) #83 takes her sweet time giving him his medicine and that she cussed him out twice for no reason. Resident #96 did not know the exact dates this occurred, but stated it was not too long ago. This allegation of abused was reported to the Nursing Home Administrator (NHA) on 06/07/22 at 9:00 am. The facility reported this allegation of abuse to appropriate state agencies on 06/07/22 at 10:22 am. The initial reporting indicated LPN #83 had been suspended pending the outcome of the investigation. On 06/14/22 at approximately 9:40 am a reportable incident involving Resident #96 and LPN #83 was reviewed. This incident occurred on 06/10/22 at 9:10 am. The brief description of the incident read as follows: Allegation of verbal abuse. Staff heard LPN, (First and Last Name of LPN #83), state to Resident, I can't be your nurse anymore because I can't take care of someone who lies about me. LPN, (First and Last name of LPN #83), was in facility in front lobby to provide statements related to previous allegations, she would not provide statements by phone. The following statements were included in the investigation: Statement from Resident #96: I, (First Name Middle Initial and Last Name of the Director of Social Services (DSS)), Director of Social Services, interviewed resident (First and Last Name of Resident #96) on this date related to the incident with LPN (First and Last Name of LPN #83). Resident said Nurse (First Name of LPN #83) was up front in the building when he was at the nurse's station. He said that the Nurse called him a liar and asked him why he was telling lies on her. Resident said he told her that she deserves to be fired and then staff member came and took the nurse out of the facility. Statement from LPN #83, This nurse inquired to (first and last name of Resident #96) why he told things to the state that weren't true. Statement from the Director of Marketing and Admissions wrote the following statement: On June 10,2022, approximately around 9:10 am I heard (First and Last name of LPN #83), and off duty nurse - tell one of the residents (First and Last Name of Resident #96) that I can't be your nurse anymore, because I can't take care of someone who lies about me. In front of the front nursing station. (First and Last Name of LPN #83) stated that in a loud voice/rude manner to (First and Last Name of Resident #96) . Since I overheard this exchange from my office, which is located in the front part of the building - I proceeded to the front nursing station. Once at the front nursing station, (First and Last Name of LPN #83) was walking away, and at the same time, the resident stated you deserve to lose your license. (First ad Last name of LPN #83) did not reply to that comment, as continued to walk down the hall. Statement given by the Activities Director (AD) read as follows: While writing on the activity board (First and Last Name of LPN #83) came into the building as she walked by (First and Last name of Resident #96) she asked him if he was going to the tell the truth about her and to stop lying. He said that he was telling the truth. She said that she will not give him care anymore that he would have to work with someone else. She said this in a loud and hateful tone. Statement given by [NAME] Clerk #87 read as follows: I was sitting I the activities office and overheard (First and Last name of LPN #83) talking to the resident (First and Last Name of Resident #96) in a hateful tone in the middle of the hallway. She was being very loud. An interview with Resident #96 on 06/14/22 at 9:55 am, revealed he was sitting at the nurse's station on 06/10/22 and LPN #83 came up to him and told him she was not going to give him medicine anymore because he was lying on her. When asked how this made him feel, Resident #96 paused and thought about it, he lowered his head and wrung his hands then looked up at the surveyor and said, I was really upset by it. He then stated, She don't need no job here if she is going to cuss the residents. Resident #96's demeanor when asked how it made him feel and his response that it really upset him was indicative of psychological harm. A review of Resident #96's medical record found he has diagnosis of Cerebral Palsy and unspecified intellectual disabilities. An interview with the Nursing Home Administrator (NHA) and the Social Service Director (SSD) on 06/14/22 at 10:23 am revealed the common practice of the facility is while the alleged perpetrator is suspended, they should have no contact with the residents. When asked why LPN #83 was allowed to have contact with Resident #96 they indicated she had refused to give a statement about the allegations made against her over the phone. They stated, she was supposed to come to the front porch of the facility and let them know she was here, but instead she barged in the front door and went straight to Resident #96 and that is when this incident occurred. An interview with The Marketing and Admissions director at 11:00 am on 06/14/22 found by the time he went from his office to the nurse's station, LPN #83 was observed by him walking down the long hall toward the back of the building. An interview with the AD on 06/14/22 at 11:23 am confirmed she did hear the nurse talking to Resident #96 in a hateful tone. She stated, I did not know who she was because she works night shift. She stated the NHA then escorted her off the unit. Review of the COVID - 19 screening kept by the facility for all visitors and staff found LPN #83 was screened for COVID-19 symptoms prior to entering the building on 06/10/22 at 8:49 am. This was 20 minutes prior to the altercation that occurred with Resident #96. An interview with the NHA at 11:42 am on 06/14/22 confirmed he was in the stand-up meeting when the incident occurred. He stated the admission Director came to the stand-up meeting to get him. He stated that once he was alerted to the situation LPN #83 was all ready back at the front desk. When asked if Receptionist #56 was aware that LPN #83 should not be in the building he stated, I would think so. We attempted to call Receptionist #56 with the NHA and she did not answer. An interview with the SSD on 06/14/22 at 11:48 am confirmed she obtained written statements from LPN #83 on the front porch of the facility, but this happened after the altercation occurred with Resident #96. A telephone interview with Receptionist #56 at 11:51 am on 06/14/22 confirmed she did screen in LPN #83. She indicated that if she was on the log then she did screen her in. When asked if she was aware LPN #83 was not allowed to be in the building she stated, No Mam I did not know that. When asked if she had known that what would she have done, she stated, I would have told her to wait outside and I would have got one of the managers to go talk to her. When asked if she heard LPN #83 say anything to Resident #96 she stated, I heard her say something like she wanted to change his mind about what he said. And (First name of Resident #96) said no I was telling the truth about what you said. She indicated she did not hear everything that was said. Review of the Investigation found Receptionist #56 did not provide a written statement in regard to this incident. b) Resident #2 A review of the medical record revealed Resident #2 had the following diagnosis: -Parkinson's Disease -Dementia without behaviors -Osteoartritis to right knee and hip -Muscle weakness -Anxiety -Chronic pain -Effusion right knee -leg pain -Alzheimer's On 06/06/22 at 9:04 PM, Resident # 2 was in a wheelchair in the doorway to her room. Resident # 2 was tearful and stated her left knee was hurting. Resident #2 said, she (pointing at Licensed Practical Nurse (LPN) #83) makes me cry every night before she will give me my medicine. Resident #2 was asked if any of the staff have ever been rude to her. Resident #2 said, that nurse (pointing at LPN #83) is hateful not just to me but everyone, she doesn't care about us at all. Resident #2 was pointing at LPN #83 as LPN #83 was pacing back and forth from the medication cart to the supply room and medication storage room. LPN #83 was not answering any of the residents that were asking for medications. Resident #2 was asked if she has told anyone about having to cry to get her medications and being treated badly. Resident #2 said she told Tall (named Director of Guest Services (DGS) #33 by his first name), but nothing changed it still happens. Resident #2 said she told him sometime last week. On 06/06/22 at 9:30 PM the Administrator was informed about Resident #2 saying she has to cry to get her medications and LPN#83 being hateful to her. Administrator said he would get someone to take over that medication cart. He said he understands the facility has some customer service issues. On 06/06/22 at 9:35 PM, DGS #33 was asked if Resident # 2 had reported to him about getting her medication late every time LPN#83 works and having to cry before she gets her medications, and that LPN #83 was hateful? DGS #33 said, Yes, I believe she told me about that last Wednesday. DGS #33 was asked if he completed a report or any type of form to address this complaint? DGS #33 stated, No, he told the Unit nurse, and it was handled eternally. DGS #33 went on to explain that Resident # 2 is the kind of person that thinks if her medications are due at 8 than it should be in her hand at 8. On 06/06/22 at 9:45 PM, the Director of Nursing (DON) was asked if someone could please help Resident # 2 because she is in pain and needs her medications. The DON said, what are her 9 o'clock medications? The DON was told there was no way for this surveyor to know, but Resident # 2 has been asking LPN#83 for her medications since 8:50 PM. During a review of facility records it was revealed there was not any concern/grievance or reportable forms completed about the above issue. A review of the facility form titled, Medication Admin Audit Report, revealed the following dates and times when Resident #2's medications were administered by LPN #83: The following medications were scheduled to be administrated at 9:00 PM every night and were not Administrated within the parameters of one hour of the scheduled times. -Ropinirole HCL 0.5 mg by mouth three times a day for Parkinson's. -Tylenol extra strength 1000 mg three times a day for osteoarthritis pain. -Carbidopa-Levodopa 10-100 mg by mouth four times a day for Parkinson's. -Tizanidine HCL 2mg three times a day for muscle spasms. -Aricept 10 mg at bedtime for Dementia related to Parkinson's. -Clobetasol Propionate cream 0.05 % apply two times a day to affected areas for eczema -IBU-200 give two tablets three times a day for pain. -Bio-freeze Professional 5% gel apply three times a day for chronic knee pain. -Buspirone HCL 5mg two tablets three times a day for Anxiety The following are the days and times the above medications were given late by LPN #83. - 05/10/22 for 9:00 PM, not given until 05/10/22 at 11:20 PM. - 05/14/22 for 9:00 PM, not given until 05/14/22 at 11:52 PM. - 05/15/22 for 9:00 PM, not given until 05/15/22 at 11:09 PM. - 05/29/22 for 9:00 PM, not given until 05/29/22 at 11:35 PM. - 06/01/22 for 9:00 PM, not given until 06/02/22 at 12:21 AM On 06/08/22 at 7:45 AM, Administrator was again informed of the allegation of abuse that Resident #2 made against LPN #83. Administrator was also informed of the above medications, what the medications are for, how many times a day they are ordered, and how late all the medications were. Also discussed the DGS #33 having knowledge of the complaint concerning Resident #2 last Wednesday and no report was made. The Administrator stated he would educate the DGS #33 on the correct way to handle complaints, and have a social worker speak to Resident # 2 today. On 06/08/22 at 12:45 PM, the Administrator and Social Worker (SW) #68 approached this surveyor in the 300 hall while observing lunch, and said SW #68 spoke to Resident # 2. SW #68 was asked if she could provide a copy of the report. SW #68 stated she did not do any report. On 06/08/22 at 1:12 PM, SW #68 came in room and stated she did not do a reportable because Resident # 2 did not complain about LPN#83 at this time she had a complaint about someone else. SW #68 was informed of the allegations Resident # 2 had made on the night of 06/06/22 at 9:04 PM. She was told these allegations were told to the Administrator at 9:30 PM on the night of 06/06/22 and that Resident # 2 had also reported this to DGS #33 last week on a Wednesday and nothing was done. SW #68 was informed that today on 06/08/22 at 7:45 AM, once again the administrator was informed. SW #68 stated she was not told that this was an allegation of abuse and would report it right away. On 06/08/22 at 4:48 PM, the Administrator asked this surveyor to go with him to answer some questions the social workers have. As we were walking down the hall the Administrator stated he did not write it down in his notebook about Resident # 2 saying the nurse makes her cry before she gets her medication, on Monday night. This surveyor asked for another surveyor to join the meeting because the surveyor was also present at the time this surveyor reported the information to the administrator on 06/06/22 at 9:30 PM. Administrator stated he did not understand why he should complete a reportable when it would be out of compliance due to the time. Administrator said he did write it down on Monday night that Resident #2 said LPN #83 was hateful to her but felt like that was a customer service issue not a form of abuse. Administrator was asked if the DGS #33 should have reported the allegations from Resident #2 on 6/01/22 on the Wednesday when Resident # 2 first told him? The Administrator was the asked why was a report not started on the night of 06/06/22 when it was reported to him at 9:30 PM, and again when it was reported to him at 7:45 AM today on 06/08/22, then once again today on 06/08/22 when it was reported to SW #68 at 1:12 PM? Please note : By the time of this interview with the Administrator it was three (3) past the fourth time staff were made aware of Resident #2's allegations. The Administrator was then asked why LPN #83 was allowed to finish the shift on 06/06/22 even after he knew of the allegation. Once again, he said he felt like it was a customer service issue and could be handle as that, and sometimes people are just in a bad mood or personalities do not match. On 06/09/22 at 8:30 AM, a copy of the reportable for allegation of abuse for Resident #2 was provided. The following information was on the facility form titled, immediate fax reporting of Allegations-Nursing Home Program Facility Name: (Named the facility by name) Alleged Victim Name: (named Resident #2) Alleged Perpetrator Name: (Named LPN #83) Position: LPN Allegation information: Date of incident: 06/06/22 at 9:04 PM. Brief description of the incident: State Surveyor reported that she interviewed Resident #2 the night of 06/06/22 at 9:04 PM. Surveyor reported that the nurse makes her cry for her medications every night before she will give them to her. Surveyor also reports Resident said the nurse is hateful to her and hateful to everyone. State surveyor said that Resident pointed to (named LPN #83) during interview. Completed by: (named Social Worker #68) dated: 06/08/22 Time of fax was 5:40 PM on 06/08/22. A typed interview with Resident #2 by Director of Social Services (DSS) #76, dated: 06/08/22, no time was noted. The following is typed as it was on the paper. I, (named first and middle initial last name of DSS #76), interviewed resident (named Resident #2 by first and last name) on this date related to Medication Administration and staff approach. Resident stated, on the nights (named first name of LPN#83) works I don't get my medicine on time. Sometimes I cry until I get my medicine because it is late. Resident reports that she has no other issues with her medication being provided timely. Resident also reports that the Nurse named (used first name of LPN #83) is hateful to her. Resident unable to provide example of the how the Nurse is hateful with her. Signed by: DSS #76 On the five-day follow-up for Resident #2 and LPN #83, dated: 06/13/22. Outcome/Results of investigation: -After further investigation, allegation of verbal abuse and neglect has been substantiated based on Resident interviews and Medications Admin Audit, Residents disclosed the LPN (used first name of LPN #83) had been witnessed being hateful. Upon further review of Medication Admin Audit, there were a total of five occasions that Resident's medication was administered late in the last 30 days. Written statement on 06/10/22, by LPN #83 reads as written: Resident (named first and last name of Resident #2) cries incessantly related behaviors and medical dx of schizophrenia. Please Note: Resident #2 does not have a diagnosis of Schizophrenia. Typed statements from residents that reside on 100 unit on 06/10/22 related to allegation made on 06/06/22 that LPN (used first and last name of LPN #83) is hateful: Question: How are your interactions with LPN (used first and last name of LPN #83)? Have you observed LPN (used first and last name of LPN #83) being hateful with any residents? If so, can you provide details about this incident(s)? Resident: (used full name of Resident #13) She has never been hateful to me. She becomes flustered when she is antagonized over and over and will ask residents to go to their rooms and let her work. States, She just tells it like it is. (Used last name of Resident #13 unable to recall specific resident's names at this time and said if she felt someone was being abused or treated poorly she would report it. Resident: (used full name of Resident #96) She is rude and hateful. (Used the first name of Resident #96) unable to state specific residents, just said this nurse is not nice. (Used the first name of Resident #96) made an allegation of verbal abuse towards this Nurse 06/07/22 which was reported and investigated. Resident: (used first and last name of Resident #100) I have heard her get hateful and use a loud rude voice. I can hear her from my room. I don't know who she is talking to. I have had no problem with her. c) Resident #212 A review of medical reports for Resident # 212, revealed this resident missed 14 doses of Neurontin (used for neuropathy pain). Resident #212 has a diagnosis of Peripheral Vascular disease, and type II Diabetes. Which both could cause neuropathy pain. The surveyor was unable to interview Resident #212 due to her not feeling well. Resident # 212 was admitted on [DATE]. There was an order that read, May hold Neurontin until arrival from pharmacy. Dated: 05/31/2022 Review of the Medication Administration Record (MAR) for the dates of 05/26/22 through current found the following: Neurontin Capsule 100 mg by mouth two times a day for neuropathy. Below are the dates and times this medication was not administered: -05/26/22 at 9 PM -05/27/22 at 9 AM and 9 PM -05/28/22 at 9 AM and 9 PM -05/29/22 at 9 AM and 9 PM -05/30/22 at 9 AM and 9 PM -05/31/22 at 9 AM and 9 PM -06/01/22 at 9 AM and 9 PM -06/02/22 at 9 AM for a total of 14 missed doses. During an interview on 06/09/22 at 10:02 AM, the Director of Nursing (DON) was asked why Resident # 212 was not given her medication for six and half days. The DON stated the facility has a problem with the current Pharmacy the facility is using. She will look for documentation to support attempts to obtain the medication. On 06/09/22 at 1:00 PM, the DON provided nursing notes by Licensed Practical Nurse (LPN) #92. Dated and timed: 05/28/22 at 10:38 PM, Neurontin Capsule 100 mg by mouth two times a day for neuropathy. Not on hand, awaiting physician signature for script. Nursing Note by LPN #92, dated and timed: 05/28/22 at 11:00 PM. Called UHC and requested script for Neurontin 100 mg BID (two times a day); script received and faxed to pharmacy; resident and provider aware; resident has no signs/symptoms of pain; rates pain 0 out of 10; awaiting script to be sent from pharmacy. Nursing Note by Registered Nurse (RN) #52, dated and timed, 06/01/22 at 10:19 AM, Neurontin 100 mg give two times a day for neuropathy. Not available. pharmacy contacted. Nursing Note by LPN #40, dated and timed, 06/01/22 at 8:40 PM, Neurontin 100 mg give two times a day for neuropathy, Script obtained. awaiting from pharmacy. Faxed pharmacy to pull from Omnicell. no authorization code provided. No other information was provided by the end of the survey. .