**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (R20) was free from abuse. The facility did not ensure R20 was free from an alleged sexual abuse by a visitor. On 7/21/23, Certified Nursing Assistant (CNA-D), observed visitor (I) inappropriately touching R20 with his hand between R20's legs and on R20's vagina. CNA-D did not immediately report this allegation of abuse. Visitor (I) remained in the facility and was later observed in R20's room with the lights off and with his hand under the covers while R20 was in bed. CNA-D did not report the observations of alleged sexual abuse until 7/24/23, allowing visitor (I) to visit R20 one more time (on 7/23/23) before being reported. The facility did not protect R20 from further potential sexual abuse. The facility's failure to keep R20 free from sexual abuse created a finding of Immediate Jeopardy, which began on 7/21/23. On 8/9/23, at 3:42 PM, Nursing Home Administrator (NHA)-A, and Director of Nursing (DON)-B were informed of the Immediate Jeopardy. The immediate jeopardy was removed on 8/14/23. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement and monitor its action plan. Findings Include: Surveyor reviewed the facility's Policy and Procedure on Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, last revised 12/1/22. .Procedure A. Individuals will be protected from abuse, neglect, and harm while they are residing at the facility. B. No abuse or harm of any type will be tolerated. C. Individuals and staff will be monitored for protection. D. The facility will strive to educate staff and other applicable individuals in techniques to protect all parties. E. The facility will encourage and support all individuals, staff, families, visitors, volunteers, and individual representatives in reporting any suspected acts of abuse to the Administrator or designee. F. The Administrator or designee will report abuse to the state agency per State and Federal guidelines. G. The facility will follow the attached comprehensive abuse, neglect, mistreatment and misappropriation of Resident property program to comply with the seven step approach to abuse and neglect detection and prevention. H. The abuse policy and comprehensive abuse, neglect, mistreatment and misappropriation of Resident property program will be reviewed on at least an annual basis and will be integrated into the facility quality assurance and performance improvement program. Overview of Seven components -Screening -Training -Prevention -Identification -Investigation -Protection -Reporting and Response Training Components It is the policy of this facility to train employees, through orientation and on-going sessions on issues related to abuse and prohibition practices. Prevention It is the policy of this facility to prevent abuse by providing Residents, families, and staff information and education on how and to whom to report concerns, incidents, and grievances without the fear of reprisal or retribution. The facility leadership will assess the needs of the Residents in the facility to be able to identify concerns in order to prevent potential abuse. Procedure: 1. Resident Assessment Every Resident is unique and may be subject to abuse based on a variety of circumstances, including physical Program, environment, the Resident's health, behavior, or cognitive level. b. Upon admission and periodically after that, each Resident will have a comprehensive assessment completed which identifies potential vulnerabilities such as cognitive, physical, psychosocial, environment and communication concerns. c. The interdisciplinary team(IDT) will identify the vulnerabilities and interventions on the Resident care program. 2. Supervision of Staff Staff will be supervised to identify inappropriate behaviors while caring for or in attendance with Residents. Identification It is the policy of this facility that all staff monitor Residents and will know how to identify potential signs and symptoms of abuse. Occurrences, patterns, and trends that may constitute abuse will be investigated. Investigation It is the policy of this facility that reports of abuse are promptly and thoroughly investigated through the organization's QAPI Incident Report and Investigation process. Additional Investigation Protocols -Law Enforcement: All reports of suspected crime and/or alleged sexual abuse must be immediately reported to law enforcement to be investigated. Protection It is the policy of this facility that the Resident(s) will be protected from the alleged offender. Procedure: Immediately upon receiving a report of alleged abuse, Administrator (NHA-A) and or designee will coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable Resident are of utmost priority. Safety, security, and support of the Resident, roommate, if applicable and other Residents with the potential to be affected will be provided. i. The alleged perpetrator will immediately be removed and Resident protected. ii. If a family member or Resident representative is possibly contributing to the potential abuse and the Resident could be at risk, evaluate the situation and identify options to put into place for Resident protection. iv. Examine, assess and interview the Resident and other Residents potentially affected immediately to determine any injury and identify any immediate clinical interventions necessary. Notify Resident physician. v. Life Coach or designee should keep in frequent contact with the Resident and/or Resident representative. vii. Notification of law enforcement and/or State Agency viii. A medical, evidentiary, or sexual assault exam should be completed as possible, as appropriate . R20 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Dysphagia, Adult Failure to Thrive, Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety, and Cognitive Communication Deficit. R20 has an activated Health Care Power of Attorney (HCPOA). R20's admission Minimum Data Set (MDS) dated [DATE] documents R20's Brief Interview for Mental Stats (BIMS) score to be 11, indicating R20 demonstrates moderately impaired skills for daily decision making. R20 has no behaviors and R20's PHQ-9 score is 6, indicating R20 has minimal depression. R20's MDS also documents that R20 requires extensive assistance of one for bed mobility, transfers, dressing, and toileting. R20 requires supervision for eating. R20 has both upper and lower range of motion impairment on one side. R20 was admitted to the hospital from home due to falls. On 8/8/23 at 3:34 PM, Surveyor was able to obtain information on R20 from Hospital Social Worker (HSW-L). Prior to admission to the facility, R20 had been living with a family member who was R20's primary caregiver. A home health care agency was going into the home, however, staff would not go back because the family member was restricting visits, and R20 was left in the same clothes for several weeks in a row, not being bathed, and not receiving incontinence care. The appropriate agencies were notified of these concerns. On 8/9/23 at 9:15 AM, HSW-M was interviewed and communicated that there were allegations of physical abuse of R20 due to bruises; further, the activated HCPOA did not want R20 to return living in the home. R20's Case Manager (CM-N) on 8/8/23 at 12:31 PM, informed Surveyor that CM-N was informed that CM-N's initial intake documents that R20's family member was abusing R20 in the home. Surveyor reviewed R20's hospital paperwork dated 5/5/23 which indicates R20 appeared weak and frail looking. There is no documented social history obtained by the facility, and/or no background information. On 8/8/23 at 11:46 AM, Surveyor asked NHA-A if a social history should have been obtained on R20. NHA-A confirmed that would be the expectation that information should have been gathered at the time of admission. Surveyor notes there was a trauma assessment completed on admission for R20, but nothing was noted on the trauma assessment except R20 would be upset if family members were to die. The facility had no prior information about visitor (I), another relative of R20. R20 had no care plan implemented for mild depression at time of admission. R20 has impaired cognitive function/dementia or impaired thought process due to dementia care plan implemented on 5/8/23. Interventions initiated on 5/8/23 include ask yes or no questions in order to determine the Resident's needs and communicate with Resident/family/caregivers regarding R20's capabilities and needs. On 7/12/23, R20 was moved from the first floor rehabilitation unit to the long-term care unit on the 2nd floor. On 8/9/23 at 10:49 AM, CNA-WW informed Surveyor that the rehabilitation unit is quiet while the second floor can be more busy and chaotic at times. CNA-WW stated it can be hard to monitor visitors on the second floor. On 8/8/23 at 11:25 AM, Surveyor interviewed CNA-D in regard to the alleged allegation of sexual abuse and then spoke with CNA-D again on 8/8/23 at 2:18 PM. CNA-D reported the following; On 07/21/23, R20 was eating in the dining room as per R20's usual and R20's visitor (I) was sitting with R20 at the table. At some point, the visitor (I) informed staff that R20 needed to be toileted and offered to assist. CNA-D stated CNA-D thought that was unusual because R20 had not indicated to staff that R20 needed to be toileted as R20's usual routine was to alert staff. CNA-D became busy with transferring Residents out of the dining room and providing cares. At approximately 7:20 PM, CNA-D heard noise in R20's bathroom, entered the bathroom, and found R20 sitting on the toilet in a nightgown and observed the visitor's (I) hand between R20's legs and on R20's vagina. CNA-D's statement included that the visitor (I) had changed R20 out of R20's clothes. Surveyor asked CNA-D if the visitor (I) had a wipe or toilet paper in their hand and CNA-D said no. CNA-D felt visitor (I) was clearly inappropriately sexually touching R20 and told Surveyor that their hand was on R20's vagina. CNA-D asked the visitor (I) what they were doing and they said, I brought R20 to the bathroom. CNA-D informed the visitor (I) CNA-D would take care of R20 and asked the visitor (I) to leave the bathroom. CNA-D completed cares and then put R20 to bed. Another CNA entered the room with R20's roommate and the CNAs asked the visitor (I) to leave the room so they could put the roommate to bed. The visitor (I) remained in the hallway outside R20's door. At this point, CNA-D had not reported the alleged sexual abuse observed in the bathroom, the police were not contacted, and the visitor (I) remained in the facility. Although the facility may not have foreseen that the incident between R20 and Visitor (I) would occur, the facility now had knowledge that it needed to protect R20 from further potential abuse. This did not occur. The CNAs exited the room and the visitor (I) went back into the room. CNA-D returned about 5-6 minutes later and thought it was unusual that the lights were out in R20's room. CNA-D entered the room, turned the lights on, and saw the visitor's (I) hand under R20's covers. CNA-D stated visitor (I) jerked their hand from under the covers as if startled. CNA-D observed visitor (I) begin walking to the elevator. Visitor (I) then returned to the room to retrieve a bag and left the room. CNA-D is uncertain at what point visitor (I) left the facility. CNA-D stated that CNA-D informed the nurse of the allegation of abuse that evening prior to the end of her shift on 7/21/23. On 8/9/23 at 11:24 AM, Surveyor interviewed Licensed Practical Nurse (LPN-C) who denies ever being made aware of the allegation of abuse. LPN-C reiterated had LPN-C been made aware of the incidents, LPN-C would have immediately reported it to the NHA-A. Surveyor asked CNA-D how R20 appeared to be during these 2 separate observations. CNA-D stated happy and enjoying what was going on as if it had been going on for some long time. CNA-D said CNA-D did not share this with the facility at the time they interviewed CNA-D. On 8/7/23 at 11:35 AM, Surveyor reviewed the facility's visitor sign in log from R20's admission to present. Surveyor notes the visitor (I) started visiting R20 three days after admission to the facility. The visitor (I) regularly visited R20 approximately 2-3 times a week and always on the PM shift. On 7/21/23, on the day of the alleged sexual abuse, visitor (I) signed in at 5:35 PM and signed out at 9:53 PM. Documentation shows that visitor (I) again visited R20 on 7/23/23 signing in at 5:23 PM and leaving at 9:00 PM. On 8/8/23 at 10:05 AM, Surveyor interviewed R20's activated HCPOA-H over the phone. HCPOA-H indicated in the past, family shared with HCPOA-H that visitor (I) had mental health issues. HCPOA-H has requested visitor (I) not visit and stated the following: if the nurse said it happened, then it probably did. On 8/8/23 at 12:52 PM, Surveyor interviewed the Director of Nursing (DON-B). DON-B confirmed on 07/24/23, 3 days after the observations of alleged sexual abuse, CNA-D reported the incidents to DON-B. DON believes it was reported on 7/24/23 after 3:30 PM but before 4:00 PM. DON-B immediately completed a skin check and pain evaluation. There is no documentation that R20's attending physician was notified or documentation that a physician came to assess R20. DON-B informed Surveyor that DON-B checked for scratches and bruises during the evaluation but there is no documentation of this. DON-B then obtained a statement from R20 who said R20 didn't think anyone touched R20 sexually inappropriately. DON-B said it was communicated that R20 was being herself and had no changes after the incidents. On 7/24/23, 3 days after the observations, CNA-D reported the incidents to DON-B. HCPOA-H was notified, and the police department was called. At 11:00 PM that night, the police notified the facility they would not be coming until the next day. On 7/25/23, the police responded to the facility and indicated there was not enough evidence for a SANE evaluation (Sexual Assault Nurse Examiner) in part due to the delay in reporting. Surveyor asked NHA-A on 8/8/23 at 11:46 AM during an interview why R20 was not sent out to the ER when notified of the alleged sexual abuse (fondling) and NHA-A stated the family did not want R20 to go. There is no documentation indicating sending R20 to the ER was discussed with HCPOA-H. The case is currently pending with the District Attorney. Surveyor attempted to get the police report but has not received anything yet. Surveyor checked the Wisconsin sex offender registry, and the visitor (I) is not listed. Surveyor reviewed the facility's investigation and notes the facility obtained multiple staff statements; all indicating they had no observations of the visitor (I) acting inappropriately or any behaviors displayed that would have indicated issues. Surveyor notes CNA-E's statement, (the CNA who was with CNA-D in R20's room at one point), states that CNA-D reported to CNA-E that CNA-D had caught visitor (I) playing with R20. CNA-E assumed the visitor had been touching R20 inappropriately. CNA-E documented in CNA-E's statement that CNA-E had seen the visitor bending over R20 but did not actually see anything. On 8/8/23 at 10:25 AM, Surveyor attempted to interview CNA-E over the phone but did not receive a return phone call back. On 8/8/23 at 3:35 PM, Surveyor spoke to Maintenance Lead (ML-F) who confirmed the facility has cameras. ML-F stated the cameras had gotten knocked out with a storm on 6/14/23 and were repaired about two weeks later. However, no one knew the cameras were not actually recording until NHA-A requested to view the footage from 7/21/23. Surveyor notes there is a picture of visitor (I) at the receptionist desk and on the units with a note stating visitor (I) is not allowed to visit and if visitor (I) attempts, the police should be notified. The facility informed Surveyor the facility took immediate action (on 7/24/23) with CNA-D, however the schedule indicated CNA-D worked on 7/25/23. On 8/8/23 at 11:46 AM, Surveyor reviewed CNA-D's punch detail and notes CNA-D worked on 7/25/23 from 2:10 PM to 10:30 PM. On 8/8/23 at 2:31 PM, Surveyor asked NHA-A about CNA-D working when the facility indicated immediate action had been taken with CNA-D. NHA-A informed Surveyor that CNA-D was talking with the police the entire time. However, Surveyor reviewed the police log which indicates the police arrived on 7/25/23 at 1:40 PM and left at approximately 5:16 PM. On 8/9/23 at 9:44 AM, NHA-A stated NHA-A took action against CNA-D on 7/26/23 after learning that CNA-D had completed abuse education. Surveyor notes that on 7/6/23 and 7/10/23, all staff received education on the abuse policy and procedure prior to this allegation of sexual abuse which occurred on 7/21/23. On 7/25/23, re-education was provided, however, it was only provided to 18 employees, all CNAs, including CNA-D who according to NHA-A should not have been in the facility. Surveyor confirmed with Nursing Staff Coordinator (NSC-J) that there is no orientation on abuse for agency staff. On 8/9/23 at 11:24 AM, LPN-C, agency nurse, confirmed that LPN-C has not received an orientation to the facility policies and procedures, including on abuse. The facility has stopped using agency aides 2 weeks ago but still has agency nurses. On 8/8/23 at 3:05 PM, Surveyor toured the 2 time clock areas and did not find any posting instructing employees on reporting any suspicion of a crime. On 8/9/23 at 8:20 AM, ML-F brought Surveyor to a break room and ML-F showed Surveyor a poster hanging in the breakroom instructing employees to report any suspicion of a crime immediately. Surveyor asked ML-F if everybody uses this break room and ML-F said no, not everybody. ML-F does not know if there is one designated person to go and report a suspicion of a crime to. The facility's self-report submitted to the state survey agency, states the facility was unable to validate if the allegation of sexual abuse occurred. This decision is based on all interviews from staff showing no observations of inappropriate behavior from the visitor(I), with the exception of CNA-D and E's statements. On 8/8/23 at 12:44 PM, Surveyor spoke to Life Coach (LC-K) in regards to R20. LC-K stated that LC-K assessed R20's cognitive status as a result of the alleged sexual abuse, and R20 scored a 3 on R20's BIMS, indicating R20 is now severely impaired for daily decision making. Surveyor asked LC-K why the significant change in cognitive status, and LC-K stated everyone has a good day and a bad day. LC-K confirmed that getting background information is very important in caring for Residents. LC-K confirmed that LC-K did not complete any referrals or develop any interventions as a result of the alleged sexual abuse, a possible new trauma. LC-K confirmed that other than speaking with R20 for two days after the alleged sexual misconduct(fondling), LC-K has not monitored for any psychosocial outcome. The interdisciplinary team (IDT) did not implement a comprehensive care plan addressing R20's alleged incident, signs/symptoms of trauma with person centered interventions to best care for R20 after the allegation of sexual abuse. Surveyor notes that the facility did not refer R20 for any psychological intervention/follow-up after the alleged sexual abuse. The facility did not intervene and monitor R20 for any signs/symptoms of behavior, pain, psychosocial changes since the alleged sexual abuse. On 8/7/23 at 1:20 PM, Surveyor observed R20 who appeared to be thin and frail. R20 was able to tell Surveyor what R20 had for lunch and what day of the week it was. On 8/8/23 at 11:07 AM, Surveyor found R20 nestled in an armchair in a lounge and appeared to be sniffling and had a Kleenex in R20's hand. Surveyor asked R20 if R20 was sad and R20 indicated R20 was, as she missed family. R20 was able to indicate that R20 is aware that the alleged perpetrator has not been in to visit since 7/24/23. On 8/9/23 at 10:15 AM, Surveyor spoke with R20 who stated that R20 was sad when asked how R20 was feeling. R20 stated R20 was sad because R20 had a lot on R20's mind, but could not pinpoint one main thing. On 8/8/23 at 2:31 PM, Surveyor shared the serious concern with NHA-A and DON-B that the facility did not ensure R20 was free of alleged sexually abused, and the facility failed to protect R20 from any further allegations of sexual abuse. Surveyor shared that after the first initial observation of alleged sexual abuse, CNA-D did not report immediately the allegation, and then CNA-D observed a second alleged sexual abuse by visitor(I) with R20. Surveyor shared visitor (I) returned to the facility and visited R20 one more time before CNA-D reported the allegations of abuse to the NHA, thus leaving R20 vulnerable for further sexual abuse and possibly other Residents. Surveyor shared that the police investigation was hampered by the fact the sexual abuse was not reported until 3 days later. Surveyor shared that the physician was not notified, and no actual physical assessment of possible sexual trauma was completed. Surveyor shared that only 18 CNAs were re-trained on the abuse policy and procedure and not all staff. NHA-A stated, we have concerns too. No further information was provided by the facility at this time. On 8/9/23 at 9:44 AM, NHA-A and DON-B spoke with Surveyor about the serious concern involving R20 and the alleged incident of sexual abuse. Both NHA-A and DON-B stated that R20 did not show signs of trauma. NHA-A and DON-B informed Surveyor that both NHA-A and DON-B do not believe the alleged incident of sexual abuse occurred. Surveyor shared that no physical or psychosocial assessment had been completed following the alleged sexual abuse. Surveyor was informed, it happens (referring to follow up with R20). NHA-A stated, NHA-A is livid it was not reported immediately and the facility did their job to educate staff on abuse. Unwanted sexual contact would cause a reasonable person to have psychosocial harm that may take months or years to manifest in R20 and have long term effects. Literature indicates that the most prevalent psychosocial outcomes of abuse are depression, anxiety, and posttraumatic disorder. Other possible outcomes can be manifested physically like weight loss, pain, repeated falls, and/or unexplained behavior changes. According to the article written by a member of the [NAME] University Law School, Grandparent Molesting: Sexual Abuse of Elderly Nursing Home Residents and its Prevention, Emotional signs and symptoms [of sexual assault in a nursing home] include denial, humiliation, flashbacks, intense fear, guilt, anxiety, depression, feelings of hopelessness and helplessness, phobias, and rage. These conditions are symptomatic of post-traumatic stress disorder or rape trauma syndrome. Because victims of sexual abuse are likely to be cognitively impaired, practitioners must consider additional effects of abuse. Often cognitively impaired individuals are unable to describe the assault event, the fears, or the feelings of helplessness. This makes it more difficult to provide these victims with necessary services because they are unable to express their needs. In addition, victims suffering from dementia, including Alzheimer's disease, often display post-rape emotional distress, including disorganized or agitated behaviors, sleep disturbance, and extreme avoidance of certain staff members. Research shows that sexual abuse may increase the victim's mortality. Injuries, but more significantly stress, from the assault may exacerbate other health conditions of the victim, such as hypertension and diabetes. http://scholarship.law.[NAME].edu/cgi/viewcontent.cgi?article=1066&context=elders In Sexual Abuse of Older Nursing Home Residents: A Literature Review, the authors note the statement by the World Health Organization, Regardless of the type of abuse [psychological, physical, sexual, financial, and neglect], it will certainly result in unnecessary suffering, injury or pain, the loss or violation of human rights, and a decreased quality of life for the older person https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4302365/ Although R20 did not immediately display reactions or behaviors, a reasonable person who has been sexually assaulted could feel Recurrent (i.e., more than isolated or fleeting) debilitating fear/anxiety that may be manifested as panic, immobilization, screaming, and/or extremely aggressive or agitated behavior(s) (e.g., trembling, cowering) in response to an identifiable situation (e.g., approach of a specific staff member.) A person who has been sexually assaulted could also experience Ongoing, persistent expression of dehumanization or humiliation in response to an identifiable situation . The facility's failure to prevent R20 from being allegedly sexually abused by visitor I, the failure of not immediately reporting the allegation of sexual abuse and not protecting R20 from further alleged sexual abuse created a reasonable likelihood for serious harm, thus resulted in a finding of an immediate jeopardy which was removed on 8/14/23 when; - A Root Cause Analysis was completed on August 10, 2023. - A Quality Assurance Committee Meeting was completed on August 11, 202 - The interdisciplinary team was educated on social history assessments, Trauma assessments, and notification of physician on August 11, 2023 - R20 did not show any signs or voice any fear, anxiety or trauma response. R20's social history was completed and care plan updated on 8/14/23 based on the social history. - No other residents were found affected by delinquent practice. - All residents are at risk for potential abuse. - All other residents were audited and a social history was completed and care plans updated as needed as of 8/14/23. - Review of the policies titled: Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy. The reasonable suspicion of a crime reporting requirement was posted at both time clocks and remains posted in break room. - Staff education was provided by Executive Director and Director of Nurses starting on August 9, 2023 on Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, Reasonable Suspicion of a Crime Mandatory and the requirement of reporting to law enforcement, administrator, and DQA. - A post quiz and signed acknowledgement of understanding of the Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy and Program, Reasonable Suspicion of a Crime and Mandatory requirement of reporting. - Director of Nursing and or designee will audit 5 resident record for 3 weeks and then after 5 times for 3 months the following new admission to validate that Social History were completed on new admissions and assessments reflected in care plan reporting any findings to the Quality Assurance Performance Improvement committee (QAPI). - Administrator and or designee will audit 5 staff members for 3 weeks and then 5 staff members for 3 months on their understating of the Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy and Program, and Reasonable Suspicion of a Crime Mandatory requirement of reporting, and will report findings to QAPI committee.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act for 1 (R20) of 1 residents reviewed where an allegation of abuse was not reported as a suspicion of a crime to law enforcement, and where 2 (R20 and R30) of 3 residents reviewed for allegations of abuse was not reported immediately, but not later than 2 hours to the state agency, and steps were not immediately taken to prevent further potential abuse. On 7/21/23, Certified Nursing Assistant (CNA-D), observed a visitor (Visitor I) inappropriately touching R20, with his hand between R20's legs and on R20's vagina. CNA-D did not immediately report this allegation of sexual abuse as a suspicion of a crime to the Nursing Home Administrator (NHA-A) or designee. The failure of CNA-D to notify NHA-A of a suspicion of a crime resulted in the facility and CNA-D not immediately reporting this allegation of sexual abuse as a suspicion of a crime to law enforcement. The facility policy for suspicion of a crime is to immediately report to law enforcement to be investigated. The failure of CNA-D to immediately report this allegation of sexual abuse resulted in the facility not reporting this allegation of abuse to the state agency within 2 hours. The failure of CNA-D to immediately report this allegation of sexual abuse allowed Visitor I to remain in the facility and later on 7/21/23 he was observed in a darkened room with his hand under the covers while R20 was in bed. For the second time on 7/21/23, CNA-D did not report the observations of alleged sexual abuse immediately to the Administrator or designee. The facility and CNA-D did not immediately report to law enforcement as per facility policy this allegation of sexual abuse as a suspicion of a crime and the facility was not able to report to the state agency the allegation of sexual abuse within 2 hours. The failure to report this allegation of sexual abuse allowed Visitor I to be able to visit with R20 one more time (on 7/23/23) before CNA-D reported the allegation of sexual abuse to Director of Nursing (DON)-B on 7/24/23. The facility failed to protect R20 from further potential sexual abuse by not immediately reporting this allegation as a suspicion of a crime to law enforcement and to the state agency. On 7/24/23 the police were notified and indicated they would respond the following day. On 7/25/23 the police responded to the facility and indicated there was not enough evidence for a sexual assault nurse examiner partly due to the delay in reporting. Failure to report the allegation to the police did not allow for a full investigation into the allegation. The facility's failure to report this allegation of sexual abuse as a suspicion of a crime to law enforcement and to the State Agency within 2 hours resulted in the failure to protect R20 and other residents from further potential sexual abuse, which created a finding of Immediate Jeopardy, which began on 7/21/23. On 8/9/23, at 3:42 PM, NHA-A and DON-B were informed of the Immediate Jeopardy. The immediate jeopardy was removed on 8/12/23. The deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement and monitor its action plan and as evidence by: * R30 reported a Certified Nursing Assistant (CNA) was rough with R30 when assisting with putting a shirt on. R30 stated the CNA grabbed R30's arm to put it through the sleeve and when R30 told the CNA she was hurting R30, the CNA told R30 to Suck it up, I'm almost done getting your top on. I know it hurts but that's the way things are. R30 reported this allegation of abuse to the Therapy Department Program Manager - RR, who in turn reported this allegation of abuse to Director of Nursing (DON)-B. DON-B did not immediately report this allegation to the Administrator who was informed of the allegation a few days after it had been reported to the DON-B. In addition this allegation of abuse was not immediately reported to the state agency. Findings include: Surveyor reviewed the facility's Policy and Procedure on Abuse, Neglect, Mistreatment and Misappropriation of Resident Property, last revised 12/1/22. .Procedure: (includes in part .) E. The facility will encourage and support all individuals, staff, families, visitors, volunteers, and individual representatives in reporting any suspected acts of abuse to the Administrator or designee. F. The Administrator or designee will report abuse to the state agency per State and Federal guidelines. G. The facility will follow the attached comprehensive abuse, neglect, mistreatment and misappropriation of Resident property program to comply with the seven step approach to abuse and neglect detection and prevention. H. The abuse policy and comprehensive abuse, neglect, mistreatment and misappropriation of Resident property program will be reviewed on at least an annual basis and will be integrated into the facility quality assurance and performance improvement program. Overview of Seven components -Screening -Training -Prevention -Identification -Investigation -Protection -Reporting and Response Investigation It is the policy of this facility that reports of abuse are promptly and thoroughly investigated through the organization's QAPI (Quality Assurance Performance Improvement) Incident Report and Investigation process. Additional Investigation Protocols -Law Enforcement: All reports of suspected crime and/or alleged sexual abuse must be immediately reported to law enforcement to be investigated. Protection It is the policy of this facility that the Resident(s) will be protected from the alleged offender. Procedure: Immediately upon receiving a report of alleged abuse, Administrator (NHA-A) and or designee will coordinate delivery of appropriate medical and/or psychological care and attention. Ensuring safety and well-being for the vulnerable Resident are of utmost priority. Safety, security, and support of the Resident, roommate, if applicable and other Residents with the potential to be affected will be provided. i. The alleged perpetrator will immediately be removed and Resident protected. ii. If a family member or Resident representative is possibly contributing to the potential abuse and the Resident could be at risk, evaluate the situation and identify options to put into place for Resident protection. iv. Examine, assess and interview the Resident and other Residents potentially affected immediately to determine any injury and identify any immediate clinical interventions necessary. Notify Resident physician. v. Life Coach or designee should keep in frequent contact with the Resident and/or Resident representative. vii. Notification of law enforcement and/or State Agency viii. A medical, evidentiary, or sexual assault exam should be completed as possible, as appropriate. Reporting and Response It is the policy of this facility that abuse allegations are reported per Federal and State Law. The facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of Resident property, are reported immediately, but no later than 2 hours after the allegation is made. Internal Reporting: a. Employees must always report any abuse or suspicion of abuse immediately to the Administrator (NHA-A). **Note: Failure to report can make employee just as responsible for the abuse in accordance with State Law. External Reporting Law Enforcement: All reports of suspected crime and/or alleged sexual abuse must be immediately reported to law enforcement to be investigated. Employee rights will be posted (identify conspicuous location) . 1. R20 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Dysphagia, Adult Failure to Thrive, Unspecified Dementia, Unspecified Severity without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, Anxiety, and Cognitive Communication Deficit. R20 has an activated Health Care Power of Attorney (HCPOA). R20's admission Minimum Data Set (MDS) dated [DATE] documents R20's Brief Interview for Mental Status score to be 11, indicating R20 demonstrates moderately impaired skills for daily decision making. R20 has no behaviors and R20's PHQ-9 score is 6, indicating R20 has minimal depression. R20's MDS also assesses R20 as requiring extensive assistance of one for bed mobility, transfers, dressing, and toileting. R20 requires supervision for eating. R20 has both upper and lower range of motion impairment on one side. R20 resided on the long-term care unit on the 2nd floor. On 8/9/23 at 10:49 AM, CNA-WW informed Surveyor that the rehabilitation unit is quiet and the second floor can be more busy and chaotic at times and CNA-WW stated it can be hard to monitor visitors up on the second floor. On 8/8/23 at 11:25 AM and again on 8/8/23 at 2:18 PM, Surveyor interviewed CNA-D regarding the allegation of sexual abuse. During Surveyor's interviews, CNA-D reported that on 7/21/23, R20 was eating in the dining room and Visitor I was sitting with R20 at the table. Visitor I informed staff that R20 needed to be toileted and he offered to assist. CNA-D was assisting other residents and at approximately 7:20 PM, she heard noise in R20's bathroom, entered the bathroom, and found R20 sitting on the toilet in a nightgown and observed Visitor I's hand between R20's legs and on R20's vagina. CNA-D's statement included that Visitor I had changed R20 out of R20's clothes. Surveyor asked CNA-D if Visitor I had a wipe or toilet paper in their hand and CNA-D said No. CNA-D felt Visitor I was clearly sexually inappropriately touching R20 and told Surveyor that their hand was on R20's vagina. CNA-D had Visitor I leave the bathroom and she completed toileting for R20, putting her to bed afterwards. Another CNA entered the room with R20's roommate and the CNAs asked Visitor I to leave the room so they could put the roommate to bed. Visitor I remained in the hallway outside R20's door. At this point, CNA-D had not reported the incident in the bathroom to anyone, the police were not contacted, and Visitor I remained in the facility. The CNAs exited the room and Visitor I went back into the room. CNA-D returned about 5-6 minutes later and thought it was unusual that the lights were out in R20's room. CNA-D entered the room, turned the lights on, and saw Visitor I's hand under R20's covers. CNA-D stated Visitor I jerked their hand from under the covers as if startled. CNA-D observed Visitor I begin walking to the elevator. Visitor I then returned to the room to retrieve a bag and left the room. CNA-D is uncertain at what point Visitor I left the facility. CNA-D stated that CNA-D informed a Licensed Practical Nurse (LPN-C) of the observations. On 8/9/23 at 11:24 AM, Surveyor interviewed LPN-C who denies ever being made aware of the allegations of sexual abuse. LPN-C reiterated had LPN-C been made aware of the allegations, LPN-C would have immediately reported it to the NHA-A. On 8/8/23 at 12:52 PM, Surveyor interviewed DON-B. DON-B confirmed that on 07/24/23, 3 days after the observations of alleged sexual abuse, CNA-D reported the allegations to DON-B. DON believes it was reported on 7/24/23 after 3:30 PM but before 4:00 PM. Surveyor notes the Alleged Nursing Home Resident Mistreatment, Neglect, and Abuse Report dated 7/24/23 was submitted at 5:46 PM. The Misconduct Incident Report was submitted on 7/28/23 at 4:47 PM. On 7/24/23, 3 days after the observations, CNA-D reported the incidents to DON-B. HCPOA-H was notified, and the police department was called. At 11:00 PM that night, the police notified the facility they would not be coming until the next day. On 7/25/23, the police responded to the facility and indicated there was not enough evidence for a SANE evaluation (Sexual Assault Nurse Examiner) in part due to the delay in reporting. Surveyor asked NHA-A on 8/8/23 at 11:46 AM during an interview why R20 was not sent out to the emergency room (ER) when notified of the alleged sexual abuse. NHA-A stated the family did not want R20 to go. There is no documentation indicating a conversation about R20 going to the ER was discussed with HCPOA-H. The case has been referred to the District Attorney. On 8/8/23 at 3:05 PM, Surveyor toured the two-time clock areas and did not find any posting instructing employees on reporting any suspicion of a crime. On 8/9/23 at 8:20 AM, Maintenance Lead (ML)-F brought Surveyor to a break room and ML-F showed Surveyor a poster hanging in the break room instructing employees to report any suspicion of a crime immediately. Surveyor asked ML-F if everybody uses this break room and ML-F said No, not everybody. ML-F does not know if there is one designated person to go and report a suspicion of a crime to. The facility's reported self-report submitted to the state survey agency, states the facility was unable to validate if the allegation of sexual abuse occurred. This decision is based on that all interviews from staff showed no observations of inappropriate behavior from Visitor I with the exception of CNA-D. On 8/8/23 at 2:31 PM, Surveyor shared the serious concern with NHA-A and DON-B that the facility failed to protect R20 from any further potential incidents of sexual abuse by the lack of immediate reporting. Surveyor shared that after the first initial observation of alleged sexual abuse by CNA-D, CNA-D did not immediately report this allegation of sexual abuse to the Nursing Home Administrator or designee and did not report this allegation of abuse as a suspicion of a crime. Surveyor indicated the facility did not report this allegation of sexual abuse as a suspicion of a crime to law enforcement and did not report this allegation of sexual abuse to the state agency within 2 hours. CNA-D observed a second incident of alleged sexual abuse by Visitor I on 7/21/23 and again failed to immediately report this allegation of sexual abuse to the Nursing Home Administrator and/or designee and failed to report the sexual abuse as a reasonable suspicion of a crime to law enforcement. Surveyor shared Visitor I visited one more time before CNA-D reported the allegations, leaving R20 and possibly other residents vulnerable to further potential sexual abuse. Surveyor shared that the police investigation was hampered by the fact the allegation of sexual abuse was not reported until 3 days later. On 8/9/23 at 9:44 AM, NHA-A and DON-B spoke with Surveyor about the serious concern involving R20 and the alleged incident of sexual abuse. Both NHA-A and DON-B stated that R20 did not show signs of trauma. NHA-A and DON-B informed Surveyor that both NHA-A and DON-B do not believe the alleged incident of sexual abuse occurred. NHA-A stated, NHA-A is livid it was not reported immediately, and the facility did their job to educate staff on abuse. According to the National Institute on Aging (NIH), Elder Abuse, abuse can happen to anyone, no matter the person's age, sex, race, religion or ethnic background. Each year hundreds of thousands of adults over the age of 60 are abused, neglected, or financially exploited. This mistreatment is called elder abuse. Abuse can happen anywhere, including in the older person's home, a family member's home, an assisted living facility or a nursing home. The mistreatment of older adults can be by family members, strangers, health care providers, caregivers, or friends .Abuse can happen to any older adult. Most victims of abuse are women, but some are men. Older adults without family or friends nearby and people with disabilities, memory problems, or dementia may be more vulnerable to abuse. Mistreatment most often affects those who depend on others for help with activities of everyday life- including bathing, dressing and taking medicine . Most importantly, if you suspect an older person is being abused, report what you see to an authority. Many adults are too ashamed to report mistreatment. Or they're afraid if they make a report, it will get back to the abuser and make the situation worse. Therefore, family and friends must step in to address problems . Some types of elder abuse may be criminal. You do not personally need to prove the abuse is occurring: professionals will investigate. Many local, state, and national social service agencies can help. These include: Adult Protective Services . The National Center on Elder Abuse . Long-term care ombudsman . http:// www.nia.nia.gov/health/elder-abuse, July 21, 2023 Although R20 did not immediately display reactions or behaviors as a result of this allegation of sexual abuse, it should be noted however, given R20's history of abuse, she may have been used to being abused and that this was a familiar pattern to which she was accustomed. Her reaction was markedly incongruent to what a reasonable person might experience. Using the reasonable person concept a reasonable person who has been sexually assaulted would want the involvement of law enforcement, would want the option to be evaluated by a sexual assault nurse examiner and would want the protection from the facility against any further sexual abuse. The facility's failure to protect R20 from further potential sexual abuse, the facility's failure to immediately report this allegation of sexual abuse as a suspicion of a crime to law enforcement as per facility policy, and to report to the state agency within 2 hours resulted in a finding of an immediate jeopardy. The immediate jeopardy was removed on 8/12/23 when: * A Root Cause Analysis was completed on August 10, 2023. * A Quality Assurance Committee Meeting was completed on August 11, 2023. * R20's social history was completed, and care plan updated based on the social history. All other residents were audited, and a social history was completed, and care plans updated as needed. No other residents were found affected by delinquent practice. * Staff education was provided by Executive Director and Director of nurses was started on August 9, 2023 on Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy and Program, Reasonable Suspicion of a Crime Mandatory requirement of reporting to law enforcement, administrator, and to the Division of Quality Assurance (DQA). A post quiz and signed acknowledgement of understanding of Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy and Program, and Reasonable Suspicion of a Crime Mandatory requirement of reporting. * The Interdisciplinary Team was education on social history assessments, Trauma assessments, notification of physician on August 11, 2023. * Review of the policies titled: Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy. * The reasonable suspicion of a crime reporting requirement was posted at both time clocks and remains posted in break room. * DON and or designee will audit 5 resident record for 3 weeks and then after 5 times for 3 months the following new admission to validate that Social History were completed on new admissions and assessments reflected in care plan reporting any findings to QAPI. * Administrator and or designee will audit 5 staff members for 3 weeks and then 5 staff members for 3 months on their understating of the Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy and Program and Reasonable Suspicion of a Crime Mandatory requirement of reporting. * Findings from the audits will be reported to the Quality Assurance Performance Improvement committee. The deficient practice continues at a scope and severity level of D (potential for harm/isolated as evidenced by: 2. R30 was admitted to the facility on [DATE] with diagnoses of right humerus fracture, compression fracture of the spine, diabetes, anxiety, depression, peripheral vascular disease, and anemia. R30's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R30 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 and the facility assessed R30 as needing extensive assistance with bed mobility, transfers, and toilet use, and limited assistance with dressing and hygiene. R30 did not have an activated Power of Attorney. On 8/14/2023 at 10:07 AM, Surveyor met R30 in R30's room. R30 had the right arm in a sling and R30 stated R30 had broken the arm when R30 fell at home. R30 stated about two weeks ago a Certified Nursing Assistant (CNA) was rough with R30 when helping put a shirt on. R30 stated the CNA grabbed R30's arm to put it through the sleeve and when R30 told the CNA she was hurting R30, the CNA told R30 to Suck it up, I'm almost done getting your top on. I know it hurts but that's the way things are. Surveyor asked R30 if R30 had told anyone when it had happened. R30 stated R30 told Therapy Department Program Manager (TDPM)-RR. Surveyor asked R30 if R30 knew the name of the CNA that hurt R30. R30 could not recall the CNA's name. Surveyor asked R30 if anyone came to talk to R30 after R30 reported the incident to TDPM-RR. R30 stated someone from administration came and talked to R30 after it was reported but could not remember what the staff member's name was. Surveyor asked if R30 saw the CNA after the incident was reported. R30 stated R30 was in the dining room later and the CNA stayed away from R30. R30 stated the incident happened about two weeks ago and had not seen the CNA since then. R30 felt the problem was resolved but stated the CNA that did that to R30 commands everybody so what this CNA says goes and other staff follow. R30 stated R30 felt safe before that happened but does not feel safe now because R30 is wondering which CNA will be next to hurt R30. R30 stated, You don't get over something like that right away. On 8/14/2023 at 3:01 PM, Surveyor requested from Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B all facility reported incidents that had occurred in the last month. No reports involving R30 were provided. In a phone interview on 8/15/2023 at 9:59 AM, Surveyor asked TDPM-RR if R30 had reported to TDPM-RR any problems with a CNA. TDPM-RR stated R30 had reported a couple of weeks ago to TDPM-RR and a physical therapy assistant that a CNA had been very rough with R30. TDPM-RR stated TDPM-RR reported the allegation to DON-B immediately and was later told DON-B and Nurse Supervisor-HH went to see R30 and did not know what the conversation was with them. TDPM-RR stated the facility had a Care Conference right after that and as far as TDPM-RR knew, the issue was resolved. In an interview on 8/15/2023 at 1:31 PM, Surveyor asked NHA-A if NHA-A was aware of R30's allegation of abuse. NHA-A stated NHA-A was not aware of the allegation until a few days after it was reported to DON-B. Surveyor asked NHA-A why the allegation of abuse was not reported to the State Agency. NHA-A stated DON-B said it was not reportable. In an interview on 8/15/2023 at 1:39 PM, Surveyor asked Life Coach (LC)-K what the facility process was for an allegation of abuse. LC-K stated the abuse is reported to NHA-A and NHA-A will let nursing know about the allegation. Nursing will do the investigation. Surveyor asked LC-K who files the reports with the State Agency? LC-K stated NHA-A does all the reportable incidents. LC-K stated staff should report the allegation as soon as possible and they must verbally tell administration what the situation is, they can't just leave a note, it must be verbally reported. In an interview on 8/16/2023 at 7:50 AM, Surveyor asked DON-B why DON-B did not feel the allegation of abuse by R30 was reportable. DON-B stated when DON-B was talking to R30 about the allegation, R30 did not know the CNA's name and could not describe the CNA. DON-B asked R30 if the CNA was just going too fast and rushing R30 as opposed to hurting R30 on purpose. DON-B stated R30 said R30 supposed it was from rushing so DON-B determined it was not abuse and was just a customer service issue. Surveyor noted DON-B asked leading questions when interviewing R30 about the allegation of abuse. On 8/16/2023 at 11:14 AM, NHA-A stated the allegation of abuse involving R30 was reported to the State Agency that morning. No further information was provided at that time.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 5 (R137, R31, R88, R21, & R87) of 5 Residents reviewed for pressure injuries. * On 1/24/2023, R137 developed a Stage 3 pressure injury to the coccyx and a Stage 3 pressure injury to the right ear A treatment was not started until 3 days later on 1/27/23. The pressure injury resolved on 2/7/23. On 1/31/2023 the Stage 3 pressure injury to the coccyx became Unstageable and no treatment was implemented at that time. The coccyx pressure injury became infected and was treated with antibiotics. A treatment for the coccyx pressure injury was not implemented until 14 days after discovery. An order was received for Santyl on 2/7/23. From 2/8/2023 to 2/28/2023, the treatment of Santyl was not administered as ordered. Staff instead treated the pressure injury with wound gel as the facility did not have Santyl. Neither Wound NP-O nor the physician were not notified of missing treatments or treatment alterations provided by staff. * On 3/24/2023 R31 was admitted to the facility with a pressure injury. The facility did not complete an assessment, including measurements or characteristics and no interventions were implemented on the baseline Care Plan. On 3/30/2023, 6 days after admission, a treatment order was obtained. On 4/4/2023, 11 days after admission, Wound NP-O did an initial assessment of the Stage 3 pressure injury and wrote orders for treatment. The treatment order was not transcribed onto the Treatment Administration Record (TAR), and the Stage 3 Pressure Injury Care Plan was not initiated. On 4/18/2023, R31's pressure injury became Unstageable. Wound NP-O ordered a new treatment. That treatment was not transcribed onto the TAR, and the recommendation of bed rest for one week was added to the TAR for three days but with documentation bed rest was not followed on those three days. On 4/25/2023, the ordered treatment was not transcribed onto the TAR. On 5/2/2023, R31's Unstageable pressure injury became infected requiring antibiotics, and the treatment was not signed out as being provided as ordered. From 5/9/2023 to 5/30/2023 Wound NP-O's weekly treatment order was not transcribed onto the TAR. On 5/30/2023 the treatment order was transcribed but facility staff did not sign out the treatments as being completed as ordered. * R88 was admitted to the facility on [DATE]. The admit/readmit screen dated 6/14/23 completed by an LPN (Licensed Practical Nurse) documents two - Stage 2 coccyx pressure injuries. There is no RN assessment and no treatment ordered until 6/20/23, six days later. The Wound Nurse Practitioner's (NP's) initial evaluation dated 6/20/23 documents a deep tissue injury to the sacrum with measurements of 11.5 cm (centimeters) x 10.5 cm x 0.1 cm. R88 was discharged to the hospital on 6/21/23 and readmitted on [DATE]. The Wound NP-O's note dated 6/27/23 documents an unstageable sacrum pressure injury with measurements of 10.0 cm x 10.0 cm x 0.1 cm and an unstageable pressure injury to the right shoulder. Although the facility began a baseline care plan, it was marked as in process and no interventions were included. Nurses notes on 6/30/23 and 7/4/23 documents the pressure injury has a foul odor and slough present. On 7/5/23 Wound NP-O assessed R88's sacrum pressure injury as Stage 4. There was a change in treatment which the Facility did not implement. On 7/12/23 the Wound NP ordered Cipro 500 mg (milligrams) twice daily for two weeks and Penicillin 500 mg twice daily for two weeks for wound infection. The facility also completed an actual skin integrity care plan on this date, which is nearly a month after R88 was first admitted with a pressure injury. On 7/25/23 R88 was identified with an unstageable left buttock pressure injury and a treatment was ordered. The treatment for R88's sacrum was changed on this date also. The facility did not pick up either order. R88 was discharged to the hospital on 7/26/23. The Facility's failure to provide care to prevent the development of pressure injuries and promote the healing of pressure injuries for R137, R88, & R31 including the failure to develop &/or update resident's pressure injury care plans and the failure to implement and carry out treatments in accordance with physician/nurse practitioner orders created a finding of Immediate Jeopardy (IJ) which began on 2/7/23. Surveyor notified NHA (Nursing Home Administrator)- A & DON (Director of Nursing)-B of the immediate jeopardy on 8/9/23 at 3:43 p.m. The immediate jeopardy was removed on 8/12/23. The deficient practice continues at a scope and severity of G (actual harm/isolated) related to the examples involving R21 & R87 and as the Facility continues to implement its action plan. * R21 was admitted to the facility on [DATE] without any pressure injuries. The Braden scale dated 12/2/22 documents moderate risk for pressure injury development. An at risk for pressure injury care plan was developed on 12/29/22. There were no interventions to offload R21's heels. The nurses note written by an LPN (Licensed Practical Nurse) on 1/13/23 documents a half dollar size blister on the left heel. There was no RN (Registered Nurse) assessment until 1/17/23, four days later, there were no revisions to R21's at risk for pressure injury care plan and an actual pressure injury care plan was not developed until 3/22/23. Surveyor was unable to locate an assessment for the week of 2/12/23 to 2/18/23. On 2/16/23 an LPN documented a lesion to R21's inner thigh fold. There was no RN assessment until 5 days later. On 2/21/23 NP-O's wound assessment documents R21's heel wound separated into 2 wounds. Unstageable left lateral heel, Stage 3 left posterior heel and an unstageable pressure injury to the right inner thigh. There was no revision in R21's at risk for pressure injury care plan and the actual pressure injury care plan was not developed until 3/22/23. * R87 was admitted to the facility on [DATE] without any pressure injuries. A Braden assessment completed on 6/16/22 & 7/3/22 identified R87 at risk for pressure injury development. On 7/4/22 a nurses note includes documentation of a dressing intact to the left heel blister. There is no documentation as to when this pressure injury developed although NP-O's wound note dated 7/5/22 documents the wound to left heel was discovered this past weekend. A pressure injury care plan was not developed until 10/10/22. R87 was hospitalized from [DATE] to 7/13/22. The admit/readmit screen completed by an LPN on 7/13/22 documents unstageable left heel pressure injury with measurements of 4 cm x 6 cm. There was no RN assessment until 5 days later. On 9/15/22 an LPN documents the left heel has yellowish/green foul smelling slough. There was no RN assessment until 5 days later and no physician notification. On 9/30/22 and 10/2/22 an LPN documents foul odor with the ADON (Assistant Director of Nursing) being notified. There was no RN assessment. On 10/4/22 R87 was identified with a DTI (deep tissue injury) to left Hallux (great toe). A pressure injury care plan was not developed until 10/10/22. Findings include: The facility's Pressure Injury Prevention and Managing Skin Integrity policy & procedure last reviewed 6/24/22 under policy documents Prevention measures are put in place to reduce the occurrence of pressure injuries. Under Procedures there are 5 sections. 1. Risk Assessment, 2. Identify Interventions and Care Plan, 3. Skin Checks, 4 Weekly Wound Rounds and 5. Administrative Review. Section 2 documents: a. Identify Interventions i. The care and intervention for any identified skin breakdown or wound is intended to prevent. further advancement of the wound or additional skin breakdown. 1. There will be collaboration with the interdisciplinary team (IDT) regarding the presence of breakdown and the intervention plan. 2. When indicated a referral to additional resources (i.e Wound Care Specialist, Registered Dietician, Physical Therapist, Occupational Therapist) may occur. 3. Identification of risk factors present or acquired that compromise skin integrity will be considered. b. Care Plan i. In developing a plan of care, the following will be considered: 1. Individual Pressure Injury History 2. Cognitive changes or impairment of the individual 3. Current state of skin integrity and personal hygiene practices of the individual that impact skin health. 4. Any cultural practices that impact the health or integrity of the skin. 5. Risk for pressure ulcer development (Braden Scale). 1.) R137 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, protein-calorie malnutrition, depression, anxiety, anemia, and compression fracture of the spine. R137's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R137 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 and the facility assessed R137 as needing limited assistance with bed mobility, transfers, dressing, and hygiene. R137 did not have an activated Power of Attorney. R137 was discharged from the facility on 3/8/2023 and was not a resident of the facility at the time of the survey. On 1/12/2023 at 7:48 PM in the progress notes, nursing charted R137 did not have any skin impairments on admission. Surveyor noted no comprehensive admission assessment was documented when R137 was admitted to the facility and the Baseline Care Plan, started by nursing staff on 1/12/2023, was in progress and never completed or implemented while R137 was in the facility. On 1/13/2023, R137 had an order for Ensure 8 ounces daily as a nutritional supplement. On 1/16/2023, R137's Braden score was 21 indicating R137 was not at risk for developing a pressure injury. On 1/20/2023, R137 had an order for Health Shake 4 ounces daily as a nutritional supplement. On 1/21/2023, R137 had an order for ProSource 30 cc daily as a nutritional supplement. On 1/24/2023, R137 was seen by Wound Nurse Practitioner (NP)-O. Wound NP-O documented R137 had a Stage 3 pressure injury to the coccyx that measured 1.6 cm x 2.5 cm x 0.1 cm with 100% granulation. A treatment was ordered for bordered foam to be changed three times a week and a recommendation was made for an alternating pressure mattress. Wound NP-O also documented R137 had a Stage 3 pressure injury to the right ear that measured 0.5 cm x 0.5 cm x 0.1 cm with a dry yellow wound base with no drainage. A treatment was ordered for foam to the area and to check placement every shift. Wound NP-O documented the current interventions in place were a pressure relieving cushion for sitting, an up and down schedule of back to bed after lunch and up for dinner and elevate heels off the bed with pillows. Surveyor reviewed the Treatment Administration Record (TAR) and no treatment for the coccyx or right ear was documented as being implemented on 1/24/2023. R137's Pressure Injury Care Plan was initiated on 1/24/2023 with the following interventions: -Administer medications as ordered; monitor/document for side effects and effectiveness. -Administer treatments as ordered and monitor for effectiveness. -Educate (R137)/family/caregivers as to causes of skin breakdown including transfer/positioning requirements, importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning. -Follow the facility policies/protocols for the prevention/treatment of skin breakdown. -Inform (R137)/family/caregivers of any new area of skin breakdown. -Monitor nutritional status; serve diet as ordered; monitor intake and record. -Staff to assist with routine toileting and skin care for incontinence. -Staff to assist with turning and repositioning. On 1/25/2023 at 1:06 PM in the progress notes, nursing charted barrier cream was applied to the buttocks for breakdown prevention. Surveyor noted the treatment ordered by Wound NP-O was not provided to the coccyx or ear. On 1/27/2023, the orders written by NP-O were first entered on the TAR. The orders included to lay down after lunch and get back up for dinner daily. R137 had an order for a treatment to the open area behind the right ear: soap and warm water wash, pat dry, apply foam, check placement every shift; if not present, reapply. On 1/31/2023, R137 was seen by Wound NP-O. Wound NP-O documented the pressure injury to the coccyx had declined. The now Unstageable pressure injury measured 3.5 cm x 3.5 cm x 0.1 cm with 100% slough to the wound base and was deep purple in color with moderate serous drainage. The treatment order was changed to Medihoney on bordered foam, changed three times a week. Wound NP-O again recommended an alternating pressure mattress and to be up no longer than two hours at a time. Surveyor noted Wound NP-O had recommended an alternating pressure mattress on 1/24/2023 that was not implemented. Wound NP-O documented R137's Stage 3 pressure injury to the right ear measured 0.4 cm x 0.4 cm x 0.1 cm with a pink base and no drainage. Wound NP-O continued with the original treatment to the area and since R137 was no longer on oxygen, Wound NP-O anticipated the right ear wound would heal in the next week or so. Surveyor noted NP-O's treatment change to the coccyx pressure injury was not entered onto the TAR on 1/31/2023. R137's Pressure Injury Care Plan was revised on 2/1/2023 to include the following intervention: -Air mattress to bed due to pressure injury. On 2/1/2023 at 7:50 PM in the progress notes for the daily Medicare charting, nursing charted the coccyx wound had slough noted and was cleansed and redressed with a foam dressing per order. At 8:08 PM in the progress notes, nursing charted R137 complained of discomfort to the coccyx and the affected area was cleansed with normal saline followed by Medihoney and a foam dressing. Surveyor noted R137 did not have any documented orders for a treatment to the coccyx on the TAR. On 2/2/2023 at 1:17 PM in the progress notes, nursing charted R137 had discomfort to the coccyx wound and a treatment was done with some visible slough and no redness or signs or symptoms of infection. At 7:21 PM in the progress notes for the daily Medicare charting, nursing charted R137's coccyx wound was cleansed with normal saline. Visible slough with no foul odor was noted. Skin prep to the peri wound was applied and Medihoney to the wound bed and covered with a foam dressing. Surveyor noted R137 did not have any documented orders for a treatment to the coccyx on the TAR. On 2/3/2023 at 3:05 PM in the progress notes, nursing charted the dressing to the coccyx wound was changed and intact with no signs or symptoms of infection. On 2/4/2023 at 1:44 PM in the progress notes, nursing charted a treatment was applied and the dressing was intact to the coccyx wound with no visible signs or symptoms of infection. At 10:44 PM in the progress notes for the daily Medicare charting, nursing charted the treatment was applied to the coccyx wound; the affected area was cleansed with wound cleanser, visible slough and no foul odor was noted, skin prep to the peri wound followed by Medihoney to the wound bed and a foam dressing was applied. At 11:54 PM in the progress notes, nursing charted the same information regarding the treatment to R137's coccyx wound that had been charted at 10:44 PM. Surveyor noted R137 did not have any documented orders for a treatment to the coccyx on the TAR. On 2/5/2023 at 7:08 PM in the progress notes, nursing charted R137's coccyx wound had visible slough and no foul odor. The affected area was cleansed with normal saline followed by Medihoney and foam dressing. At 10:14 PM in the progress notes for the daily Medicare charting, nursing charted the same information that had been charted at 7:08 PM. Surveyor noted Wound NP-O had ordered the dressing to be changed three times a week and per the progress notes, nursing had been changing the dressing daily if not more than once a day. With no order transcribed onto the TAR to be signed out when completed, Surveyor was unable to determine when or how often the treatment was being done, if the charting was that nurse's personal assessment, if they completed the treatment at the time of the charting, or if the information was being passed along from other nurses on previous shifts. On 2/7/2023, R137 was seen by Wound NP-O. Wound NP-O documented the coccyx wound was evolving and continued to be an Unstageable pressure injury that measured 3.9 cm x 3.2 cm x 0.1 cm with 100% slough with moderate serosanguineous drainage. The peri wound had erythema (reddening) and had slight warmth. The treatment order was changed to Santyl on bordered foam to be changed daily. Wound NP-O documented the coccyx wound was infected and ordered Doxycycline 100 mg twice daily for ten days. Wound NP-O documented the pressure injury to the right ear had resolved. Surveyor noted staff had not been following the treatment orders given by Wound NP-O from 1/24/2023 through 2/6/2023 and subsequently the Unstageable pressure injury became infected requiring antibiotics. On 2/7/2023 on the TAR, a treatment order for the coccyx was entered to wash wound with wound cleanser, pat dry followed by Santyl followed by a foam border dressing daily. This was the first treatment order on the TAR since the wound was discovered on 1/24/2023, 14 days later. On 2/8/23 the ProSource and Ensure supplements that R137 was receiving for malnutrition were discontinued and Health Shake, 4 ounces, three times a day was ordered. On 2/8/2023 at 12:48 PM in the progress notes, nursing charted R137's dressing was changed due to the bandage being soiled. On 2/8/2023, 2/9/2023, 2/10/2023, and 2/13/2023 on the TAR, Santyl was not available in the facility. No documentation was found that Wound NP-O or the physician were notified that the Santyl was unavailable. On 2/9/2023 at 8:41 PM, on 2/10/2023 at 7:13 PM, and on 2/13/2023 at 11:03 PM in the progress notes, nursing charted the coccyx wound was cleansed with wound cleanser followed by topical wound gel and covered with a foam dressing. No documentation was found indicating Wound NP-O or a physician were consulted with regarding wound gel being applied instead of the ordered Santyl. On 2/14/2023, R137 was seen by Wound NP-O. Wound NP-O documented the Unstageable pressure injury to the coccyx had improved and measured 3.5 cm x 2.5 cm x 0.1 cm with 100% slough with moderate serosanguineous drainage. Wound NP-O continued the treatment of Santyl on bordered foam daily. No documentation was found that Wound NP-O was aware the Santyl had not been applied and was unavailable or that wound gel had been used on the wound instead of the Santyl. R137's Pressure Injury Care Plan was revised on 2/14/2023 to include the following interventions: -Assess/record/monitor wound healing weekly by the wound team; measure length, width, and depth where possible; assess and document status of wound perimeter, wound bed, and healing progress; report improvements and declines to the physician. -Monitor the dressing every shirt to ensure it is intact and adhering; report loose dressing to treatment nurse. -(R137) needs assistance of one to turn/reposition at least every 2 hours, more often as needed or requested. -(R137) requires supplemental protein, amino acids, vitamins, minerals as ordered to promote wound healing. -Treat pain as per orders prior to treatment/turning etc. to ensure (R137's) comfort. On 2/14/2023, 2/15/2023, 2/16/2023, 2/18/2023, and 2/19/2023 on the TAR, Santyl was not available in the facility. No documentation was found that Wound NP-O or the physician were notified that the Santyl was unavailable. On 2/14/2023 at 7:39 PM, on 2/15/2023 at 11:58 PM, on 2/16/2023 at 11:55 PM, on 2/18/2023 at 7:18 PM, and on 2/19/2023 at 10:45 PM in the progress notes, nursing charted the coccyx wound was cleansed with wound cleanser followed by topical wound gel and covered with a foam dressing. No documentation was found indicating Wound NP-O or a physician was consulted with regarding wound gel being applied instead of the ordered Santyl. On 2/19/2023 at 10:27 PM in the progress notes, nursing charted the order for Santyl was refaxed with wound measurements to the pharmacy. On 2/21/2023, R137 was seen by Wound NP-O. Wound NP-O documented the Unstageable pressure injury to the coccyx measured 3.5 cm x 2.8 cm x 0.2 cm with 100% slough with moderate serosanguineous drainage. No documentation was found that Wound NP-O was aware the Santyl had not been applied and was unavailable or that wound gel had been used on the wound instead of the Santyl. Wound NP-O changed the treatment order to Medihoney on border foam and change three times a week. Surveyor noted the treatment for Medihoney to the Unstageable coccyx pressure injury was not entered onto the TAR as ordered by Wound NP-O on 2/21/2023. The order for the daily application of Santyl to the wound continued as the treatment on the TAR. On 2/21/2023, 2/22/2023, and 2/23/2023 Santyl was not available in the facility. No documentation was found that Wound NP-O or the physician were notified that the Santyl was unavailable. Had staff contacted Wound NP-O about the inability to attain Santyl, the treatment order may have been corrected to include Medihoney. On 2/21/2023 at 11:49 PM, on 2/23/2023 at 12:01 AM, and on 2/23/2023 at 8:04 PM in the progress notes, nursing charted the coccyx wound was cleansed with wound cleanser followed by topical wound gel and covered with a foam dressing. No documentation was found indicating Wound NP-O or a physician was consulted with regarding wound gel being applied instead of the ordered treatment. The treatment of Santyl to the coccyx wound followed by a border foam dressing was signed out as being completed on 2/24/2023, 2/25/2023, 2/26/2023, and 2/27/2023. Surveyor noted Santyl was not the current treatment that Wound NP-O had ordered. On 2/28/2023, R137 was seen by Wound NP-O. Wound NP-O documented the Unstageable coccyx pressure injury measured 3.5 cm x 2.6 cm x 0.2 cm with 75% slough and 25% granulation with moderate serosanguineous drainage. Wound NP-O changed the treatment order to Santyl on bordered foam, nystatin powder and zinc ointment to the peri wound and change daily. No documentation was found that Wound NP-O was aware the Santyl had continued as the order and not changed to Medihoney as ordered on 2/21/2023 and wound gel had been used on the wound instead of the Santyl. On 3/1/2023 on the TAR, a treatment order for the coccyx was entered: wash wound with wound cleanser, pat dry followed by antifungal powder followed by zinc followed by Santyl followed by a foam border dressing daily. On 3/7/2023, R137 was seen by Wound NP-O. Wound NP-O documented the coccyx pressure injury was now a Stage 3 that measured 3.1 cm x 1.7 cm x 0.2 cm with 10% slough and 90% granulation. Wound NP-O changed the treatment to Medihoney on bordered foam and nystatin powder and zinc to the peri wound changed three times a week. On 3/8/2023, R137 was discharged from the facility as planned. In a phone interview on 8/8/2023 at 12:44 PM, Surveyor asked Wound NP-O how Wound NP-O became aware of R137's pressure injuries. Surveyor shared with Wound NP-O that no documentation was found of any skin impairments prior to Wound NP-O seeing R137 on 1/24/2023. Wound NP-O stated generally Wound NP-O is notified by the facility of new wounds when Wound NP-O comes to the facility on Tuesdays to do wound rounds. Wound NP-O did not know the details of how or when R137's pressure injuries were discovered. Surveyor asked Wound NP-O what the process was on wound round days regarding seeing residents and having treatment orders entered onto the TAR. Wound NP-O stated either the Director of Nursing (DON) or the Assistant Director of Nursing (ADON) would accompany Wound NP-O when assessing the residents. Wound NP-O stated Wound NP-O would verbally tell whoever was assisting the treatment order, whether it was to continue the current treatment or to change the treatment to something different. Wound NP-O stated whoever was assisting would then enter the new orders into the resident's medical record. Wound NP-O stated the facility was going through a transition with administrative staff at one point and that may have been when R137 was in the facility. Wound NP-O stated Wound NP-O would give all paperwork to the Nursing Home Administrator (NHA) or the interim DON after rounds. Surveyor asked Wound NP-O if Wound NP-O would be notified if a specific treatment could not be completed as ordered due to not having the necessary supplies or if a different treatment was done due to lack of supplies. Wound NP-O stated Wound NP-O would expect to be notified. Surveyor shared with Wound NP-O the initial order on 1/24/2023 for R137's right ear Stage 3 pressure injury was not started until 1/27/2023 and the initial order for the coccyx Stage 3 pressure injury was not started at all and when the treatment order was changed on 1/31/2023, that was not started either. Surveyor shared with Wound NP-O that R137 did not have a treatment to the coccyx until 2/8/2023, two weeks after the wound was discovered. Surveyor shared with Wound NP-O that the Santyl treatment was not completed as ordered due to not receiving the Santyl from the pharmacy and the nursing staff substituted wound gel for the Santyl. Surveyor asked Wound NP-O if Wound NP-O was aware of the substitution. Wound NP-O was unaware of the facility not having Santyl available and stated the wound gel would not have been a substitution that Wound NP-O would have ordered. Surveyor shared with Wound NP-O that when Medihoney was ordered on 2/21/2023, the order was never entered onto the TAR and the facility continued with the Santyl order and the wound gel substitute. Wound NP-O was not aware of any of Surveyor's concerns and had not been notified by the facility of any alterations in treatment or that treatments were not changed when new orders were provided. The DON and ADON that were in the facility at the time R137 was a resident were no longer employed at the facility and unavailable for interview. On 8/9/2023 at 12:46 PM, Surveyor met with Nursing Home Administrator (NHA)-A and DON-B to discuss the concerns with R137's pressure injuries including the missed treatments orders, incorrect treatments used, and failure to notify Wound NP-O or the physician of the inability to complete a treatment as ordered. NHA-A and DON-B did not have provide any further information at that time. 2.) R31 was admitted to the facility on [DATE] with diagnoses of dementia with psychotic disturbance, diabetes, sarcoidosis (a condition that causes small patches of swollen tissue to develop in the organs of the body which could affect the skin), osteoarthritis, and Bell's Palsy. R31's admission Minimum Data Set (MDS) assessment dated [DATE] indicated R31 had moderate cognitive impairment with a Brief Interview for Mental Status (BIMS) score of 9 and the facility assessed R31 as needing extensive assistance with bed mobility, transfers, and toilet use and limited assistance with all other activities of daily living. R31 had an activated Power of Attorney (POA). Hospital discharge paperwork was reviewed and R31 did not have any documentation of skin breakdown while at the hospital. No treatment orders were on the discharge summary. On 3/24/2023 at 2:02 PM in the progress notes, nursing charted R31 had an open area to the coccyx. No further description was documented. At 6:38 PM in the progress notes, nursing charted R31 had a Stage 3 pressure injury to the coccyx with serosanguineous drainage. Both entries were written by Licensed Practical Nurses (LPNs). No assessment of R31's skin was documented by a Registered Nurse (RN). On 3/24/2023, a Baseline Care Plan was completed and indicated R31 had a current skin integrity issue to the coccyx. No measurements or descriptors were documented, and no interventions were implemented from the Baseline Care Plan. On 3/24/2023, R31's Braden assessment had a score of 13 putting R31 at moderate risk for skin breakdown. No treatment order was obtained from a physician and there was no documentation a physician was consulted with regarding R31's pressure injury. On 3/25/2023 at 3:28 PM in the progress notes, nursing charted R31 had an open area to the coccyx and a treatment was in place. Surveyor noted nursing did not chart what treatment was in place to the coccyx and no physician treatment order had been obtained. On 3/26/2023, an order for ProSource twice daily was implemented. Additionally, on 3/29/2023, an order for Boost 8 ounces daily was implemented. On 3/30/2023, a treatment order to cleanse the coccyx with normal saline, apply Xeroform and then apply Allevyn and cover with a border dressing daily was implemented. On 4/4/2023, R31 was seen by Wound Nurse Practitioner (NP)-O. Wound NP-O documented this assessment was the initial encounter with R31 and current interventions in place were pressure relieving cushion for sitting, every two hours turns while in bed, and elevate heels off bed with pillows or boots. Surveyor noted R31 did not have a Care Plan in place on 4/4/2023. Wound NP-O documented R31 had a Stage 3 pressure injury to the coccyx that measured 2.0 cm x 1.0 cm with 100% granulation and a scant amount of serosanguineous drainage. The peri wound was intact and blanchable with no signs or symptoms of infection. Wound NP-O ordered a treatment of Medihoney and bordered foam daily. Surveyor noted the new treatment order was not placed on the Treatment Administration Record (TAR). The facility continued with the treatment that had been implemented on 3/30/2023. On 4/10/2023, R31 tested positive for COVID-19. On 4/11/2023, R31 was seen by Wound NP-O. Wound NP-O documented the coccyx Stage 3 pressure injury measured 2.0 cm x 1.0 cm x 0.2 cm with 10% granulation and 90% healed with scant amount of serosanguineous drainage. Wound NP-O continued the current treatment of Medihoney daily. There is no indication that Wound NP-O was made aware that the Medihoney order was not implemented on 4/4/2023. R31's Stage 3 Pressure Injury Care Plan was first initiated on 4/11/2023 with the following interventions: -Administer medications as ordered; monitor/document for side effects and effectiveness. -Administer treatments as ordered and monitor for effectiveness. -Assess/record/monitor wound healing weekly by the wound team; measure length, width, and depth where possible; assess and document status of wound perimeter, wound bed, and healing progress; report improvements and declines to the physician. -Follow the facility policies/protocols for the prevention/treatment of skin breakdown. -Inform (R31)/family/caregivers of any new area of skin breakdown. -(R31) to have air mattress on bed to reduce pressure and pressure relieving cushion in wheelchair -Staff to assist with routine toileting and skin care for incontinence. -Staff to assist with turning and repositioning with all care and as needed. On 4/15/2023, Magic Cup 4 ounces daily was ordered as a supplement. On 4/17/2023, R31 was diagnosed with pneumonia in addition to COVID-19. Doxycycline 100 mg twice daily was ordered for seven days. On 4/18/2023, R31 was seen by Wound NP-O. Wound NP-O documented the coccyx pressure injury was now Unstageable measuring 2.0 cm x 2.0 cm x 0.4 cm with 100% yellow slough and moderate serosanguineous drainage. Wound NP-O continued the current treatment of Medihoney daily and recommended bed rest for one week and an alternating pressure mattress. There was no indication that Wound NP-O was aware that R31 was not receiving the Medihoney treatment as ordered since 4/4/2023. R31 continued to receive the treatment of Xeroform and then apply Allevyn an