**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure one (#1) out of three sample residents were kept free from abuse. The facility failed to provide increased oversight and monitoring to ensure Resident #1, who had severe cognitive impairment and was unable to consent to sexual contact of any type, was protected from sexual abuse by Resident #2, who was cognitively intact. On 2/13/24, Resident #2 was observed watching television in Resident #1's room by two different staff members. At 9:23 p.m., over an hour after the last known observation of the two residents, certified nurse aide (CNA) #1 entered Resident #1's room while doing routine rounds. Resident #1's door had been closed and when CNA #1 entered Resident #1's room, he observed Resident #2, who was nude, lying on top of Resident #1, who was also nude, and having sexual intercourse with her. A nurse was alerted and Resident #2 was removed from Resident #1's room and placed on one-to-one supervision. However, due to the facility's failures to provide increased oversight and monitoring of the residents once Resident #2 was observed in Resident #1's room, Resident #1 sustained sexual abuse by Resident #2. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/1/24-4/2/24, resulting in the deficiency being cited as past noncompliance with a correction date of 2/15/24. I. Incident of sexual abuse A. Sexual abuse investigation The 2/13/24 sexual abuse incident investigation documented the following: The nurse was alerted by CNA #1 while he was doing his rounds, he found Resident #1 (female), nude, supine (lying flat on her back) on her bed with Resident #2 (male), nude, lying on top of her having intercourse. The nurse removed Resident #2 from Resident #1's room. This incident occurred at approximately 9:30 p.m. The nurse and CNA #1 assessed Resident #1 for marks and bruising and placed a clean brief onto the resident. They placed the resident in bed, under the covers and left the lights on in the room. The physician, the NHA (nursing home administrator), the DON (director of nursing) and both residents' power of attorneys (POA) were notified. Upon arrival to the facility by the NHA, Resident #1 had no recollection of the incident. Resident #1 was transferred to the hospital, within one hour of the incident. At the hospital, a SANE (sexual assault nurse examiner) exam was completed and the police were notified. Resident #2 was placed on one-to-one supervision immediately following the incident and then transferred to a secured room, with a security guard, at the hospital. Staff were notified of the event, monitoring was put in place for Resident #1. B. Resident #2 interview Resident #2 was interviewed by the NHA and assistant director of nursing (ADON) in the hospital. Resident #2 said he and Resident #1 were having fun, laughing, chatting and watching television in the common area together. He said they went to her room. Once they were in the room, he said Resident #1 started getting flirty and I accepted it. She was being touchy feely, putting her hands on my neck and touching my hair and rubbing my leg. Resident #2 said he then got out of his wheelchair and sat on the edge of her bed. The female resident then got out of her wheelchair (he said he had to help her) and sat next to him on the bed. He said she continued to act interested by fondling him. He said they both helped each other take off their clothes, got onto the bed and began to get intimate. When asked if he asked the female for consent to take her clothes off, he said he did not. When asked if he had any knowledge or understanding about the female resident's cognitive ability to consent to sexual acts, he said it had never crossed his mind. C. Timeline of events based on the camera footage On 2/13/24, the facility determined a timeline of events based on camera footage: -At 5:53 p.m. Resident #2 entered Resident #1's room. Resident #1 was not in her room. -At 5:54 p.m. Resident #2 exited Resident #1's room with her rabbit. He went down the hallway where Resident #1 was and gave her the rabbit. She smiled and hugged the rabbit. -At 5:55 p.m. Resident #1 went into her room alone and came back out at 6:51 p.m. -At 6:54 p.m. Resident #2 went to her room and grabbed her rabbit again and gave it to Resident #1 in the common area. -At 7:14 p.m. both residents started down the hallway toward Resident #1's room. -At 7:14 p.m. and 52 seconds, Resident #2 entered Resident #1's room. Resident #1 stayed out in the hallway. -At 7:18 p.m. CNA #1 spoke with Resident #1 in the hallway. -At 7:19 p.m. Resident #1 entered her room. Resident #2 was still in the room. -At 8:08 p.m. CNA #1 checked on Resident #1 and Resident #2. He reported both residents were sitting in their wheelchairs watching television. -At 8:19 p.m. the nurse entered the room to administer medications. She reported that both residents were sitting in their wheelchairs watching television and talking to one another. -At 9:23 p.m. (over an hour later), CNA #1 entered the room (the door was closed) and then immediately exited the room to get the nurse. Both CNA #1 and the nurse then re-entered the room and removed Resident #2 from the room. II. Facility correction A. Immediate action The NHA, police department, adult protective services, each resident's POA and physicians were notified appropriately. Upon arrival at the facility, the NHA noted that the victim did not have any recollection of the incident and was confused about why she was going to the hospital. Resident #1 was transferred within one hour to the hospital for assessment and a SANE exam. The NHA accompanied Resident #1 to the hospital until the POA arrived. No further interventions were required during the hospital visit. Resident #2 was placed in his room with one-to-one supervision. This continued but was unsustainable at the facility long term. He was considered a risk to other residents' safety and well-being. The POA was notified of the incident. He was transferred to the hospital with one-to-one care within a few hours of the incident. An immediate discharge notice was delivered in person on 2/14/24, which was signed by the resident and POA. Administrative staff at the facility worked with the case management at the hospital to find an appropriate placement for Resident #2. The Risk Management Team from the health system was brought in for guidance. The team included the CEO (chief executive officer), the chief medical officer, the NHA, the assistant NHA, risk management, the quality director, the DON, the ADON and the physician. The incident, including the interventions, were presented at the Quality and Outcomes committee. All interviewees were cooperative with the investigators. Staff interviewed who witnessed the incident. Resident #1 was not able to recall the incident. Resident #2 was interviewed on 2/14/24. Resident #1 returned to the facility within 24 hours of the incident. Staff were notified of events, monitoring to be conducted and new protocols put in place within 36 hours of the incident. B. Interventions put into place A risk management module in the electronic medical record (EMR) was utilized effectively for documentation of communications around the incident. Fifteen minute checks were implemented upon Resident #1's return. This was in an effort to monitor for signs of trauma or psychosocial behaviors that may be attributed to trauma. Repeated assessments of well-being displayed no signs of trauma or behaviors. After five days, the 15 minute checks were discontinued. The care plan for Resident #1 was updated to address behavioral health needs, trauma informed care and potential triggers. Effective immediately new protocol: Residents are allowed to be in each other's rooms, as long as both residents consent. The door must remain open at all times and staff will round on them frequently. If residents do not have the ability to consent, they will not have other residents in their rooms. Notify the NHA for further assessment if questions arise. The administrative team compiled a list of vulnerable residents who may have increased risk for abuse. After a thorough review of this list, it was decided to have all residents have a complete skin assessment to look for possible injury of unknown origin, particularly in the peri-area (private area). This was decided to make sure nothing was missed or overlooked. This was operationalized with the next bath for each resident. Staff were made aware of the situation, what to be watching for in regards to other potential victims and Resident #1's potential behaviors. The NHA had conversations with other senior care agencies and advocates to help with suggestions around protocols or policies that should be considered. Assessments of other residents were completed and abuse training for all staff and training for all residents at resident council: how to feel safe, is the facility addressing safety and facility response to safety timely. Added resident to resident interactions to the weekly risk meeting agenda with the interdisciplinary team (IDT). C. Resident #1 adjustments to the comprehensive care plan The trauma informed care plan, initiated on 10/16/23 and revised on 3/5/24, documented the resident had a history of trauma related to a previous marriage. It indicated the resident had potentially been the victim of a sexual assault, which had potential to cause psychosocial harm. The interventions included being sensitive when providing personal care and contacting behavioral health services and the physician if the resident showed signs and symptoms of distress. -It indicated that the facility had reached out to a therapist about doing a mental health evaluation for the resident following the potential sexual assault incident. The therapist advised against labeling trauma for the resident and that a mental health consult should only be done if the resident expressed fear, grief, regret or trauma about the incident. At this time, the resident did not remember the sexual assault incident, did not speak about the sexual assault incident and had not expressed any of the above emotions. III. Resident #1 A. Resident status Resident #1, age [AGE], was readmitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety and major depressive disorder. The 2/20/24 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. She was dependent with upper and lower body dressing, personal hygiene and substantial assistance with walking. She required partial to moderate assistance with lying to sitting on the side of the bed, sit to stand, chair to bed transfer and toilet transfer. The resident did not exhibit any behavioral symptoms during the assessment period. B. Record review The activities of daily living (ADL) care plan, initiated on 9/28/23 and revised on 10/5/23, documented the resident had self-care needs. It indicated she required partial assistance from staff to turn and reposition in bed and transfers and maximal assistance by staff to dress and for personal hygiene. The communication care plan, initiated on 9/28/23 and revised on 10/5/23, documented the resident had communication impairment related to dementia and had difficulty in word finding. The interventions included anticipating and meeting the resident's needs; asking yes or no questions; encouraging the resident to continue stating thoughts even if the resident was having difficulty focusing on a word or phrase that made sense; gaining attention before talking; and observing facial expressions and body language and attempt to interpret. The cognitive impairment care plan, initiated on 10/16/23, documented the resident had cognitive impairment and impaired thought processes related to dementia. It indicated the resident participated in a cognitive assessment and scored a three out of 15, which indicated severe cognitive impairment. The interventions included asking the resident yes or no questions; cueing, reorienting and supervising as needed; providing the resident with a homelike environment; and reminiscing by using photos of family and friends. IV. Resident #2 A. Resident status Resident #2, age younger than 65, was admitted on [DATE] and discharged to the hospital on 2/13/24. According to the February 2024 CPO, diagnoses included Parkinson's disease with dyskinesia (movement disorder that often appears as uncontrolled shakes, tics or tremors) and major depressive disorder. The 1/22/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. He was independent with all ADLs. It indicated the resident did not exhibit any behaviors during the assessment period. B. Record review The cognitive care plan, initiated on 10/27/23, documented the resident participated in a cognitive assessment where he scored 13/15, which indicated he was cognitively intact. The behavioral care plan, initiated on 10/27/23 and revised on 2/19/24, documented the resident had impulsivity issues, had been known to wander, reject care and take items that did not belong to him. He had a reported history of gambling. It indicated the resident's impulsivity was heightened when he felt he was not getting enough attention. The interventions included assisting the resident to develop more appropriate methods of coping and interacting; encouraging him to express his feelings appropriately; providing opportunity for positive interaction, attention; stopping and talking to the resident as you passed by; intervening as necessary to protect the rights and safety of others; approaching and speaking in a calm manner; diverting attention; removing the resident from the situation and taking to an alternate location as needed; praising any indication of the resident's progress/improvement in behavior; and providing a program of activities that was of interest and accommodates the resident's status. The adjustment care plan, initiated on 11/2/23, documented the resident was having difficulty adjusting to his admission affecting his psychosocial well-being. He reported having a hard time accepting the fact that he lived in a nursing home at his young age and he felt lonely. The interventions included encouraging the resident to participate in activities of choice; encouraging the resident to participate in conversations with staff and other residents daily; encouraging ongoing family involvement by inviting the resident's family to attend special events, activities and meals; and introducing the resident to other residents with similar backgrounds, interests and facilitating interactions. V. Staff interviews The NHA, the ADON and the DON were interviewed on 4/1/24 at 5:15 p.m. The DON said Resident #1 and Resident #2 were friendly but not necessarily friends. She said they were more like acquaintances. She said they both participated in group activities and spent a lot of time in the common area. The DON said Resident #2 had sat with Resident #1 and her husband in the common area. The NHA said CNA #1 was aware Resident #1 and Resident #2 were in Resident #1's room. CNA #1 had reported the door must have closed at some point when he was assisting other residents. The NHA said the residents had not been checked on for over an hour. The NHA said CNA #1 entered the room to put Resident #1 to bed and saw both residents nude with Resident #2 on top of Resident #1. She said CNA #1 did not immediately ensure Resident #1's safety but instead went and got the nurse. She said CNA #1 was in shock and apologized for leaving to get the nurse. The NHA said she accompanied Resident #1 to the hospital. She said Resident #1 had no recollection of the incident and was unsure as to why she was going to the hospital. She said Resident #1's POA came and that was when consent was obtained for the SANE exam. The ADON said Resident #1 had not experienced any trauma from the incident. She said Resident #1 had not exhibited any changes in behavior. She said when they referred the resident for a mental health evaluation, the mental health practitioner said she would not complete the evaluation if the resident did not remember nor spoke anything about the incident. She said she would not want to re-traumatize the resident. The ADON said the facility monitored Resident #1 every day with no negative results observed. The NHA and the DON said Resident #1 and Resident #2 should not have been left alone in the room with the door closed for an hour. They said someone should have seen that the door had been closed and checked on both residents. The NHA said Resident #2 was placed under one-to-one supervision and immediately transferred to a room at the hospital with a security guard monitoring. She said Resident #2 was presented with an immediate discharge notice from the facility. She said the facility worked with the hospital discharge planners to find an appropriate facility. The NHA said the facility implemented a policy that any resident who had cognitive impairment was not able to be in a room with a cognitively intact resident with the door closed. She said meetings would be held with the residents' responsible parties to determine if residents could be left alone. The social services director (SSD) and the activity director (AD) were interviewed on 4/2/24 at 9:16 a.m. The AD said Resident #2 was a well-known member of the community. She said he was very outgoing and very social. She said he usually exhibited behaviors after a negative interaction with his spouse. The AD said Resident #2 saw a therapist regularly and had peer support. She said he attended group activities and loved games such as BINGO, cards and baking. The SSD said Resident #1 and Resident #2 ate in the dining room but did not remember seeing them eating at the same table. She said she did not remember them ever really interacting together privately. The SSD said Resident #1's husband would come to the facility every day. She said he would sit in Resident #1's room and watch television. She said they did this almost daily. She said Resident #1 and her husband would hold hands.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to prevent pressure injuries for one (#25) of two residents reviewed for pressure injuries out of 25 sample residents. The facility failed to assess and implement interventions for a newly placed medical device (knee brace). The facility further failed to regularly assess Resident #25's skin integrity underneath the knee brace after she was deemed to be high risk for pressure ulcer development. These failures led to the development of an unstageable pressure ulcer to the resident's right lower extremity caused by the leg brace. The pressure ulcer caused the resident to experience pain in the wound area as well as to endure painful dressing changes. Findings include: I. Facility policy and procedure The Pressure Injury Prevention-Long Term Care policy, reviewed 6/14/2019, provided by the director of nursing on 3/11/2020 at 4:23 p.m. read, review the residents medical record, including previous medical history, comorbid conditions, medications, and skin conditions, to identify intrinsic and extrinsic risk factors for pressure injuries. Regularly assess and inspect the residents skin, including skin color, temperature, texture or turgor, integrity, and moisture status. Focus on such high risk areas such as bony prominences, areas of erythema, and areas under medical devices. II. Resident #25 status Resident #25, age over 70, was admitted on [DATE]. According to the March 2020 computerized physician orders, diagnoses included pathological fracture of right tibia and fibula dated 1/3/2020, muscle weakness, and need for assistance with personal care. According to the most recent minimum data set (MDS) assessment completed 1/7/2020, the resident scored a seven out of 15 on the brief interview for mental status (BIMS) exam, indicating severe cognitive impairment. The resident required extensive physical assistance of two-plus staff for bed mobility, and was totally dependent on staff for transfers. Based on a formal and clinical assessment the resident was at risk for the development of pressure ulcers, but did not have any current or non healing pressure injuries of any stage. III. Record review Progress notes prior to wound development A nursing progress note, dated 1/1/2020 at 8:47 p.m., showed the resident was complaining of right knee pain all day shift per the nurse aide. The resident stated her knee felt better after a cold pack was placed on her knee for 10 minutes and Tylenol was administered. The nurse notified the resident's daughter of the pain. A nursing note on 1/2/2020 at 11:13 a.m. showed the resident was complaining of severe pain that morning. The physician was called and notified, and they increased the resident's Tylenol to 1000 mg three times a day. The daughter was called and requested that something more be done for the resident's pain. A physician progress note dated 1/2/2020 showed Resident #25 was complaining of pain in the right ankle joint, and they were unsure of the etiology. There was no rash or evidence of infection or specific evidence of fracture. An orthopedic referral was made and the physician noted to send the resident to the emergency room if the signs or symptoms worsened, returned, changed, or any new symptoms developed. On 1/3/2020 at 11:09 a.m. a nursing progress note showed a licensed practical nurse (LPN) requested the registered nurse (RN) assess the resident as she was not doing well. Upon assessment it was noted the resident complained of pain when the RN moved the resident's right lower leg. The right lower leg was noted to be hot to touch with bruising behind the right knee and old bruising to the right shin. The right leg was slightly larger than the left leg. The RN notified the physician and the power of attorney and the decision was made to transport the resident to the emergency room for evaluation. A nursing progress noted on 1/3/2020 at 9:42 p.m. showed the resident returned to the facility from the ER. The report from the hospital documented the resident had a fracture of the right tibia and fibula around the old hardware (past surgery) in the knee. A skin assessment was performed with no new areas except for bruising on the right knee. The resident exhibited increased pain and was given PRN oxycodone. A physician progress note dated 1/8/2020 showed the resident had a fracture of the tibia and fibula, and it was unclear how the fracture was sustained. The physician had consulted with the orthopedic physician who recommended it was ok to weight bear if able, but not if causing pain; and ok to pivot transfer but not if causing pain; and a brace for comfort, otherwise not necessary. B. Braden scale The resident's quarterly Braden Scale for predicting pressure sore risk, completed 1/2/2020, scored the resident an 11, at high risk for the development of pressure injuries related to very limited sensory perception, occasionally moist, chairfast, completely immobile, probably inadequate nutrition, and a problem with friction and shearing. C. Wound documentation 1. Weekly wound observation assessments A weekly wound observation assessment, dated 1/31/2020, showed the first documentation of the wound acquired in the facility on the posterior right calf. The wound was specified as a device related pressure injury. The measurements were noted to be 34 mm x 15 mm x 0 mm with 25% slough and/or necrotic tissue present. There was no odor, but a moderate amount of serous drainage was noted. A comment on the observation assessment documented the resident was in a brace status post fracture. The brace was not to be removed. However, upon removal, a small abrasion was noted. (The order from the physician was for comfort, otherside not needed. There was no order to not remove the brace.) The wound observation note read the wound was new and to request wound care orders and to cover until orders were received (wound care orders were not placed until 2/11/2020, 11 days later). The next weekly wound observation assessment, dated 2/14/2020 (no wound observation for the previous week), documented the wound was still with 25% slough and necrotic tissue with measurements of 32mm x 12 mm x 0 mm. There was moderate serosanguinous drainage and no odors. The weekly wound assessment, dated 2/21/2020, showed the wound was with slough and granulation tissue and no odor. Measurements were 32 mm x 12 mm with 25% necrosis or slough and moderate serosanguinous drainage. The weekly wound assessment, dated 2/28/2020, showed the wound measurements as 37 mm x 2 mm x 0 mm. The wound bed was 75% slough or necrosis with no odor and moderate serous drainage. The weekly wound assessment, dated 3/6/2020, showed the wound was 45mm x 20mm x 2 mm with 75% slough and moderate serous drainage and no odor (see dressing change observation below). 2. Skin observation tool noting areas of concern The skin observation tool to be completed by a licensed nurse showed the following: -12/30/2019: skin clean, dry, and intact, (old) left shin wounds freshly dressed. No other concerns at this time. -1/4/2020: skin in good condition, no bruising or skin tears noted. -1/27/2020: skin dry and intact, bruising noted to left shin and left lower extremity, red area to back of lower left leg. (There were no documented skin observations between 1/4/2020 and 1/27/2020 provided.) -2/3/2020: right heel breaking down with 1 cm in diameter; scab above right heel 2x4 cm. -2/10/2020: scab above back of right ankle, 1 cm x 2 cm -3/2/2020: right heel is dry and pink, purplish red area to side of right foot just below the 5th toe, wound to right calf, redness under left breast. -3/9/2020: skin clean, dry, and intact; redness beneath left breast, will apply as-needed nystatin. D. Care plan Resident #25's care plan, initiated 6/13/2015 and most recently revised on 3/6/2020, documented the resident was at risk for impaired skin integrity, skin tears, and pressure ulcers related to fragile skin, limited mobility, incontinence, and the resident enjoyed lying in bed for long periods of time. Interventions on the care plan included: -2/11/2020: wound nurse to evaluate right leg injury as ordered; -3/6/2020: treatment as ordered to the right posterior calf. There were no interventions noted on the care plan related to the knee brace. The resident's actual skin breakdown and skin condition were not documented in the care plan. The care plan did not address pain management related to the resident's wound. E. Physician's orders The physician ordered on 1/8/2020 for the resident to wear a brace for comfort, otherwise not necessary. There were no orders not to remove the brace, or to remove the brace regularly to assess the resident's skin condition. Wound orders dated 2/11/2020 documented, Right posterior calf wound; cleanse with dermal wound cleanser or saline and apply therahoney to wound base. Cover with optimfoam and change on bath days or three times a week (there were no wound orders prior to 2/11/2020). Pain medication ordered for the resident was noted to be oxycodone 5 mg, give 0.5 tablet every 8 hours for pain as needed. The resident was also receiving acetaminophen 1000 mg three times a day for pain, regularly scheduled. F. Wound care nurse consult notes and physician note The wound nurse consult note, dated 2/11/2020, showed the resident had a 3.5 cm x 2 cm area of black, dry, adherent eschar to the posterior calf. There was slight periwound erythema and slight induration of about 0.1 cm around the wound. There was no branching erythema, odor or drainage noted. From the history it could be determined that this was a medical device related unstageable pressure injury from the knee brace. This was the only documented visit from the consulted wound care nurse; no other visits were noted. A physician progress note, dated 3/4/2020, showed a diagnosis of a pressure ulcer of other site, unstageable. The physician noted the pressure ulcer was to the right calf. A physician progress note, dated 3/13/2020, provided after survey exit, noted the physician was considering vascular causes for the poor healing of the wound as well as the other area of concern around the distal aspect of the foot near the 5th toe. No new orders were placed. The physician's note referenced the poor healing of the existing wound; it did not say the wound was caused due to poor vascular status. The wound nurse (on 2/11/20) and physician (on 3/4/20) both documented (see above) that the resident's wound was an unstageable pressure injury. IV. Wound observation/resident interview A dressing change was observed with RN #1 and the DON on 3/11/2020 at 11:15 a.m. RN #1 said she attempted to premedicate Resident #25 prior to the dressing change but she had refused (this was not documented in the medication administration record or nursing progress notes). The resident was wincing in pain just from having the heel protector boots removed, and the resident was voicing that it hurts. RN #1 removed the old dressing from over her wound, and as she removed the dressing, green slough was pulled with the dressing. The resident was complaining of pain and jumping as RN #1 removed the dressing. The wound was over the resident's right Achilles tendon area and leading up to the lower aspect of the posterior calf. RN #1 went to cleanse the wound with a 4x4 gauze soaked in wound cleanser, and the resident was jumping in bed yelling no! repeatedly. RN #1 then applied medihoney and the new dressing, and the resident was yelling please don't! and kicking and jumping in the bed. RN #1 did not offer pain medication in response to the resident's pain, during or after the dressing change. Resident #25 was interviewed on 3/9/2020 at 2:59 p.m., before the observed dressing change above. She said she had a wound on her right foot that caused her really bad pain, and they gave her Tylenol for the pain. She said the Tylenol helped thank god, cause I wouldn't know what to do without it. Resident #25 was interviewed again on 3/11/2020 at 5:23 p.m., several hours after the dressing change observation. She said the pain was in her right heel and the back of her leg, and the pain was terrible. She said it hurt at a level of 8 or 9 (out of 10) and the Tylenol they gave her helped bring it down to two or three. V. Staff interviews RN #1 was interviewed on 3/11/2020 at 11:25 a.m. She said Resident #25 would complain of pain in the mornings and she would usually take her pain medication. She said the resident would say her heel hurts her but she would touch her heel and the resident would not complain of pain. She said the resident's pain was in the wound area, not the heel. She said the resident complained of pain during dressing changes as well. She said the wound looks pretty yucky but she guessed it was getting better (although per documentation it was larger and deeper). She said the resident had a fracture and then a knee brace which was rubbing and then some necrotic tissue followed. She said the brace was for comfort but was always on when she worked. She said she thought they took it off at night and for her baths and skin assessments. She reiterated the brace was just for comfort. RN #2 was interviewed on 3/10/2020 at 2:48 p.m. She said she thought the wound was from the brace she was wearing after her injury as it was resting on the back of her leg. She said they were doing repositionoing and floating her leg and feet, but they should have been doing skin assessments under the brace. She said she had not been doing those when she worked because she had to cover both hallways when there were only two nurses working and it was not manageable to do all that. She said she did not have the time to do the skin assessments on the resident. She said the brace was always on when she worked and she was unsure if they took it off at night. She said the brace had been discontinued when the wound was discovered. Life enriching care aide/certified nurse aide (LEC) #3 was interviewed on 3/11/2020 at 2:19 p.m. She said they had put a huge brace on Resident #25 after her fracture and it was just rubbing on her leg. She said it had gotten to a point where there was ooze from the wound on the brace. She said the brace was on all the time, and they would only remove it when they got her dressed. She said they would put the brace over her clothes as well. She said the brace would even rub when the resident was in the wheelchair, and they should have been assessing the skin but she was not sure if they were. The physical therapist (PT) was interviewed on 3/12/2020 at 9:19 a.m. She said the resident was in a hinged knee brace that was monitored by nursing, which she believed they threw away after it was soiled. She said she was the staff member who first identified the wound when they were looking at her toes, and she saw the necrotic area. She said it started as friction from the device (knee brace). She said it was acquired in the facility and may have initially started as a deep tissue injury but was currently a decub (decubitus ulcer). She also said she thought it should be stageable at this point. The DON was interviewed on 3/12/2020 at 9:59 a.m. She said Resident #25 had a fracture and initially afterwards was wearing a leg brace at all times (there was no documentation to support the brace to be worn at all times), but the order was later changed for comfort. She said they performed a skin assessment after removing the brace and there was an abrasion; however, the wound care and physician notes reflect differently. She said they needed to keep the brace off at that point. She said the resident was at risk for developing pressure injuries due to her self limiting behaviors. She said Resident #25 suffered from chronic pain and hallucinations, and the resident had apparently eaten oxy (oxycodone) like it was candy prior to her coming to the facility. She said the resident's skin was assessed weekly routinely, with the brace on as well. She said there were no additional assessments for when the brace was put on. She said the wound was just a surface layer friction area that was reddened, similar to a rug burn. She said it was the device (the knee brace) that caused the resident's wound and the wound nurse had concurred. She said no new assessments or interventions were put in place for the knee brace other than the weekly skin checks and ensuring circulation. She said the charge nurse was responsible for assessing residents' skin and on a weekly basis. She said the resident had requested to keep the knee brace on at times. The DON said Resident #25 did complain of pain at the wound site during dressing changes, and that's when she was notified. She said they were treating the resident's pain with oxycodone and it typically was effective. She said the resident had spit out her meds the day of the wound observation.