**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for accidents, the facility failed to ensure the resident received supervision assistance during mealtime in accordance with the plan of care which resulted in a choking incident. The findings include: Resident #2 's diagnoses included hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a cerebral infarction (death of brain tissue/stroke) affecting the right dominant side, dysphagia (difficulty swallowing), aphasia (language disorder), apraxia (motor disorder), epilepsy and dementia without behavioral disturbances. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 had a staff assessment for Mental Status conducted identifying both short-term and long-term memory problems indicative of severely impaired cognition and required setup and cleanup assistance with eating, substantial assistance with bed mobility and was dependent on staff for transfers. The Resident Care Plan (RCP) dated 3/4/25 identified Resident #2 had dysphagia related to a stroke. Interventions included ensuring all meals and fluid intake occurred under staff supervision and providing speech therapy services as ordered. A Speech Therapy Discharge summary dated [DATE] identified that Resident #2 had been on speech services starting 3/12/25 and was discharged on 3/27/25. The summary identified Resident #2 required supervision/assistance at mealtime due to swallowing safety 0-25 percent (%) of the time and to facilitate safety and efficiency. The summary identified that the Resident #2 ' s prognosis (expected outcome) was good with consistent staff follow-through A nurse's note dated 4/1/25 at 4:30 PM identified Resident #2 began coughing and choking while eating lunch, the Heimlich maneuver was performed and a code was called for immediate assistance to the room. The facility Reportable Event (RE) Form dated 4/1/25 identified that at 12:15 PM, Resident #2 had a choking episode, during lunch, in his/her room. The RE identified that upon entry to Resident #2 ' s room, NA #5 observed Resident #2 coughing and turning red in color. The RE identified that another NA went to notify the nurse and that the Advanced Practice Registered Nurse (APRN #2) was nearby during the incident and intervened by successfully performing the Heimlich maneuver. The RE identified Resident #2 ' s diet was downgraded immediately, speech therapy was notified to screen Resident #2, orders were obtained for vital signs and lung sounds every four (4) hours, to obtain bloodwork and a chest x-ray, and for supplemental oxygen as needed and a hospice consult. The facility Summary Report dated 4/2/25 identified the RCP directed supervision during meals but the supervision requirements were not effectively communicated by the Speech Therapist (ST) to the care team and was not implemented. Following the incident, the ST would be required to document all dietary and supervision changes in the therapy Activities of Daily Living (ADL) evaluation immediately and then the Assistant Director of Nursing Services (ADNS) would be responsible for reviewing and locking the evaluation confirming the receipt of updates from the ST. The summary identified there would be written communication/documentation from the ST to nursing for changes made to the RCP and nursing would communicate the changes to the NA's every shift for 24-hours following the changes. Interview with APRN #2 on 4/15/25 at 12:28 PM identified that on 4/1/25 Resident #2 appeared to be choking. She indicated Resident #2 was rigid and it took multiple staff to lean him/her forward in his/her customized wheelchair, to assist with the Heimlich maneuver, and Resident #2 continued to cough and expel copious amounts of secretions. APRN #2 identified that a code was called, and a male staff member responded and stood Resident #2 up. Resident #2 then coughed up chicken, continued to cough, and his/her lung sounds were still not clear. She reported Resident #2 was encouraged to continue coughing and he/she eventually coughed up another piece of chicken which ceased the coughing. Interview with ST #1 on 4/15/25 at 1:18 PM identified that Resident #2 was referred to ST in March 2025 for weight loss and to ensure his/her diet was appropriate. She reported Resident #2 was discharged from ST services on 3/27/25 with an unchanged regular texture diet and thin liquids, and indicated she had no concerns. She identified that if new diet orders were placed, she would have verbally communicated the new orders to the charge nurse but since the diet remained unchanged and the RCP already identified Resident #2 required supervision for meals, she did not verbally notify the charge nurse of the strategy recommendations. She identified that when she re-evaluated Resident #2 following the 4/1/25 choking incident, Resident #2 had an evident decline to include new left sided weakness, facial droop, and Resident #2 was not triggering a swallow at all. Interview with NA #6 (accompanied by the DNS) on 4/15/25 at 1:30 PM identified that on 4/1/25, she was in the hallway passing lunch trays when NA #5 called her from Resident #2's doorway stating Resident #2 was choking and needed help. NA #6 reported she observed Resident #2 coughing and turning red and she then alerted LPN #1. NA #6 identified she knew Resident #2 well and he/she had always been a setup for meals, not requiring staff supervision. Interview with NA #5 (accompanied by the DNS) on 4/15/25 at 1:41 PM identified she was responsible for providing care for Resident #2 during the 7:00 AM to 3:00 PM shift on 4/1/25 and was regularly assigned to provide care for Resident #2. NA #5 identified that, according to the Resident Care Card (RCC) (quick-reference sheet used by NAs which lists information about daily care needs), Resident #2 was a setup only for meals. NA #5 reported that on 4/1/25, she went to check on Resident #2, after feeding another resident, and when she observed Resident #2 from the hallway, he/she was sitting in the wheelchair with his/her mouth open and tongue sticking out. NA #5 reported that LPN #1 came into the room immediately and they attempted looking into Resident #2 ' s mouth, but he/she would not allow them to perform a finger sweep. NA #6 identified that APRN #2 came in to assist and LPN #1 then performed the Heimlich maneuver from the front of Resident #2, which dislodged a one-inch cubed shaped piece of chicken but Resident #2 continued to cough so they called a code for additional assistance. Interview with NA #4 on 4/15/25 at 2:33 PM identified she delivered Resident #2's lunch tray on 4/1/25, and Resident #2 wanted to eat in his/her room while in his/her customized wheelchair. NA #4 reported Resident #2 was a meal setup per the RCC, so she cut the chicken into one-inch pieces, ensured Resident #2 had everything he/she needed and then left the room. Interview with LPN #1 on 4/16/25 at 11:41 AM identified that on 4/1/25 NA #5 reported to her that Resident #2 was choking. She identified that she floats to work on all the facility units and was unsure of Resident #2 ' s meal assistance level at the time of the incident. Interview with the DNS on 4/15/25 at 1:55 PM identified that the RCP directed Resident #2 required supervision for meals. The DNS indicated she thought Resident #2 was a setup only, as he/she was on a regular texture diet with thin liquids. Interview with ADNS #2 on 4/15/25 at 2:04 PM identified she was unaware that Resident #2 required supervision assistance with meals prior to the 4/1/25 choking incident and was also unaware that the RCP directed supervision with meals since 2017. She identified that during the incident investigation it was identified that the RCP interventions, to include supervision with eating, were initially entered incorrectly, so did not appear on the RCC. She reported that subsequent to that finding, the facility did a whole house audit to ensure all RCPs were reflected on RCCs. Interview with the DNS, ADNS #1, ADNS #2 and RN #6 (Regional nurse) on 4/15/25 at 2:21 PM identified that they initiated a Plan of Correction (POC) immediately on 4/1/25 regarding the choking incident with Resident #2 including reviewing emergency response procedures, both Speech Therapy and nursing staff responsibilities involving the 'Therapy ADL evaluation', a written Care Plan revision communication tool to be implemented to ensure critical care plan changes are communicated effectively, mandatory training for all direct care staff to include dysphagia management, dietary modifications and meal supervision, the implementation of competency assessments to ensure that staff understand choking prevention protocols and intervention strategies and meal supervision audits. The facility will also monitor clinical alerts in the electronic health record and review NA documentation regarding meal consumption and any changes/difficulties that residents have exhibited, review residents with a diagnosis of dysphagia to ensure Care Plans and Speech Therapy recommendations match and re-educate staff as needed and refer to Speech Therapy any residents in question. Additionally, they identified that for the pre-populated dysphagia Care Plan, under the interventions, it automatically says supervision for eating, but it doesn't automatically carry over to the Care Plan, stating that in their new Therapy ADL evaluation, when meal assistance/supervision is checked off, it automatically carries over to the [NAME]. Although requested, a facility policy for providing assistance with meals was not provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, facility documentation review, facility policy review, and interviews for two of four residents (Resident #177 & #69) who were at high risk for the development of pressure ulcers and who developed facility acquired pressure ulcers, the facility failed to ensure that resident specific comprehensive interventions were implemented, failed to assess the wound in a timely manner inclusive of description, measurements, and stage upon initial discovery of an opened area, and failed to provide consistent turning and repositioning to offload the sacrum contributing to the advanced worsening of the wound. The findings include: 1. Resident # 177's diagnoses included Alzheimer's dementia, contracture of left and right hands, gastrostomy, and functional quadriplegia. The physician's order dated 1/3/23 with an origination date of 7/27/22 directed to complete skin checks weekly and document skin checks in the nurse's notes and air mattress set to the most current weight and check setting and function every shift. The Braden Scale Assessment (used to predict risk for pressure ulcer development) dated 7/24/22 identified the resident had a score of 10 which is indicative of the resident being at high risk for the development of a pressure ulcer. The annual MDS assessment dated [DATE] identified Resident #177 had severe cognitive impairment, was totally dependent for transfers, hygiene, toileting, and dressing, was always incontinent of bladder and bowel, was at risk for the development of pressure ulcers but did not currently have a pressure ulcer. The Resident Care Plan (RCP) dated 1/26/23 identified Resident #177 was at high risk for skin breakdown related to dementia, incontinence, history of pressure ulcers and immobility. Care plan interventions directed to apply protective skin barrier cream, pressure reducing cushion and mattress and two persons for turning and repositioning. Review of the RCP failed to identify resident specific interventions related to the positioning of the resident. Review of the weekly skin checks documented in the nurse notes from 1/6/2023 through 2/6/23 identified Resident #177 had no notable skin issues. Review of the turning and repositioning task nurses' aide documentation from 1/6/23 through 2/6/23 identified Resident #177 was not consistently repositioned every two hours (the form is formatted in two-hour increments of time). The nurse's note dated 2/7/23 at 3:48 PM identified Resident #177 had a resident care plan meeting with the interdisciplinary team present. Resident #177 and his/her responsible party were invited but chose not to participate in the care plan meeting. The note further identified Resident #177 had been stable medically and nutritionally throughout the last quarter. The nurse's note dated 2/7/23 at 9:54 PM written by LPN #2 identified Resident #177 had an open area in the same location as a previous pressure ulcer wound. The nurse's note did not contain any further information concerning the opened area. There were no measurements documented and no specific area identified. A Dietician's note dated 2/9/23 at 11:12 AM identified Resident #177 had a new stage 3 pressure ulcer wound to the coccyx. The note further identified the resident would have a liquid protein supplement twice per day added to his/her diet. The Situation, Background, Assessment, Recommendation (SBAR) nurse's note dated 2/9/23 at 12:28 PM (written by the unit manager (RN) identified Resident #177 had a stage 3 pressure ulcer wound to the coccyx that measured 1.0 centimeter (cm) in length by 1.0 centimeter (cm) in width. The note further identified the resident did not appear to be in distress or discomfort at that time. The wound nurse, nurse practitioner and family were updated. The physician's order dated 2/9/23 directed to cleanse the coccyx area with normal saline, pat dry then apply Calcium Alginate (wound treatment) followed by gauze dressing on a daily basis and as needed. The Braden scale assessment dated [DATE] identified the resident was at a very high risk for the development of a pressure ulcer (there were no documentation of a Braden scale assessments completed between 7/24/23 and 2/9/23 when the resident was identified as having a stage 3 pressure ulcer). Review of the clinical record failed to identify the open area identified on 2/7/23 was assessed by a registered nurse, or that a physician/APRN was notified or that a treatment was put in place prior to 2/9/23 (two days after the area was noted). The RCP dated 2/9/23 identified Resident #177 had a pressure ulcer related to contracture, history of pressure ulcers, immobility, and sensory impairment. Care plan interventions directed for a dietician evaluation, monitor the wound for signs of symptoms of infection, weekly wound evaluation per protocol, treatment as ordered by the physician, and turn and reposition. The nurse's note dated 2/10/23 at 7:00 AM identified Resident #177's wound dressing to the coccyx was clean, dry, and intact and had no signs and symptoms of pain and nurse's aide repositioning the resident every two hours. The initial wound evaluation and management summary dated 2/14/23 completed by the Wound Specialist identified Resident #177 had a stage 4 full thickness wound to the sacrum related to pressure. The wound size was documented as 1.2 cm in length by 1.0 cm in width and 0.4 cm in depth. The treatment plan directed: apply Calcium Alginate once a day for thirty days, limit sitting to 60 minutes, offload wound, reposition per facility protocol, and turn side to side in bed every 1 to 2 hours if able. The wound evaluation dated 4/4/23 identified the stage 4 pressure full thickness wound to the sacrum would benefit from debridement of the peri-wound macerated skin edge. The wound size was documented as 1.0 cm in length by 0.7 cm in width by 0.3 cm in depth. The treatment plan directed to apply gauze island with border once a day. The wound evaluation dated 4/25/23 identified the stage 4 to the sacrum was surgically debrided to remove devitalized epidermis and/or dermis and to remove dried exudate or debris. The wound size was documented as 1.5 cm in length by 0.9 cm in width by 0.2 cm depth. The treatment plan directed to apply collagen sheet and gauze island with border dressing daily. Further review of the wound evaluations conducted by the Wound Specialist (MD #1) along with the facility's Wound Nurse (LPN #4) identified that he assessed the wound on a weekly basis and performed debridement of the wound on 5/9/23, 5/16/23, 6/13/23, 7/11/23, 8/15/23, 9/12/23, and 10/10/23, 11/9/23, and 12/19/23. The wound evaluation 1/2/24 identified the stage 4 to the sacrum was surgically debrided to remove biofilm. The wound size was documented as 1.7 cm in length by 1.8 cm in width by 0.9 cm in depth with undermining at 11:00 o'clock. The treatment plan included the application of a collagen sheet and gauze island with border dressing daily with a recommendation for diathermy therapy. Review of the weekly wound evaluations for the period of 2/14/23 to 1/2/24 identified the recommendations to limit sitting to 60 minutes, offload the wound and reposition per facility protocol, turn side to side in bed every 1 to 2 hours if able. Review of the RCP and the treatment administration record failed to identify the implementation of the recommendation for the 1-to-2-hour side to side repositioning and the offloading of the wound. Observation on 1/7/24 at 9:30 AM identified Resident #177 lying in bed on his/her back with the head of the bed raised to approximately 30 degrees, continuous tube feeding in place and the alternating air loss mattress was set at 350 lbs. Review of the clinical record identified Resident #177's weight was documented as 178 pounds on 1/8/24. Review of the nurse aides' turning and repositioning documentation dated 1/7/24 identified Resident #177 was positioned on his/her back from 4:00 AM to 3:59 PM (approximately 12 hours passed before Resident #177 was turn to his/her right side). Observation on 1/8/24 at 9:30 AM identified Resident #177 lying in bed on his/her back with the head of the bed raised to approximately 30 degrees with the continuous tube feeding in place and the alternating air loss mattress setting was noted to be set at 350 lbs. Intermittent observations every hour on 1/8/24 between 9:30 AM and 2:00 PM (4 hours and 30 minutes) identified Resident #177 lying in bed, on his/her back with the head of the bed raised to approximately 30 degrees, continuous tube feeding in place and the alternating air loss mattress set at 350 lbs. Review of the NA turning and repositioning documentation for 1/8/24 identified Resident #177 was positioned on his/her back from 5:38 AM to 1:12 PM (approximately 7 hours). Further review identified there was no documentation completed to indicate the resident's position from 1:12 PM to 7:29PM. At 7:29 PM, the documentation noted Resident #177 was repositioned to his/her left side. Observation of wound care on 1/8/24 at 2:00 PM with LPN #3 identified Resident #177 lying on his/her back, with the alternating air mattress set at 350 pounds (lbs.). Resident #177's sacrum had a foam dressing with a scant amount of drainage to the foam dressing. The dressing change was completed without incident and the setting of the air mattress remained at 350 lbs. and the resident remained positioned on his/her back with the head of the bed raised to 30 degrees. Interview with LPN #2 on 1/5/24 at 12:45 PM identified that she performed the weekly skin check on Resident #177 on 2/7/23 and identified the open wound to the coccyx. She further identified that Resident #177 had a history of a pressure ulcer in the same location. In addition, LPN #2 identified that she notified the nursing supervisor at that time but could not recall the nursing supervisor she notified. She noted that the nursing supervisor typically would assess the wound and obtain a treatment order. Interview with NA #3 (NA for 7-3 shift) on 1/8/24 at 1:00 PM identified Resident #177 was totally dependent for all care including turning and repositioning. She also identified that Resident #177 was non-verbal and compliant with care. She identified Resident #177, needed to be turned and repositioned at least every 2 hours and was also aware that he/she had a pressure ulcer on his/her bottom. She further noted that she documents the resident's position in the computerized task section of the NA documentation. Interview with LPN #3 (charge nurse for 7-3 shift) on 1/8/24 at 2:30 PM identified Resident #177 at high risk for skin breakdown because of the history of pressure ulcers, current stage 4 open wound to the sacrum and immobility. She further noted she was responsible for ensuring the nurse aides turn and reposition Resident #177 at least every 2 hours but she could not identify when Resident #177 had last been turned and repositioned prior to completing the wound care and dressing change. Subsequently, LPN #3 repositioned Resident #177 on his/her left side. In addition, LPN #3 identified that the alternating pressure air mattress should be set between 150-200 lbs. depending on the resident's comfort, but she did not correct the setting at that time. Interview with LPN #4 (wound nurse) on 1/8/24 at 3:00 PM identified Resident #177 had a care plan for turning and repositioning every two hours, alternating air pressure mattress and protein supplement. The facility practice and/or policy is that when a new skin issue is identified, the charge nurse notifies the nursing supervisor and the nursing supervisor assess the characteristic or condition of the wound, provides an immediate treatment, and documents the assessment in the resident's clinical record. LPN #4 could not recall whether she was notified that Resident #177 had an open wound to the coccyx on 2/7/23. In addition, she could not identify documentation that the wound was assessed and/or that a treatment order was obtained prior to 2/9/23. She further identified that the wound nurse conducts the weekly wound rounds with MD #1 and is responsible for ensuring recommendations are implemented. She did not offer a reason as to why the recommendation for the resident to be positioned side to side while in bed to maintain off-loading of the sacrum was implemented. Interview with MD #1 (Wound Care Specialist) on 1/9/24 at 10:30 AM identified Resident #177's sacral wound was due to pressure and noted the resident was at high risk for skin breakdown because of his/her immobility, incontinence, co-morbidities, and history of pressure ulcers in the same area. He identified the sacrum was difficult to heal because of the previous history of a pressure wound to the same area and frequent pressure ulcers to the same location make it more difficult to heal due to the formation of scar tissue. He further identified that the alternating air mattress was not a replacement for frequent repositioning, and the facility should continue to turn and reposition the resident to offload the pressure to the sacrum. In addition, MD #1 identified that he conducts wound rounds at the facility on a weekly basis accompanied by the Wound Nurse. He also noted that frequent offloading is the responsibility of the nursing staff. In addition, MD #1 identified that the facility should follow the manufacturer's guidelines for the proper setting of the alternating air pressure mattress to promote the healing of the pressure ulcer injury and to prevent further skin injury. Interview and review of clinical record with the DNS on 1/9/24 at 2:30 PM identified that the facility process was the charge nurse would notify the nursing supervisor when there was a new onset of open wound and the nursing supervisor should assess the wound, immediately notified the physician to obtain an appropriate treatment and it should be documented in the nurse's note. Review of nurse's note and physician's orders from 2/7/23 through 2/9/23 with the DNS failed to identify documentation that Resident #177's sacral wound was assessed by an RN on 2/7/23 or that a treatment was put in place. Continued interview and review of the clinical record with the DNS on 1/9/24 at 3:00 PM identified that residents at high risk for pressure ulcer development should be turned and repositioned every two hours at a minimum and when needed more frequently. She further identified Resident #177's plan of care directs to turn and reposition every two hours and document the position. The DNS further noted that the nurses are responsible for ensuring that the nurses' aides turn and reposition the resident at least every two hours. The documentation of the turning and repositioning should be entered into the task section under NA documentation. Review of the NA documentation on 1/7/24 and 1/8/24 with the DNS identified Resident #177's was not consistently receiving the turning and repositioning every two hours in accordance with the resident's plan of care. Further, the DNS identified that the facility air pressure mattress was set based on the resident's current weight and there should be a physician's order to set the air mattress with the resident weight and check for the setting and function of the mattress every shift in the TAR. She also identified that her licensed staff should ensure that correct setting of the air pressure mattress to ensure the correct setting and the function of the air mattress. Review of the manufacturer guidelines for the specific alternating pressure system with low air loss mattress utilized by Resident #177 identified it was designed to treat and prevent wounds by facilitating blood circulation and decreasing the pressure of each tissue contact area. The weight button was to adjust based on the patient's weight. The scale was only for an approximation and adjust the weight setting when the mattress was too soft or too firm to suit each patient's needs. It is still recommended that the patient be repositioned periodically while using this mattress. The facility policy for Guideline for use of Support Surfaces identified the usage of the support surfaces would be based on the interdisciplinary team recommendations. The correct setting would be set by the nurse based on the resident's current weight and comfort level, monitoring of the support surface inflation would be done by the nurse every shift and documented in the TAR and a support surface does not replace the need to turn and reposition and/or offload heels based on the resident risk factors for developing pressure injuries. The policy for Pressure Injury Prevention Protocol identified that based on a comprehensive evaluation of the resident, the facility ensures that a resident receives care consistent with professional standards of practice to prevent pressure injuries and does not develop pressure injuries unless the individual's clinical state demonstrates that they are unavoidable. A resident with pressure injuries receives necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing. 2. Resident #69's diagnoses included cerebral infarction, persistent vegetative state, functional quadriplegia. The quarterly MDS assessment dated [DATE] identified Resident #69 had severe cognitive impairment, required total dependence on staff for all activities of living, was always incontinent of bowel and bladder functioning, and utilized a feeding tube for nutrition. The assessment further identified the resident was at risk for the development of pressure ulcers with no current pressure ulcers identified. The Resident Care Plan dated 1/15/23 identified Resident #69 had an increased risk of skin breakdown with interventions that directed to provide protective skin care as needed, and skin treatments as needed, incontinence care as needed. The care plan further identified a self-care performance deficit with interventions that included two staff for turning and repositioning in bed. Review of the NA positioning documentation identified the following: • On 2/18/23 the resident was positioned on his/her back from 6:00 PM to 8:00 AM (14 hours) • On 2/19/23 the resident was positioned on his/her back from 4:00 PM to 2:00 AM (10 hours) • On 2/21/23 the resident was positioned on his/her back from 4:00 AM to 8:00 AM (4 hours) and from 4:00 PM to 2:00 AM (10 hours) • On 2/22/23 the resident was positioned on his/her back from 4:00 AM to 8:00 AM (4 hours) The wound assessment dated [DATE] completed by LPN #4 (wound nurse) identified Resident #69 had an open area to the sacrum that measured 2.5 centimeters in length by 0.5 centimeters in width and no depth recorded. Treatment included Triad Hydrophilic wound dressing paste to the area twice per day. The Braden Scale Assessment (used to predict risk for pressure ulcer development) dated 2/22/23 identified the resident was at high risk for the development of pressure ulcers. Review of physician's orders identified an order dated 2/22/23 that directed to apply Triad hydrophilic wound dress paste apply to sacrum topically every day and evening shift. The orders further identified that the order for Triad hydrophilic was discontinued on 3/1/23. In addition, the wound physician's order for house barrier cream was not transcribed or added to the treatment record. The wound physician's (MD #1) assessment dated [DATE] identified a non- pressure area to the sacrum measuring 1.5 centimeters (cm) in length by 0.6 cm in width by 0.1 cm in depth. The treatment plan included house barrier cream to be applied every shift (3x/day) for 16 days. The wound physician's assessment dated [DATE] identified that he would not be overseeing the care of the resident's wound and noted the wound measured 1.5 cm by 0.6 cm by 0.1 cm and would be followed by the facility's wound nurse. Review of physician's orders failed to identify an order for barrier cream and review of the treatment administration record failed to identify that eh order was transcribed or followed. Review of the clinical record failed to identify further assessments or treatment of the sacral wound after 3/21/23. Interview with LPN #4 (the current infection control nurse and former wound nurse) on 1/10/24 at 10:00 AM identified that she was the nurse that worked with the wound physician and was responsible for monitoring the wound once the wound physician conceded care. She further noted that she could not locate any subsequent monitoring of the wound after 3/21/23; although, LPN #4 indicated further follow up would have been warranted. In addition, LPN #4 noted she had no documentation of any further assessments of the wound, including measurements or documentation that the wound healed or worsened and/or what treatment was in place after 3/1/23. LPN #4 further indicated she had no idea how this oversight could have happened and noted Resident #69 did not have behaviors inclusive of resistance to care and/or declining care. The nurse's note dated 6/4/2023 at 6:27 PM (written by RN supervisor) indicated the resident had a reopening of an old closed sacral wound. The note described the area as superficial with redness and no signs or symptoms of infection. The note further identified that the physician was notified, and order given for triad paste to sacrum three times daily for five days. Review of the clinical record failed to identify wound measurements or the outcome of the wound. There was no indication of when the wound healed/resolved. Review of the weekly skin assessments for the period of 3/7/23-6/4/23 failed to indicate any concerns with the resident's skin although the resident had the presence of wounds in March. Further interview with LPN #4 (the current infection control nurse and former wound nurse) on 1/10/24 at 10:00 AM identified that Resident #69 should be turned and repositioned every two hours. After review of the NA documentation for turning and repositing, LPN #4 noted that it was inappropriate for the resident to be left for several hours in the same position. Review of the weekly skin assessments completed for August/2023 did not indicate any concerns with the resident's skin. A physician's order dated 8/22/23 directed to start Mepilex (a bordered foam dressing used to treat pressure ulcers. Leg and foot ulcers and traumatic wounds) to the sacrum and to change every three days. Review of the clinical record failed to identify nurses' notes or wound assessments that identified a reason for the order of Mepilex. The skin and wound evaluation dated 8/29/23 completed by LPN #4 identified Resident #69 had a facility acquired unstageable pressure ulcer to the sacrum that measured 2.9 cm in length by 2.2 cm in width by 0.5 cm in depth. The assessment further noted an order for Santyl (used to remove damaged tissue from chronic skin ulcers and severely burned areas). The physician's order dated 8/31/23 directed Santyl external ointment applied to sacral wound every day. The care plan identified the added interventions after the identification of the unstageable pressure ulcer wound that included: provide incontinence care as needed, provide protective skin care, air mattress according to most current weight, avoid constrictive clothing, skin treatments as needed. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Review of the care plan failed to identify specific resident centered interventions related to the unstageable pressure ulcer The wound physician's evaluation completed on 9/5/23 identified the wound was from trauma/injury and noted the measurements as 2.5cm by 2.0 cm by 0.1cm with light serous exudate, and fifty percent granulation tissue. The note further noted that the wound had persisted from March/2023. The wound physician's evaluation completed on 10/10/23 identified the resident had a stage 4 pressure wound on the sacrum, that measured 4.1cm by 1.6 cm by 0.9 cm. Recommendations identified limit sitting to 60 minutes, offload wound, reposition per facility protocol, and turn side to side in bed every 1 to 2 hours as able. Review of the wound notes identified that MD #1 has consistently monitored the wound on a weekly basis since 9/5/23. The wound physician's evaluation completed on 1/2/24 identified the sacral wound measured 5.7 cm by 3.5 cm by 1.8 cm, with undermining of 3.6 cm noted at 7:00 o'clock, light serous exudate and 30%thick adherent devitalized necrotic tissue. Recommended the ruling out of osteomyelitis with x-ray, white blood cell count and ESR estimated sedimentation rate. Observation on 1/2/24 at 9:45 AM identified Resident #69 was lying on his/her right side in bed awake with the head of the bed elevated at approximately 30 degrees, with tube feeding running, and resident appeared to be diaphoretic. Observation on 1/2/24 at 11:50 AM identified Resident #69 was lying on his/her right side in bed appeared to be asleep with the head of the bed elevated at approximately 30 degrees, with tube feeding running her cheeks were red. The care plan dated 1/9/24 identified the resident had a stage 4 pressure ulcer to the sacrum, with interventions that included dietician evaluation as needed, monitor for signs and symptoms of wound infection, treatment as ordered and turn and reposition every one to two hours. Review of the NA turning and repositioning documentation for the period of December/2023 through January/2024 identified that Resident #69's position was not consistently changed every two hours and the resident was not kept on a schedule of side-to-side repositioning as recommended by the wound physician. Wound care observation on 1/9/24 at 10:23 AM identified the Resident #69 initially lying on the right side and was repositioned to the left side for wound care to be completed with LPN#2 (current wound care nurse). The wound appeared to be a stage 4 full thickness wound with light serous exudate that measured 5.5cm Length by 4.5cm Width by 2.cm Depth. Interview with LPN #5 on 1/9/23 at 2:30 PM indicated she did not recall the skin assessment completed on 8/29/23, however would only note new areas on her skin assessments and not old areas that the wound team knew about. LPN #5 did not identify how she would know if the wound had been previously identified and was being followed by the facility's wound nurse. Interview with MD#1 (wound physician) on 1/9/24 at 10:23 AM indicated the wound began approximately 10 months ago, and initially he diagnosed it as non-pressure ulcer wound due to the borders being irregular, which could indicate a traumatic tear, however he noted that the wound was a pressure area. He further identified that he could not speak to the how often the resident was turned and repositioned or if the patient was turned and repositioned due to the fact he was only in the building once a week for a short period of time. Interview with the DNS on 1/10/24 at 11:30 AM indicated that the NA turning and repositioning documentation was inappropriate because it shows a pattern of the resident not being turned and/or repositioned for hours at a time. It is also failed to identify that the resident is being turned side to side and being kept off of his/her back as recommended by MD #1. She further noted that wound documentation could not be located to ascertain the progression of the sacral wound after 3/21/23 and after 6/4/23. The DNS noted that documentation should be completed concerning the resolution of a wound. Review of the facility policy Pressure Injury Prevention Protocols dated 3/2023 directed the facility to prevent pressure injuries begin with identification of the resident's risk of developing a pressure injury based on a comprehensive evaluation of the resident's skin integrity and any predisposing factors and reposition in bed per care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two sampled residents (Resident #199) reviewed for falls, the facility failed to appropriately monitor the placement of a pelvic positioning belt on an adaptive wheelchair to ensure safety, leading to a subsequent fall that resulted in an injury. The findings include: Resident #199 's diagnoses included fifth lumbar vertebra fracture, left femur fracture, low back pain and abnormal posture. A fall risk assessment dated [DATE] identified Resident #199 was at high risk for falls due to history of falling, confusion, and impaired gait. The physician's order dated 11/9/23 identified Resident #199 required a two person assist for bed mobility and transfers via the Hoyer lift (mechanical lift). The quarterly MDS assessment dated [DATE] identified Resident #199 had severe cognitive impairment and was totally dependent for transfers, toileting, hygiene, dressing, was non-ambulatory and utilized a wheelchair for mobility. The physician's order dated 11/28/23 directed Resident #199 to be out of bed to the adaptive wheelchair with a pelvic positioning belt as a part of a 24-hour positioning plan. The Resident Care Plan (RCP) dated 12/19/23 identified Resident #199 was at risk for falls with interventions that directed non-skid socks/non-slip soles on shoes, place resident in common area, ensure urinal within reach and neurological checks per facility protocol. The Situation, Background, Assessment, Recommendation (SBAR) nurse's note dated 1/4/24 at 4:03 PM identified Resident #199 was found on the floor near his/her bed laying on his/her right side and bleeding from the back of the head. Neurological assessment performed, and pressure applied to the back of the head. Resident #199 denied pain and blood pressure was elevated at 157 (systolic)/ 87 (diastolic). Resident #199 was sent to the hospital for further evaluation. The hospital Discharge summary dated [DATE] at 7:51 PM identified Resident #199 was treated in the emergency department for a head injury and scalp laceration and noted that the wound to the scalp was closed with surgical staples. The reportable event report dated 1/4/24 at 9:53 PM identified Resident #199 fell from his/her adaptive wheelchair, was bleeding from the top of the head, reported that he/she was trying to pick up something on the floor. The report further noted that the resident was sent to the hospital to be evaluated. The nurse's note dated 1/4/24 at 11:18 PM identified Resident #199 returned from the hospital emergency department via stretcher in stable condition with four staples in place to the top of the head. The note further identified that the Computed Tomography (CT) scan of Resident #199's head was negative for bleeding in the brain. In addition, the note identified Resident #199 had full range of motion to the lower and upper extremities, pupils were equal, round, and reactive to light and accommodation (PERRLA) with strong hand grasps. Resident #199's family was updated on his/her return from the hospital. Interview and observation with NA #1 (NA for 7-3 shift) on 1/8/24 at 11:30 AM identified Resident #199 utilized a pelvic positioning belt to his/her wheelchair and she had not observed Resident #199 remove the seatbelt while seated in the wheelchair. NA #1 who was able to communicate in the same language as Resident #199 asked him/her to remove the seatbelt. Resident #199 was unable to remove the seatbelt and communicated to NA #1 that he/she did not have enough strength in his/her fingers to push the button to release the seatbelt. NA #1 further identified that she did not feel Resident #199 would have fallen from the wheelchair if the seatbelt was properly placed. Interview with RN #1 (unit manager) on 1/8/24 at 11:50 AM identified she was called go to Resident #199 room on 1/4/24 because he/she was on the floor. She identified Resident #199 had fallen from the adaptive wheelchair. She further identified that she did not feel Resident #199 could remove the seatbelt on his own and noted that if the seatbelt was in place, the resident would not have fallen from the wheelchair. In addition, RN #1 identified that during the course of her investigation into the fall, she had not ascertained whether the seatbelt had been properly placed prior to the resident's fall. Interview with NA #2 (NA for 3-11 shift) on 1/8/24 at 2:00 PM identified that she was assigned to care for Resident #199 on 1/4/24 and noted that she had placed the resident's seatbelt on him/her. She further identified that Resident #199 could remove the seatbelt and could not recall if she had reported this ability to the charge nurse. Review of occupational therapy notes identified Resident #199 received treatment for the period of 11/13/23 to 11/26/23. Interview with OT #1 on 1/9/24 at 12:05 PM identified that she evaluated and treated Resident #199 for the adaptive wheelchair due to his/her poor trunk control and noted the use of the pelvic positioning belt was to help the resident to maintain his/her proper posture while sitting in the wheelchair. OT #1 further identified that Resident #199 was unable to self-remove the seatbelt because he/she did not have the strength in the fingers to push the button to release the seatbelt latch. In addition, she evaluated the resident that day and reaffirmed Resident #199 did not have the strength to release the seatbelt on his/her own. She also noted that the resident would not have fallen from the wheelchair if the pelvic positioning seatbelt was properly in place. Interview with LPN #1(charge nurse on Resident 199's unit) on 1/9/24 at 12:20 PM identified Resident #199 utilized the pelvic positioning seatbelt to maintain his/her position while seated in the wheelchair. He further noted that he had never witnessed the resident remove the belt but had observed the seatbelt to not be secured at times. In addition, he identified that if the belt was properly secured, the resident would not have fallen from the wheelchair. Interview with the DNS on 1/9/24 at 2:30 PM identified she investigated Resident #199's fall and noted NA #2 told her that Resident #199 was able to remove his/her seatbelt. The DNS did not identify that this information was expressed by any other staff member or that she had confirmed this information herself. In addition, she noted that when a resident can remove the seatbelt, there is a care plan that is put in place for the staff to check the resident's ability to remove the belt. She further noted that this resident did not have a plan in place to monitor his/her ability to self-remove the seatbelt. She further identified that the resident would not have fallen from the wheelchair if the pelvic positioning belt had been properly placed and secured. The Fall Prevention Program policy identified that the purpose of the program is to reduce the incidence of falls for residents identified at high risk. It further noted that the facility would review the resident's medical records, evaluate interventions, and develop further interventions as necessary to prevent falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #2) reviewed for abuse, the facility failed to ensure a resident was protected from an alleged sexual abuse when Resident #3, with known wandering, intrusive and sexual behaviors was noted in Resident #2's room for 12 minutes and Resident #2 was noted to be visibly upset and exposed from the waist down. The findings include: 1. Resident #3's diagnoses included chronic kidney disease, diabetes mellitus, dementia and disorder of adult personality and behavior. The annual Minimum Data Set (MDS) form dated 11/3/2022 identified Resident #3 had severe cognitive impairment, ambulated independently, and had behaviors not directed toward others such as hitting, public sexual acts, pacing, disrobing, or verbal/vocal symptoms one (1) to three (3) of the prior seven (7) days. The facility reportable event form and investigation dated 11/4/2022 identified staff observed Resident #3 approach a female resident and touch her right breast. Both parties were immediately separated, and Resident #3 was placed on a one-to-one observation, psychiatry was updated to visit with resident. Corrective action plan identified staff to assist with no contact boundaries and notify provider of increased intrusive behavior towards female peers. The Resident Care Plan (RCP) dated 11/07/2022 identified Resident #3 had psychosocial well-being problems and an incident with a peer on 11/4/2022. Interventions directed for behavioral interventions: 1:1 initiated after immediate separation from peer, close observation checks every 15-minutes, psychiatry and social services to follow up, medication review, staff assist with no contact boundaries and notify provider of increased intrusive behavior towards peers, and to provide redirection of increased intrusive behaviors towards female peers. Further clinical record review identified the every 15-minute checks were discontinued during 11/2022. 2. Resident #1's diagnosis included Alzheimer's disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 was able to be interviewed, had severe cognitive impairment, required limited assist of one staff for bed mobility, and was frequently incontinent of bowel and bladder. The RCP dated 12/28/2022 identified an impaired cognitive function. Interventions directed to anticipate needs. Psychiatry note dated 1/23/2022 identified Resident #1 was seen after return from the hospital related to an incident on 1/22/2023, and was alert and oriented to self only. The note further indicated Resident #1 was a poor historian and in no distress. 3. Resident #2's diagnoses included malignant neoplasm of brain, Alzheimer's Disease, dementia with behavioral disturbances, major depressive disorder, and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #2 was able to be interviewed, had severe cognitive impairment, ambulated independently, required limited assist of one staff for bed mobility, and was frequently incontinent of bowel and bladder. The Resident Care Plan (RCP) dated 12/15/2022 identified Resident #2 had impaired cognitive function or impaired thought processes related to dementia. Interventions directed to ask yes/no questions to determine the resident's needs, cue, reorient and supervise as needed, assist with resident needs, such as supervision/assistance with all decision making, and to administer medications as ordered and monitor/document for side effects and effectiveness. The nurse's note dated 1/22/2023 at 4:49 AM identified during the early night, Resident #3 was observed leaving Resident #2's room and Resident #2 was noted to be upset, but unclear of any incident in the room. The APRN was notified, and new orders were obtained to transfer Resident #2 to go to the hospital for further evaluation. The facility incident report and investigation dated 1/22/2023 identified video footage was submitted to the local police department that identified Resident #3 entered Resident #2's room at 12:03 AM and exited at 12:15 AM on 1/22/2023 (Resident #3 was fully clothed and did not appear to have his/her clothing out of place). NA #1 entered Resident #2's room, and identified the bed sheets were turned down, Resident #2's johnny was pulled up and a incontinent brief was off, exposing Resident #2 from below the waist. The report further identified Resident #2 was upset, but could not state a reason clearly. The hospital indicated no signs of trauma, and a rape kit was not completed. Although requested, video footage was unable to be viewed during survey due to the video storage time/date to be viewed had lapsed. Review of the hospital discharge summary for Resident #3 dated 1/24/2023 identified Resident #3 was brought to the emergency department related to being visualized exiting a room occupied by two female residents. A NA was recently in resident's room and had put blankets over both residents prior to the incident. The facility identified when Resident #3 was observed exiting resident's room, she went in and found both residents were uncovered. Resident #2 was found with his/her johnny coat rolled up and under chest area and sheets pulled down to end of bed. Resident #2 was exposed and naked from the waist down. Resident #1 was found with a pull-up/brief intact, however, the sheets/covers were pulled down to end of bed. Interview with RN #1 (Unit Manager) on 2/9/2023 at 11:35 AM identified Resident #3's behaviors should be monitored when he/she was around female peers and should be separated when in close contact with previous resident's that Resident #3 had an incident with. Although RN #1 could not explain what had occurred when Resident #3 was unsupervised in Resident #1 and #2's room, and Resident #1 and #2 were found exposed after Resident #3 left the room, RN #1 indicated Resident #3 should not have been able to be in Resident #1 and #2's room unsupervised. Interview with NA #1 on 2/9/2023 at 12:20 PM identified upon the start of the 11:00 PM to 7:00 AM shift on 1/22/2023, NA #1 performed rounds on all her residents. NA #1 indicated at the start of her shift she assisted Resident #1 and #2 with toileting needs and afterwards for bed/sleeping. NA #1 identified when she left Resident #1 and #2's room after all care was performed both residents' were in bed, dressed and bed covers placed appropriately over both residents for sleep. NA #1 reported before midnight (unsure of the time), Resident #3 came out of his/her room and requested a beverage, per his/her usual routine. NA #1 gave Resident #3 a beverage and continued with care for other residents. NA #1 identified at about 12:15 AM, as she was charting, she observed Resident #3 walk out Resident #1 and #2's room. NA #1 indicated she immediately went into Resident #1 and #2's room and observed the covers were off (pulled down) on both Residents #1 and #2. Resident #1 was awake and was bothered. Resident #1 indicated Resident #3 pulled the covers off him/her and informed NA #1 that he/she heard Resident #2 screaming. NA #1 noted Resident #2's depends/brief was on the floor, his/her johnny coat was bundled up to the upper chest area, and his/her peri-area was exposed and was visually reddened. Resident #2 was unable to articulate what happened but while pointing to his/her perineal area, verbalized why did he/she do that to me? NA #1 indicated Resident #2's perineal area was visually red, and Resident #2 appeared visibly upset at the situation. NA #1 further identified she was unaware of any other related incidents involving Resident #3 in the past related to resident-resident incidences. Interview with RN #2 on 2/9/2023 at 1:15 PM identified she was the shift supervisor when the incident occurred on 1/22/2023. RN #2 indicated Resident #2 was upset when she assessed Resident #2, but Resident #2 was shaking and was unable to verbalize what had occurred when Resident #3 was in the room or why he/she was upset. RN #2 further indicated the residents may have been scared when Resident #3 was in the room and they were exposed. Interview with SW #1 on 2/9/2023 at 2:35 PM identified Residents #1, 2 and #3 were unable to verbalize what had occurred on 1/22/2023 when Resident #3 was in Residents #1 and 2's room. SW #1 further indicated during follow up visits with the residents, the residents were unable to recall the incident. SW #1 further indicated staff should be mindful of the resident's whereabouts on the unit and re-direct Resident #3 if in close contact with residents involved in this and previous altercations. Interview with the DON on 2/9/2023 at 10:15 AM identified the DON could not explain what had occurred when Resident #3 was unsupervised in Resident #1 and #2's room, and Residents #1 and #2 were found exposed after Resident #3 left the room. Review of facility Abuse Policy dated 1/2023 directed in part, each resident has the right to be free from abuse, neglect and misappropriation of resident property and exploitation. The Policy defined sexual abuse as non-consensual sexual contact of any type with a resident, and included but was not limited to sexual harassment, sexual coercion, or sexual assault.