**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and document review, the facility failed to ensure adequate supervision and a comprehensive assessment was completed to help prevent resident to resident sexual abuse. As a result of the facilities failures an immediate jeopardy (IJ) situation was identified when resident (R2) wrote unwanted paper notes that were sexual in nature and hand delivered them to R1, resulting in psychosocial harm related to triggering symptoms of PTSD (Post-Traumatic stress disorder) derived from childhood sexual abuse and feelings of insecurity for 1 of 2 residents (R1) reviewed for abuse. The IJ began on 3/27/25 when three residents reported inappropriate behavior by R2, including writing notes that were sexual in natural and touching residents. The facility administrator and director of nursing (DON) were notified of the IJ on 5/22/25 at 4:10 p.m. The IJ was removed on 5/28/25 at 11:09 a.m., but non-compliance remained at the lower scope and severity of D. Findings include: A Vulnerable Adult Maltreatment Report submitted to the State Agency (SA) on 5/16/25 at 12:00 p.m., alleged abuse and neglect to R1 when R1 reported feeling unsafe at the facility due to R2 being sexually inappropriate, sexually harassing, and making unwanted sexual advances by writing letters and talking about sexual desires R2 had with R1. Several of the female residents stated they did not feel safe in the facility because of R2's behaviors. A Nursing Home Incident Report (NHIR) submitted to the SA on 5/16/25 at 1:57 p.m., alleged abuse when a resident (R1) reported during resident council on 5/15/25 that they did not feel safe because a resident (R2) stares at them. R1 R1's New admission Information dated 10/15/24, indicated R1 had diagnoses of Alcoholic encephalopathy, Post Traumatic Stress Disorder (PTSD), anxiety, and depression. R1's cognition was confused, and behaviors were confused but pleasant. The form also identified R1 was independent with activities of daily living (ADLs). The facility was to provide occupational therapy (OT), speech therapy (ST), and substance abuse treatment. R1 was admitted with a commitment order (court ordered mandate to be involuntarily place in an institution for treatment or care). Additional information included R1 had poor cognition, very forgetful, needs reminders that R1 had completed tasks. R1's admission Trauma Informed Care History dated 10/16/24 identified R1 was molested as a child. Triggers that make it worse were indicated as use to have a lot of them but overcame them with counseling. R1's care plan initiated on 10/16/24, identify a potential for ineffective coping related to PTSD and reported history of traumatic event(s) from her childhood attention seeking behavior of sexual comments towards men. Goal was to feel safe and enjoy daily activities of her choice for the next 90 days. Interventions included allow to express feeling, communicate with them that they are safe, it's not their fault, you are sorry this happened and you are glad they are alive; identify support system and us them as appropriate; and provide a safe therapeutic environment where they can regain control as needed. R1 is a smoker and can smoke unsupervised. R1 has impaired cognitive function/dementia or impaired thought processes related to Wernicke's encephalopathy (brain and memory disorder), diagnoses and BIMS (brief interview of mental status) score. Interventions included administer medications, cue, reorient, and supervise as needed; has a pad of paper in her room to put information on for her to remember; and has a sign on the wall to remind her that her wallet is with her husband and nursing has her cigarettes. R1's safety is at risk and there is a potential for abuse due to anxiety, chemical dependency, current medical condition, use of medications and need for assistance with cares and mobility. Interventions were to remove R1 from potentially dangerous situations. R1's Preadmission Screening and Resident Review (PASARR) screening dated 11/11/24, identified serious mental disorder, intellectual disability or related disorder existed. R1's Vulnerability and Susceptibility to Abuse assessment dated [DATE], indicated R1 was at risk for abuse related to cognitive impairment, alcohol/substance abuse, physical impairment. R1's significant change Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment, minimal depression, no behaviors, and no hallucinations or delusions. Diagnoses included Wernicke's encephalopathy insomnia, history of suicidal behavior, anxiety, depression, post-traumatic stress disorder (PTSD), and alcoholic hepatitis (inflammation of the liver). R1's Montreal Cognitive Assessment (MoCA) dated 3/4/25, indicated R1 had higher mild cognitive impairment. R1's Cognitive care area assessment (CAA) dated 3/10/25, identified risk for psychosocial well-being changes d/t recent hospitalization and factors of cognitive loss and ETOH (alcohol) abuse. At risk for further clinical declines, re-hospitalization if psychosocial well-being is not addressed. R1's Nursing Note dated 5/4/25 at 2:24 a.m., identified R1 and another resident approached writer at 7:40 p.m., and stated that they did not feel safe as R2 was harassing them by calling them offensive names when they were out in the smoking area. R1 further stated that the harassing resident [R1] stays at his door and when they go out to smoke, he follows them. Writer request R1 to stay away from the other resident as much as they could. Writer offered an alternative smoking area for the meantime and in the event [R1] wanted to go to the regular smoking area to inform staff so they could be with staff all the time. Law enforcement involved. Director of nursing DON was notified and social worker to be informed. (no other mention of feeling unsafe in the notes) R1's Resident Location charting dated 4/27/25, 4/28/25, and 4/29/25 indicate 15-minute checks for protection. (no other information given) R1's psychiatry Therapy note dated 5/23/25, identified R1 reported getting letters from a male resident a couple of months ago and have become inappropriate over time and R1 notified staff of this. R1 now feels uneasy around the person. R1 further reports feelings of unease like tension in her chest when wondering if she will see that person and brings up feelings like when she was sexually abused as a child. R1 feels she needs to watch her back and protect herself since reporting her concerns about the peer. R1 reports it is taking a long time to get to sleep and waking up 2-3 times a night. R1 requested to increase her session frequency to two times a week for additional support at this time. R1's record lacked indication a comprehensive assessment was completed to determine psychosocial harm, interventions put in place to ensure safety, supportive services provided, or monitoring systems for supervision and mood/behavior changes were implemented to keep R1 safe from ongoing abuse. R2 R2's quarterly MDS dated [DATE], identified R2 had moderately impaired cognition, with no hallucinations or delusions, no wandering or rejection of cares. R2 had verbal behaviors directed towards others 1 to 3 days weekly and behavioral symptoms not directed at others 1 to 3 days weekly. R2's diagnosis list includes emotional lability, alcohol use, depression, anxiety disorder, osteonecrosis (death of the bone due to lack of blood supply). R2's care plan initiated 1/25/25 indicates potential for ineffective coping related to reported history of traumatic event no triggers noted. Interventions included allow to express feelings, provide a safe therapeutic environment where they can regain control as needed; prefers female caregivers; does not want male caregivers for intimate cares. R2 requires assist of staff with bed mobility, toileting, transferring, and dressing lower body. R2 does not ambulate. R2 is a smoker and can smoke unsupervised. R2 used psychotropic medications related to depression and anxiety. Interventions included monitor/record occurrence of target behavior symptoms of rapidly shifts between different emotions, self-isolation, sense of impending doom, and hyper-fixation. Target behavioral interventions is journalling, talk therapy, distractions/redirections, remind to focus on what is controllable, and drawing. R2 is at risk and there is a potential for abuse due to anxiety, and chemical dependency. Interventions include: ensure I am safe around others that might take advantage of my confusion, encourage participation in separate meaningful activity, provide positive reinforcement when resident handle conflicts appropriately. R2's care plan lacked updates or potential sexual behaviors toward others. R2's progress notes dated 3/27/25 at 4:28 p.m., three female residents approached writer and another nurse manager to report that a male resident has been acting inappropriately toward them. They shared that the resident writes notes to them and follows them to the smoking area. The residents expressed feeling uncomfortable with his behavior. The writer and other nurse spoke with R2 about the concerns and R2 explained he only wrote letters to one of them [R1], who had shown interest in him. Education given to the resident, verbalize understanding. R2's Nursing Note dated 4/27/25 at 4:51 p.m., R2 was reported being sexual [sexually] inappropriate to R1. Per R1 she has been sexually abused by this resident and does not feel comfortable. R1 safety is being ensured by checking on R1 when she goes out to smoke. R2 was educated on sexual abuse and verbalized understanding. R2's 15-30-60 Minute Monitoring Flowsheet dated 5/3/25 and 5/4/25, identified R2 was on 15-minute checks for safety reasons, started 5/3/25 at 2:45 p.m. to 5/4/25 at 11:30 a.m. R2 flowsheet lacked monitoring on 5/4/25 between 11:45 a.m. to 6:00 p.m. then resumed on 5/4/25 at 6:00 p.m., with last entry at 5/5/25 at 5:45 a.m. R2's record lacked additional behavior management, assessments or monitoring to mitigate risk of R2's alleged sexual behaviors towards R1. During an interview on 5/19/25 at 1:42 p.m., the business office manager (BOM) indicated she attended the resident council meeting on 5/15/25 and concerns were expressed about feeling unsafe at the facility related to R2 writing some notes to R1 and R2 watching and waiting for R1 to go out to the smoking area and R1 did not want to be by R2. The BOM reported the ombudsman was in the meeting and was going to follow up on the concern and did report their concerns to the DON and administrator. The BOM denied having prior knowledge of the letters. During an observation and interview on 5/19/25 at 2:15 p.m., R2 identified he was in trouble at the facility because he had a relationship with R1 and wrote her some love notes. R1 decided she did not want them anymore; they called the cops and we were supposed to stay away from each other. Law enforcement returned on Friday 5/16/25 and talked to me again. R2 stated, all the staff knew about it and the social worker told R2 that he was stalking R1 but could not remember when that conversation occurred. R2 reported writing love notes to R1 for approximately two months. During observation and interview on 5/20/25 at 8:55 a.m., R1 stated she had concerns about her safety because of R2 saying stuff to me like he likes me and started passing me some sexual notes. R1 indicated being married and would not consent to a relationship with R2. R1 further identified the notes started to get disturbing and showed staff the notes a week or so ago, can't remember. R1 indicated R2 would usually approach her in the smoking area, which was unsupervised by staff. During an interview on 5/20/25 at 9:05 a.m., R4 indicated R2 was obsessed with R1 and would sit in the doorway and stare at her, write letters to R1, and play love songs for R1 to hear. R4 further indicated about a month ago, R1 and R3 told the DON about the letters and the DON made copies of the letters and they moved R2 to a room even closer to R1. R4 indicated the DON told them they were all adults and needed to work it out. During an interview on 5/20/25 at 9:20 a.m., R3 indicated R2 sexually harasses R1 and has read the letters that R2 had written to R1, and they were sexual and graphic. R3 stated, R2 is scaring the [expletive] out of her. R3 indicated the allegation was reported to the social worker and nursing staff about six weeks to two months ago but moved R2's room even closer to R1. R3 said after the resident council meeting on 5/15/25, R1 and R2 were to go to two different smoking areas. During an interview on 5/20/25 at 9:50 a.m., NA-B indicated the conflict between R1, R2, and R3 is an everyday thing. NA-B indicated night shift had reported seeing R2 in R1's room and reported it to the charge nurse. NA-B identified R1 expressed concerns with the letters from R2 a couple of weeks ago that R1 continued to receive letters from R2 and that R1 wanted them stopped, stating R1 felt stalked. NA-B reported to the charge nurse. NA-B identified they were told to supervise the hallways as much as we can but there are no restrictions on what R1 and R2 can do but, R1 is good about not being in the same area as R2. During an interview on 5/20/25 at 10:15 a.m., R5 indicated being upset because of the sexual harassment to R1 by R2 and stated, it has to stop. R5 reported she had read the letters and found them to be sexual harassment but not threatening. R5 further indicated R1 had expressed her concerns with the letters and given them to registered nurse (RN)-A and the DON about six weeks ago and the facility made copies of the letters but did nothing to help R1. During an interview at 5/20/25 at 10:30 a.m., RN-A indicated she was made aware of the letters to R1 written by R2 sometime in April. RN-A described the letters she read to be kind letters, like you are beautiful, and want you to be my friend. RN-A identified she talked to R2, and he did not feel the letters were inappropriate for their relationship. RN-A stated R1 was concerned enough about the letters that she brought them to us and law enforcement was called a couple of times. RN-A identified she did not feel R1 had the capacity to consent and needed to figure something out [related to the relationship between R1 and R2]. During an interview on 5/20/25 at 11:08 a.m., the director of nursing (DON) indicated she was aware that R1 and R2 had an off and on relationship that had been ongoing for a while. Indicated R1 has memory issues but R2 does not. The DON indicated R1 brought the letters to her back in April sometime, did an investigation, interviewed both R1 and R2, and determined R1 knows what she is doing so did not report the concern to the State Agency. The DON was not sure how they determined R1's capacity to consent. The DON indicated she was not made aware of any further concerns about the letters until resident council meeting on 5/15/25. After the resident council meeting, implemented 15-minute checks on R1 and told staff to make sure R1 and R2 are not seen together. During an interview on 5/20/25 at 11:32 a.m., family member (FM-A) identified R1 calls her about eight times a day and had concerns about R1's safety and security related to the unwanted letters, treats, snacks, and gifts from R2. FM-A further indicated R1 had called her crying because the abusive situation is triggering R1's PTSD symptoms from earlier childhood trauma. FM-A indicated the facility has talked to R2 and told him to stop but, it was just ramping it up. FM-A shared concerns that the facility was not following through with their safety plan because he was still writing R1 letters and handing them to her. During an interview on 5/20/25 at 1:04 p.m., the activity director (AD) reported R1 felt unsafe around R2 and received letters from in the past. The AD indicated the letters were given to management and grievances were written. The AD indicated the letters were given to the social worker and R2 did stop writing letters for a while. During an interview on 5/20/25 at 2:36 p.m., social service designee (SSD) with administrator present during interview. The SW identified she was aware of a mutual relationship between R1 and R2 and described the relationship as R2 is infatuated and R1 enjoys the attention. The SW further indicated R1 and R2 are close friends and two adults but their relationship depends on the day. The SW did not know when the letters first started but did not think they had all the letters because she felt the letters that were copied were friendly in nature with some drawings. The SW identified the letters were in a soft file. The SW based R1's capacity to consent off the brief interview for mental status (BIMS) which indicated a score of seven which equated to severe cognitive impairment and the totality of knowing [R1]. The SW indicated she felt R1 could make decisions in the moment but 5-6 hours later would not be confident in her choices. During a follow up interview on 5/22/25 at 11:05 a.m., R1 reported receiving letters from R2 for at least a few months and brought her concerns and the notes to staff at least twice before bringing her concerns to the resident council meeting with the ombudsman in attendance. R1 identified the first time she reported her concerns about the notes written by R2, she was told (by facility staff) they would talk to him; the second time she approached staff about the notes, she did not receive any follow up on what had happened. R2 continued to write, and hand deliver the notes to R1 in the designated smoking area or in the hallway. R1 stated, I would hold my breath going down the hallway, hoping he didn't see me. R1 stated, the sexual abuse PTSD really amped up and brought it back. R1 reported informing her counselor of the PTSD and the unwanted attention and the doctor was going to look at adjusting one of my medications but don't know if that happened. R1 was tearful and continued to report trouble sleeping since the notes started as R1 worried about R2 coming into her room at night when the staff was not looking. R1 stated R2's notes made her feel disgusting, unsettled, and disturbed. R1 indicated the letters from R2 stopped after the resident council meeting on 5/15/25. The letters provided by the facility are as follows: 3/27/25: My Luv Bug, you are my favorite addiction Miss Lovely in every xxxxxx way. BTW: I love your tight [NAME]. Yummy to my tummy. Any ways I'm leaving here when you leave becuz [unreadable] I need, want, and love will be gone when you depart my lady. I love you [R1] Undated letter: I just hope you know I am taking an onslaught of haters by expressing my affection for you Lovely. I am about ready to tap out. It doesn't mean I don't love you, but I am gonna let off the gas pedal soon. I can only hope you still wanna lay in my arms someday. All night, All night. 4/2/25: Baby I still love you [R1] always will. [phone number written] Last letter circled. Letters provided by R1: 4/10/25 at 9:26 p.m.: [R1] I love you always [R2]. I will give U [NAME] love 4 a lifetime if I can trade u my heart for your beautiful body baby bunz. 4/21/25 at 7:57 p.m.: Love [R2] I want 2 kiss you forever and a day [R1]! I will always love you. U lifted up baby 4/23/25 at 9:56 p.m.: I want to kiss your smile smile. I'm falling 4 you [R1] badly. I love you so much I feel you in my bones baby. I want to kiss you forever. 4/26/25 at 7:35 p.m.: 4 ever love [R2] I will never stop adoring you everything you do drives me crazy 4 you [R1] and I love you 4 it more. Undated: Happy May Day my lady. Good morning my lover and best friend you were so amazingly perfect to my eyes. I just longed to touch you everywhere on your baby silk smooth flawless skin. You allowing me to touch you and massage your back and legs gave me a soothing peace I need every day. You are my darling and will and always enjoy pleasuring you anywhere any day {R1]. [heart sign] R2 Undated: Happy may day baby - to [R1] we need a night 2getherness. Good morning [R1] I love you more today than before. Thank you for letting me touch you and caress your [unreadable] last night. I need to touch you more. Your body is so silky smooth is soothing you know for me more than it probably is too you. Love [R2] Undated: Baby Bunz, you look so absolutely stunning today. I want to kiss you until me and you both feel loved. [R1] you look more beautiful than ever before. U make me wanna .69 long .until .cream. Undated: [R1} I love u and I know it! I have fallen 4 you [R1] 2 me through my eyes u are the most beautiful women I have ever had a soul connection with by far. No matter what happens you will never be forgotten and will always have a special piece of my [arrow drawn]. There is just something about you baby. Undated: Zangi.com(a private messaging app) [R2's number is listed] Undated: I feel better just being in love with you Undated: P.S .I [heart drawn]U [R1]! I hope someday we can be alone so I can kiss and hold you until you feel my love. Undated: To my lady [R1] my lover, my lady, my friend, my woman, my wife, my life, my love, yours always [R2] Undated: I need you to know how I feel about you. Its not even funny you're the first and the last thought in my head every day even when we [unreadable] together, just cant get enough of you. The look on your face when you are telling me how you feel about me makes me about melt or when your pushing my buttons trying to be cute makes my head swim even though its frustrating as xxxx it doesn't bother me. The hardest part is trying to not let how I feel show on my face all day long. I selfish and want you all to myself for the remainder of the time we have together. I guess what Im really saying is that I love you and everything about you. Facility documents R1's Grievance Form dated 4/2/25, indicated R1 did not want letters from R2 anymore. The investigation summary identified the DON spoke with R2 about letter writing and R2 wrote his last letter. Attached to the grievance form was a letter written by R1dated 4/2/25, indicated last letter with baby, I still love you, always will with phone numbers written on the note. A county sheriff's office Incident Report dated 5/3/25 at 8:15 p.m., indicated the sheriff's office received a 911 call indicated residents harassing each other and one feels unsafe. Residents were separated and advised to leave each other alone. The residents involved were R1, R2, and R3. The facilities Resident Council Minutes dated 5/15/25, identified social services concerns were resident feelings of being stalked and harassed by other residents and social worker stretched thin (over worked). The facility's undated policy titled, Abuse, Neglect and Exploitation identified it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implanting written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Sexual abuse is defined as non-consensual sexual contact of any type with a resident. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The facility will make efforts to ensure all resident are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. The facility's undated policy titled, Resident Right, identifies the resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The resident has the right to voice grievances to the facility or other agency without discrimination or reprisal. Such grievance includes those with respect to care and treatment which has been furnished as well as that which has not been furnished; the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The resident has the right to and the facility must make prompt efforts by the facility to resolve grievances the resident may have. The immediacy of the IJ was removed on 5/28/25 at 11:09 a.m., when it was verified, the facility had implemented the following: 1) R1 immediately assessed by nursing and social service staff for psychological impact related to PTSD, behavioral changes, mood, and cognitive status. 2) R1 had an appointment over the phone with rural psychiatry services on 5/23/25 at 11:00 a.m. 3) R1 and R2 were placed on 15-minute checks by facility staff. R1's 15-minute checks were to monitor for signs of distress, anxiety, or change in behavior. R2's 15-minute checks were for behavior monitoring. 4) R1 reassured of right to safety and privacy. 5) R1 was offered emotional support services and a counseling session was scheduled for 5/23/25 at 11:00 a.m. 6) Mental health provider will be completing a capacity to consent. The facility is in the process of finding a provider that is able to complete this. 7) Primary care provider and rural psychiatry services were updated of the sexual abuse of R1 by R2 on 5/22/25. 8) Social service designee had routine check-in's with R1 on 5/22/25 and 5/23/25. Check-in's will continue on Tuesday, Thursday, and Saturday evenings. 9) IDT meeting held on 5/22/25 which included increased supervision for R1 and R2, ensure supervising staff are briefed on relevant background and IJ findings, review of current living/social environment for safety and appropriateness, offer relocation to a different facility if resident wishes, remove or limit access to triggering individuals or settings where possible, remove or limit access to triggering individuals or settings where possible, counseling arranged to occur as needed, engage family or guardians where/when appropriate, engage commitment manager/relocation, worker/therapist/clergy when/where appropriate. 10) R2's care plan and behavioral intervention plans updated to include all written and verbal communications with R1 would be monitored by staff to ensure appropriateness and maintain a respectful, safe environment. 11) All residents were assessed to ensure no others were impacted by similar behavior from R2. 12) Abuse policy was revised to include written/verbal communications and resident to resident sexual harassment procedures. 13) Mandatory in-service training on 5/22/25, including definitions and examples of sexual abuse including written communications and mandated reporting. 14) System in place to determine capacity to consent on admission for all residents. 15) Weekly audits of resident interactions both written and verbal for 4 weeks, monthly for 3 months, and reviewed at quality assurance and performance improvement (QAPI) meetings. 16) All allegations of abuse will be reviewed immediately by IDT and brought to QAPI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review the facility failed to complete comprehensive pressure ulcer assessments and ensure physician ordered wound vac therapy was adequately managed for 2 of 3 residents (R1, R3) who required wound vac therapy. The facility's failures resulted in an immediate jeopardy (IJ) for R1's when their pressure ulcer deteriorated resulting in necrosis, bone exposure and hospitalization. The immediate jeopardy began on 6/26/23, when wound clinic identified R1's wound had deteriorated to the bone from improper dressing placement and mismanagement of the wound vac. The IJ was identified on 7/10/23 and the administrator, assistant administrator, and director of nursing (DON) were notified of the IJ on 7/10/23 at 5:45 p.m. The immediate jeopardy was removed on 7/12/23, but noncompliance remained at the lower scope and severity level of D- isolated with no more than minimal harm that is not immediate jeopardy. Findings include: Stage 4 pressure ulcer as defined by the State Operation Manual, last updated 11/22, is full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Negative Pressure Wound Therapy (NWPT) also known as a wound vac helps to heal wounds by providing a moist environment, promote new tissue formation, and removing excess fluid and infection. Negative pressure wound therapy uses suction, tubing, and wound dressing to remove excess exudate and any infectious material that may be present in the wound. Negative pressure wound therapy, also called wound vac or NPWT, provides an ideal and clean environment to promote wound healing in acute or chronic wounds. Offering significant clinical benefits for large, chronic wounds and acute, complicated wounds, negative pressure wound therapy is used by healthcare teams and wound care specialists to support faster wound healing. The negative pressure or vacuum suction is provided by a pump that is connected to a wound. A foam dressing is placed in the wound and covered with an occlusive dressing. The fluid that is removed is collected in a canister on the pump. A Vulnerable Adult Maltreatment report submitted to the state agency (SA) on 6/27/23 at 9:10 a.m., indicated the facility incorrectly followed wound care orders which caused worsening of R1's stage 4 sacral (a bone located at the base of your spine) ulcer and additional skin breakdown of 25.0 centimeters (cm) x 8.0 cm of previously good skin. The mismanagement of the wound vac and ulcer resulted in further necrosis (death of living tissue), infection, and hospitalization. A second Vulnerable Adult Maltreatment report submitted to the SA on 6/28/23 at 2:45 p.m., noted concerns regarding the facilities' ability to manage R1's stage 4 sacral ulcer and wound vac due to the deterioration of the ulcer while under their care resulting in R1's excess pain and long hospitalization stay. R1's Medical Diagnosis List last updated on 6/12/23, identified diagnoses of stage 4 pressure ulcer of sacrum, diabetes with polyneuropathy, severe chronic kidney disease, and heart failure. R1's hospital document titled, Discharge to Skilled Nursing Facility dated 6/12/23, identified an order for NWPT (wound vac) to sacral ulcer with further direction to use one large, black granufoam dressing, pack wound to skin level (including undermining). Recommended skin prep and 2-inch barrier ring to periwound skin and bridge wound up to hip, do not place [NAME] pad over the wound or over any bony prominence. Change Monday, Wednesday, and Friday. Cleanse wound with saline or wound cleanser when dressing changed. Suction set at 125 mmHg continuous. The patient's NPWT device should be on at least 22 hours of every day. If there is a malfunction of the pump, trouble shooting failed, and suction is off for 2 hours, you should remove the foam packing from the wound and pack gauze moistened with saline or sterile water. Change this dressing twice daily until the dressing can be replaced. The patient education section included: *The canister is changed once/week or when it is full. R1's Hospital discharge orders dated 6/12/23, included the aforementioned treatment orders for the wound vac dressing change to the sacral ulcer. R1's Skin Wound Evaluation dated 6/12/23, included stage 4 pressure ulcer in the middle of the sacrum present on re-admission to the facility. The wound measured 7.2 cm in length, 6.2 cm wide, 6.5 cm deep, with 6.5 cm of undermining (wider area of breakdown under the wound opening) and no tunneling (forms passageways underneath the surface of the skin). The pressure ulcer showed no signs of infection. Surrounding tissue is fragile skin and risk for breakdown. Primary dressing was wound vac. No further assessment of the sacral wound was identified. R1's Braden assessment dated [DATE], indicated R1 was at mild risk for pressure ulcers. R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had severe cognitive impairment. Required extensive assist of staff for bed mobility, dressing, toileting, repositioning, transferring, and mobility. R1 was occasionally incontinent of bowel and had a urinary catheter. R1 was identified to be at risk for pressure ulcers. R1 had one stage four pressure ulcer, one venous ulcer, and one surgical wound. The MDS identified the following interventions were in place: pressure reducing device for chair and bed, turning and repositioning program, nutrition/hydration intervention to manage skin problems, pressure ulcer/injury care, application of non-surgical dressings, applications of ointments/medications to feet and areas other than to the feet. R1's Care Plan initiated on 6/14/23, indicated R1 had a stage 4 pressure ulcer to sacrum related to immobility, left hemiplegia, polyneuropathy. Interventions included administer treatments as ordered and monitor for effectiveness; avoid positioning the resident on back; monitor nutritional status; serve diet as ordered; monitor and record intake; the resident needs assistance to turn/reposition every two hours or more often as needed or requested; up in chair for no more than 1 ½ to 2 hours; air mattress to bed and cushion in chair, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate. R1's care plan did not address interventions or direction for the wound vac. R1's Nurse-readmission assessment dated [DATE], indicated R1 was readmitted from the hospital on 6/12/23. The assessment identified R1 had a pressure ulcer on the sacrum that required a wound vac. The assessment did not include wound measurements, drainage, pain presence, periwound skin integrity, or wound vac function. The assessment further indicated R1 had an alternating air mattress. Facility Negative Pressure Wound Therapy policy dated 2014, directed the following: NPWT is contraindicated in residents who have wounds with necrotic tissue with eschar, untreated osteomyelitis, non-enteric fistula or a malignancy. Documentation: 1. The wound status at time of application of negative pressure. 4. The resident's tolerance of the procedure. 6. The date and time negative pressure therapy was started and stopped. Reporting: 1. any problems with procedure. 2. Marked changes in the wound from baseline or previous dressing change. Physician order dated 6/14/23 included a wound clinic referral. R1's Treatment Administration Record (TAR) identified the wound vac dressing change order that directed to change R1's wound vac three times a week on Monday, Wednesday, and Friday. R1's dressing changes were completed on 6/14/23 by registered nurse (RN)-A. On 6/16/23, the dressing change was marked completed by the director of nursing (DON). On 6/19/23 and on 6/21/23, the TAR identified R1's dressing had not been changed and was marked with a chart code of 9 which indicated the treatement was not completed and directed to see progress notes. Progress notes dated 6/19/23 and 6/21/23 did not identify why the wound vac treatment was not completed. Review of R1's medical record from 6/12/23 to 6/16/23, did not include any routine monitoring for signs/symptoms of infection, amount of drainage including color, wound bed characteristics, and skin surrounding the pressure ulcer. There was no indication if R1 had any pain that was associated with wound vac placement or if the wound vac suction was set at 125 mmHg continuous at 22 hours every day as ordered by the physician. R1's progress note dated 6/16/23, at 2:30 p.m. indicated R1 voiced coccyx area discomfort when sitting in her chair; the tubing and [NAME] were directly over the wound was causing discomfort, she was assisted to bed which was helpful. R1 also has phantom limb pain and polyneuropathy pain. She had been administered as needed hydromorphone (narcotic pain medication) in the morning and scheduled Tylenol which were effective. R1 declined stronger pain medication at that time. In a subsequent note at 2:35 p.m. the physician was notified who then ordered Oxycodone (narcotic pain medication) 10 milligrams (mg) every 12 hours. R1's progress note dated 6/16/23, at 9:55 p.m. indicated R1 complained of almost constant pain from her sugical site on right stump and coccyx/sacrum area. R1 rated her pain 10 out of 10; she had non-verbal signs of pain facial expressions and protective body movements that indicate pain as well. She recieved scheduled and as needed medications of hydromorphone, Tylenol, and Oxycodone. Repositioning and rest help to alleviate some of her pain as well. Although the TAR dated 6/16/23, identified R1's wound vac treatment was changed, it was not evident the pain evaluation included checking the placement and/or integrity of the wound dressing as a causal factor of R1's pain. After 6/16/23, R1's record identified the next progress note was a physican visit dated 6/21/23. R1's wound clinic After Visit Summary dated 6/21/23, indicated it was R1's initial visit. R1 received wound care services for ongoing management of ulcerations that included sacral stage 4 pressure ulcer. The note included Wound VAC dressings were removed from the sacrum. This was not applied properly. The dressing was to be bridged to one of R1's hips however, they (facility staff) had the plastic flange directly over R1's sacrum; there was not enough black foam exposed for the plastic flange to adhere. 200 milliliters (ml) of drainage in the canister. Measurements of the wound showed the ulcer measured 5.8 cm x 6.0 cm x 4.0 cm. Undermining noted throughout the wound; at the 12 o'clock position 3.5 cm, 1 o'clock 4.5 cm, 3 o'clock 3.0 cm, 6 o'clock 1.0 cm, and 9 o'clock 3.0 cm. Wound bed is roughly 2% necrotic tissue and 50% granular. No periwound erythema, induration, stricture, or fluctuance. The wound was debrided to the level of the muscle. The following detailed instructions were given for the NWPT dressing changes to the sacrum: Clean wound bed with gauze and wound cleanser Treat periwound with skin barrier prep Place transparent dressing in the periwound skin for protection, this should be draped up to her hip for bridging. Pack the wound with the black granufoam (be sure to pack all undermined areas) and bridge this up to the hip over the transparent dressing. Be sure that all of the black foam is touching and not in contact with R1's skin. Secure all down with another transparent drape Cut out a 1.0 cm hole over the bridged portion to expose the black foam Place the plastic flange over the exposed black foam Secure the plastic flange down with transparent strips Turn the wound vac on at -125 mmHg continuous pressure. Be sure there are no leaks. Change Monday, Wednesday, and Friday. The visit note further included: It is very important that the wound vac is applied correctly and that it is bridged to the hip. Continue to check the wound vac through the day at least every shift or more often to be sure that there is a good seal and not malfunctioning. R1 should be on a pressure relieving mattress, change position ever 1-2 hours to reduce pressure to the sacrum. Plan is to see R1 at the facility next visit (6/26/23) as it would be beneficial to show the facility nursing staff how to place the wound vac appropriately for R1's safety. R1's care plan revised on 6/21/23, added the intervention of wound vac to sacral wound per orders. R1's TAR indicated registered nurse (RN)-A completed the wound vac dressing change to the sacral wound on 6/23/23. In review of R1's medical record between 6/17/23 to 6/26/23, the record did not include evidence of routine monitoring for signs/symptoms of infection, comprehensive wound assessments, evaluations for wound improvement or deterioration with dressing changes, and comprehensive pain assessment associated with wound vac placement. Additionally, not evident the wound vac was monitored for drainage amounts and continuous function. R1's Wound Care Follow Up Progress Notes written by nurse practitioner (NP)-A dated 6/26/23, indicated the wound team completed R1's visit at the facility with RN-A present. The note indicated R1 continued to have pain in the coccyx region. R1's dressing was removed from the coccyx but unfortunately, when the foam was bridged to the hip, there was not transparency drape placed under the foam [as ordered] so it did cause skin damage and is quite irritated. No drainage in the wound vac canister and a moderate odor was noted to the wound. Wound bed is full thickness, 75% eschar/slough, 25% granular. The wound bed measures 6.5 cm x 5.5 cm x 4.0 cm with undermining noted of the entirety and exposed bone that is easily felt. With appearance of wound on buttocks, vitals were obtained by nursing facility nurse, temp 100, blood pressure was not hypotensive, heart rate 86, respiratory rate 20. Mild temp, bone exposed, worsening wound erythema, advised that she should be seen in the emergency department. Likely will need imaging and lab work to rule out osteomyelitis and may need to see surgeon for bone debridement and wound debridement. R1 was sent to the emergency room for further evaluation. R1's facility progress note dated 6/27/23, indicated R1 had been transferred from the emergency room to a higher-level hospital and was receiving antibiotics. A follow up progress noted on 6/28/23, indicated R1 would not tolerate a surgery at that time and is getting debridement (a procedure to remove debris or infected/dead tissue from a wound) on the sacral wound. R1's social service note dated 7/11/23, indicated R1 would be discharged from the hospital on 7/12/23 after spending 16 days in the hospital for wound management. During an interview on 7/6/23 at 4:23 p.m., RN-A stated awareness of R1's wound vac dressing's being applied incorrectly. Further stated the facility had not provided any formal training but had worked with wound vacs at prior facilities. Normal process is to check for drainage when you walk by, RN-A had not recorded the checks, but stated it was something staff should be doing. During an interview on 7/10/23 at 11:30 a.m., contracted wound care certified medical assistant (MA)-A stated they first saw R1's wound on 6/21/23, at the wound care clinic. MA-A explained the wound vac dressing was done incorrectly; the tubing was placed directly over the sacral ulcer, the dressing was loose and not sealed adequately to allow for proper suction. MA-A indicated R1 was having a lot of pain at the time. R1's sacral dressing was replaced in the clinic and detailed instructions were provided to the facility on how to correctly change and bridge the dressing. MA-A stressed the black foam could not be on good skin because it would cause breakdown; the healthy skin needed to be protected by a transparent film. MA-A stated R1's next visit on 6/26/23, was at the facility. When taking off R1's dressing the black foam had been placed on healthy skin and caused skin irritation of about 25 centimeters(cm) x 8.0 cm and the bone was exposed so the nurse practitioner(NP)-A advised sending R1 to the emergency department (ED) as a result of the facility not provding adequate care and oversight of the wound vac. During an interview on 7/10/23 at 11:40 a.m., NP-A stated on R1's wound clinic visit on 6/21/23, the wound vac dressing was not applied the way the provider ordered it. The 6/26/23 visit was conducted at the facility so the facility staff could be educated on how to perform the dressing change according to the physician orders. NP-A explained the facility staff would have put the dressing on R1's wound on 6/23/23. When that dressing was removed on 6/26/23, the dressing had been bridged but transparency film was not put down first to protect the health skin which caused R1 pain when removing the black foam. The area of R1's skin that was denuded (loss of skin caused by moisture and friction) measured 25.0 cm x 8.0 cm. Also noted exposed bone in the wound bed, necrotic (death of living tissue) skin, and elevated temperature which resulted in an order to transfer to the ED. During an interview on 6/26/23 at 5:16 p.m., RN-B indicated she and the DON had completed R1's wound vac sacral dressing changes twice but did not bridge it as ordered because there was no explanation why the bridging needed to be done. RN-B verified she did not contact the wound care clinic or surgeon to clarify the order. During an interview on 7/6/23 at 11:20 a.m., DON stated normally she completed wound rounds once a week which included documenting and taking a picture. The DON verified the facility nurses did not have any documented wound vac training in their personnel files. The DON stated she was made aware by the wound clinic team of missing the step of putting the barrier down and then not bridging correctly for R1's dressing change. The DON then identified the need for wound vac training so scheduled the wound vac supplier to train nurses on 7/17/23. R3's hospital After Visit Summary dated 7/1/23, indicated R3 was discharged to the facility following hospitalization for an abscess spinal epidural (infection in the spine) and laminectomy. This document included an order to leave wound vac on for 5 days and to change dressing pads as needed. R3's admission MDS dated [DATE], indicated R3 did not have cognitive impairment. R3 required assist of two staff with bed mobility, transferring, dressing, toileting. R3 did not walk or get up in a wheelchair. R3 had one surgical wound. R3's Braden Scale for Predicting Pressure Sore Risk dated 7/1/23, indicated R3 was moderate risk for pressure sores. R3's wound vac physician order dated 7/5/23, directed to place incisional wound vac change every third day, take picture of incision with every change, set wound vac at 75 mmHg of continuous suction. R3's Care plan last updated 7/5/2, indicated R3 had a potential/actual impairment to skin integrity and identified interventions of barrier cream. The care plan lacks any documentation of R3's wound vac, management, and monitoring. R3's Skin and Wound Evaluation initially done on 7/10/23 at 10:39 a.m. (10 days after admission) identified R3 had a surgical wound closed with 15 sutures present upon admission to the facility. The surgical wound measured 7.3 cm long and 0.9 cm wide. The evaluation did not include any other wound characteristics such as drainage, presence/absence of signs/symptoms of infection, dressing type, or wound vac therapy. R3's July 2023 treatment administration record (TAR) did not identify the physician orders for wound vac dressing changes nor indicate the dressings had been completed per the physician order. Further in review of R3's medical record it was not evident of ongoing monitoring for signs/symptoms of wound infection and not evident of ongoing monitoring of wound vac function and efficacy. During observation and interview on 7/6/23 at 2:30 p.m., R3 stated the wound vac had been unplugged and not working for an undetermined amount of time and had not heard the wound vac making suction noises since the previous day (7/5/23). No wound drainage observed in the wound vac drainage chamber. Family member (FM)-A stated the wall plug-ins were loose and it must have fallen out again. R3 stated no one checked her wound vac unless she asked them to and was still waiting for the new wound vac and dressing change. During an interview on 7/6/23 at 4:23 p.m., the DON was informed of R3's report and evaluator's observation of R3's wound vac being unplugged for an undetermined amount of time. The DON verified that staff did not routinely check the wound vac for proper functioning. DON had not been aware of R3's wound vac not working and would add a check for wound vac function to R3's treatment administration record. During observation on 7/6/23 at 5:32 p.m., RN-B and the DON changed R3's wound vac and dressing. DON was unable to get the camera to take a picture of the wound. No wound assessment was completed or documented by RN-B or the DON. The wound vac was observed to be functioning. During observation and interview on 7/10/23 at 10:14 a.m., FM-A stated R3's machine was noted to be unplugged the previous morning (7/9/23) at 8:00 a.m. and immediately plugged it in and it started to suction. FM-A did not know how long the wound vac had been unplugged and R3 stated she was not aware the wound vac was unplugged until FM-A told her. A small amount of drainage was observed in the wound vac tubing. During an observation on 7/10/23 at 10:30 a.m., RN-A and licensed practical nurse (LPN)-A changed R3's wound dressing. R3 told RN-A that a picture was supposed to be taken of the wound with the dressing change. RN-A left the room to get the tablet computer. RN-A stated the camera on the tablet automatically measured the wound but if the camera was not functioning, they were to manually measure the wound, and document in the medical record. RN-A verified the wound vac was not functioning properly at 140 mmHg (which was not consistent with the physician order that directed 75 mmHg) RN-A then left R3's room. RN-A stated she was unsure of the battery life of the wound vac, there was an instruction book on the wound vacs but was not sure where it was located and would have to check with the DON. During a follow up interview on 7/10/23 at 11:31 a.m., RN-A verified R3's wound vac was set at 140 mmHg of pressure but thought it was supposed to be set at 125 mmHg. After checking with the DON, RN-A stated the physician order was for 75 mmHg and would change the settings immediately. During an interview on 7/10/23 at 11:40 a.m., NP-A indicated a wound vac setting of 140 mmHg causes more suction and could cause increased pain. Recommendation was to start with a lower pressure setting as most people can't tolerate a setting of 140 mmHg. During an interview on 7/10/23 at 12:09 p.m., DON verified wound measurements and assessment were not done on R3 during the 7/6/23, dressing change. DON stated she was unsure of how the suction setting would have been changed on R3's wound vac and unaware that it had been unplugged. Interview on 7/11/23 at 2:12 p.m., the Administrator stated wound vacs were new to the facility within the past month and anytime there is something new like that (wound vacs) there needs to be education. The facility policy titled, Negative Pressure Wound Therapy, last revised 2/2014 directs to assess the wound prior to selecting the type, size, and thickness of dressing material. Create a barrier dressing to protect healthy skin; there should be at least a 1-inch barrier around the margins of the wound. Initiate negative pressure settings on the pump as ordered. Document in the resident's medical record the wound status at the time of application of negative pressure, the number of sponge pieces used in the wound dressing, the negative pressure and time settings on the pump, and the resident's tolerance of the procedure, the date and time of the dressing application/change, the date and time negative pressure therapy was started and stopped, the names and initials of the person performing the dressing change. The immediate jeopardy that began on 6/12/23, was removed on 7/12/23, when it could be verified the facility implemented the following; -Reviewed facility policy/procedures for wound vac and wound care -Identified residents who were at risk, completed comprehensive wound assessments, reviewed/revised care plans and physician orders according to assessments. -Nursing staff were provided with Wound Vac training and demonstrated competency.