Based on observation, interview, and record review, the provider failed to ensure that all residents had appropriate supervision to prevent accidents. Specifically, one resident was given reheated coffee that spilled and caused scalding burns, which required hospitalization in the burn unit. Additionally, another resident fell out of bed and sustained a head laceration that required sutures when a CNA raised the resident's bed and momentarily left the resident unattended, and a third resident fell during a staff-assisted transfer due to the resident's wheelchair not being locked by staff before initiating the transfer. Resident Identifiers: 3, 4, and 5. Findings include: 1. On April 30, 2025, the surveyor interviewed Resident 5. Resident 5 stated that she had an incident where a staff member heated her coffee, but the staff did not check the temperature before giving it to her. Resident 5 stated that she had to go to the hospital for the burns and that she still has redness where she was burned. The surveyor reviewed resident 5's medical records, and the following entries were observed: a. Resident 5's care plan and assessments indicated Resident 5 required staff assistance during hands-on activities and was unable to feed themselves. b. A nurse documented in a nursing note on December 14, 2024, that a Certified Nurse Assistant (CNA) reported that Resident 5 had spilled coffee. The nurse documented that they performed a skin check and redness to the chest, right abdomen, and right hip/buttock was noted. The nurse documented that the Director of Nursing (DON) and the Medical Doctor (MD) were notified of the incident, and the MD said to monitor and clean the site if the blisters open. c. A nurse documented in a nursing note on December 14, 2024, that a follow-up burn injury assessment was completed, and blisters and redness were noted. The nurse notified the DON and the MD. d. A nurse documented in a nursing note on December 15, 2025, that the blisters appeared to be worsening. The nurse notified the MD and the resident's family. The resident was sent to a burn unit at a local hospital. Resident 5's hospital documentation was reviewed and revealed she was admitted to the burn unit due to a 3.5% total body surface area partial and full thickness burn to the torso, abdomen, and right breast. The resident was admitted to the burn surgery service for wound management, pain management, and possible surgical intervention. On April 30, 2025 an interview was conducted with CNA 1. CNA 1 stated that when a hot beverage is provided to a resident, they must first check the temperature. CNA 1 stated that thermometers were provided to staff along with guidelines for the temperatures. On April 30, 2025, an interview was conducted with the DON. The DON stated that Resident 5 liked to have really hot coffee and would ask staff members to reheat her coffee. A CNA warmed Resident 5's coffee up and then walked away. Resident 5 was able to move the coffee a bit, and it tipped over and fell on her. Nursing was involved, the physician was notified, and Resident 5 went to the hospital. After the incident, a policy was implemented that established a temperature limit for hot liquids provided to residents and required staff to verify the temperature of the liquid before serving it to the resident. 2. The surveyor reviewed resident 4's medical records, and the following entries were observed: a. Resident 4's care plan revealed that resident 4 was at risk for falling off of his bed due to his diagnoses of spastic quadriplegic cerebral palsy. The interventions, which were initiated on March 13, 2025, revealed that resident 4 had a bed and mattress that was lowered to the floor. b. Resident 4's Minimum Data Set from February 24, 2025, revealed that resident 4 required a two person physical assist with transfers. c. A nurse documented in a nurses note on April 14, 2025 at 10:00 AM that resident 4 had a fall from his bed and sustained a laceration to the left top side of his scalp and a scratch near the left eye. The nurse documented that the provider and family were contacted, and the resident was transferred to the hospital. d. A nurse documented in a nurses note on April 14, 2025 at 4:52 PM that resident 4 returned from the hospital with sutures in the left side of his forehead. The facility reported to the state survey agency that CNA 2 had elevated Resident 4's bed to prepare for a transfer before bringing a Hoyer lift into the residents room. CNA 2 had begun to leave the room while Resident 4's bed was elevated, and Resident 4 rolled out of bed. The facility reported that the CNA was able to catch Resident 4's lower body, but Resident 4 sustained a head laceration. The facility reported that education was provided to CNA 2 to leave Resident 4's bed in the lowest position with fall prevention measures in place prior to leaving the bedside. On April 30, 2025, the surveyor interviewed the DON. The DON stated that CNA 2 had raised Resident 4's bed into a high position, and then CNA 2 stepped out to see if a Hoyer lift was in the hall. The DON stated that when CNA 2 stepped away from Resident 4, Resident 4 began to roll out of bed. CNA 2 was able to catch Resident 4's lower half of his body, but Resident 4 sustained a head injury. The DON stated that staff are instructed to bring the Hoyer lift into the room, along with any other necessary equipment, prior to raising a resident's bed in preparation for a transfer. The DON stated staff should not raise a resident's bed and walk away. The DON stated that CNA 2 was trained and knew the protocol. 3. Resident 3's medical record was reviewed, and the following entries were observed: a. Resident 3 had a care plan that revealed Resident 3 required assistance with all activities of daily living due to weakness. An intervention, initiated on November 26, 2024, revealed that Resident 3 required maximum assistance with one staff member for stand pivot transfers, and to use a gait belt. b. A nurse documented in a nurse's note on February 17, 2025 that Resident 3 had a fall during the day shift and was sent to the emergency room per family request. c. A nurse documented in a nurse's note on February 18, 2024 that a CT scan of the resident's pelvis and lumbar spine was performed and there were no abnormalities noted. Facility staff documented in an incident report dated February 17, 2025 that a CNA was transferring Resident 3, and the wheelchair slipped out from under the patient. The incident report revealed that the CNA did not lock the resident's wheelchair. The incident report revealed that a bruise was identified on the resident's right lower back, and no other injuries were noted. On April 30, 2025, the surveyor interviewed Resident 3. Resident 3 stated that she had a fall during a transfer because the CNA did not lock her wheelchair. Resident 3 stated that the wheelchair slid out from underneath her, and she fell on her backside. Resident 3 stated that her back hurt from the fall. Resident 3 stated that the CNA did not work with her after that incident. On April 30, 2025, the surveyor interviewed the DON. The DON stated that the CNA did not ensure that resident 3's wheelchair was locked, and the CNA did not use a gait belt. The DON stated that the CNA was new and had completed the training and knew that he needed to use a gait belt and to lock the wheelchair. The DON stated that the CNA was no longer working at the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 20 sampled residents, a resident that was not diabetic was administered Insulin instead of Heparin, was hypoglycemic, and was admitted to the hospital. Resident identifier: 111. Findings included: Resident 111 was admitted to the facility on [DATE] and discharged on 7/27/24 with diagnoses which included, but were not limited to, anoxic brain damage, neuromuscular dysfunction of bladder, post traumatic stress disorder, major depressive disorder, anorexia, cardiac arrest, chronic respiratory failure, urinary tract infection, Methicillin-resistant Staphylococcus aureus (MRSA), pressure ulcer of sacral region unstageable, hypotension, dysphagia, cachexia, unspecified convulsions, pneumonia, poisoning by unspecified drugs, insomnia, and tremors. Resident 111's medical record was reviewed on 11/5/24 through 11/7/24. On 7/10/24, a physician's order documented Sodium (Porcine) Injection Solution 5000 UNIT/ML [milliliter] (Heparin Sodium (Porcine)) Inject 1 ml subcutaneously every 12 hours for Clot prevention. The Order Summary Report for resident 111 was reviewed. There were no physician's orders for Insulin. On 7/21/24 at 11:22 AM, a Nursing Progress Note documented Note Text: Around 0930 [9:30 AM] pt [patient] appeared uncomfortable and diaphoretic. VS [vital signs] were taken and BP [blood pressure] 106/66, HR [heart rate] 105, RR [respiratory rate] 20, temp [temperature] 97.8, and o2 [oxygen] 98. Blood sugar was checked and was 46. Pt immediately given 4 oz [ounces] of juice and MD [Medical Director] was notified. 1mg [milligram] of Glucagon given per MD orders. Bloodsugar [sic] checked again and was 42. Emergency services called for further assessment. When ambulance arrived pt's BS [blood sugar] had gone up to 66 and all other VS stable. Pt alert and appeared comfortable. Before EMS [Emergency Medical Services] left with pt, BS had increased to 86. Pt's mother was at bedside during this time and is aware. On call ADON [Assistant Director of Nursing] notified. On 7/21/24 at 11:32 AM, the Emergency Documentation from the hospital documented a chief complaint reason for visit of, Accidental drug administration. The medical decision making Emergency Department course documented, Review her previous notes including the notes from her visit a week ago, she had a positive urine at the time though her urine culture just grew mixed organisms. Her sputum culture grew MRSA. She was placed on 10 days of Keflex and so should be still on this medication. Initial glucose on the patient was 110s. We did contact the patient's skilled nursing facility and it sounds like this possibly could have been an overdose on Humulin, the nurse who takes care of the patient really is not sure what she gave. She [sic] patient's labs are significant for leukocytosis to 20, and looking at her labs from a week ago her white count was only 5. Her CMP [comprehensive metabolic panel] was notable for LFTs [liver function tests] that seem to be uptrending fairly significantly over the past week and a half. Because of this because of the white blood cell count and her inability to really localize any complaints a CT [computed tomography scan] of her chest and abdomen was ordered again. Check of the patient's glucose approximately an hour and a half after her arrival was 23. After this she was given half an amp [ampule] of D [dextrose] 50. This blood sugar was checked again 1/2-hour later and it was 57. The additional half amp of D50 was given to the patient. She was started on D10 half-normal saline drip. I spoke with poison control regarding this patient, the hemoglobin actually has a half-life of up to 8 hours and I think given the fact that she has had to have multiple doses of D50 she needs given need to be admitted . CTs of her abdomen were significant for may be some ductal dilatation, her LFTs are elevated but her bilirubin is normal so I have lower suspicion for obvious acute intra-abdominal pathology and particularly pathology related to the gallbladder. On 7/21/24 at 2:32 PM, the History and Physical Reports from the hospital documented a chief complaint of Pt brought in by EMS for potentional [sic] medication error at [facility name redacted] today. Pt may have gotten 100 units of insulin (Humilin [sic] R [regular] Instead of 1 ml of heparin today @0900 [at 9:00 AM]. Pt BS dropped to 40@facility [sic], given glucagon. The history of present illness documented, Patient is a [AGE] year-old female with a history of cardiac arrest, anoxic brain injury who is currently at [facility name redacted] who presents with what sounds like a medication error. At around 9 AM this morning the nurse at the facility gave the patient 1 mL of the medication that she thought was heparin, however could have possibly been 100 units of Humalin [sic] R. About an hour later the patient was getting sweaty, tachycardic and blood glucose was checked and was found to be 40. She was given glucagon. While in the ED [Emergency Department] patients lowest blood glucose level was in the 20's. ED physician asked hospitalist for admission. The assessment and plan documented #) Medication Error #) Hypoglycemia Was accidentally given 100 U [units] Humalin R Lowest BG [blood glucose] was 23. Was given 50 ml dextrose and started on D10 drip Most recent BG was 79 Continue close monitoring with q2h [every two hour] BG checks Continue D10 drip @ 125ml/hr [milliliters per hour]. On 7/22/24 at 8:43 AM, the Progress Notes from the hospital documented Subjective Patient appears comfortable today. blood sugars are much improved. No other issues overnight. Assessment/Plan #) Medication Error #) Hypoglycemia Was accidentally given 100 U Humalin R Lowest BG was 23. She was given D50 last night and then was on a D10 drip overnight. Her blood sugars have been trending up and are now around 140s. I will discontinue the D10 and see how she does. We will start her tube feeds . On 7/23/24 at 12:53 PM, a Nursing Progress Note documented Note Text: Patient returned to facility. She was transferred from [hospital name redacted] via stretcher. Orders were reviewed and implemented. Patient was transferred to bed and positioned properly. On 11/6/24 at 7:30 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that injectable medications were labeled with the resident's name. RN 1 stated the opened injectable medications were labeled with the resident's prescription and expiration date. RN 1 stated that once a medication was opened the nurse would label the medication with an open date. RN 1 stated any overstock of injectable medications were stored in the locked medication room. RN 1 stated that she currently did not have any residents prescribed Heparin. RN 1 stated the facility was really trying to stay away from having Heparin in the facility. RN 1 stated enoxaparin was being prescribed to the residents, since there was less risk associated with the medication. RN 1 stated that the Heparin and Insulin vials look similar and it was easy to mix them up. RN 1 stated that Heparin was not stored in the medication carts. On 11/6/24 at 8:20 AM, an interview was conducted with RN 2. RN 2 stated that she did not have any Heparin stored in her medication cart or in the medication room. RN 2 stated that any insulin that was stored in the medication cart was for specific residents and the box was labeled with the resident's name and order information. On 11/6/24 at 9:00 AM, an interview was conducted with RN 3. RN 3 stated that Heparin was not stored in the medication carts to prevent medication errors. RN 3 stated that any insulin stored in the medication cart or the medication room was labeled with the resident's name. RN 3 stated that the facility had moved away from Heparin and residents were being prescribed Lovenox. On 11/7/24 at 9:58 AM, an interview was conducted with RN 4. RN 4 stated on the day of the medication error the Insulin and Heparin were stored next to each other in the medication cart. RN 4 stated that both vials of medication had orange on them and looked the same. RN 4 stated that right after she had administered the medication to resident 111, she had not noticed what she had done. RN 4 stated that she had went in to resident 111's room about an hour and a half after she had administered the medication and resident 111 did not look right and was sweating. RN 4 stated that she took a set of vital signs and they were all within normal limits, so she got a blood sugar and that was when she noticed that she must have given resident 111 Insulin. RN 4 stated that she notified the MD immediately, administered glucagon to resident 111, and sent resident 111 to the hospital. RN 4 stated that both medication vials were not in their boxes. RN 4 stated the vials of medicine would come in bags and when the vials were removed from the bags and opened staff would put the labels with resident information on the vials. RN 4 stated on the day of the error the vials were labeled with resident information but she did not notice that she had grabbed the wrong vial. RN 4 stated that Heparin did not come in prefilled syringes but Lovenox did. RN 4 stated the Insulin was an intermediate acting Insulin that was administered to resident 111. RN 4 stated that after the error staff were instructed to put a yellow or red sticker on the Insulin vial to identify that the vial was Insulin and the nurses were to double check the medication with another nurse prior to administration. RN 4 stated that resident 111 was not diabetic and there were no orders to do routine BS checks for resident 111. RN 4 stated that resident 111 was to receive Heparin 1 ml and RN 4 had administered 1 ml of Insulin instead. RN 4 stated that she currently did not have any resident that were on Heparin. On 11/7/24 at 10:38 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that when the incident happened the nurse called management and reported that she accidentally gave Insulin instead of Heparin to resident 111. The DON stated that resident 111 was trending hypoglycemic and had signs and symptoms. The DON stated that the Heparin and Insulin were stored together in the top drawer of the medication cart. The DON stated that resident 111's mom was in the room and was aware of what happened and resident 111 was sent to the hospital. The DON stated that after the error a process was put in place to have colored stickers put on the Insulin vials and staff would write the open date on the sticker. The DON stated that staff were also instructed to store Insulin vials in the top drawer on the right side of the medication cart. The DON stated that other injectable medications were to be stored somewhere else in the medication cart but not the top drawer. The DON stated the new process was implemented facility wide. The DON stated if a resident was going to be admitted to the facility on an injectable medication staff would see about an oral substitution. The DON stated that after the incident the nurse completed some additional training, had a record of discussion, and was removed from working with resident 111.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to prevent abuse, neglect, misappropriation of resident property, and exploitation. Specifically, for 1 out of 11 sampled residents, a staff member who preformed a blood draw left a tourniquet on a resident's leg for multiple hours, resulting in a pressure injury (PI). Resident identifier: 6 Findings included: Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included quadriplegia, displaced fracture of third cervical vertebra, displaced fracture of second cervical vertebra, dissection of vertebral artery, intentional self-harm by other firearm discharge, dependence on respirator status, acute and chronic respiratory failure, narcolepsy, major depressive disorder, and unspecified psychosis. The facilities reported incidents document, form 358, was reviewed. Form 358 documented that the Administrator became aware of the incident on 6/14/23 at 5:30 PM. Form 358 documented, Upon investigating a different issue with [Registered Nurse (RN) 1] I heard the [sic] our ADON [Assistant Director of Nursing] [name redacted] talk about redness on [Resident 6's] leg that she was [sic] reported to the doctor. Upon investigating as to the cause it was brought to my attention that [RN 1] had left [Resident 6] with a tourniquet from a lab draw left on his left calf after drawing the labs for an extended period of time leaving the area where the tourniquet was red and appears to be blistering. [RN 2] notified the on call [name redacted] PA [Physician Assistant] who was at the facility and he went and evaluated [Resident 6]. Wound care dressed the site and stated below the dressing looks okay. Form 358 documented that the incident occurred some time within RN 1's shift in resident 6's room. The injuries included redness to skin where tourniquet was placed and appears to be blistering. Form 358 documented, [RN 1] is suspended pending investigation and does not have access to any of the residents. [Resident 6] and his mother were notified of the issue. [Resident 6] was evaluated by [PA] and the wound nurse and treated. Interdisciplinary team to review and implement any additional training that may be needed for staff. The facilities investigation report, form 359, was reviewed. The document revealed that Resident 6 ended up with a stage 2 pressure injury from where the tourniquet was placed. The summary of interviews with Resident 6 documented, [Resident 6] does not believe the nurse [RN 1] left the tourniquet on him on purpose. He stated that that particular night was a bad night for staff because the computers went down. [RN 1] appeared frantic and just messed up. [Resident 6] likes [RN 1] and does not have any concerns in regards to [RN 1] caring for him. The summary of interview with witnesses documented, The CNA [Certified Nursing Assistant], [CNA 1], was in the room when this incident occurred. She said she wasn't aware that it occurred and didn't find out about it until just barely. She said it was dark in the room and they had a small light where the blood draw occurred so it wasn't too bright for the resident that late at night. The summary of interviews with RN 1 documented, [RN 1] was interviewed regarding this incident. He was surprised to hear that he did that as he was unaware. He stated, 'I can't believe I did that. I feel bad.' He expressed feeling of concern and asked how [Resident 6] was doing. Form 359 documented that the allegation was verified by the facility and documented, This allegation was verified as evidenced by staff on the next shift finding the tourniquet still on [resident 6's] leg which is where [resident 6's] blood draw was done by the nurse, [RN 1]. Although [RN 1] did not intentionally leave the tourniquet on it is still considered neglectful and resulted in [resident 6] receiving a stage 2 pressure injury. Actions taken as a result of the investigation stated that RN 1 received written education on blood draws and standard of practice in regard to removing tourniquets. Resident 6's medical record was reviewed on 2/20/24. The annual Minimum Data Set assessment dated [DATE], documented that Resident 6 required total dependence from staff for; bed mobility, transfers, locomotion on unit, dressing, toilet use, personal hygiene, and bathing. A care plan Focus initiated on 5/11/22, documented RESOLVED: Skin Integrity / Pressure Ulcer/ Wounds - [resident 6] is at risk for skin integrity issues secondary to Quadriplegia, risk for decline in nutrition, incontinence of bowel and dependence on feeding tube, and trach. 6/16/23 [resident 6 developed a stage 2 PI due to a device being left on his leg. The interventions included, but were not limited to, RESOLVED: Pressure Ulcer - Assess size, color, odder, wound bed and underlying etiology of wound. Assess for factors that may delay or expedite healing and make appropriate interventions. Listen to resident and family input regarding wound. Provide wound care, medications, and dietary interventions as ordered. Report significant findings to MD [Medical Director]. A wound evaluation was completed on 6/14/23 at 2:14 PM. The evaluation documented that resident 6 acquired a medical device related pressure injury stage 2. The dimensions of the pressure injury were: area 7.8 centimeters (cm) squared, length 10.55 cm, width 1.2 cm. A physician's order dated 6/15/23, documented, Wound Care orders for Stage 2 Pressure Injury from medical device: Doff Previous dressings to the circumference of the Left lower leg. Cleanse the wound area with Wound cleanser and gauze. Apply Medihoney to the open areas of the Pressure as the Primarydressing (sic). Secure with two 6x6 foam border dressings so that one covers the back of the leg and the other covers the front of the leg as the secondary dressing. Once a day on Patient's shower days. one time a day for Stage 2 Pressure Injury from medical device. The physician's order was discontinued on 7/5/23. On 2/20/24, an interview was attempted with resident 6. Resident 6 was unavailable for an interview. On 2/20/24 at 12:30 PM, an interview with the ADON was conducted. The ADON stated that RN 1 no longer worked at the facility. The ADON stated that RN 1 left a tourniquet on resident 6 after a blood draw and the staff did not find it until the next day. On 2/20/24 at 12:38 PM, an interview with the Wound Care Nurse (WCN) was conducted. The WCN stated that resident 6 was difficult to draw blood from, so staff would often draw out of his feet. The WCN stated that RN 1 was an agency nurse at the time, and RN 1 left a tourniquet on resident 6's ankle. The WCN stated that resident 6 was unable to feel the tourniquet. The WCN stated that blood draws typically happened between 3:00 AM and 4:00 AM, and that the tourniquet was found in the morning between 8:00 AM and 9:00 AM. The WCN stated that the incident resulted in resident 6 having a mark on his skin that ended up blistering, and that it resolved about three weeks later. The WCN stated that the injury could have been prevented. The WCN stated that nurses were educated after the incident. On 2/20/24 at 12:55 PM, an attempt was made to contact RN 1. RN 1 did not respond and was unable to be interviewed. On 2/20/24 at 12:57 PM, an attempt was made to contact CNA 1. CNA 1 did not respond and was unable to be interviewed. On 2/20/24 at 1:50 PM, an interview with the Director of Nursing (DON) was conducted. The DON stated that the incident could have been prevented. The DON stated that when staff were hired, including agency staff, the facility had a competency check list that was completed upon hiring and then yearly after that. The DON stated that the competency check list included standards of practice for blood draws. The DON stated that RN 1 had completed the competency check list upon hiring. The Facility Abuse Policy was reviewed. The original date of the Abuse Policy was 1/1/2011, and the policy was revised on 1/6/2016. Scope: All employees, Licensed Independent Contractors, Licensed Practitioners and volunteers (Healthcare workers) are responsible for ensureing (sic) that all residents are free from all types of abuse. Policy: It is the policy of [name redacted] to provide care to all residents in an environment which is free from abuse of the resident. Purpose: It is the policy of [name redacted] to provide care to all residents in an environment which is free from abuse of the resident. Definitions of terms Neglect Means one of the following: 1. The negligent failure of any caregiver of an adult or child, to exercise that degree of care that a reasonable person in a like position would exercise. 2. The negligent failure of the person themselves (if an adult) to exercise that degree of care that a reasonable person in a like position would exercise. Neglect includes, but is not limited to: 1. Failure to assist in the personal hygiene, or in the provision of food, clothing, or shelter. 2. Failure to provide medical care for physical and mental health needs (unless it is withheld due to the person's reliance on treatment by spiritual means through prayer alone in lieu of medical treatment). 3. Failure to protect from health and safety hazards. 4. Failure to prevent malnutrition or dehydration. 5. Failure of a person to provide the needs specified in numbers 1 through 4, inclusive, for themselves due to ignorance, illiteracy, incompetence, mental limitation, substance abuse, or poor health. PROCEDURE: [name redacted] incorporates the 7 components of abuse prevention at all times when there is a report of actual abuse, reasonable suspicion of abuse or when there is an injury of unknown source/origin. 1. Screening: a. Conduct background checks on all prospective HealthCare Workers. b. Obtain reference checks from previous and/or current employers. c. Primary Source Verification with appropriate licensing boards and registries. 2. Training: a. Conduct education and training to all healthcare workers during orientation, annually and as needed on issues related to abuse prohibition practices . 3. Prevention: a. Provide residents, families and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and provide feedback regarding the concerns that have been expressed. b. Encourage all personnel, residents, family members, visitors, etc., to report any signs or suspected incidents of abuse to facility management immediately. c. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is more likely to occur . 4. Identification: a. Identify events, such as suspicious bruising of residents, occurrences, patterns and trends that may constitute abuse. 5. Investigation: a. Timely and thorough investigation of all allegations of or suspicion of abuse. b. Determine direction of the investigation. c. Investigate different types of incidents. d. Identify the staff member responsible for the initial reporting, investigation of alleged violations and reporting of results to the proper authorities. e. Utilize process established by [name redacted], as well as other reporting agencies, to investigate and report any suspected abuse. f. The nurse will assess the individual and document related findings . 6. Protection: a. Protect residents from harm during the investigation b. If the suspected perpetrator is another resident the staff will separate the residents so they do not interact with each other until circumstances of the reported incident can be determined. c. If the suspected perpetrator is a staff member the supervisor will remove the individual from the care of the resident and suspend him/her during the investigation. d. If the suspected perpetrator is a visitor, escort the visitor out of the building. Future unsupervised access to residents will be denied during the investigation. 7. Reporting/Response: a. Report all alleged violations and all substantiated incidents to the state agency and to all other agencies as required, in a timely manner .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, it was determined, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, for 1 out of 4 sampled residents, a resident developed a pressure injury after staff found the tracheostomy (trach) chain to be imbedded into the resident's neck and there was no monitoring of the trach chain. Resident identifier: 1. Finding included: Resident 1 was admitted to the facility on [DATE] and readmitted after a hospitalization on 5/31/23 with diagnosis which included, but were not limited to, chronic respiratory failure with hypoxia, multiple congenital malformations, communication deficit, disturbances of salivary secretions, and dependence on respirator status. Resident 1's Medical Record was reviewed on 6/8/23. A quarterly Minimum Data Set assessment dated [DATE], documented that resident 1 was at risk of developing pressure ulcers and resident 1 had no unhealed pressure ulcers. A care plan focus initiated on 5/31/23, documented Oxygen / Respiratory Status- [Resident 1] requires mechanical ventilation at night and for periods of rest. In the day she can tolerate HME (Heat Moisture Exchanger). [Resident 1] produces copious oral secretions that are managed with medications. Interventions included, but were not limited to: a. [Resident 1] will pull her trach out frequently. Grandmother has consented for use of a chain to her trach, however she is still able to frequently decannulate. [Resident 1] will be placed in highly visible areas as often as possible and will have continuous pulse oximeter monitoring. Date Initiated: 05/31/2023. b. Respiratory General - Assess respiratory status including s/sx [signs and symptoms] hypoxia, rate, breath sounds, depth of breath, use of accessory muscles, SPO2 [oxygen saturation], and other clinical indicators. Administer oxygen, medications, and treatments as ordered. Monitor for effectiveness and potential complications. Assess for skin breakdown at likely places (Ears, tubing, pulse oximeter site). HOB [Head of bed] elevated to 30 degrees unless providing care or resident request. Inform physician of significant clinical findings. Date Initiated: 05/31/2023.] [Note: A care plan with interventions addressing resident 1's trach chain was not initiated prior to 5/8/23, when the pressure ulcer was identified.] On 5/7/23 at 4:06 PM, a Respiratory Therapist (RT) progress note documented, Note text: . Pt [patient] received her AM flovent treatment along with her trach care and oral care. Pt is stable with no signs of respiratory distress. Pt has received suctioning for moderate amounts of thick cloudy white secretions. Pt is stable . On 5/7/23 at 11:25 PM, a Licensed Nurse (LN)- Daily Skilled Note documented, . Resident uses oxygen continuously. Resident needs suctioning. Resident receives tracheostomy care. Resident received ventilator services. Resident has rales/rhonchi. Resident had a cough. Patient does not have pain. [Resident 1] has been playing in her room this evening with no s/s [signs or symptoms] of pain or distress noted at this time. no new concerns noted. On 5/8/23 at 11:14 AM, a LN- Daily Skilled Note documented, . Resident uses oxygen as needed. Resident uses oxygen continuously. Resident needs suctioning. Resident received ventilator services. Resident has rales/rhonchi. Patient does not have pain. Pt has had a good morning so far with no notable events. Pt has been sleeping on and off this morning. Pt is currently resting in bed with no s/s of pain. On 5/8/23 at 11:32 AM, a Skin Assessment documented No skin issues noted at this time. On 5/8/23 at 6:11 PM, a Nursing Progress Note documented, Note Text: New skin issue noted on pt's [patient's] R [right] side of neck under trach chains. Chains became imbedded under pt's skin. Wound care nurse and ADON [Assistant Director of Nursing] were consulted and orders were given with treatment plan, entered into PCC [Point Click Care]. RN [Registered Nurse] used wound cleanser and removed chains from skin as directed by wound care. Tx [treatment] put in place. Chains were removed and trach ties were applied. MD [Medical Director] notified via tiger text. Pt tolerated procedure. On 5/9/23 at 9:25 AM, a Skin and Wound Evaluation documented that resident 1 had a medical device related pressure injury (PI) to the neck. The PI was acquired in house on an unknown date. The wound measurement area was 2.2 centimeters (cm), length 0.9 cm, width 2.5 cm, and depth 0.3 cm. The Notes section documented Weekly Wound Assessment: Patient has a new stage 3 pressure injury caused by a trach chain to her neck .There is adipose tissue exposed .Wound care orders are in place and wound dressed as ordered, the chain was taken off the patient last night and a soft material trach tie replaced the chain. On 5/9/23 at 11:36 AM, a Nursing Progress Note documented, Note Text: Patients mother notified of new the [sic] wound on patients neck. Patients mother expressed concern for patients pain management. She requested that care team discusses with the MD about further interventions for the patients pain management. The patient has received PRN [as needed] and scheduled pain management medications this morning. MD notified of mothers request. On 5/9/23 at 12:27 PM, a Nursing Progress Note documented, Late Entry: Note Text: IDT [Interdisciplinary] note Event review/summary: Nurse noted new pressure injury to left anterior neck at trach chain site. Chain appeared to be imbedded in skin. Nurse removed chain from wound after cleansing area with wound cleanser and sterile gauze, Admin [Administrator] and MD notified. Ordered to place medi honey and foam border dressing over area and wound nurse to evaluate in morning. Wound nurse evaluated on 5/9/23 staging wound as a stage 3 PI. Risk Factors: CHRONIC RESPIRATORY FAILURE WITH HYPOXIA, TRACHEOSTOMY STATUS. Resident/Staff Education: Respiratory Therapists educated to complete trach cares in daily and report any skin conditions to Admin, MD and wound team. Interventions: tracheostomy chain discontinued, fabric trach ties in place. Attendees: MD, ADMIN. On 5/9/23 at 4:33 PM, a Nursing Progress Note documented, Note Text: MD ordered for soft trach ties to be used, instead of chain. RT notified of change. On 5/15/23 at 10:37 AM, a LN-Daily skilled Note documented, . Resident uses oxygen continuously. Resident receives nebulizer treatments. Resident needs suctioning. Resident receives tracheostomy care. Resident received ventilator services. Resident has rales/rhonchi. Patient does not have pain. [Resident 1] is currently laying in bed playing with a book. She has tolerated her feed and medications well. Pt displayed discomfort during wound care to neck, Currently pt is not showing any s/s of distress. On 6/6/23 at approximately 10:30 AM, an interview was conducted with RT 2. RT 2 stated that she had worked at the facility for nine years and was very familiar with the duties required. RT 2 stated that tracheostomy care was done on shower days and the RT's would change the tracheostomy ties. RT 2 stated that tracheostomy care was done around the stoma by replacing the drain sponge and inspecting the site. RT 2 stated that she would observe and care for the tracheostomy once every 12 hour shift. RT 2 stated that having a resident in tracheostomy chains was uncommon and were used only if a resident self decannulate's frequently. RT 2 stated that resident 1 was pulling her tracheostomy out multiple times a shift. RT 2 stated the physician, care team, and family discussed the use of the trach chain and everyone agreed to resident 1 having the trach chain. RT 2 stated that resident 1 had a lot of oral secretions and drooled often. RT 2 stated the oral secretions may have played a part in the wound caused by the trach chain. RT 2 stated that resident 1 would get very agitated by any trach care and the respiratory therapist did not want to draw attention to her trach because resident 1 would try to pull on it. RT 2 stated that where the wound was located it was a difficult area to see when resident 1 was in bed, the wound was on the opposite side of the bed from where the care team would stand. RT 2 stated in order to observe the part of the neck where Resident 1's wound was located, Resident 1 would need to be repositioned, and repositioning her would agitate her. RT 2 stated that staff did not like to cause resident 1 any agitation and would avoid moving her and her trach if the staff could. RT 2 stated that since the facility rarely had residents with trach chain the Certified Nursing Assistants (CNA's) would also observe the chain area during the resident bath. RT 2 stated that the CNA's should be the first to notice break down from the chains. On 6/6/23 at 11:36 AM, an observation was conducted of resident 1. Resident 1 was observed to be on transmission based precautions. Resident 1 was observed in bed playing with a toy and positioned on her right side. Resident 1's bed was observed low to the ground with fall mats stacked next to the bed. On 6/6/23 at 11:40 AM, an interview was conducted with RN 2. RN 2 stated that resident 1 did not have the trach chains anymore and they had switched resident 1 to the trach ties. RN 2 stated that resident 1 would rip her trach ties out often and would decannulate. RN 2 stated the trach chain was implemented on resident 1 several years ago. RN 2 stated the wound on resident 1's neck was now healed. RN 2 stated that two weeks ago resident 1 was at the hospital and the hospital noted the wound as a light pink spot. RN 2 stated there were no other residents that use the trach chains on the kids hall that she was aware of. On 6/6/23 at 12:03 PM, an interview was conducted with RT 1. RT 1 stated that she was the therapist that worked with resident 1. RT 1 stated there was currently a resident that had trach chains and the trach chain was removed on Saturday (6/3/23) and switched to the trach ties. RT 1 stated that the resident had orders to check the trach chain every day and the resident was getting some redness. RT 1 stated that resident 1 did not have orders on the Medication Administration Record (MAR) or the Treatment Administration Record to check the trach chain. RT 1 stated the trach chains were checked as an assumption check. RT 1 stated there were now orders on the MAR since the incident with resident 1. RT 1 stated that resident 1 came back to the facility with the trach chains and resident 1 was really grabby and the trach chains prevented resident 1 from pulling the trach out more. RT 1 stated she worked the weekend before resident 1's wound was discovered and resident 1 was hard to see because she leaned to the right. RT 1 stated that they did not use drain sponges on resident 1 either because resident 1 would pull on the drain sponges. RT 1 stated she would clean the trach area but by not putting drain sponges on resident 1 the neck area went missed. RT 1 stated that trach care was done twice a day. RT 1 stated that trach care included cleaning the stoma and making sure it looked fine. RT 1 stated that resident 1 turned her neck to the right and her vent was on that side. RT 1 stated that she would stand on resident 1's left side and resident 1 had never showed any pain. RT 1 stated that CNAs should check resident 1's neck area when they wash resident 1's hair. RT 1 stated that when resident 1 came from another long term care facility resident 1 had the trach chains and they never had any problems with the trach chains. On 6/6/23 at approximately 1:00 PM, an interview was conducted with the wound care nurse (WCN). The WCN stated that the nurses should do a thorough head to toe skin assessment once a week. The WCN stated that the respiratory therapist should be assessing the area of the tracheostomy and trach ties with every shift. The WCN stated that the trach area was the respiratory therapist care area. The WCN stated that once the wound was discovered on resident 1 it was staged as a stage three wound. The WCN stated that the trach chains were removed immediately, and regular trach ties were placed, and wound care was completed. On 6/8/23 at 10:33 AM, an interview was conducted with CNA 1. CNA 1 stated that resident 1 was mostly a bedbath due to her being on transmission based precautions. CNA 1 stated that typically the CNAs do a sheet change with the shower or bedbath. On 6/8/23 at 10:39 AM, an interview was conducted with CNA 2. CNA 2 stated that typically a skin check would be done during a shower. CNA 2 stated that when doing resident 1's hair she would double check the trach chain. CNA 2 stated that resident 1 liked to lean to the right because her Alexa device was attached to the right side of the bed. CNA 2 stated when resident 1 was in the shower chair resident 1 was able to sit up exposing the right side of her neck. CNA 2 stated she would double check resident 1's neck when her hair was washed. CNA 2 stated that resident 1's shower days were Monday, Wednesday, and Friday. CNA 2 stated that resident showers were documented in the electronic medical record and the facility did not do paper charting shower sheets. CNA 2 stated that she would try and wash resident 1's hair with every shower day. CNA 2 stated the facility had shower caps with dry shampoo in them. CNA 2 stated if resident 1's hair was really dirty she would try and wash resident 1's hair and CNA 2 would put a towel underneath resident 1. On 6/8/23 at 10:42 AM, an interview was conducted with RN 1. RN 1 stated that she was the nurse that was on shift when the wound was identified on resident 1. RN 1 stated that the RT was doing trach changes and noticed the wound on resident 1. RN 1 stated the RT had called RN 1 into assess resident 1 and RN 1 stated that she had noticed that the trach chain was imbedded in the right side of resident 1's neck. RN 1 stated that she had removed the trach chain, took pictures of the wound, notified the wound nurse, Assistant Director of Nursing, and the provider. RN 1 stated the wound nurse suggested that RN 1 remove the trach chain, cleanse the area, treat with medihoney, and put a foam dressing like mepilex over the area to prevent further damage. RN 1 stated that she was the RN that did the treatment. RN 1 stated that their were two RTs in the room during the treatment to make sure that resident 1's trach was in place and two CNAs because resident 1 could become combative and remove the trach. RN 1 stated that she changed the trach chain on resident 1 and replaced it with trach ties. RN 1 stated that they were to do daily skin assessments on all residents. RN 1 stated dayshift would do one side of the hall and nightshift would assess the other side of the hall. RN 1 stated that the weekly skin checks were more thorough. RN 1 stated that typically the neck area of a resident would be assessed by the RT. RN 1 stated that yes the neck area would be assessed by the RT. On 6/8/23 at 11:33 AM, an interview was conducted with Physical Therapist (PT) 1. PT 1 stated that to his knowledge resident 1 was not contracted on the right side of her neck. PT 1 stated that resident 1 did favor the right side but resident 1 was able to realign her position. On 6/8/23 at 12:02 PM, an observation was conducted of resident 1. Resident 1 was observed in bed. The Alexa device was observed attached to the right side of resident 1's bed and covered in a plastic case. Resident 1 was observed to have her head turned to the right side of the bed. On 6/8/23 at 12:19 PM, an interview was conducted with the Administrator (Admin). The Admin stated that if a resident had an injury she would report within two hours and without an injury she would report within 24 hours. The Admin stated with resident 1 she did not think neglect but she knew that the wound to resident 1's neck was bad. The Admin stated that she did not inspect wounds. The Admin stated she thought it was a regular trach thing and she did not know it was a significant wound. The Admin stated that once she knew the significance of resident 1's wound she submitted the report. The Admin stated reports would go to the corporate office for review. The Admin stated that she would report the incident before it was sent to the corporate office. The Admin stated the incident with resident 1 should have been reported but she did not realize it. The Admin stated the corporate office did a double check and the information was sent back to the Admin as a wound. The Admin stated that she did not identify the wound as neglect. The Admin stated that she was the abuse coordinator. The Admin stated that resident 1's orders for showers were suppose to switch over and when resident 1 came back to the facility they did not switch over automatically. The Admin stated that the CNAs should have noticed that they could not click the shower box. The Admin stated the CNAs do have a paper brain to track resident showers. The Admin stated that one side of the hall was one day and the other side of the hall was the other day. The Admin stated there would be no way to know if resident 1 had a shower. The Admin stated that the staff should look at the computer and verify the order. The Admin stated that nursing, CNAs, and RTs should be watching the neck area on residents, especially the nurse and RT. The Admin stated that resident 1 always leaned to the right and had an aversion to touching people. The Admin stated that resident 1 could also remove the Velcro trach straps and the trach would fall out. The Admin stated that resident 1 was very strong. The Admin stated if a child drooled a lot the staff would switch to the trach chains because the trach ties could cause breakdown. The Admin stated that resident 1 did drool a lot.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable. Specifically, for 1 out of 26 sampled residents, a resident developed a pressure injury after their alternating pressure mattress deflated. In addition, there was a delay in treatment. Resident identifier: 18. Findings included: Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, sequelae of cerebral infarction, chronic respiratory failure, dependence on respirator, chronic diastolic heart failure, epilepsy, dysphagia, hypertension, sepsis, cerebral infarction, and tracheostomy status. Resident 18's medical record was reviewed on [DATE]. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 18 required total dependence of two persons for bed mobility. Bed mobility included how a resident moved to and from a lying position, turned side to side, and positioned body while in bed or alternate sleep furniture. In addition, the MDS assessment documented that resident 18 was at risk of developing pressure ulcers and resident 18 had no unhealed pressure ulcers. A care plan Focus initiated on [DATE], documented Skin Integrity & Wounds- [Resident 18] is at risk for pressure ulcers and skin integrity issues secondary to decreased cognition, decreased ADL [activities of daily living] ability, incontinence, risk for decline in nutrition, trach/vent[tracheostomy/ventilator] dependence. [Resident 18] has a large amount of secretions that can cause MASD [moisture associated skin damage] to multiple areas of skin, interventions in place. A care plan Goal initiated on [DATE] and revised on [DATE], documented [Resident 18] will be clean and be free of avoidable skin problems. Hygiene tasks will be completed and per resident preferences (hair, nails, skin moisturizer, etc). Privacy and dignity will be maintained at all times. [Resident 18's] bedding and clothing will be changed and cleaned on a regular basis. [Resident 18] will be repositioned on a regular basis to prevent skin complications. Wounds will be effectively managed and will resolve or show expected improvements this quarter. The care plan Interventions included, but were not limited to, a. Foam cushion to wheelchair. Initiated on [DATE]. b. Alternating Pressure Mattress - Provide resident with an alternating pressure air mattress. Ensure pump is plugged in and is functioning properly prior to resident transferring to bed. Check setting to ensure settings match resident weight. Repair or replace any equipment that is not functioning adequately. Initiated on [DATE]. c. Pressure Ulcer to right buttock- Assess size, color, odor, wound bed and underlying etiology of wound. Assess for factors that may delay or expedite healing and make appropriate interventions. Listen to resident and family input regarding wound. Provide wound care, medications, and dietary interventions as ordered. Report significant findings to MD [Medical Director]. Initiated on [DATE]. A Braden Scale for Predicting Pressure Sore Risk dated [DATE], documented that resident 18 was at High Risk for pressure sores with a score of 12. [Note: A score of 10 to 12 indicated High Risk.] On [DATE] at 5:15 AM, a Nursing Progress Note documented Note Text: At 0415 [4:15 AM], CNA [Certified Nursing Assistant] was doing brief change and noticed a small quarter sized skin tear to coccyx with bruising and some swelling. CNA denied seeing this during previous brief changes. Upon further assessment, similar bruising with some swelling with skin intact was found on upper middle back. Pushing on mattress to place pillows reveled that the mattress had become extremely deflated and the metal bars beneath the mattress could be felt. The air mattress machine was still on, green and set to the correct settings. No alarm had gone off. After trouble shooting, both CNA's, RT [Respiratory Therapist] and RN [Registered Nurse] transferred pt [patient] from current bed to a bed with padded mattress using the slide board. Pt remained calm with no signs of px [prognosis] or distress. Metahoney [sic] and a 4x4 padded bandage were applied to skin tear. Pt was floated with several pillows to relieve as much pressure as possible to boney areas. ADON [Assistant Director of Nursing] notified and incident report completed. Pt appears comfortable and VS [vital signs] are at baseline for patient. On [DATE] at 11:58 AM, a Skin Assessment documented that resident 18's skin was clean, dry, and intact. On [DATE] at 9:38 AM, a Skin and Wound Evaluation documented that resident 18 had a pressure related deep tissue injury (DTI) to the sacrum. The DTI was acquired in house on [DATE]. The wound measurement area was 22.1 centimeters (cm), length 8.2 cm, and width 4.8 cm. The Notes section documented DTI to coccyx assessed today. Wound noted by staff on [DATE] related to malfunction of air bed. Previous dressing doffed, area cleansed with wound cleanser and sterile gauze. Area has some open areas with red beefy granulation tissue. Skin that is not open is discolored purple/dark red. Area treated with medihoney, skin prep and a foam border dressing. Pt tolerated fair. [Note: The DTI was identified on [DATE], according to the documentation in the Nursing Progress Note.] On [DATE], a physician's order documented Wound care to DTI on coccyx: Remove previous dressing. Cleanse wound with wound cleanser and sterile gauze. Apply medihoney to wound bed. Secure with skin prep and a 6x6 foam border dressing. To be completed every day shift and PRN [as needed]. every day shift for wound care. The physician's order was discontinued on [DATE]. [Note: Treatment for the DTI was started six days after the DTI was identified by facility staff.] On [DATE] at 12:54 PM, a Skin and Wound Evaluation documented . Wound treated with SANTYL, oil emulsion and secured with skin prep and a foam border dressing. Pt tolerated well. Nurse stated that wound NP [Nurse Practitioner] would evaluate and treat on Friday. The wound order was not initiated until [DATE]. [Note: The [DATE] Treatment Administration Record (TAR) documented that resident 18's treatment provided was according to the physician's order dated [DATE].] On [DATE], a physician's order documented Wound care to DTI on coccyx: Remove previous dressing. Cleanse wound with wound cleanser and sterile gauze. Apply SANTYL to wound bed and cover with oil emulsion dressing. Secure with skin prep and a 6x6 foam border dressing. To be completed every day shift and PRN. every day shift for wound care. The physician's order was discontinued on [DATE]. On [DATE] at 10:56 AM, a Skin/Wound Note documented Note Text: [Resident 18] was assessed and treated today by [name removed] Wound Care NP today for PI [pressure injury] to sacrum area. Wound was cleansed with wound cleanser and sterile gauze prior to treatment. NP debrided wound with 3 mm [millimeter] curette. Light/moderate bleeding noted. Pt tolerated well. Dressing change completed as ordered. On [DATE], a Progress Note Details from the wound care NP documented that the post debridement Stage was noted a Stage 3 Pressure Injury. Wound orders for the posterior coccyx documented to clean wound with anacept wound cleaner. Barrier ointment to surrounding skin and skin prep up to and including wound edges. [Note: The wound orders were not initiated.] On [DATE] at 1:27 PM, a Skin/Wound Note documented Note Text: Patient had debridement treatment today by [name removed] Wound Care NP. Previous dressing doffed, light amount of exudate noted on previous dressing, Wounds cleansed with wound cleanser. No odor noted coming from wound beds. Debridement completed. Patient tolerated treatment well. Wound care completed as ordered. On [DATE], a Progress Note Details from the wound care NP documented wound orders for the posterior coccyx documented to clean wound with anacept wound cleaner. Barrier ointment to surrounding skin and skin prep up to and including wound edges. [Note: The wound orders were not initiated.] The March and [DATE] TAR was reviewed. Resident 18 received the following wound care to DTI on coccyx from [DATE] to [DATE], . Remove previous dressing. Cleanse wound with wound cleanser and sterile gauze. Apply SANTYL to wound bed and cover with oil emulsion dressing. Secure with skin prep and a 6x6 foam border dressing. To be completed every day shift and PRN. On [DATE] at 11:02 AM, a Skin and Wound Evaluation documented that the wound measurement area was 3.5 cm, length 1.7 cm, and width 3.6 cm. On [DATE] at 1:03 PM, an observation was conducted of resident 18 lying in bed. An alternating pressure air mattress was observed on resident 18's bed. On [DATE] at 1:10 PM, an interview was conducted with CNA 1. CNA 1 stated if a resident had an alternating pressure mattress the CNAs did not track the mattresses. CNA 1 stated the alternating pressure mattress would be a nursing task. CNA 1 stated she only knew to put a white chux on the alternating pressure mattresses. On [DATE] at 1:13 PM, an interview was conducted with RN 3. RN 3 stated that she worked the shift after resident 18's pressure injury was identified. RN 3 stated she had received report that resident 18's mattress was not working. RN 3 stated that resident 18 had an alternating pressure mattress. RN 3 stated that during the last rounds prior to shift change resident 18's mattress was flat and RN 3 was not sure how long the mattress had been flat. RN 3 stated the staff switched out the mattress and put resident 18 on a different mattress. RN 3 stated when the maintenance worker came in that morning she had them come and look at the mattress. RN 3 stated the CPR plugs for the mattress were pulled out. RN 3 stated the CPR plugs were located on the right side of the bed by the bar. RN 3 stated if the bar was lowered on the bed that may have caused the CPR plugs to become disconnected. RN 3 stated that once she had figured out the problem resident 18 was moved back to the original mattress. RN 3 stated that treatment orders were initiated and input by the treatment team. On [DATE] at 1:30 PM, a followup interview was conducted with RN 3. RN 3 stated the residents were weighed every weekend. RN 3 stated the alternating pressure mattress had a setting on the motor where the nurse entered the resident weight and the mattress would alternate based on the weight of the resident. RN 3 stated the nurses should be checking the mattress every shift but there was not a way to track that the mattress had been checked. On [DATE] at 1:58 PM, an interview was conducted with RN 4. RN 4 stated she was the Wound Nurse at the facility. RN 4 stated that she had not been working at the facility at the time resident 18's pressure injury was identified. RN 4 stated that resident 18's alternating pressure mattress deflated and it was not caught in time. RN 4 stated she was not sure how long resident 18's mattress had been deflated. RN 4 stated ADON 2 was the Wound Nurse prior to her employment and ADON 2 would have input the original treatment orders for resident 18. RN 4 stated that today she had changed the wound orders because resident 18's wound was improving and the wound no longer had slough. The pictures of resident 18's pressure injury were observed with RN 4. RN 4 stated the pressure injury was on resident 18's sacral coccyx area and the wound edges were currently flush with the wound and had slough in the center of the wound. RN 4 stated the wound edges were coming in and the wound center had a nice and beefy wound bed. RN 4 stated that debridement of resident 18's wound was being done onsite from the wound care team. RN 4 stated that the cause of the wound was from resident 18 being on the bed railing. RN 4 stated heck yes it should have been preventable if the bed had not malfunctioned. On [DATE] at 2:37 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that once a wound was identified the physician was to be notified. The DON stated that the wound team would come in and stage the wound. The DON stated the wound team worked five days a week. The DON stated the wound team would set interventions and input wound orders. The DON stated that an incident report regarding the identified wound would be completed. On [DATE] at 2:43 PM, an interview was conducted with ADON 2. ADON 2 stated that part of the problem with the delay in orders was that ADON 2 was out of town the Thursday and Friday after resident 18's pressure injury was identified. ADON 2 stated that she did not take pictures of resident 18's pressure injury until the 20th of March. ADON 2 stated the floor nurse told her that they were doing medihoney and a bandage on resident 18's pressure injury but there were no orders.