**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. R107 was admitted on [DATE], with a readmission on [DATE], with a diagnosis of traumatic subdural hemorrhage. R107 is nonverbal, on a ventilator, on tube feeding, and totally dependent on staff for activities of daily living. The admission MDS (minimum data set) assessment completed on 9/13/23 indicates R107 was at risk for a pressure injury and has no current pressure injury. The Quarterly MDS assessment completed on 10/13/23 indicates R107 is a risk for pressure injury and has no current pressure injury. R107's physician orders on 10/8/23 direct staff to monitor bilateral ears and assure both are suspended every shift for wounds. (Suspended means the ears were not to directly rest against a pillow or other object.) R107's plan of care for At Risk for Further/Impaired Skin Integrity, related to age, trach dependence, unresponsiveness, immobility, incontinence, and pain, was initiated on 9/20/23. There are no interventions created related to the pressure injury on the left ear, and then on the right ear. These areas are not identified as a revision until 12/5/23. The care plan was revised to Actual skin impairment related to limited mobility, history of skin breakdown, Braden of 9-very high risk. DTI (deep tissue injury) to left ear and DTI to right pointer finger. The plan of care does not identify intervention revisions specific to the pressure injuries to both ears. Surveyor noted the care plan was not revised until Surveyor brought the care plan to the facility's attention. This is an electronic generated computer system. The care plan entries will generate a Kardex for staff to reference for care needs. There was no revision with the plan of care. The Skin Wound assessments indicate measurements. The Skin Wound assessments do not consistently include the percentage characteristics of the wound to determine changes. R107 Skin Assessments are the following: -On 10/9/23 a stage 3 pressure injury to the left ear measuring 0.5 cm by 0.4 cm by 0.1 cm. The notes indicate this wound was present upon leave of absence on 10/7/23. - On 10/23/23 the skin notes indicate the left ear wound is resolved and is at high risk for reopening due to head deviating to the left. -On 11/11/23 the right ear has a stage 3 pressure injury measuring 1.1 cm by 1.7 cm by 0.1 cm. The root cause is moisture, immobility, and friction. -On 11/16/23 the right ear is a stage 3 pressure injury measuring 0.5 cm by 0.4 cm by 0.1 cm. On 11/28/23 at 10:32 AM, Surveyor observed R107 lying in bed. R107's head viates to the left. There was no visualization of the left ear because t.he left ear was against the pillow. On 11/29/23 at 8:00 AM, Surveyor observed R107 lying in bed. R107's head deviates to the left. There was no visualization of their left ear. The left ear was against the pillow. On 11/29/23 at 11:05 AM, Surveyor spoke with Wound (Registered Nurse) RN-O. They indicated the right ear area is healed and there is no treatment. On 11/30/23 at 10:54 AM, Surveyor observed R107 lying in bed. R107 head deviates to the left. There was no visualization of their left ear. The left ear was against the pillow. On 11/30/23 at 11:31 AM, Surveyor spoke with Wound RN-O regarding the skin assessment process. Wound RN-O reported the floor nurse conducts the admission skin assessment. The floor nurse will do the Skin Observation form and for the resident re-admissions. Wound RN-O does a head-to-toe assessment the next day. The Wound RN will get admission paperwork for residents with wounds upon admission. The floor nurse will get the treatment orders and notify the WCT (wound care team) regarding a wound. Everybody does the resident care plan. Nursing starts the plan of care and revises it as needed. The resident care plan recommendations, or interventions, could be added to the care plan by a number of people. The Wound Assessment in PCC (point click care) Wound RN-O will pick the worse tissue type from a drop-down box. There is no drop-down boxes for wound characteristic percentages. The NP (Nurse Practitioner) will have percentages in their notes that are documented weekly on Friday. Wound RN-O reports findings at clinical meetings daily. Then the staff would take the responsibility from there to add the recommendations to the care plan. On 11/30/23 at 12:26 PM, Surveyor spoke with Wound RN-O regarding prevention of ear ulcers on the plan of care. R107's plan of care did not include pressure injury to ears and preventive interventions. No further information was provided. On 11/30/23 at 1:43 PM, Surveyor observed R107 lying in bed. R107 head deviates to the left. There was no visualization of their left ear. The left ear was against the pillow. On 11/30/23 at 3:32 PM at the facility exit meeting, Surveyor shared the concerns with R107's pressure injury development, and the lack of care plan interventions for the right and left ears. On 12/04/23 at 8:05 AM, (Vice President of Clinical Operations) VPCO-J and (Director of Nurses) DON-B spoke with Surveyor. They reviewed R107 preventative measures however, there was no interventions related to ear off-loading. On 12/04/23 at 10:09 AM, Surveyor observed R107 sitting up in a Broda chair. R107 has a pillow behind their head. R107 left ear is not visible and is against a pillow. 6. R88 was admitted to the facility on [DATE] with diagnoses of cerebral infarction, obstructive hydrocephalus, nontraumatic subarachnoid hemorrhage, and dysphagia requiring all nutrition to be supplied through a gastrostomy tube. R88's quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated R88 had severe cognitive impairment per staff assessment and required extensive to total assistance with all activities of daily living. R88 had a legal Guardian. R88's Potential Skin Impairment Care Plan was initiated on 5/18/2023 with the following interventions: -Observe skin during care and report any concerns to nurse. -Turn and reposition to maintain skin integrity. -Pressure reducing mattress. -Skin check weekly. -Wheelchair cushion. R88's Potential Skin Impairment Care Plan was revised on 6/2/2023 with the following interventions: -Bilateral heel boots. -Nutritional supplements per orders to aid in wound healing. On 9/7/2023 on the Skin Only Evaluation form, Wound Registered Nurse (RN)-O charted R88 sustained a traumatic injury to the right lateral ankle causing an open wound that measured 0.9 cm x 1.2 cm x 0.1 cm with granulation tissue. The assessment was not comprehensive of the wound with no percentage of tissue type documented to determine if granulation tissue was the only tissue type present. Wound RN-O charted the cause of the open wound was likely due to friction in a boot and a different heel boot was placed. The Potential Skin Impairment Care Plan was not revised to reflect a different heel boot was to be used. Wound RN-O documented measurements of the right lateral ankle wound on 9/14/2023 and 9/21/2023 with granulation tissue to the wound bed and no detailed description of the percentage of tissue type to show if the wound was improving or declining. On 9/28/2023 on the Skin Only Evaluation form, Wound RN-O charted the right lateral ankle wound changed from a trauma wound to an Unstageable pressure injury that measured 1.8 cm x 1.3 cm x 0.1 cm with slough to the wound bed. Wound RN-O did not document the percentage of slough to the wound bed or if there were any other tissue types present. Wound RN-O charted the cause of the pressure injury was due to R88 favoring the right side with the right leg having outward rotation. Wound RN-O charted the heel boot was not to be used on the right foot and was to be floated on a pillow instead. The Potential Skin Impairment Care Plan was not revised to reflect Wound RN-O's recommendation. Wound RN-O documented measurements of the Unstageable right lateral ankle wound on 10/5/2023, 10/12/2023, 10/19/2023, and 10/26/2023 with slough to the wound bed and no detailed description of the percentage of tissue type to show if the wound was improving or declining. On 11/2/2023 on the Skin Only Evaluation form, Wound RN-O charted the right lateral ankle wound was a Stage 3 pressure injury that measured 0.8 cm x 1 cm x 0.1 cm with granulation to the wound bed. No percentage of tissue type was documented to indicate if granulation tissue was the only tissue type present. On 11/10/2023 on the Skin Only Evaluation form, Wound RN-O charted the right lateral ankle wound was a Stage 3 pressure injury that measured 1.6 cm x 1.8 cm x 0.1 cm with slough to the wound bed. Wound RN-O charted staff reported the family had been putting shoes on R88. The Potential Skin Impairment Care Plan was not revised to reflect R88 should not be wearing shoes. R88 was seen by the Wound NP with Wound RN-O and the Wound NP documented the same measurements as Wound RN-O with the additional documentation of 50% slough, 20% granular, 30% epithelial tissue. This was the first comprehensive assessment of the wound, two months after the wound first developed. On 11/10/2023, R88 received an order to start ProStat, a protein supplement, 30 ml daily for wound healing. In an interview on 11/30/2023 at 1:18 PM, Surveyor asked Registered Dietician (RD)-R why ProStat was not started until 11/10/2023 when R88 had a pressure injury to the right lateral ankle since 9/28/2023. RD-R stated the ProStat was not started until the wound was Stageable because the tube feeding formula was meeting R88's needs up until that time. Surveyor clarified with RD-R that if a resident has an Unstageable pressure injury, they did not have increased protein needs. RD-R stated the resident does not have increased needs until the wound becomes stageable. Surveyor asked RD-R if R88's tube feeding formula had been changed to increase protein needs. RD-R stated no. Surveyor asked RD-R if RD-R is alerted to residents that have wounds so they could be assessed for increased protein needs. RD-R stated RD-R receives a log of the wounds from Wound RN-O and is alerted in morning meetings or at the at risk meetings once a week of all the residents that have wounds. Surveyor noted R88 did not have any changes to the tube feeding formula or rate of feeding since admission with no increase to protein intake with the development of a pressure injury. Wound RN-O documented measurements of the right lateral ankle wound on 11/17/2023 with slough to the wound bed and 11/24/2023 with granulation tissue to the wound bed and no detailed description of the percentage of tissue type to show a complete picture of the wound. On 11/27/2023 at 11:30 AM, Surveyor observed R88 sitting up in a wheelchair with socks and slip-on shoes to both feet. Heel boots were observed to be lying on the bed with an air mattress in place. R88 was non-verbal. On 11/29/2023 at 1:54 PM, Surveyor observed R88 sitting up in a wheelchair with a slip-on shoes to both feet. Heel boots were observed to be lying on the bed. In an interview on 11/30/2023 at 11:32 AM, Surveyor asked Wound RN-O why percentages are not used when describing the tissue type in a wound bed. Wound RN-O stated Wound RN-O picks the worst tissue type present and documents that in the computer charting system. Wound RN-O stated the computer charting system does not have the capability of having more than one tissue type and there is no drop-down box to chart the percentage. Surveyor asked Wound RN-O if there was a place on the form in the computer charting system to free-type where more detailed descriptions could be documented. Wound RN-O stated there is an area where notes can be written but had not used it for that. Wound RN-O stated the Wound NP puts the percentages in their notes, so Wound RN-O does not double document. Surveyor reviewed the Wound NP notes for R88. Surveyor shared with Wound RN-O that the Wound NP saw R88 for the first and only time on 11/10/2023. Wound RN-O stated R88 was just picked up by the Wound NP because the Wound NP's caseload was too heavy up until then. Surveyor shared the concern with Wound RN-O that none of R88's wound assessments were comprehensive with complete descriptions of the wound bed until 11/10/2023. Wound RN-O agreed there were no percentages documented. Surveyor asked Wound RN-O how Wound RN-O's recommendations for interventions are communicated with other staff members. Wound RN-O stated Wound RN-O does not tell anyone of care plan revisions as the assessments are being completed but communicates those recommendations at the daily clinical meetings. Wound RN-O stated whoever is responsible for putting the intervention into place would take that information from the meeting and implement it into the care plan. Surveyor asked Wound RN-O why R88's Potential Skin Impairment Care Plan was not revised on 9/7/2023 when R88's right lateral ankle wound was determined to be a caused by heel boots. Wound RN-O stated R88 had little booties from the family that the family thought were friction reduction booties and Wound RN-O determined those were the boots that R88 should not use and could wear the normal heel boots provided by the facility. Wound RN-O stated that should be in the care plan. Surveyor shared with Wound RN-O the recommendation documented by Wound RN-O on 9/28/2023 when the pressure injury developed that the heel boot was not to be used on the right foot and was to be floated on a pillow instead. Surveyor informed Wound RN-O that intervention was not put into the care plan and the care plan continued to have the intervention of wearing heel boots with no specification as to what type of boot. Wound RN-O stated there was a time when the potential for skin impairment and the actual skin impairment care plans were in place, and they got mushed and interventions were lost. Surveyor shared with Wound RN-O the recommendation documented by Wound RN-O on 11/10/2023 that R88 should not be wearing shoes brought in by the family. Surveyor informed Wound RN-O that intervention was not put into the care plan and the care plan continued to have the intervention of wearing heel boots. After the conversation with Surveyor, Wound RN-O revised the Skin Integrity Care Plan to include the intervention: bilateral heel offloading boots or pillows to offload; not small green friction prevention boots and tennis shoes not to be worn. On 12/4/2023 at 12:16 PM, Surveyor observed R88 sitting up in a wheelchair with socks and heel boots on both feet. On 12/4/2023 at 1:51 PM, Surveyor shared with Nursing Home Administrator (NHA)-A, [NAME] President of Operations-AA, [NAME] President of Regulatory Services-I, [NAME] President of Clinical Operations-J, Consultant-U, and Medical Director-BB the concern R88 had a wound to the right lateral ankle that developed into a pressure injury with no revisions to the care plan recommended by Wound RN-O to prevent the development of the pressure injury and the assessments of the pressure injury were not comprehensive, detailing the tissue types in the wound bed. Surveyor shared R88 was observed to be wearing shoes when the care plan stated to have heel boots on at all times. On 12/5/2023 at 1:33 PM, Surveyor observed R88 sitting up in a wheelchair with a neck pillow to the back of R88's neck. Tube feeding formula was being administered through a pump. R88 had socks on with a slip-on shoe to the left foot and a slip-on shoe to the right foot had fallen off onto the floor. In an interview on 12/5/2023 at 1:38 PM, Surveyor asked Certified Nursing Assistant (CNA)-L if R88 wears heel boots. CNA-L stated R88 wears heel boots when in bed, but when R88 is up in a wheelchair, R88 wears slip-on shoes or little tennis shoes that R88's family brings in and puts on R88. CNA-L stated R88 only wears heel boots when in bed. Surveyor noted CNA-L was not aware of the Skin Integrity Care Plan interventions added on 11/30/2023 stating tennis shoes were not to be worn. No further information was provided at that time. 3. R100 was admitted to the facility on [DATE] and has diagnoses that include Castleman's Disease, Acute Respiratory Failure with hypoxia, Tracheostomy, Cerebrovascular Disease, Gastroparesis, chronic embolic CVA (Cerebrovascular Accident) leading to obstructive hydrocephalus, occipital craniotomy, and C1 laminectomy for decompression on 5/28/23 F/B (followed by) shunt placement 6/14/23. The facility Skin only evaluation dated 9/8/23 documents: Does Resident have current skin issues? No. The Admission/re-admission Nursing Evaluation dated 9/8/23 documents no skin abnormalities at time of assessment. R100's admission Minimum Data Set (MDS) dated [DATE] documents no pressure injuries. Is this resident at risk of developing pressure ulcers/injuries? Yes. Bed mobility as extensive 1-person physical assist. R100's Skin Observation tool dated 9/15/23 documents: Intact, no concerns. R100's Braden Scale for Predicting Pressure Ulcer Risk dated 9/15/23 documents a score of 8, indicating Very High Risk. The Certified Nursing Assistant (CNA) Kardex dated 11/29/23 documents R100 as dependent on staff of 2 assist with bed mobility, transfers, and toileting. R100's November 2023 Treatment Administration Record documents: Reposition q (every) 2 to 3 hours side to side q shift - start date 9/28/23. R100's Care Plan documents: (Resident) is at risk for impaired skin integrity related to immobility, incontinence, and cachetic state. 9/19/23- DTI (deep tissue injury) vs (versus) suspected abscess to sacrum discovered in facility, ultrasound verified. Debrided by NP (Nurse Practitioner); bone palpable - now stage 4 (unavoidable) 10/5/23- stage 3 (previously unstageable) pressure injury to right posterior scalp, developed in facility (moisture, neck contracture)- (unavoidable) 10/23/2023- unstageable pressure injury to right hip, developed in facility (likely started as MASD (Moisture Associated Skin Damage)/shearing)- (unavoidable) 10/30/2023- unstageable (previously DTI) pressure injury to left hip, developed in facility (unavoidable). DTI to left ischium, developed in facility 11/10 (unavoidable). DTI to right medial heel, acquired in facility 11/25/23. unstageable pressure injuries to posterior scalp & left posterior scalp, developed in facility 11/30/23. All wounds unavoidable d/t (due to) resident's declining overall status, despite all preventative measures in place. Initiated 9/8/23, revision on 11/27/23. Interventions: - Reposition every 2-3 hours when in bed. Utilize draw sheet when available for repositioning to reduce risk of friction/shear. Verify resident's body is free from contact with environmental hazards (not pressing into side rails or foot board, not laying on tubes, etc.). Initiated 9/8/23, revision on 9/20/23. - Nursing will assess skin upon admission, weekly on day of scheduled shower, PRN (as needed) and with any change in condition. Any abnormalities will be documented in chart and reported to primary physician and Wound Care Team for follow up. Initiated 9/8/23. - Offload resident to reduce direct pressure on bony prominences. Utilize heel boots and/or pillows to keep heels floated when possible as resident allows. Monitor offloading devices with each encounter to ensure proper positioning. Avoid positioning devices directly over wounds/bony prominences. Initiated 9/8/23. - Incontinence care every shift and as needed for incontinence episodes. Initiated 10/12/23. - Nursing to monitor dressing integrity with each resident encounter and replace dressing if soiled/loose/missing. Dressing location: sacrum, right posterior scalp, right hip, left hip, left ischium. Initiated 10/12/23. - Referral to Registered Dietitian for evaluation related to impaired nutrition impacting wound healing. Provide supplements per MD (Medical Doctor)/NP orders. Initiated 10/12/23. - Specialty mattress: LAL (low air loss) mattress, check function q shift and prn. Initiated 10/12/23. (Wound RN (Registered Nurse)-O reports mattress in place upon admission). - Sharps debridement to be performed as needed by Nurse Practitioner for wound bed preparation. Initiated 10/12/23. - **BED REST** Initiated 10/18/23 (Per wound care notes, bed rest ordered 9/28/23). - neck pillow for neck contracture (added to care plan 11/28/23). (Resident) has (Specify: Functional) bladder incontinence r/t (related to) Impaired Mobility, communication impairment. Initiated 9/26/23. Interventions: - Clean peri-area with each incontinence episode. - Monitor/document for s/sx (signs and symptoms) UTI (urinary tract infection) pain, burning, blood-tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, Urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns - Monitor/document/report PRN any possible causes of incontinence: bladder infection, constipation, loss of bladder tone, weakening of control muscles, decreased bladder capacity, diabetes, Stroke, medication side effects. Requires assistance with ADL's (activity of daily living) r/t weakness, impaired cognition, decreased mobility, debility. Initiated 9/21/23. Interventions: - Staff to reposition resident. He is dependent on staff with proper body alignment while in bed as needed. - Resident dependent on staff of 2 assist with bed mobility, transfers, toileting. (Resident) is at risk for impaired skin integrity related to immobility, incontinence, and cachetic state. Interventions: - Incontinence care every shift and as needed for incontinence episodes. Initiated 10/12/23. (Resident) has bowel incontinence r/t immobility - initiated 10/3/23. Interventions: - Check resident every two hours and assist with toileting as needed. - Provide peri care after each incontinent episode. R100's Certified Nursing Assistant (CNA) Kardex dated 11/29/23 documents: Turn and reposition every 2-3 hours. Resident dependent on staff of 2 assist with bed mobility, transfers, toileting. Staff to reposition resident. He is dependent on staff with proper body alignment while in bed as needed. Bedrest. Offload resident to reduce direct pressure on bony prominences. Utilize heel boots and/or pillows to keep heels floated when possible as resident allows. Monitor offloading devices with each encounter to ensure proper positioning. Avoid positioning devices directly over wounds/bony prominences. Neck pillow for neck contracture. R100 developed 6 facility acquired pressure injuries since admission. Wound documentation on the facility Skin Only Evaluations document: SACRUM 9/19/23 sacrum SDTI (Suspected Deep Tissue Injury) 1.9 x 2.6 cm (centimeters) - wound bed epithelial, no exudate. Deep purple discoloration over protruding sacrum. Warmth, induration and fluctuance present. In addition, wound margins are irregular which suggest cause is suspected abscess vs (versus) infectious process, not pressure. Findings reported to NP ultrasound requested. NP also putting resident on Doxycycline x 7 days. Facility progress note dated 9/19/23 at 1:58 PM documents: Resident noted by WCT (wound care team) with possible abscess to sacrum area. Area assessed by NP, NOR (new order received) for ultrasound of Sacrum dt (due to) possible abscess. Surveyor confirmed order for Doxycycline Hyclate Oral Tablet 100 MG Give 1 tablet by mouth two times a day for possible abscess until 9/28/23. 9/20/23 Pelvic ultrasound results: Possible sacral abscess. Findings: The tissue appears edematous although a discrete abscess collection is not seen. Conclusion: Edematous tissue without a discrete abscess. Cellulitis cannot be excluded. Wound documentation on Skin Only Evaluations (continued): 9/21/23 Abscess sacrum 1.5 x 2.6 cm - wound bed epithelial, no exudate. Ultrasound + for abscess. Wound etiology is full thickness secondary to underlying cutaneous abscess. 9/28/23 Abscess (full-thickness wound) sacrum 3.5 x 5.2 x 0.3 cm - wound bed slough, serosanguineous exudate. NP assessed. Skin discoloration now with marbled slough present. Course of Doxycycline completed. Started on Linezolid. Resident put on bedrest d/t pronounced bony prominences and risk of rapid skin decline. Surveyor confirmed order for Linezolid Oral Tablet 600 MG (Linezolid) Give 1 tablet via G-Tube (gastrostomy) two times a day for wound infection start 9/29/23 until 10/6/23. 10/6/23 Abscess sacrum 2.3 x 5 x 0.1 cm - wound bed slough, serosanguineous exudate, minimal dressing saturation. Full thickness wound showing mild improvement with current treatment. 10/13/23 Abscess sacrum Full-Thickness 4 x 5.6 x 0.2 cm. Slough, serosanguineous exudate, moderate dressing saturation. Sacral wound is stable-larger, but slough breaking down and releasing wound edges. 10/20/23 Sacrum Stage IV pressure injury - full thickness tissue loss 4.8 x 5.8 x 1.3 cm. Slough, serosanguineous exudate, moderate dressing saturation. Sacral wound is now stage 4 - sharp debridement completed by NP with bone palpable. TX (treatment) changed to Hydrofera blue to promote continued autolytic debridement of remaining slough. 10/27/23 stage IV 5.2 x 6 x 1.1 cm. Slough, serosanguineous exudate, moderate dressing saturation. Undermining - yes. (No location or depth). Foley requested for wound healing. 11/3/23 stage IV 5.6 x 6.3 x 1 cm. Granulation, serosanguineous exudate, heavy dressing saturation. Undermining - no. 11/10/23 stage IV 5.6 x 6 x 0.8 cm. Slough, serosanguineous exudate, heavy dressing saturation. Undermining - Yes (No location or depth) 11/17/23 stage IV 5.2 x 6 x 0.6 cm. slough, serosanguineous exudate, moderate dressing saturation. Undermining - yes. (No location or depth). All wounds stable or showing minimal improvement. 11/24/23 stage IV 5.3 x 5.6 x 0.6 cm. Granulation, serosanguineous exudate, moderate dressing saturation. Undermining - yes. (No location or depth). All wounds stable or showing minimal improvement. Surveyor noted no new care plan revisions to include increased turning, repositioning, or offloading implemented after R100 was put on bedrest 9/28/23. The sacrum wound progressed to a stage IV pressure injury on 10/20/23 and the care plan was not revised. There was no consideration or inquiry of a more specialty mattress or if there was a need for increased turning, repositioning, or offloading. In addition, R100 was totally incontinent of bowel and bladder and dependent on staff for incontinence care. There was no comprehensive assessment completed to determine if R100 needed increased checking/changing and incontinence care prior to the Foley catheter placement. (Cross reference F690). Weekly wound documentation does not include a comprehensive assessment to include the percentage of slough observed in the wound bed and the location and degree of undermining present in the wound. R100 subsequently developed facility acquired unstageable and stage 3 pressure injuries to his right and left trochanter, ishium, posterior scalp and heel. RIGHT POSTERIOR SCALP 10/5/23 (New) unstageable pressure injury 1.8 x 3.4 x 0.1 cm. Slough, serosanguineous exudate, peri wound maceration. Seen at request of nursing for assessment of head d/t drainage found on pillow. Irregular shaped unstageable pressure injury noted to right posterior scalp, beneath hair. 80% dry tan slough and 20% epithelial with moist wound edges. Root cause is moisture, friction, and neck contracture. 10/6/23 unstageable 1.8 x 3.4 x 0.1 cm. Slough, serosanguineous exudate. Therapy provided resident with neck pillow to provide better offloading d/t residents hyper extension of neck. (Surveyor noted the neck pillow was not implemented on R100's care plan.) 10/13/23 unstageable 1 x 2.5 x 0.1 cm. Slough, serosanguineous exudate, minimal dressing saturation, peri wound maceration. Wound slightly improved. 10/20/23 Stage 3 full thickness skin loss 1.1 x 2.5 x 0.1 cm. Granulation, serosanguineous exudate, minimal dressing saturation. Wound stable. (Surveyor noted the wound now documented as stage 3). 10/27/23 stage 3 - 1.1 x 2.1 x 0.1 cm. Granulation, serosanguineous exudate, moderate dressing saturation. 11/3/23 stage 3 - 1.4 x 4 x 0.1 cm. Granulation, serosanguineous exudate, moderate dressing saturation. Larger with area of eschar along lateral edge. 11/10/23 stage 3 - 1.3 x 2.5 x 0.1 cm. Granulation, serosanguineous exudate, moderate dressing saturation. 11/17/23 stage 3 - 0.9 x 2.9 x 0.1 cm. Granulation, serosanguineous exudate, moderate dressing saturation. 11/24/23 stage 3 - 0.6 x 2 x 0.1 cm. Granulation, serosanguineous exudate, minimal dressing saturation. All wounds stable or showing minimal improvement. R100 developed an unstageable pressure injury, which progressed to a stage 3 pressure injury on his posterior scalp. Surveyor noted no care plan revisions to include increased turning, repositioning, or offloading. Wound care notes indicate the root cause of the pressure injury as moisture, friction, and neck contracture. Intervention of a neck pillow was recommended but was not implemented on R100's care plan. There was no evidence R100 was assessed for or provided a different/specialized pillow to provide cooling or moisture reduction versus the standard pillow provided. RIGHT TROCHANTER 10/23/23 (New) unstageable pressure injury 1.2 x 2.2 x 0.1 cm. Slough, serosanguineous exudate. Seen for scheduled treatments. Upon assessment, small wound observed to right trochanter. Irregularly shaped, but with thin light yellow slough base-unstageable pressure injury that likely started as shearing. Unavoidable despite all proper interventions in place and further skin breakdown and/or wound declines anticipated. Root cause is cachexia, contractures, and overall decline. 10/27/23 unstageable 1.2 x 2.2 x 0.1 cm. Slough, serosanguineous exudate, minimal dressing saturation. Hydofera blue added to treatment and Foley requested for wound healing. 11/3/23 unstageable 2 x 2.2 x 0.3 cm. Slough, serosanguineous exudate, minimal dressing saturation. Sharp debridement by NP. 11/10/23 unstageable 4.5 x 3.6 x 0.3 cm. Slough, serosanguineous exudate, moderate dressing saturation. Right trochanter larger and with more drainage. Super absorbent added to treatment. 11/17/23 unstageable 7.5 x 5.4 x 0.9 cm. Slough, serosanguineous exudate, heavy dressing saturation. Right trochanter significantly larger, X-ray requested. 11/24/23 unstageable 7 x 6.1 x 0.7 cm. Slough, serosanguineous exudate, heavy dressing saturation. Surveyor noted although R100 continued to develop facility acquired pressure injuries, no new care plan revisions were implemented. Weekly wound documentation does not include a comprehensive assessment to include the percentage of slough observed in the wound bed. The radiology report dated 11/15/23 documented: Hip uni w (with) or wo (without) pelvis 2-3 view right. No acute osseous abnormality. No definitive evidence of osteomyelitis. Consider repeat multi-view study in 1 week or sooner if symptoms continue to persist or progress. Recommend MRI (Magnetic Resonance Imaging) for further evaluation. Surveyor noted no further x-rays were completed and there was no evidence the recommended MRI was scheduled or completed. Surveyor noted R100 received Ertapenem Sodium 1 GM (gram) IV (intravenously) in the morning for wound infection from 11/18/23 - 11/25/23. On 11/30/23 at 12:29 PM Surveyor spoke with Wound RN (Registered Nurse)-O. Surveyor asked why R100 received IV antibiotics 11/18/23 - 11/25/23. Wound RN-O stated: It was for the right hip wound; it was significantly larger with more drainage. The X-ray was negative for osteomyelitis, but the NP felt it was infected and needed antibiotic treatment. Surveyor advised Wound RN-O of the 11/15/23 radiology report recommendations for MRI and asked if it was ordered or completed. Wound RN-O stated: No. They always say that every time someone has an X-ray, they recommend an MRI for further evaluation. The wait time for that is awful. It's impossible to

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility did not ensure that residents with pressure injuries received necessary treatment and services, consistent with professional standards of practice, to promote healing, and prevent new pressure injuries from developing for 2 of 5 (R58 and R77) residents reviewed for pressure injuries. The facility assessed R58 to be at risk for the development of pressure injuries. The facility did not implement a turning and repositioning program despite R58's assessed risk. R58 developed a facility acquired stage 3 pressure injury to the right knee that was assessed to have necrotic tissue. The facility identified the root cause of this pressure injury to be immobility, heavy perspiration, and pressure. The facility did not revise R58's care plan with interventions to address the identified root cause. The facility did not complete treatments per physician orders. R58 also developed a stage 4 pressure injury to the right elbow with bone exposed. R58 had a prior Suspected Deep Tissue Injury (SDTI) to the right elbow that healed. The facility identified the root cause of the pressure injury to be increased moisture from perspiration and upper extremity edema. The facility did not revise R58's care plan with interventions to address the identified root cause of the right elbow pressure injury. The facility did not complete treatments per physician orders. Surveyor observed R58's pressure injury care plan interventions not in place and R58 was not repositioned per care plan. The facility's failure to provide prescribed treatments and implement care plan interventions to prevent new pressure injuries created a finding of immediate jeopardy that began on 5/12/23. Surveyor notified Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of the immediate jeopardy on 6/1/23 at 2:42 PM. The Immediate Jeopardy was removed on 6/2/23 when the facility implemented its action plan. The deficient practice continues at a D (potential for harm/isolated) based upon the following example and the residents at risk for pressure injuries residing in the facility. -R77 did not have heels offloaded for 2 days of survey. Findings include: 1.) R58 admitted to the facility on [DATE] and has diagnoses that include chronic respiratory failure, ventilator status, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, osteomyelitis of vertebra, sacral and sacrococcygeal region, severe protein-calorie malnutrition, intracranial hemorrhage, vascular dementia, and atherosclerotic heart disease. R58's Quarterly Minimum Data Sets (MDS) dated [DATE] and 1/25/23 indicate R58 requires extensive assist of two staff for bed mobility. R58 is at risk for pressure injuries having unhealed pressure injuries. R58's Quarterly Minimum Data Set, dated [DATE] documents bed mobility as total dependence 1 person assist. Functional Limitation in Range of Motion impairment 1 side left upper and left lower extremity. The MDS indicates R58 is at risk for pressure injuries with unhealed pressure injuries. Surveyor noted for all MDS assessments there is no indication of a turning and repositioning program for R58 despite risk for pressure injuries, range of motion impairment and total dependence for bed mobility. R58's Braden Scale for Predicting Pressure Ulcer Risk, dated 12/1/22 documented a score of 10, indicating R58 is at High Risk. R58's Brief Interview for Mental status score dated 3/12/23 was 00 - indicating severe cognitive impairment R58's care plan documents: (Resident) is at risk for further impaired skin integrity r/t (related to) impaired mobility, impaired cognition, history of pressure injuries, and incontinence - Date Initiated 7/15/22. Interventions include: - Apply house moisturizing lotion as needed to keep skin hydrated. Avoid applying between toes and other moist areas. - Nursing will assess skin upon admission, weekly on day of scheduled shower, PRN (as needed), and with any change in condition. Any abnormalities will be documented in chart and reported to primary physician and Wound Care Team for follow up. - Offload resident to reduce direct pressure on bony prominences. Utilize heel boots and/or pillows to keep heels floated as resident allows. Monitor offloading devices with each encounter to ensure proper positioning. Avoid positioning devices directly over wounds/bony prominences. - Provide resident assistance with repositioning every 2-3 hours when in bed. Avoid positioning resident on back when possible. Utilize draw sheet when available for repositioning to reduce risk of friction/shear. Verify residents' body is free from contact with environmental hazards (not pressing into side rails or foot board, not laying on tubes, etc.). - Support surfaces for pressure reduction: standard pressure reduction mattress. Evaluate for effectiveness/proper function with each resident encounter. R58's care plan documents: (Resident) has impaired skin integrity, as evidenced by stage 3 (previously unstageable) pressure injury to right knee, acquired at facility 1/4 - Date Initiated 1/4/23, revised 4/10/23. Interventions include: - Nursing to monitor dressing integrity with each resident encounter and replace dressing if soiled/loose/missing. Dressing location: right knee - Staff to ensure pillow between legs when repositioning. - Wound assessment/measurement performed weekly/PRN by Wound Care Team. If resident is unavailable, assessment will be completed at earliest availability. - Wound care treatment to be performed by Wound Care Team/Nursing as ordered by MD/NP (Medical Doctor/Nurse Practitioner). R58's care plan documents: (Resident) has impaired skin integrity, as evidenced by unstageable pressure injury to right elbow (lateral), present on return from LOA (Leave of Absence) 3/6 - initiated 3/7/2023 (Resident) has impaired skin integrity, as evidenced by unstageable pressure injury to right elbow, acquired at facility 1/13. Now 2 separate areas upon return from LOA (leave of absence) 3/6, site is now right elbow (medial). On 5/5, 2 elbow wounds communicate as slough breaking down (anticipated) and will be followed as 1 - Date Initiated 1/13/23, revised 5/16/23. Interventions include: - Nursing to monitor dressing integrity with each resident encounter and replace dressing if soiled/loose/missing. Dressing location: right elbow - Resident's arms to be elevated on pillows with repositioning - Sharps debridement to be performed as needed by [named clinic] NP (Nurse Practitioner) for wound bed preparation. - Wound assessment/measurement performed weekly/PRN by Wound Care Team. If resident is unavailable, assessment will be completed at earliest availability. Record review of R58's pressure injuries: Current stage 4 pressure injury to coccyx present on admission. Current stage 3 pressure injury right knee. Current stage 4 pressure injury right elbow. Previous SDTI (Suspected Deep Tissue Injury) right elbow - resolved 10/21/22. Previous left ear stage 4 pressure injury - resolved 4/28/23. The facility Skin Observation Tool completed by floor nurses on 12/29/22 and 1/12/23 had nothing marked under the body sites. Surveyor was advised the WCT (wound care team) weekly wound care assessments and measurements are documented on the Skin Only Evaluation form. R58's Skin Only Evaluation form, dated 1/4/23 documents: Right knee, unstageable 1.5 cm (centimeters) x 1.4 x 0.1 necrotic. Resident seen by Wound Care Team for scheduled treatments and head to toe skin check. New unstageable pressure injury noted to right medial knee. Root cause is immobility, heavy perspiration, and pressure from left knee. Pillow to be placed between knees at all times. Surveyor noted although R58's prior care plan included intervention to offload resident to reduce direct pressure on bony prominence's/monitor offloading devices with each encounter to ensure proper positioning, the specific care plan intervention of pillow between knees was not implemented until after the pressure injury was identified. The facility root cause of the pressure injury included heavy perspiration however, there were no care plan revisions related to R58's heavy perspiration. R58's Skin Only Evaluation form, dated 1/13/23 documents: Right elbow, unstageable 2 x 1.7 x 0.1 slough. Resident seen by Wound Care Team for weekly assessment. New superficial unstageable pressure injury to right elbow. Root cause is increased moisture from perspiration and UE (upper extremity) edema. Arms to be elevated on pillows and tx (treatment) order received. Surveyor noted R58's prior care plan included intervention to offload resident to reduce direct pressure on bony prominences/monitor offloading devices with each encounter to ensure proper positioning. The facility was aware R58 had a previous SDTI to the right elbow in October 2022, however the specific care plan intervention to elevate arms on pillows was not implemented until another pressure injury developed on the right elbow. In addition, the facility identified the root cause of the pressure injury to be from increased moisture from perspiration and upper extremity edema however, there were no care plan revisions related to moisture, perspiration, or edema. Weekly wound assessments and measurements were completed by the WCT weekly. Treatments were changed accordingly. R58's Skin Only Evaluation form, dated 3/3/23 documents: Right knee 1.9 x 2.1 x 0.2 slough, unstageable Right elbow 1.2 x 3.3 x 0.1 slough, unstageable Resident seen by Wound Care Team for weekly assessment. All wounds showing slight improvement. Eschar to right elbow & right knee unstable - debrided by NP and hydrofera blue added to right knee tx (treatment). R58's Skin Only Evaluation form, dated 3/7/23 (readmit from hospital) documents: Right knee 2.2 x 2.2 x 0.1 slough, unstageable R (right) elbow medial 1.2 x 0.8 x 0.1 slough, unstageable R elbow lateral 1.4 x 1.1 x 0.1 slough, unstageable Resident seen by Wound Care Team for skin assessment upon return from LOA (leave of absence-hospitalization). Skin remains impaired, evidenced by stage 4 pressure injuries to coccyx & left ear, and unstageable pressure injuries to right elbow (medial/lateral), right 1st finger, and right knee, all present on re-admission. Surveyor noted the facility Skin Only Evaluation on 4/7/23 documented the right knee pressure injury was assessed to be a stage 3 pressure injury (full thickness skin loss with granulation tissue present) from prior assessments as an unstageable pressure injury. Measurements were 2.2 x 2.4 x 0.1. R58's Skin Only Evaluation form, dated 5/5/23 documents: Right knee 1.9 x 1.7 x 0.1, granulation Right elbow 1.8 x 3.1 x 0.3, slough Resident seen by Wound Care Team for weekly assessment. All wounds appear stable. Right elbow wounds now communicate d/t (due to) autolytic debridement of slough (anticipated) and will be followed as 1 wound. New tx order received. Surveyor noted the facility Skin Only Evaluation on 5/12/23 documented the right elbow was changed to a stage 4 pressure injury (full thickness tissue loss from prior unstageable assessments.) Surveyor noted despite the decline in the condition of the elbow pressure injury, the facility made no changes to the care plan to prevent worsening or to promote healing of the pressure injury. R58's Skin Only Evaluation form, dated 5/19/23 documents: Right knee stage 3, 1.9 x 1.5 x 0.1 Right elbow stage 4, 2.7 x 3 x 0.4 Weekly assessment completed by Wound Care Team. Right elbow wound larger with more bone exposed. No visible signs of infection- NP ordered xray to r/o (rule out) osteo (osteomyelitis). All remaining wounds improved. See Wound NPs visit note for further assessment details. WCT will continue to follow. Nursing to notify WCT of any new concern or change in skin condition. R58's Radiology report dated 5/22/23 documented: No radiographic evidence of osteomyelitis seen. R58's Skin Only Evaluation form, dated 5/26/23 documents: Right knee, stage 3, 2 x 2 x 0.1, slough Right elbow, stage 4, 2.7 x 3.6 x 0.3, slough Resident seen by Wound Care Team for weekly assessment. Right elbow is stable - undermining present d/t (due to) autolytic debridement of slough. Coccyx improving and right knee stable. No signs indicating possible infection noted. Braden score 9. Risk factors remain unchanged and include: Age, s/p (status post) ICH (intracranial hemorrhage) with left hemiplegia/hemiparesis, seizures, vascular dementia, ventilator dependence, immobility, contractures, incontinence, and pain. Interventions in place and include: every 2 hour turning/repositioning (dependent), offloading with pillows, heel boots as resident tolerates, alternating pressure mattress, pain management, incontinence cares, and weekly skin assessment by nursing. Resident does not appear receptive to any education at this time. WCT will continue to follow. Nursing to notify WCT of any new concern or change in skin condition. R58's Skin Only Evaluation, dated 6/2/23 documents: Right knee 2.2 x 1.9 x 0.1, slough Right elbow 2.5 x 3.3 x 0.3, slough On 5/30/23, at 9:54 AM, Surveyor observed R58 lying in bed on his back. Surveyor noted R58 to be on an air mattress and wearing Prevalon boots on both feet. R58's left arm was elevated on a pillow and his right arm was lying directly on the bed next to the residents' body. R58's right knee was bent and resting directly on his left knee with no pillow or offloading device to prevent pressure from bone on bone of the knees. Surveyor observed R58's right elbow wrapped with Kerlix dated 5/26 with the initials WCT. Surveyor observed a pink foam dressing on his right medial knee dated 5/26 with initials WCT. Surveyor observed the knee dressing had drainage shadowing 75% of the dressing. Surveyor noted R58 had not had a dressing change to these areas in 4 days despite stage of wounds and physician orders to complete treatments/dressing changes every Monday Wednesday and Friday and as needed. The facility did not complete treatments and dressing changes on Monday 5/29 as ordered. On 5/30/23, at 12:10 PM, Surveyor observed a facility Respiratory Therapist (RT) standing next to R58's bed for a few seconds before she left the room. Surveyor observed R58 to be in the same position as previously observed: Lying in bed on his back, left arm on pillow, right arm remains on bed next to body. Right knee bent and resting directly on the left knee with no pillow to prevent pressure of knees. Same Kerlix dressing on right elbow dated 5/26, same dressing on right knee dated 5/26. Although R58's care plan interventions include a pillow between legs and pillows under arms, R58 did not have these interventions in place and the RT did not reposition or ensure the interventions were in place before leaving the room. On 5/30/23, at 1:59 PM, Surveyor observed R58 to be in the same position as previously observed: Lying in bed on his back, left arm on pillow, right arm remains on bed next to body. Right knee bent and resting directly on the left knee with no pillow to prevent pressure of knees. Same Kerlix dressing on right elbow dated 5/26, same dressing on right knee dated 5/26. On 5/30/23, at 2:13 PM, Surveyor observed R58 to be in the same position as previously observed: Lying in bed on his back, left arm on pillow, right arm remains on bed next to body. Right knee bent and resting directly on the left knee with no pillow or offloading device to prevent bone on bone pressure of knees. Same Kerlix dressing on right elbow dated 5/26, same dressing on right knee dated 5/26. Review of R58's May 2023 Treatment Administration Record documents: Cleanse coccyx wound with Puracyn, apply collagen particles, gently pack with opticell, cover with super absorbent, and secure with bordered foam dressing. Change MWF (Monday, Wednesday, Friday) and PRN. One time a day every Mon, Wed, Fri. Cleanse right elbow wound with Puracyn, apply Anacept gel to wound bed, place oil emulsion over exposed bone, then cover with hydrofera blue foam, followed by super absorbent, and secure with bordered foam dressing and light kerlix. Change MWF and PRN. One time a day every Mon, Wed, Fri Cleanse right knee wound with Puracyn, apply collagen powder, cover with oil emulsion, followed by bordered foam dressing. Change MWF and PRN. One time a day every Mon, Wed, Fri. Surveyor noted the above treatments were not signed out as having been completed on Monday, 5/29/23. On 5/31/23, at 7:42 AM, Surveyor observed R58 lying in bed on his back, wearing Prevalon boots on both feet, a pillow between his knees and under his right arm, his left arm was resting on the bed. Surveyor noted a new Kerlix dressing on the right elbow and new pink foam dressing on the right knee, both dated 5/31 with initials WCT. On 5/31/23, at 9:32 AM, Surveyor observed R58 to be in the same position as previously observed: Lying in bed on his back, wearing Prevalon boots on both feet, pillow between knees and under right arm, left arm resting on the bed. On 5/31/23, at 11:13 AM, Surveyor observed R58 to be in the same position as previously observed: Lying in bed on his back, wearing Prevalon boots on both feet, pillow between knees and under right arm, left arm resting on the bed. Surveyor noted R58 continues to have a pressure injury to the coccyx that is not being offloaded On 5/31/23, at 11:30 AM, Surveyor observed R58's room door was closed. On 5/31/23, at 12:30 PM, Surveyor observed R58 lying on his back, slightly turned to left side, wearing a new gown. His right arm was elevated on a pillow, left arm was on the bed. Prevalon boots on both feet. Surveyor noted there was no pillow between his knees to prevent bone on bone pressure. R58's right knee was bent and resting directly on the left knee. On 5/31/23, at 12:51 PM, Surveyor spoke with facility Wound Care Nurse (WCN)-K to discuss R58's pressure injuries. Surveyor asked how she thought the right knee pressure injury developed. WCN-K stated: From knee-on-knee pressure and probably moisture from sweating. Surveyor asked how she thought the right elbow pressure injury developed. WCN-K stated: The same, from pressure and sweating, and also he gets increased edema in that arm when positioned on that side. Surveyor reviewed the care plan interventions of a pillow between the knees and pillow under arms were implemented after the pressure injuries was identified. Surveyor asked why a pillow was not utilized prior to the development of the pressure injuries? WCN-K stated: I can't say if one was used or not, I know it is now. Surveyor advised WCN-K of observations on 5/30/23 - no pillow between knees, with the knees resting directly on each other, right arm lying on bed/not offloaded, no change of position for greater than 4 hours. Surveyor asked how often R58 should be repositioned. WCN-K stated: Well anyone at risk we say every 2-3 hours, but for him, because he has wounds, he should be repositioned at least every 2 hours minimum. We have educated and told them (referring to aides and nurses) many, many times about repositioning, and that just because they're on an air mattress, they still have to be repositioned at least every 2 hours. WCN-K reported the wound care team does all treatments Monday through Friday, and nurses are responsible for doing treatments on weekends, holidays or if the dressing falls off. Surveyor advised WCN-K of observation on 5/30/23 of right elbow and right knee dressings dated 5/26. WCN-K stated: Apparently the treatment wasn't done on Monday (5/29). WCN-K reported she did the dressings this morning (5/31) and thought the wounds looked better. She reported decreasing the treatments to twice weekly dressing changes. Surveyor asked what time she did the treatment this morning. WCN-K stated: We usually try to get scheduled treatments done early. He was done probably between 6-6:30 AM. Surveyor advised WCN-K of observation R58 in same position from 7:42 AM - 11:13 AM. WCN-K stated: My guess is he's still in the same position as I left him this morning. On 5/31/23, at 3:10 PM, Surveyor advised Nursing Home Administrator (NHA)-A and Director of Nursing (DON)-B of observations and concern related to R58 lack of repositioning, not having care plan interventions in place and treatment not completed as scheduled. On 6/1/23, at 11:28 AM, Surveyor spoke with NHA-A and DON-B. Surveyor asked who was responsible for skin checks in between weekly WCN assessments. DON-B reported the floor nurses and nurse managers can assist with skin checks. DON-B reported the expectation is the nurse generally looks for new issues and does not document existing issues. Surveyor asked if the facility would expect Certified Nursing Assistants (CNA) to do skin checks. DON-B reported shower sheets have an area to address skin, and CNAs should document any concerns, sign and give to the floor nurse who also signs, then give to Nurse Manager to review before they are scanned in (to the electronic medical record). Surveyor asked what the facility policy for overall assessment and monitoring of residents' skin is. DON-B reported a skin assessment is done on shower days, But everyone is of course looking at residents' skin when providing cares or turning/repositioning, essentially we are always assessing skin in a sense. If the aides find any areas concerning, they are to notify the nurse immediately. Surveyor was advised the facility identified the root cause of R58's elbow and knee pressure injuries to be from perspiration and/or edema and noted there were no care plan revisions related to the identified root cause. DON-B reported she would have to look. On 6/5/23, at 8:19 AM, Surveyor met with Medical Doctor (MD)-L with VP-F present. MD-L stated: As far as the moisture, we wouldn't want to pad or cover the area for protection - that would cause increase moisture. We would want to just offload bony prominences. Caring for the moisture and sweating would just fall under normal cares, keeping him clean and dry - we wouldn't specifically care plan this, it would be done with cares. Surveyor advised the facility root cause of the pressure injuries listed perspiration, heavy sweating, and moisture, yet there was no evidence of interventions to address this issue. MD-L stated: That's because it's not something we would normally care plan. It would fall under normal cares for the resident. On 6/5/23 the facility provided a statement written by MD-L regarding R58's pressure injuries and R58's comorbidities. MD-L indicates in this statement the most appropriate management for this patient to reduce risk of developing or worsening wounds is appropriate nutrition, air mattress, frequent turning/positioning and off-loading, and management of microclimate. MD-L goes on to indicate R58 is currently on a turning schedule and every 2-4 hours is appropriate. Surveyor noted this is not consistent with the wound practitioners' recommendations and is potentially an even greater amount of time for R58 to not be repositioned. Surveyor also noted if frequent repositioning is important for R58 this area was not individually assessed or implemented as an individualized intervention based upon assessment as the MDS did not assess or indicate a turning/repositioning program for R58 as part of the assessment. MD-L also indicates to manage R58's microclimate, no further or additional measures are recommended other than frequent turning and regular cares to keep skin dry. Surveyor noted with each facility skin only assessment the facility did not assess the surrounding skin tissue to determine if skin was impacted by the microclimate. Surveyor also noted there is no indication the facility assessed for moisture reducing bedding or hospital gowns, room temperature, etc. to alleviate moisture and perspiration. The facility's failure to treat and implement care plan interventions to prevent new pressure injuries created a finding of immediate jeopardy that began on 1/13/23. The Immediate Jeopardy was removed on 6/2/23 when the facility implemented the following: -R58 was immediately evaluated by the wound nurse and all ordered pressure relieving devices immediately put into place and a pain evaluation was competed. -Rounds were completed on all residents to ensure treatments have been completed per physician orders and all orders for pressure relieving devices were in place, and all residents have been turned and repositioned -A Braden assessment was completed on all Residents -All Residents identified to be at high risk for skin breakdown were reviewed to ensure appropriate preventative skin breakdown measure are in place. -Care plans were reviewed for all Resident at risk for skin breakdown or with actual skin breakdown to ensure appropriate interventions were in place. -An ad hoc QAPI meeting was held to review the Immediate Jeopardy removal plan. -Education was given to the Director of Nursing, nursing administration, Nursing Home Administrator, Assistant Administrator, and all managers on the facility policy and procedure on Pressure Ulcer Prevention and standards of practice for treatment and turning and repositioning with a follow up posttest. -Education was provided to all licensed nurses on the standards of practice related to following physician orders for treatments, ensuring residents plan of care is followed, resident turning and repositioning and pressure ulcer prevention policy and procedure. -Education was provided to all licensed nurses on how to appropriately complete weekly skin observations, identify new area with a posttest completed. -Education initiated for all Certified Nursing Assistance related to the facility policy and procedure for Pressure Ulcer Prevention, standards for practice for turning and repositioning, following resident [NAME] to ensure preventive skin interventions are in place, and identification of any skin area noted and reporting to their nurse with a posttest required. -A Performance Improvement Tool was developed to monitor compliance with following physician orders, ensuring turning and repositioning is completed, and preventative devices are in place. -Nursing administration team will review weekly skin observations and the results will be forwarded to QAPI committee for review. -Department managers that participate in daily Angel Care rounds will monitor repositioning, ensuring pressure relieving devices are in place and visible dressings are clean, dry, and dated appropriately, during rounds. The deficient practice continues at a D (potential for harm/isolated) based upon the following example for R77 and the residents at risk for pressure injuries residing in the facility. 2.) R77 was admitted to the facility on [DATE] with diagnosis that included Aphasia, and Schizophrenia. R77 was admitted to the facility with a stage 3 pressure injury which had healed at the time of the survey. R77's Quarterly Minimum Data Set (MDS) dated [DATE] was reviewed and indicated R77 was at risk for developing pressure injuries. R77's Brief interview for Mental Status was a score of 0, indicating she has a severe cognitive deficit. On 6/1/23 R77's Braden Scale for Predicting pressure Ulcer Risk dated 5/24/23 was reviewed and indicated R77 scored a 9 (very high risk). On 5/30/23 R77 was observed in bed at 10:30 AM, 12:30 PM and 2:15 PM. R77's heels were observed to be directly on the mattress and no device to elevate her heels was observed in her bed. In R77's closet a pair of pressure relief boots were observed on the floor of the closet. R77's heels were observed to be free from redness or pressure injuries. On 5/31/23 R77 was observed in bed at 8:30 AM, 10:30 AM and 2:00 PM. R77's heels were observed to be directly on the mattress and no device to elevate her heels was observed in her bed. In R77's closet a pair of pressure relief boots were observed on the floor of the closet. R77's heels were observed to be free from redness or pressure injuries. On 5/31/23 R77's current care plan titled Risk for impaired skin integrity related to limited mobility, incontinence and altered nutrition with a start date of 4/21/22. Interventions for R77 included: Offload resident to reduce direct pressure on bony prominence's. Utilize pillows to keep heels floated when possible start date 4/21/22. On 6/1/23 at 1:14 PM Director of Nurses-B was interviewed and indicated that R77 should have her heels offloaded while in bed. The above findings were shared with the Administrator -A and Director of Nurses-B at the daily exit meeting on 6/1/23 at 3:00 PM. Additional information was requested if available. None was provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to protect the resident's right (R9's right) to be free from sexual abuse by R10 of 6 sampled residents reviewed. On 3/5/23 R10 was observed in R9's room, while R9 was sleeping and partially disrobed. R10 was observed to be standing next to R9's bed and watching her sleep. Licensed Practical Nurse (LPN) K wrote a nurses note of her observation and reported her concerns that R10 should not be in R9 room and questioned why was R10 watching R9 sleeping. LPN K told LPN J her concerns and LPN J, who was also concerned with R10's behavior, told LPN K to report it to the supervisor. LPN K reported this concern to RN Supervisor I. Certified Nursing Assistant (CNA) N, who also observed R10 in R9's room while R9 was sleeping was concerned with R10's behavior. RN Supervisor I stated she didn't find the behavior unusual and stated she couldn't prevent R10 from walking around the facility, RN Supervisor I did not report this incident to administration. The facility did not investigate this further to determine why R10 was on the second floor of the facility and in R9's room while R9 was sleeping. R10 resides on the 1st floor of the facility. On 3/26/23 R10 was observed to be sucking on R9's breast, in the activity room. The facility separated the residents and placed R10 on 15-minute checks. The facility investigation revealed R9 expressed she did not like R10's sexual behavior and did not want it to occur again. The facility investigation also revealed the police were not called until 3/27/23. The facility's failure to investigate the 3/5/23 incident to understand what happened on 3/5/23 when 3 staff expressed concern about the incident lead to a failure to potentially safeguard R9 and assess possible need for increased supervision of R10. The facility did not further assess to determine why R10 was in R9's room while she was sleeping and partially undressed. During the Survey, facility administration insisted R9 and R10 were friends and nothing unusual happed on 3/5/23 despite the facility not completing a thorough investigation or a root cause analysis into the incident. The facility did not further assess R9 or R10 following the 3/5/23 incident to determine their ability to consent or understand relationships or sexual relations despite the facility insisting they were friends. The facility did not keep R9 safe from sexual abuse on 3/26/23 when R10 engaged in sucking on R9's breast in the activity room. This created a finding of immediate jeopardy that began on 3/26/23. Surveyor notified NHA (nursing home administrator) A of the immediate jeopardy on 4/12/23 at 11:45 p.m. The immediate jeopardy was removed on 4/14/23. However, the deficient practice continues at a scope/severity of (scope/severity) E (potential for harm/pattern) as the facility continues to implement its action plan. Findings include: The facility's policy Protection of Residents during Abuse Investigations dated September 2022 indicates: Sexual Abuse 1. Sexual abuse is non-consensual sexual conduct of any type with a resident. Sexual abuse includes, but is not limited to: a. Unwanted intimate touching of any kind especially of breasts or perineal area; b. All types of sexual assault or battery, such as rape, sodomy, and coerced nudity; c. Forced observation of masturbation and/or pornography; and d. Taking sexually explicit photographs and/or audio/video recordings of a resident(s) and maintaining and/or distributing them (e.g posting on social media). This would include, but is not limited to, nudity, fondling, and/or intercourse involving a resident. 2. Generally, sexual contact is nonconsensual if: a. The resident appears to want the contact to occur, but lacks the cognitive ability to consent; b. The resident does not want the contact to occur; c. The resident is sedated, is temporarily unconscious, or is in a coma; or d. Consent is obtained through intimidation, coercion or fear, whether it is expressed by the resident or suspected by staff. 3. Any forced, coerced or extorted sexual activity with a resident, regardless of the existence of a pre-existing or current sexual relationship, is considered to be sexual abuse. 4. Residents have the right to engage in consensual sexual activity. However, anytime there is a reason to suspect that a resident may not have the capacity to consent to sexual activity, the facility will take steps to ensure that the resident is protected from abuse, including evaluation whether the resident has the capacity to consent to sexual activity. R9 was admitted to the facility on [DATE] with diagnoses of bipolar, CVA (cerebral vascular accident) dysphagia, aphasia and type 2 diabetes. R9 has a legal guardian appointed. R9's quarterly MDS (minimum data set) dated 2/22/23 indicate a BIMS (brief interview for mental status) score of 10, which indicates moderate cognitive impairment. It also indicates R9 needs extensive assistance with bed mobility, dressing and hygiene. R10 was admitted to the facility on [DATE] with diagnoses of incomplete quadriplegia, type 2 diabetes and alcohol abuse. R10 was his own decision maker. R10's significant change MDS dated [DATE] indicate R10 has a BIMS score of 15, which indicates R10 is cognitively intact. It also indicates R10 needed limited assistance with walking and bed mobility and needed supervision with dressing and hygiene. On 4/10/23, at 9:12 a.m., Surveyor observed R9 in her room dressed and in her Broda chair. R9 was not receptive to Surveyor attempts to speak to R9 and Surveyor was unable to understand R9. Surveyor observed on 4/10/23, R9's room is located down a long hallway and around the corner. R9's room is across from the activity/dining room for the 2nd floor. R9 resides in a room without a roommate. R10 resides on the first floor. Review of a nurse's note dated 3/5/23, 14:50 (2:50 PM) indicates R10 was observed, in R9's room, standing with his walker next to R9's bed, while R9 was sleeping in bed. The nurse's note indicates R9 had a sheet over her with gown partly off due to BM (bowel movement) being present on gown and R9 had a brief on. The note continues to indicate that R10 was told to leave the room and that R10 should not be in R9's room. R10 apologized and left the room. The nurses note indicates the supervisor was made aware. The nurse's note dated 3/26/23 indicates CNA H observed R9 and R10 in the dining room. CNA H indicated he observed R9 with her shirt up and R10 sucking on R9's breast. Surveyor reviewed the facility investigation into this sexual incident. The facility investigation dated 3/26/23 indicates on Sunday, March 26th, after the activity (word list) was completed in the [NAME] activity room on the 2nd floor (CNA H) during his rounds around 2:45 pm, found R9 and R10 in the [NAME] activity room on the second floor. CNA H stated as he walked in (R9's 2nd floor room), R9 was not in her room. CNA H began to look for R9 and later found her in the activity room on the second floor with R10. CNA H stated he saw R9 holding up her shirt and R10 was being inappropriate with R9, precisely sucking her breast. R9 saw CNA H and CNA H indicated R9 was smiling; CNA H stopped them and notified the nurse. The investigation indicates R9 and R10 were separated and R9 was moved to her room. The investigation indicates no other residents were in the activity room at the time. The investigation indicates R10 was placed on 15-minute checks immediately after the incident. The investigation indicates the police were not immediately called but were called the following day on 3/27/23. (Cross-reference F609). The medical record indicates R10 was taken by the police on 3/27/23 and released from jail on 3/31/23. The medical record indicates R10 was not allowed back to the facility. The facility conducted skin checks on all non interviewable residents and other residents were interviewed to determine if anyone else was harmed. Medical Director M was in the facility, on 3/26/23, at the time of the incident. Medical Director M's progress note dated 3/26/23 indicates she evaluated R9 shortly after the incident with R10. Medical Director M's note indicates R9 stated R10 was sucking on her breast and denies R10 touched any other part of her body. The note indicates R9 told Medical Director M that R9 did not like or want it and admits R9 did not ask R10 to stop. R9 stated she did not want it to occur again and did not want to see R10 again. The note indicates R9 denies feeling unsafe or afraid but did admit to feeling anxious, but it is unclear if R9 was anxious about the situation or the questions/conversations. R9 also indicated this had not happened prior. Medical Director M's examination revealed no bruising or physical trauma noted. Medical Director M's note also indicates R9 was able to recall the events consistently, but it is unclear at this time if she can consent to sexual activities as she may not fully comprehend the consequences of her actions. Interview with R10 indicates R10 denied sucking R9's breast and was just helping her pull her shirt down. On 4/11/23, at 10:45 a.m., Surveyor interviewed Social Service Director (SSD) L. Surveyor asked SSD L if an assessment was completed for R9 and/or R10 regarding their ability to consent to a sexual relationship prior to the 3/26/23 incident. SSD L stated an assessment for consent was not completed. SSD L stated she completed a BIMS on R9 after the 3/26/23 incident and R9 scored 13 (cognitively intact). SSD L stated not everyone knows how to communicate with R9 and they need to take their time when communicating with R9. SSD L stated she communicated with R9 after the incident and R9 indicated she was fine and had no trauma as a result of the 3/26/23 incident. The facility completed interviews with staff regarding R10's behavior. CNA N's statement dated 3/29/23 indicates: Question: Did you ever see resident go into anyone's room? CNA N answer: Caught him 2 weekends ago standing over (R9) on AM shift and she was sleeping. He didn't touch her just looking at her. Told (LPN K). After that next day (R10) came back up there and (CNA N) told him to go back downstairs. When aide addressed him, he (R10) acted like he couldn't speak English and went back downstairs. After that saw him in the hallway but not in anyone's room. Question: Have you ever heard of the resident talking or being inappropriate with staff or residents? CNA N answer: No Question: Do you have any concerns with this resident? CNA N answer: Absolutely Resident (R10) shouldn't be upstairs and he shouldn't be up there with her (R9) On 4/11/23, at 12:30 p.m., Surveyor interviewed CNA N regarding his 3/29/23 statement. Surveyor asked CNA N if he was concerned when he found R10 standing over R9's bed. CNA N stated he was concerned because R9 was sleeping and often disrobes/undresses so R10 had no business in R9's room. CNA N stated even after being caught standing over R9 while she was sleeping, R10 would sneak upstairs. Surveyor asked CNA N if R10 had friends upstairs. CNA N stated R10 did not have any friends but would sometimes hang out with a male resident from the 2nd floor. The male resident resided on the other side of the building far from R9's room. CNA N stated there was no reason for R10 to be near R9. Surveyor asked CNA N if he told anyone about his observation of R10 and CNA N stated he told LPN K. The facility did not obtain an interview with LPN K regarding R10's behavior. On 4/11/23, at 12:45 p.m., Surveyor interviewed LPN K. Surveyor asked LPN K if she remembers the incident where CNA N told her that R10 was observed standing over R9 while she was in bed. LPN K stated she doesn't remember CNA N speaking to her but remembers around March 5th, LPN K's own observation of R10 standing over R9 while she was in bed sleeping. LPN K stated R10 usually was found eating lunch on the 2nd floor dining room or just hanging out in the dining room. LPN K stated she didn't think anything of R10 being upstairs on occasion until she observed him in R9's room. LPN K stated when she observed him in R9's room she told R10 he needed to leave the room and that he shouldn't be in R9's room. LPN K stated after finding R10 in R9's room she kept a closer eye on R10 if he was on the 2nd floor. LPN K stated this incident created a red flag regarding R10's behavior. LPN K stated she told RN Supervisor I of her concerns immediately. The facility obtained LPN J's statement on 3/30/23 regarding R10's behavior Question: Did you ever see resident go into anyone's room? LPN J answer: Yes .knew from (name of staff LPN K), then I started watching him closer. Stays in dining room north hall Question: Have you ever heard of the resident talking or being inappropriate with staff or residents? LPN J answer: No Question: Do you have any concerns with this resident? Yes, he spent extended time down that hallway. I assumed everyone knew what was going on.It's creepy to me because why does he keep going down there especially with her (R9) taking off her clothes coming in the hallway like she does all the time. On 4/11/23 at 2:15 p.m. Surveyor interviewed LPN J. LPN J stated LPN K told her that she found R10 in R9's room just standing over R9 while she was sleeping. LPN J stated she told LPN K that she needs to report that to the supervisor. LPN J stated she works on the other hall (hall opposite R9's hallway) but when she heard about R10 being in R9's room, she paid more attention to him. LPN J stated R9 isn't in her right mind and is known to masturbate and disrobe so R10 doesn't need to be down the hallway R9 resides. The facility interviewed RN Supervisor I on 3/29/23 regarding R10's behavior Question: Did you ever see resident go into anyone's room? RN Supervisor I answer: No Question: Have you ever heard of the resident talking or being inappropriate with staff or residents? RN Supervisor I answer: No Question: Do you have any concerns with this resident? RN Supervisor I answer: No On 4/12/23, at 8:10 a.m. Surveyor interviewed RN Supervisor I. Surveyor asked RN Supervisor I if she remembers the sexual incident with R9 and R10 on 3/26/23. RN Supervisor I stated she didn't hear about this incident. Surveyor asked RN Supervisor I does she remember LPN K telling RN Supervisor I her concerns regarding observing R10 standing beside R9's bed while R9 was sleeping. RN Supervisor I stated she remembers that conversation. RN Supervisor I stated she felt it was harmless and felt LPN K just didn't want R10 up on the 2nd floor. RN Supervisor I stated R10 walks all over the facility and had no concerns with R10. Surveyor reviewed R10's care plan and it does not indicate any increase supervision after the 3/5/23 observation. The facility does not have any investigation or root cause analysis related to the 3/5/23 observations of R10 in R9's room. Surveyor reviewed R9's care plan and it does not indicate R9 tends to disrobe/remove clothes and masturbates. The care plan does not indicate any privacy or safety measures have been put in place because R9 disrobes and masturbates. On 4/11/23, at 2:30 p.m. during the daily exit meeting with Director of Nursing (DON) B, Nursing Home Administrator (NHA) A and VP of Operations D, Surveyor explained the concern that on 3/5/23 R10 was observed in R9's room and the three staff involved (CNA N, LPN K and LPN J) were concerned about R10's behavior. There is no evidence this incident was investigated, there was no facility self-report and there was no increase in supervision for R10, in turn R10 was able to roam the 2nd floor and sexually assault R9 on 3/26/23. Surveyor also explained the concern the police were not called immediately, and this self-report was not reported to the state agency within 2 hours of the discovery. Surveyor also explained there is no evidence R9 and R10 had an assessment regarding the ability to consent to a sexual relationship. R9 did not have a trauma history assessment performed prior to the incident or after the incident. (Cross-reference F745). VP of Operations D stated in their opinion R9 and R10 were friends and so an assessment to consent to a sexual relationship was not needed. Surveyor asked for evidence of this friendship. Surveyor explained the interviews conducted with staff indicate there was no friendship between R9 and R10. VP of Operations D indicated R9 was seen smiling during the incident, implying it was consensual. Surveyor explained R9 told Medical Director M that she did not like or want the interaction with R10 and did not want to see R10 again. VP of Operations D continued to indicate R10 was just a friendly guy and had many friends including R9 without providing or sharing any evidence of these friendships. VP of Operations D indicated she didn't feel the 3/26/23 incident was abuse because R9 had a smile on her face when found and VP of Operations D stated R9 didn't say no despite having no knowledge of what led up to R10 engaging a sexual event with R9. VP of Operations D stated that no staff indicated through interviews that they were concerned with R10's behavior on 3/5/23 when R10 was found in R9's room. Surveyor explained the facility interviews indicate LPN J and CNA N had concerns with R10's behavior when interviewed by the facility and no follow up/investigation into the documented concerns was noted. Surveyor also explained LPN K was not interviewed by the facility but indicated when interviewed by Surveyor she was concerned by R10's behavior and even wrote a nurses note indicating her concern. VP of Operations D continued to reiterate R9 and R10 were friends and it was not strange for R10 to be standing beside R9, while R9 was in bed sleeping. VP of Operations D indicated R10 probably was checking R9 to see if she was awake. VP of Operations D reiterated she did not feel any of this was abuse. Surveyor reviewed the police report dated 3/27/23. The police report indicates on 3/27/23, the police officer attempted to speak with R9. It indicates R9 was unable to communicate with me and was only able to making (sic) grunting noises. The police report indicates they spoke with R10. R10 told the police he did not have any specific friends or people that he's met in the past 10 months he was at the facility. R10 told the police he likes to go to the activities room upstairs to play games. The police report indicates R9 was initially reported to be nonverbal and non-communicative due to a stroke she previously suffered. She is also diagnosed with bipolar disorder, altered mental status and disruptive mood dysregulation disorder. Due to (R9's) medical and mental health conditions, it was believed she was in a position where she could not give consent for sexual contact. The police report indicates R10 admitted he does not know R9 well and only knows her from attending several activities together. Activities sometimes happen four days a week, but R9 does not attend them all. R10 admitted he does see R9 on a weekly basis and sometimes more than once a week. The statement from R10 to the police officer indicated R10 stated he knows (R9) as she goes to activities a lot and her room is next to activities. (R10) stated he believed her name is (R9's name). R10 was asked if he has ever talked to her before and he responded she cannot talk. R10 stated he was just in the room and wasn't doing anything else. The report continues to indicate: Police Officer V asked (R10) if something took place between him and the female that would make people think that something happened between him and the (R9) and he responded no. R10 stated they were just talking and that sometimes she sits next to him but she cannot talk and sits in a wheelchair. The detective's (Detective W's) narrative on 3/27/23 indicates (Detective W) asked (R10) if ever (sic) has any conversations with (R9). (R10) replied, she cannot talk and that someone needs to push her in her wheelchair. (Detective W) asked him if she (R9) can read or write, and he stated he did not know. (R10) has never had or attempted to have a conversation with (R9). (R10) then told me (R9) can talk but real slow. (R10) again confirmed that he has never talked with (R9). An interview on 3/27/23, at 1640 (4:40 PM) hours indicates (R10) stated he was in the room with a lady in a wheelchair (R9) and a guy named (name of guy) came in the room. R10 then said oh, okay. Bye (name of R9) and that he gave her a kiss on her cheek. (R10) claimed that was all that happened. (R9) is another resident (at the name of the facility) and R10 admitted this interaction took place in the activity room. After the activity residents attended was over, (R10) and (R9) stayed in the room and listened to the radio. (Detective W) asked who (the name of the other resident was named by R10), and he stated he was in the room with them, left to go to his room and then came back to the activity room. Surveyor noted there is no indication in the facility's investigation that they asked how R9 and R10 came to be in the activity room without supervision and when staff last saw the residents. Surveyor noted the facility investigation did not include details to determine if other residents were present or witness etc. The Detective W's interview continues indicating R10 was told an employee was accusing R9 of having her shirt up. (R10) stated she always have (sic) like this and lifted his shirt up to expose his belly. The report indicates R10 was told that an employee observed (R10's) mouth on (R9's) breast. (R10) stated the employee was lying and he has never had sexual contact with (R9). (R10) was asked if he knew that having sexual contact with (R9) would be wrong. (R10) stated Yeah. The detective goes on to tell R10 that she cannot communicate or consent and that she is confined to a wheelchair, (R10) agreed and that she does not have much mobility movement (sic). (R10) again denied kissing or placing his mouth on (R9's) breast and stated another resident named (name of resident) was there with them. (R10) believed (the name of other resident) may have observed him kissing (R9's) cheek. (R10) also claimed it was the first time he had kissed (R9) goodbye. The detective's (Detective W) note dated 3/27/23, at 5:30 p.m. indicates there was an interview with CNA H. It indicates CNA H confirmed he actually saw R10's mouth on R9's breast. CNA H stated when he walked in the room, he thought R10 would immediately stop but R10 did not remove his mouth from R9's breast until CNA H called out and confronted him. CNA H indicated there were no other residents in the room at the time. CNA H informed the detective R9 is able to communicate with someone she is comfortable with and R9 told CNA H that it was R10's idea to kiss R9's breast. The detective note indicates CNA H assisted the detective with R9 when answering the detective's questions. The note indicates with assistance of CNA H, R9 indicated she did not consent to having R10 touching her. R9 also indicated that this was not the first time R10 touched her. R9 again indicated she did not consent to R10 touching her. All of R9's responses were her shaking her head no and responded with saying no to the Detective W's questions. The failure to supervise R10, who had a history of being in R9's room, without R9 being aware R10 was in her room and subsequently on 3/26/23 R10 was observed to be sexually assaulting R9, created a finding of immediate jeopardy. The facility removed the jeopardy on 4/14/23 when it had completed the following: The facility initiated education on the facility's abuse policy and procedure including protecting residents during an investigation. Staff will be tested prior to staring their next shift. Residents with a BIMS score of 8 or above were interviewed. No allegations of abuse were received from residents. Skin evaluations were also completed on all residents with BIMS score of less than 8 with no negative findings. Social Service initiated a record review for all residents to ensure a Trauma informed care evaluation is completed and any triggers are appropriately care planned and added to nursing assistant [NAME]. Care plans will be updated as necessary. A sexuality screen will be completed on all current residents that are able to understand and able to answer the sexuality screening questions appropriately. Based on the outcome of the screening the facility will set up a care plan meeting with the resident's/participants guardian or other legal representative for health care decisions to discuss the resident's expression of sexuality along with the resident/participant. Residents who are incompetent or incapacitated or display diminished capacity to appraise personal conduct and also demonstrate an indicated need for additional sexuality screening based on factor including but not limited to resident interactions, relationship status, ongoing observations and history, the Social Worker/Designee will do an assessment of the residents/participants to consent to sexual activity using the guidelines in the facility Sexuality and Intimacy Policy. Once evaluations are completed a care plan will be developed for the staff to follow and [NAME] will be updated New admissions will have a trauma informed care evaluation completed by Social Services and a care plan will be initiated based on evaluation and [NAME] update. A sexuality screen will be completed on all new admissions that are able to understand and able to answer the sexuality screening questions appropriately. Based on the outcome of the screening the facility will set up a care plan meeting with the resident's/participants guardian or other legal representative for health care decisions to discuss the resident's expression of sexuality along with the resident/participant. New residents who are incompetent or incapacitated or display diminished capacity to appraise personal conduct and also demonstrate an indicated need for additional sexuality screening based on factor including but not limited to resident interactions, relationship status, ongoing observations and history, the Social Worker/Designee will do an assessment of the residents/participants to consent to sexual activity using the guidelines in the facility Sexuality and Intimacy Policy. Once the evaluation is completed a care plan will be developed for staff to follow and [NAME] will be updated. Assistant Administrator and DON were re-educated on the facility's Abuse Policy, including: abuse prevention; safeguarding the resident during a abuse investigation; reporting timeframes and requires under the Elder Justice Act; and timely reporting allegations to the appropriate agencies, including the state survey agency and local police. The Administrator was also educated on the procedure of notifying the [NAME] President of Operations and the Regional [NAME] President of Clinical Services with all allegations of Abuse. Facility staff will receive education on facility policy and procedure related to resident sexuality and intimacy to include any indicators that residents may be entering into a relationship and who and when to report any potential relationship to and when increased supervision may be needed to include a post test. A Performance Improvement Tool has been developed to monitor timely compliance of abuse reporting to state agencies and local law enforcement. The PI tool will be completed by the Director of Operations or the Regional [NAME] President of Clinical services with each state agency reportable to ensure timely notification of law enforcement and timely notification to state agencies for 3 months with results being forwarded to the QAPI committee for any further recommendations and/or resolution. A Performance Improvement Tool has been developed that will monitor compliance with Trauma Informed Care Evaluations for new admission, including care plan and [NAME] updates. PI tool will be completed by the Administrator/Designee Monday through Friday with all new admissions for 30 days, then 2 times weekly for 30 days then monthly for 3 months to ensure Trauma informed evaluation, care plan and [NAME] completed as necessary. Results will be forwarded to the QAPI for any further recommendations and/or resolution. A Performance Improvement Tool has been developed that will monitor compliance with newly admitted residents' ability to understand and consent to sexual activity. PI tool will be completed Monday through Friday by Administrator/Designee for 30 days, then 2 times weekly for 30 days then monthly for 3 months with results being forwarded to the QAPI committee for any further recommendations and/or resolution. A questionnaire has been developed and will be completed by 10 staff members to determine staff knowledge in regards to resident rights to have intimacy, identification of potential relationship, reporting of potential intimacy and increased supervision until capacity for intimacy has been determined, daily Monday through Friday for one month, then 2 times weekly for one month, then monthly for 3 months with results being forwarded to the QAPI committee for any further recommendations and/or resolution. New employees will receive resident sexuality and intimacy education upon hire.