**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure the safety for one resident (Resident 1) when Resident 1 did not receive adequate supervision and assistance during breakfast. This failure resulted in burns and blisters to two of Resident 1's fingers and pain to the affected area. Findings: A review of Resident 1's admission record indicated Resident 1 was admitted to the facility in May 2020 with diagnoses which included parkinsonism (brain conditions that cause tremors) and ataxia (loss of muscle control in arms and/or legs). A review of a nurse progress note dated 4/22/24 at 2:33 p.m. indicated, [Resident 1] was attempting to feed self this AM [morning] without CNA assistance. Due to tremors [Resident 1] spilled hot cereal over and burn 2 fingers to left hand. Index finger blister measuring apprx [approximately] 2.5x1 .middle finger 2x2. [Resident 1] was advised to wait for staff to assist w [with] feeding. NP [Nurse Practitioner] .wrote new orders to monitor site. During a concurrent observation and interview on 6/5/24 at 9:50 a.m. with Resident 1, in Resident 1's room, Resident 1 was observed sitting up in bed, with tremors noted to her right hand. Resident 1 stated she needed assistance with eating due to her tremors because she was not able to hold the utensils steady. Resident 1 stated the Certified Nursing Assistant 1 (CNA 1) was assisting her the day of the incident and had taken the hot cereal to heat it in the microwave. When the CNA 1 returned with the hot cereal, Resident 1 stated the CNA 1 then stepped away from the bedside. Resident 1 stated she picked up her fork to check the temperature of the hot cereal, brought the hot cereal to her lips, dropped the fork because the cereal was so hot, the hot cereal spilled on her left hand and the bowl fell to the floor. Resident 1 stated, I screamed bloody murder, it was the most painful thing. I let out a blood curdling yell, but I don't think staff took it seriously. The charge RN (Registered Nurse) never came to evaluate me or the wound nurse until a few days later. During an interview on 6/5/24 at 10:22 a.m. with CNA 1, the CNA 1 stated she was not familiar with Resident 1's care, although she did know Resident 1 needed assistance with her meals. On the day of the incident, it was the second time CNA 1 had been assigned to care for Resident 1. The CNA 1 stated she microwaved Resident 1's hot cereal that morning. The CNA 1 stated, I put the cereal in the microwave and set the timer for one minute, but I took it out before the timer went off. I admit it, it was my fault, it was probably too hot. The CNA 1 stated she placed the hot cereal on Resident 1's tray and then stepped away, approximately four feet, behind the curtain to get Resident 1's coffee. Resident 1 yelled out and CNA 1 turned back around to check on Resident 1. The CNA 1 stepped around the curtain and noticed Resident 1's left hand between the third and fourth fingers were red. The CNA 1 stated she reported the incident immediately to the Licensed Vocational Nurse 1 (LVN 1). The CNA 1 stated, I assumed she would wait to let me help her with the cereal, I'm supposed to help her. She [Resident 1] was screaming, I noticed her hand immediately, her fingers blistered between one to two hours after [the spill]. During an observation on 6/5/24 at 11:35 a.m. the microwave across from the nursing station on D unit was observed. Taped to the top of the microwave was a laminated sign which stated, Re-Warming Liquids, Temperature Should Not Exceed 145 Degrees. Test all liquids with a thermometer before giving to your resident/patient. To the left of the microwave a digital thermometer was hanging in a black pouch on the wall. A cup from the kitchen with approximately 1.5 in (inches, a unit of measure) of water was placed inside the microwave and the microwave was set to one minute. At 41 seconds the cup, which did not feel hot, was removed from the microwave. The thermometer was placed into the cup of water and was held in place for 15 seconds. When the thermometer was removed the temperature on the thermometer read 166.4 degrees Fahrenheit (F, a unit of measurement). During an interview on 6/5/24 at 12:05 p.m. with CNA 2, the CNA 2 stated, There's a thermometer in there [room next to nursing station] but I don't use it. The cereals in the morning are already nice and warm, there's no reason to reheat them. During an interview on 6/5/24 at 12:43 p.m. with CNA 3, the CNA 3 stated, Resident 1 will end up spilling her food because she shakes, she gets food everywhere, we [CNAs] have to assist her. CNA 3 stated Resident 1 attempts to use her spoon or fork, but she shakes and the food drops everywhere. During a concurrent observation and interview on 6/5/24 at 12:57 p.m. with CNA 2 and CNA 3 (CNA 1 was unavailable) the microwave and thermometer was observed. The CNA 2 and CNA 3 confirmed they were aware of the sign and the thermometer, and they have received education in the past on how to use the microwave and thermometer. During an interview on 6/5/24 at 1:45 p.m. with the Director of Nursing (DON), the DON confirmed CNA 1 should not have left Resident 1 unattended during breakfast. The DON stated Resident 1 needed assistance and supervision with meals, she has tremors and is unable to feed herself. A review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, revised July 2017, the P&P indicated, Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident (Resident 1) out of three sampled residents received proper foot care when: 1. Lack of documentation indicating Resident 1's wound on the right foot second toe was being assessed per nursing standards; and 2. Transportation services were not provided to Resident 1's podiatry (the medical care and treatment of the human foot) appointments. These failures resulted in Resident 1 not receiving foot care per nursing standards which led to a partial right foot amputation (surgical removal of part of the body). Findings: A review of Resident 1's face sheet, dated 3/1/24, indicated Resident 1 was admitted to the facility [EC1] on 11/11/20 with diagnoses which included peripheral vascular disease (PVD, a narrowing of a blood vessel which decreases circulation of blood to a body part), diabetes (DM 2, a chronic condition that affects the way the body processes blood sugar, which slows the body's ability to heal wounds), heart failure (CHF, when the heart does not pump blood efficiently throughout the body), peripheral neuropathy (nerve damage that can cause weakness, numbness, and pain that usually affects the hands and feet), history of diabetic foot ulcer (wound on foot that develops in people with diabetes), osteomyelitis (swelling caused by infection of the bone) and partial left foot amputation. A review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 11/23/23, indicated resident had no memory impairments. A review of Resident 1's care plan, created on 12/3/20 and edited on 11/27/23, indicated, Problem .Self care deficit r/t [related to] h/o [history of] osteomyelitis[EC2] of [left] foot with partial foot amputation, PVD, DM 2 with peripheral neuropathy[EC3] , CHF .Goal .Resident will be able to function at the highest possible level as evidenced by X [times] 3months [EC4] [sic] .Approach .[nurses will] Shower/Bathe two times each week as scheduled . A review of an electronic mail (e-mail), dated 10/9/23 at 11:51 a.m., indicated Resident 1 had an appointment with his Podiatrist (a medical professional who specializes in the treatment of disorders of the foot, ankle, and related structures of the leg) on 10/11/23 at 11 a.m. Resident 1 missed the appointment and there was no documented reason. A review of an e-mail, dated 11/3/23 at 1:22 p.m., indicated Resident 1 had an appointment with his Podiatrist on 11/7/23 at 11:10 a.m. Resident 1 missed the appointment and there was no documented reason. A review of Resident 1's care plan, edited 11/27/20 and on 11/27/23, indicated, Problem .At risk for impaired skin integrity r/t .decreased sensation to BLE [both lower extremities] hitting .against bed/bedside table and is unaware of the incident .[h/o] left partial foot amputation .Approach .Licensed nurse to assess resident skin head to toe weekly .Monitor feet/heels for s/s [EC5] [signs and symptoms] of skin breakdown, poor circulation such as redness, dry skin and/or open area. Notify MD[EC6] [medical doctor] if found .Observe skin for s/s of skin breakdown .Podiatry as ordered .Wound consultant as needed . A review of Resident 1's order summary report indicated, .[Starting on 12/4/23, nurses were to] Dry scab to right 2nd toe .leave area open to air. Monitor area daily. Every day shift . This order summary report also indicated an order for, Podiatry for skin/nail problem conditions .order date 12/23/23. A review of a nurse progress note dated 12/24/23 at 12:45 p.m. indicated, [Resident 1] was taking off his [Left] leg/foot brace [with] right foot and upon doing so tore right second toe ulcer scab and started bleeding, cleaned .wrapped [with gauze], Treatment nurse made aware of incident. A review of Resident 1's Orders- Administration Note, written by the Treatment Nurse 2 (TN 2), dated 1/11/24 at 1:46 p.m., indicated, Dry scab to right 2nd toe . leave open to air. Monitor area daily. Every day shift. Scab re-opened; covered with bandaid, MD notified A review of Resident 1's SNF [Skilled Nursing Facility] Custodial Visit , dated 1/30/24, by Resident 1's Primary Care Physician (PCP), indicated no documented evidence Resident 1's right foot had been assessed.[EC7] [VAE8] A review of Resident 1's SNF Visit and Generalized Body Pains note written by the Nurse Practitioner 1 (NP 1), dated 2/9/24 for a visit conducted on 2/8/24, indicated, [Resident 1] tells me he feels 'achy' and didn't want to eat much this morning .last saw [Podiatrist] 9/28/23, was to follow up in one month? Was a now [sic] show for podiatry appts in October, Nov, December .Extremities- has dry scab on right foot second toe, old healed scabs from scratching on legs .2/9/24 labs now show WBC [white blood cell count] 19.2 [expected range 5-10] .DM 2 [with] ULCER OF RIGHT FOOT Unchanged, not sure why patient was no show will message [nurse] to call SNF with appointment . A review of a nurse progress note dated 2/10/24 at 2:07 p.m. indicated, [Resident 1] on [oral antibiotic for] foot infection .foot has scabbed. [Resident 1] encouraged not to pick at scabs .will continue to monitor. A review of a weekly wound observation tool, dated 2/12/24 at 4:50 p.m., indicated, .Wound type .Diabetic ulcer .Describe other .Probably moisture-related .Present upon admission .No .What date wound was identified .2/12/24 .Length .1.3 cm [centimeters, a unit of measurement] .Width .1.5 [cm] .Depth .0.2 [cm] .Exudate [fluid that leaks out of blood vessels into nearby tissues which may ooze from cuts or from areas of infection] .Moderate .Exudate Type .Serosanguineous[EC9] [thin, watery, pale, red/pink drainage] [and] purulent [containing pus] thick, opaque [cannot see through], tan/yellow drainage .Wound Stage .Stage 3: full thickness skin loss .Describe Wound Edge/Margin .Erythema[EC10] : [Redness of the skin] .Unable to fully visualize wound bed due to location. Wound edges are erythematous [abnormal redness of the skin] A review of a skin/wound note, dated 2/12/24 at 4:55 p.m., indicated, [Resident 1] is not sure how injury occurred. He has a [history] of diabetic neuropathy [nerve damage caused by diabetes that can cause weakness, numbness and pain that usually affects the hands and feet] [EC11] and has frequent injuries to bilateral lower extremities that he cannot recall. Spoke with [staff] at [Podiatrist's] office .who states [Resident 1] has missed several recent appts over the last few months but has scheduled appt with wound care this Fri., 2/16. Office informed of new wound and states a message will be sent to [Podiatrist] in the meantime .[NP 1] informed .[NP 1] will photograph wound in [morning] . A review of telephone encounter note from Podiatrist 1 (PD 1), dated 2/13/24, indicated, .it does appear that [Resident 1] has missed several appts [appointments]-both with preventative RN staff AND me over past year . [NP 1] to assess for the infection . if there is infection, patient should be seen in [Emergency Room] . A review of a SNF Transfer and Toe Problem note, dated 2/13/24 at 4:10 p.m., indicated, . [Resident 1] toes had multiple scabs but today his right foot second toe is edematous, macerated[EC12] [softening and breaking down of skin resulting from prolonged exposure to moisture] with what looks like necrotic tissue [dead tissue] between, the toes .Transfer to ED [Emergency Department] for further evaluation, high risk patient . A review of a nurse progress note dated 2/13/24 at 5:01 p.m. indicated, Received orders to send [Resident 1] to hospital to r/o [rule out] sepsis[EC13] [a severe response to infection which can lead to organ damage] r/t [related to] second toe wound. A review of Resident 1's skilled nursing facility Discharge summary, dated [DATE], indicated, . [Resident 1] is a long term care patient . after . left midfoot amputation .today his right foot second toe is edematous, macerated with what looks like necrotic tissue between the toes .transfer to ED for further evaluation, high risk patient . A review of Resident 1's hospital ED treatment note, dated 2/13/24, indicated, [Resident 1] .present with concerns for an ulcer between his right toe .there is some necrotic tissue along the lateral aspect [the side] [EC14] of the second toe with ulceration [break in skin] . A review of Resident 1's hospital podiatry consult note, dated 2/14/24, indicated, [Resident 1] .Patient present with ongoing swelling, infection to the right lower extremity second digit[EC15] [toe or finger]. Positive probe to bone, indicative of osteomyelitis .Podiatry team will plan for right foot second digital amputation on 2/14/24 . A review of Resident 1's hospital Discharge summary, dated [DATE], indicated, .hospital course and significant findings .admitted with diabetic ulcer right foot, s/p [status post] TMA [transmetatarsal amputation[EC16] : surgery to remove part of foot] [2/24/24] . In an interview on 3/1/24 at 9:10 a.m., the Executive Director (ADM) stated the facility's Social Services Coordinator (SSC) was expected to arrange transportation services to outside appointments, such as podiatry appointments, for long term residents. In an interview on 3/1/24 at 12:27 p.m., Resident 1 stated the facility was supposed to set-up transportation to his podiatry appointments and he was aware he had missed at least one podiatry appointment. Resident 1 stated staff did not explain why he had missed his podiatry appointments. Resident 1 confirmed he developed a wound on his right foot in December of 2023. Resident 1 stated he felt safe in the facility but was upset and felt the care of his foot had not been prioritized. In an interview on 3/1/24 at 1:25 p.m., Licensed Nurse 1 (LN 1) stated she cares for residents who have wounds by reviewing the documented history of the wound(s) and carefully reading the treatment administration record. In an interview on 3/1/24 at 1:35 p.m., Certified Nursing Assistant 2 (CNA[EC17] 2) stated if staff did not monitor skin issues, then open wounds could become infected and can affect the bone which can change the way a resident can function. The CNA 2 added the infection could be painful and cause the resident to not want to eat. In an interview on 3/1/24 at 1:50 p.m., Treatment Nurse 1 (TN 1) confirmed she worked at the facility as a dedicated treatment nurse. As a treatment nurse, TN 1 stated she attended weekly wound meetings with the Assistant Director of Nursing (ADON) to discuss concerning wounds. The TN 1 stated she was expected to conduct and document weekly assessments of resident wounds. In an interview and concurrent record review on 3/1/24 at 2:37 p.m., the ADON stated a wound that was persistent for two months would have been discussed in the weekly wound meeting which consisted of the ADON, the unit manager, treatment nurses, and a dietician. The ADON also stated she expected persistent wounds to be documented at least weekly to determine if it was improving or worsening. The ADON stated she believed Resident 1's dry scab on the right second toe had healed but was unable to provide documentation the wound had resolved. The ADON stated she could not recall discussing Resident 1's wound in any of the weekly wound meetings or interdisciplinary team meetings and verified Resident 1's medical chart showed no documented evidence of such discussions between December 2023 and February 2024. The ADON acknowledged, based on documentation available, the wound on Resident 1's right second toe had been present from December 2023 to February 2024. The ADON stated transportation for outside appointments were arranged by the social services department. The ADON further stated if there is no documentation in the resident's chart, then it was not done. In an interview on 3/1/24 at 3:30 p.m., the Social Services Director (SSD) stated the social services department arranged transportation to outside appointments when the nurse notified them of the resident's appointment. The Social Service Coordinator (SSC) then communicates to the nursing unit of the confirmed transportation. The SSD stated the unit nurses were responsible for getting the resident up and ready for transportation. In an interview on 3/1/24 at 3:40 p.m., the SSC confirmed she arranged for transportation for Resident 1's podiatry appointments. The SSC stated she was first made aware of Resident 1's missed podiatry appointments in early February of 2024 by the NP 1. The SSC stated the last podiatry appointment transportation she arranged for Resident 1 was in November 2023. In an interview on 3/20/24 at 9:18 a.m., the SSC stated there was a failure in communication which led to Resident 1's missed podiatry appointments. In an interview on 3/20/24 at 9:55 a.m., LN 2 stated a resident with diagnoses of PVD and DM 2 would have a risk of developing wounds and added vascular and diabetic ulcers are difficult to treat and heal. The LN 2 stated he expected each wound to have a care plan which included monitoring and documentation of the monitoring. The LN 2 further stated measurements of the wound needed to be documented to determine its progress. An interview on 3/20/24 at 10:20 a.m., TN 2 accessed Resident 1's medical records on her computer. The TN 2 stated she had been monitoring Resident 1 for a non-healing scab since December 2023. The TN 2 stated she monitored the wound by looking at it and would report to physician if she felt there was a change to the wound that needed to be addressed. When asked how she would know if the wound was changing, she replied because I look at it and know. When asked if there was any documentation indicating descriptions of the size or changes to the wound on the right second toe before 2/12/24, she confirmed there was not. When asked if it was a concern that Resident 1 had a wound on his foot from December to February, the TN 2 replied, it's a gray area . I was monitoring a dry scab . something that is not concerning. When asked how she would know if the wound was improving, the TN 2 disclosed, I was not monitoring that closely and alleged she was not aware of the right second toe lateral wound until 2/12/24 and added, it was hard to see. The TN 2 confirmed she knew having a diagnosis of DM2 and PVD were high risk factors for poor wound healing, but she had not notified NP 1 about Resident 1's right second toe wound until 2/12/24. The TN 2 added, Resident 1 had always had a podiatrist due to his other foot issues and expected he was getting podiatry services. In an interview and concurrent record review on 3/20/24 at 11:16 a.m., in the Director of Nursing (DON) office, the DON stated residents with diagnoses of DM2 and PVD would be at high risk for developing wounds and poor wound healing. The DON stated she expected nurses to monitor wounds, document descriptions of wounds and notify the physician of any changes. The DON added she expected the physician to be notified if the wound was not responding/healing within two weeks and added, we need to do something else. The DON stated if a resident had a wound on the foot that was not healing the physician would refer the resident to a podiatry specialist. The DON accessed Resident 1's medical records on her computer, confirmed she could read Resident 1's progress notes and assessments since December 2023. The DON confirmed the progress note written on 12/24/23 which indicated Resident 1 had a wound on his right second toe without any further descriptors such as size, presence of exudate or necrotic tissue. The DON also confirmed the progress note written on 1/11/24 which indicated Resident 1 had a scab reopen on right second toe but also had no other descriptions of the wound. The DON continued to search Resident 1's medical records and confirmed she could not find any documentation that clearly described Resident 1's wound on his right second toe until 2/12/24. The DON acknowledged, without descriptions of the wound documented, it would not be possible for staff to know if the wound was improving. The DON reiterated a wound that does not improve should always be a concern. In an interview on 3/20/24 at 1:20 p.m., the NP 1 stated she was aware Resident 1 had a history of wounds on his right foot and a partial left foot amputation. The NP 1 stated she discovered in early February 2024 Resident 1 had missed his podiatry appointments (in October, November, and December of 2023) that she documented in a progress note. When asked if it was a concern for Resident 1 to miss podiatry appointments, the NP 1 stated, Of course it is a concern. The NP 1 added Resident 1 was at high risk for infection and losing toes due to his DM2 and concluded, If [Resident 1] wasn't high risk he wouldn't be seeing the podiatrist. The NP 1 confirmed she evaluated Resident 1's right foot on 2/13/24 and determined he should be sent to the hospital for further evaluation and treatment of suspected infection to right foot. A review of the facility's policy and procedure titled, Prevention of Pressure Injuries, revised April 2020, indicated, .Skin Assessment .During the skin assessment, inspect .presence of erythema .Temperature of skin and soft tissue .edema[EC18] [swelling cause by trapped fluid] .inspect the skin on a daily basis .identify . darkly pigmented skin, inspect for changes in skin tone, temperature and consistency .Monitoring [expectations] .Evaluate, report and document potential changes in the skin .Review the interventions and strategies for effectiveness on an ongoing basis. A review of the facility's policy and procedure titled, Pressure Ulcers/Skin Breakdown- Clinical Protocol, revised April 2018, indicated, .nurse shall describe and document/report the following .full assessment of pressure sore [area of damage to skin and underlying tissue caused by pressure] [EC19] including location, stage, length, width and depths, presence of exudate or necrotic tissue .Monitoring [expectations] .During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds .The physician will guide the care plan as appropriate, especially when the wounds are not healing as anticipated . A review of the facility's policy and procedure titled, Transportation, Social Services, revised December 2008, indicated, Our facility shall help arrange transportation for residents as needed .social services will help the resident.