**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure one of the residents (Resident (R) 161) in the sample was free from accident hazards from the use of a mechanical lift. A facility staff independently operated the mechanical lift without assistance form another staff member. As a result of this deficient practice, R161 sustained multiple fractures to his vertebra and ribs. This deficient practice has the potential to affect all residents that require the use of a mechanical lift for transfers. Findings include: Review conducted for the Facility Reported Incident (FRI) document retrieved from Aspen Complaints/Incidents Tracking System (ACTS) 10397. Initial report was submitted to the Office of Healthcare Assurance on 06/29/23 and the completed report on 07/07/23. Type of incident was listed as Other, Serious Bodily Injury. Details of incident stated that on 06/29/23, R161 was being transferred from the wheelchair to the bed using a mechanical lift by a Certified Nurse Assistant (CNA) when the lift malfunctioned and R161 fell to the floor from an approximated height of three feet. R161 was transferred to a local acute care hospital and subsequently admitted for multiple acute fractures of his spine and ribs. The CNA was immediately placed on administrative leave until the investigation was completed. The mechanical lift was removed from service and inspected by maintenance team on 06/29/23. A facility-wide inspection of all mechanical lifts was completed on the same day. It was identified that the lifting strap failed and all other were confirmed to be functioning properly. Maintenance inspections were being completed monthly with the last one done on 06/14/23. On 07/06/23, maintenance and inspections were transitioned to a different team and completed per manufacturer guidelines. The CNA that transferred the resident confirmed that she was operating the mechanical lift without the assistance of another staff member. On 06/30/23, all staff were required to watch a training video on the proper use of the mechanical lift. Education was also provided on the facility policy where two staff members must always be present for all resident transfers using the mechanical lift. Skills validation training was also conducted and documented. The training and skills validation was made mandatory for all employees and was completed on 07/27/23. All new employees hired after the incident were also required to complete the mechanical lift training and skills validation. After completion of the mandatory training, the facility developed focused rounds to monitor compliance of the staff when using the mechanical lifts. Findings were reported in the Quality Assurance and Performance Improvement (QAPI) meetings monthly for 90 days. On 10/27/23 at 09:44 AM, interview conducted with Restorative Aide (RA) 2 in the hallway of [NAME] Lane unit. RA2 verbalized that two staff members are required when using the mechanical lift and safety checks need to be completed prior to its use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview with staff members, the facility failed to ensure residents received care to prevent development of new pressure inuries and provide care to promote healing and prevention of infections from developing for two (Residents 11 and 54) of four residents included in the sample. The facility failed to develop a person-centered care plan for the prevention of development and infection of pressure injuries; implement the resident's care plan to facilitate healing of the pressure injuries (application of foam boots and elevating feet); and provide resident with informed choices regarding the treatment of the pressure ulcers. As a result of the deficient practice, Resident (R)11 developed two facility-acquired pressure injuries which worsened, Stage 4 pressure injury to the left heel and Stage 3 pressure injury to the right buttock. R11's pressure injury also became infected requiring antibiotic treatment. R54 was admitted to the facility with deep tissue injury (DTI) to the left heel. The facility failed to develop a person-centered care plan to prevent the development of pressure injuries and infection of pressure injuries. As a result of this deficient practice, R54 had pressure injury related infections, including osteomyelitis (infection to the bone) requiring four rounds of antibiotic treatment (orally and intravenously) for treatment of infection and developed pressure injuries to the coccyx, spine/back, and right foot (Stage 3). Findings include: 1) Cross Reference F656 (Comprehensive Care Plan). Resident (R)11 was admitted to the facility on [DATE]. Diagnoses include, essential hypertension, benign prostatic hyperplasia without lower urinary tract symptoms, chronic obstructive pulmonary disease, malignant neoplasm of colon, peripheral vascular disease, anxiety disorder, and edema. Observation during the initial tour of the facility on 10/10/22 found R11 seated in a recliner with a urinal hanging on his rubbish can. R11's head was hanging down to the right and appeared asleep. R11 has an air mattress and on oxygen. On 10/11/22 at 07:41 AM observed R11 sleeping in his recliner. He was upright and slouched over to the right side. R11 was wearing socks and feet were not elevated. His lower legs were wrapped. Second observation at 10:49 AM, R11 was lying on his left side in bed, uncovered with his personal brief open. Two staff members entered and R11 was asked whether he wanted to be covered up and get out of bed. R11 was agreeable. Observation at 12:40 PM, R11 was seated in his recliner, leaning to his right side and feet were not elevated. R11 had earphones on and did not respond to greeting by surveyor. On 10/11/22 at 10:58 AM, Registered Nurse (RN)7 was observed leaving R11's room. RN7 reported the wound team saw R11 and the pressure injury on the buttock has worsened, it's not getting better. RN7 reported they will be changing treatment and awaiting physician orders. On 10/12/22 at 01:15 PM and 02:15 PM, R11 was seated in the recliner, his feet were not elevated. At 02:15 PM, R11 was asleep, leaning on the right of the armrest. At 03:15 PM, R11 had a shower and was assisted back to bed. On 10/13/22 at 08:32 AM, R11 observed seated in his recliner, wearing socks and his feet were not elevated. Second observation at 09:30 AM, the privacy curtain was drawn, staff stated pericare was being provided. At 09:45 AM, staff asked whether he wanted to go back to his recliner. R11 was agreeable to transfer back to his recliner. Restorative Nurse Aide (RNA) waited for assistance to transfer R11 via mechanical lift. Certified Nurse Aide (CNA)2 assisted with the transfer. R11 was placed in the recliner, no foam boots and legs were not elevated. CNA2 was asked whether R11's foam boots should be applied. CNA2 responded the RNA will apply and thinks it is applied only when in bed. CNA2 further reported she needs to read the [NAME] as she is new to the facility. RNA reported R11 does not like to wear foam boots, he will get mad if it is applied and will kick it off. RNA also reported R11 does not like to elevate his feet, he just wants to sit in his recliner. RNA placed a pillow to R11's right side and proceeded to tidy the resident's bed. Observed R11's air mattress was not covered with a sheet; a sheet was laid across the bed under the resident's lower half of his torso. Review of R11's admission Minimum Data Set (MDS) with an assessment reference date of 07/12/22 noted he yielded a score of 14 (cognitively intact) when the Brief Interview for Mental Status was administered. R11 was also noted to require extensive assistance with two+ (plus) person physical assist for bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed or alternate sleep furniture) and toilet use. R11 was coded as occasionally incontinent (less than 7 episodes of incontinence) for bladder and always incontinent of bowel. In Section M - Skin Conditions, R11 noted to be at risk of developing pressure ulcers and no unhealed pressure ulcer(s) at Stage 1 or higher. Review of R11's Braden Scale (standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure injuries) for 07/14/22, 07/21/22 and 07/28/22 documents a score of 15 (moderate risk). A review of the PCC Skin & Wound: Total Body Skin Assessment for 07/14/22 and 07/21/22 documents no wounds. The assessment for 07/28/22 and 08/04/22 documents one new wound. The assessment includes skin turgor (elasticity), color (ashen, pale, cyanotic, flushed, jaundiced, mottled), temperature, moisture (normal, moist, diaphoretic, clammy), condition (extremely dry, dry, normal, oily, friable), and number of new wounds. A review of the progress note dated 07/28/22 documents R11 developed a pressure injury - DTI (deep tissue injury) to the left heel. Also noted, the outer layer of skin has ruptured and about 40% of wound filled with eschar (a dry, dark scab or falling away of dead skin). The plan was to apply bordered foam every evening shift, foam boats to both feet, and consult wound specialist. Review of the wound note of 08/02/22 notes R11 is a [AGE] year-old with wound on left heel, wound occurred by pressure mechanism, started as deep tissue injury (DTI) prior to admission. R11 was admitted from an acute hospital due to femoral neck fracture and post-surgery. Subsequent wound consult note dated 08/16/22 documents R11 with a pressure ulcer to the left heel, unstageable. Subsequent note of 08/23/22 notes an unstageable pressure ulcer of the left heel and a non-pressure chronic ulcer of other part of left lower leg. R11 noted with severe peripheral artery disease, limited elevation, and worsening edema. Culture of the wound found bacteria, enterococcus, MSSA, and mixed GNR indicative of an infection. R11 was prescribed antibiotic (Augmentin from 08/30/22 to 09/09/22 and cipro from 10/04/22 to 10/11/22). Review of the physician order notes treatment for multiple wounds on the lower extremities (left lower leg/shin, left dorsal foot, left heel. right toe, and right lower leg). R11 also noted with a sacral wound. The diagnoses included pressure ulcer of left heel, unstageable and pressure ulcer of sacral region, Stage 3. R11 has a care plan for pressure injury (Stage 4 pressure injury to the left heel and Stage 3 pressure injury to the right buttock). Interventions included: -Administer treatments as ordered and monitor for effectiveness; -Foam boots to bilateral feet in bed and in wheelchair; -Pressure injury to left heel (report to nurse if dressing is soiled or displaced); -Remind resident to keep pressure off left heel when transferring and ambulating; and -Roho cushion and dycem for offloading. There was no care plan including interventions for the prevention of pressure injuries and prevention of infection. Review of the Task bar which provides direction to CNAs regarding care did not include offloading or ensuring position change. On 10/13/22 at 10:00 AM an interview was conducted with the Assistant Director of Nursing (ADON). ADON confirmed R11's pressure ulcer was facility acquired. ADON reported the pressure ulcer to the heel started as a deep tissue injury, a blister. ADON further reported R11 spent a lot of time sitting up in bed and has poor circulation, so they brought a recliner for him to keep his feet slightly elevated off the ground. ADON explained R11's pressure ulcer became infected as he was very swollen and with the use of diuretics his legs were really weeping providing opportunity for bacterial growth. ADON also reported R11 is not compliant with wearing the foam boots and elevating his legs. Inquired whether R11 was provided with informed choices about his treatment (i.e., treatment options, consequences of refusing treatment) and offering of alternative treatment. ADON referred to Wound Care Consult report where it is documented education was provided. The ADON stated the facility was concerned about R11's comfort. ADON was agreeable to follow up on providing care plan for the prevention of pressure ulcers and documentation of the facility's discussion with R11 regarding informed choices and offering of alternative treatment. On 10/13/22 at 12:20 PM, ADON provided a copy of the care plan for skin integrity. The date of initiation was 07/20/22 (14 days after admission) and documents resident has moisture associated skin damage (MASD) and pressure ulcers due to weakness and impaired mobility. This care plan was initiated/developed after R11 presented with skin breakdown. The interventions include: -Administer treatments as ordered and monitor for effectiveness -Educate the resident/family/caregivers as to cause of skin breakdown; including transfer/positioning requirement; importance of taking care during ambulating/mobility, good nutrition, and frequent repositioning -Follow facility policies/protocols for the prevention/treatment of skin breakdown The ADON did not provide documentation of the facility's discussion with R11 regarding informed choices and offering of alternative treatment. 2) R54 was admitted to the facility on [DATE]. Diagnoses include spondylosis (a condition in which there is abnormal wear on the cartilage and bones of the neck, cervical vertebrae), radiculopathy (injury or damage to nerve roots in the area where they leave the spine), spinal stenosis (narrowing of the spinal canal), and occlusion and stenosis of right carotid artery. On 10/11/22 at 07:45 AM, R54 was interviewed in his room. R54 was observed lying in bed with his blanket suspended off his feet by a wired apparatus and an IV pole next to his bed. R54 reported that he currently has an infection in the bone and has sores to the left heel and on the right side. He reported the sores were very painful and the wired apparatus helps to keep the weight of his blanket off his feet. R54 reported he also had a sore on his backside. On 10/11/22 at 12:53 PM, R54 reported the wound team came to see him and he requires two more weeks of antibiotics and wounds have healed up. R54 stated he will be discharged to his home after he completes the antibiotics. On 10/12/22 at 01:15 PM, R54 was observed in bed. Inquired whether staff reposition him while in bed. He replied, staff do not assist to reposition him. Observed R54 has an air mattress and no sheet covering the mattress. Queried whether a sheet is used on his mattress, he replied a sheet is not used. He commented the mattress is slippery and he slides down, so he needs to be pulled up every four hours. R54 reported he wears the foam boots in bed and the doctor has told him he can remove the boots when out of bed. R54 further reported he received education about his wounds and has been cooperative. He stated that he was not aware the wound was present upon admission to the facility. Subsequent observation at 02:15 PM, R54 was seated in a wheelchair with prevalon boots on. On 10/13/22 at 08:32 AM, R54 was lying in bed, he was observed wearing his prevalon boots. Review of the admission MDS with an ARD of 11/22/21 notes upon administration of the BIMS, R54 yielded a score of 15 (cognitively intact) required extensive assist with one-person physical assist for bed mobility, toilet use, and personal hygiene. Section M. Skin Conditions, documents R54 was at risk for development of pressure ulcer and had one unhealed pressure ulcer at Stage 1 or higher. The pressure ulcer was documented as unstageable. The treatment included pressure reducing device for chair, pressure reducing device for bed and pressure ulcer care. A review of the resident's care plan provided by the facility found a focus area for infection (resident has IV antibiotic treatment due to osteomyelitis of the right lateral foot), there were no interventions for prevention of infections. The care plan for pressure injury with the goal to remain free from infection does not include interventions to ensure prevention of wound infections. Interventions include administer treatment as ordered and monitor for effectiveness, air mattress, apply foam boots to both feet while in bed, elevate resident's both legs with heel suspension/leg elevation cushion while in bed, monitor nutritional status, and weekly treatment documentation to include measurement of each area of skin breakdown's width, length, type of tissue and exudate. The first documentation of wound care note (11/23/21) documents R54 with a DTI on left heel which reportedly occurred after falling asleep sitting down with foot down about 1.5 months prior to admission. R54 was admitted from home. Summary of subsequent wound care notes include: -12/21/21: DTI on the left heel measuring larger with a new DTI to right lateral foot which may be related to use of new footrests. The impression was pressure injury of deep tissue of left heel and pressure injury of deep tissue of right foot. -01/11/22: coccyx appears healed with dimple deformity. -02/08/22: addition of pressure injury of deep tissue of toe on right foot. Also noted, resident reporting he slips down his bed and fee are up against the footboard. On 03/02/22 R54 assessed with MASD to right buttock as resident insists on sitting in his wheelchair. -03/01/22: culture of the wound found mixed skin-type flora -03/22/22: new opening to spine/back and R54 on IV antibiotic for bacteremia -05/03/22: pressure injury of right foot (Stage 4) and pressure injury to left heel (unstageable), there is exposure of bone on right lateral foot, and poor compliance with prevalon boots. -05/24/22: bone culture of left heel grew staph lugdunensis (bacteria) and recommendation was for treatment -06/14/22: R54 completed course for oral doxycline (antibiotic) for right foot infection -06/28/22: missed appointment with wound team due to COVID-19 infection and poor compliance to boots and pillow offloading (elevating feet) -08/02/22: culture of left heel and right foot grew MRSA, poor compliance with prevalon boots and pillow offloading -08/16/22: R54 on oral doxycline for right and left wound infection -09/13/22: wound not visualized as R54 in hurry for PICC line insertion, recommendation for IV antibiotics for six weeks (vancomycin and Zosyn) -10/04/22: R54 continues IV antibiotics, left heel intact, and right foot (stage 4 pressure injury). Also noted under Miscellaneous the resident received meropenem for bacteremia (03/17/22 to 03/24/22), doxycycline for right foot wound infection (05/24/22 to 06/07/22), and doxycycline for left heel infection (08/02/22 to 08/16/22). Review of the weekly wound care notes from 07/05/22 through 10/04/22 documents R54 had poor compliance with the application of prevalon boots since 11/18/21. However, a review of R54's treatment record provided by the facility found from December 2021 through October 2022 there was no documentation of refusal for the application of bilateral foam boots. On 10/13/22 an interview was conducted with the ADON, the identified Infection Preventionist. ADON reported osteomyelitis (infection of the bone) was in the left lateral foot and R54 developed the pressure injury on his right foot due to poor circulation. Inquired how did R54 develop osteomyelitis. ADON reported organisms causing infections are introduced to the wound. ADON further reported she tracks infections and has observed facility staff performing dressing change and there has not been infection control breeches. The ADON suggested the surveyor contact the wound consultants. A review of the facility's policy and procedure, titled Quality of Care Skin Integrity. The guidelines include the following: -3. The facility will implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors. -6. A resident identified as at risk of developing PU/PIs (pressure ulcer/pressure injury) will have individualized interventions implemented to attempt to prevent PU/PI from developing. Interventions will be monitored for effectiveness. The resident's care plan will reflect the interventions. -15. Prevention and treatment plans will be individualized and consistently provided. -41. The first sign of infection in a PU/PI may delay in healing and an increase in exudate. In a chronic wound, signs of infection may include: a. Increase in amount or change in characteristics of exudate; b. decolonization and friability of granulation tissue; c. Undermining; d. Abnormal odor; 3. Epithelial bridging at base of the wound; and f. Sudden pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that adequate pain management was provided to one resident (R34) in the sample. As a result of this deficient practice, R34 experienced pain that interfered with his movement, affected his mood, and diminished his appetite, thereby preventing him from attaining his highest practicable level of well-being. Findings include: Resident (R)34 is a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that include muscular dystrophy, heart failure, and chronic pain syndrome. On 10/11/22 at 01:29 PM, an interview was done with R34 at his bedside. R34 reported constant pain everywhere, but worse in his neck and hands. When asked, R34 stated that the pain medications he was on did little to relieve his pain. Concurrent observations noted several signs indicating severe pain. R34 was observed grimacing, biting his lower lip, holding his breath and or taking very shallow breaths, speaking in few words at a time, frequently stopping to catch his breath. His posture was stiff, and he moved slowly, making small, careful movements. R34 rated his pain at the time as a 10 out of 10 and stated that he was waiting for the Licensed Practical Nurse (LPN) to bring him his pain medication. R34 shared feelings of hopelessness, acute depression, and feeling overwhelmed. I'm miserable, I hate it here, I hate being here, but I feel like there is no way I will ever get out of here now [due to constant pain affecting his mobility]. Expressed many fatalistic thoughts, feels he will die here. When asked if he gets out of bed, R34 stated I just can't . it hurts . just everywhere. At 01:58 PM when LPN2 brought in his pain medication, he asked her to put the tablet in his mouth and hold the water cup and straw for him because his hands hurt too much. On 10/12/22 at 03:52 PM, a review of R34's medication orders noted an order for acetaminophen 500 milligrams (mg) every 6 hours as needed for pain rated 1-6/10, and an order for hydrocodone-acetaminophen 10-325mg every 6 hours as needed for pain rated 7-10/10. Despite the diagnoses of muscular dystrophy and chronic pain syndrome, no orders were found for continuous, round-the-clock, scheduled pain management. A review of R34's comprehensive care plan noted no non-pharmacological interventions for pain management. A review of R34's progress notes noted a dietary note on 10/11/22 documenting, The resident is having decreased appetite . pain in his hands/arms, affecting his appetite . A nursing note from 10/08/22 documented Resident has poor intake and requires increased assistance with eating. OT (occupational therapy) eval (evaluation) requested. On 10/13/22 at 08:40 AM, observed R34 lying in bed with his breakfast tray on his bedside table. Some of his oatmeal was eaten, but nothing else on the tray had been touched. R34 reported severe pain and that he was waiting for pain medication. R34 stated he takes hydrocodone for pain but that it does not help much. R34 was observed with facial grimacing and shallow breathing, speaking in short, slow sentences, and seemed short of breath. When asked if he wanted the Surveyor to get his nurse, R34 stated no, I'm tired of arguing with them, f*ck, I don't want to get you involved. R34 reported that the pain in his hands was so bad, it made it hard to eat or do much of anything.