**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** R24 is a [AGE] year-old resident initially admitted to facility on 04/04/2019 and has diagnoses including but not limited to pressure ulcer of sacral region stage 3, pressure ulcer of right heel unstageable, pressure ulcer of left heel stage 3, rheumatoid arthritis, muscle weakness and age-related debility. Minimal Data Set (MDS) section C dated 09/11/2024 documents Brief Interview for Mental Status (BIMS) score of 14 which suggests cognition is intact. Section GG of same MDS documents resident is dependent of staff in the areas of toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, and personal hygiene. Section GG also documents R24 needs substantial/maximal assistance in the areas of oral hygiene and upper body dressing. Progress note dated 04/25/2019 documents: Note Text: Seen and exam by V7 (Wound Doctor) with orders made, dressings done, right buttocks dry and resolved. Director of Nursing and Power of Attorney notified. Coccyx almost healed, 0.2cm x 0.2 cm. Right heel left face wound no change and left heel decreased in size. Will keep monitoring. Progress note dated 08/16/2024 documents: Late Entry: Note Text: Upon repositioning resident in bed this morning, noted with facial grimacing upon lifting left lower extremity. Upon skin check, left heel noted with scab peeling off with skin opening noted underneath. Noted with minimal drainage. Initial treatment done post-NSS (normal saline solution) cleanse then covered with dry dressing. Procedure well tolerated by resident. BLE (bilateral lower extremities) kept elevated with pillow to offload heels. Offered pain medication however resident declined. Resident stated that she only experience pain upon touch. MD (Medical Doctor) V19 informed and agreed for wound consult. Order carried out. Informed Wound Care nurse (V8). Son aware at 08:47 AM, verbalized understanding. DON (V2) aware. AM NOD (nurse on duty) informed of the above matters. Progress note dated 08/28/2024 documents: Note Text: IDT has agreed to do an MDS Significant Change in Status Assessment related to Stage 3 Pressure Ulcer on her left heel. Progress note dated 08/29/2024 documents: Note Text: Seen by Wound doctor (V7) today for referral of the right heel, noted both heels swollen and with wounds, initial assessment done to right heel, with orders made, carried out, for right heel deep wound culture and sensitivity (c/s). Notified Supervisor for wound swabbing, called lab to bring wound swab for c/s, called Son and notified regarding the bilateral heels wound and aware. Notified Floor Nurse. Progress note dated 09/05/2024 documents: Note Text: Wound nurse (V8) noted a new open sore on resident sacrum and informed writer (V20). Wound nurse (V8) informed that wound doctor (V7) is ordering for Calcium alginate and santyl ointment for wound dressing. Writer (V20 registered nurse) did a head-to-toe assessment on the resident to look for any other skin concerns. No new concerns noted except the new sacral sore. Wound nurse (V8) called and informed son. Informed primary doctor (V19) regarding this. V19 ordered for CBC (complete blood count), CMP (complete metabolic profile) and UA (urinalysis)& culture and V7 ordered Albumin and prealbumin levels. No other concerns. Care continuing. Progress note dated 09/05/2024 documents: Note Text: Seen by Wound MD (V7), with orders, Pt seems not on herself and wound deteriorating, poor appetite, noted sacrum wound, notified floor Nurse to notify V19, and V2 DON (Director of Nursing) notified and aware. Called Son- but not answering his phone, left a message to call back. V7 change treatment, doxycycline ordered, deep wound c/s results still pending, awaiting, notified Floor Nurse to follow up. still with bilateral foot swollen. offload bilateral heels with boots. Reposition per facility protocol. Progress note dated 10/24/2024 documents: Note Text: Seen by wound doctor (V7), debridement done, initial assessment done to right buttock cause by friction/moisture, with orders made, carried out, applied dressings, repositioned per facility protocol. Bilateral heels offload with foam booties, with stage 4 special mattress. On 10/30/2024, Surveyor was provided shower skin check sheets for R24 from 09/05/2024-10/29/2024 by V2 (DON). Thirteen of seventeen shower skin check sheets document no skin abnormalities. The dates for these are as follows: 09/10/24, 09/17/2024, 09/20/2024, 09/24/2024, 09/27/2024, 10/01/2024, 10/04/2024, 10/08/2024, 10/11/2024, 10/15/2024, 10/18/2024, 10/22/2024, and 10/29/2024. On 10/30/2024, Wound Evaluation & Management Summaries dated 08/22/2024-10/24/2024 were provided to surveyor by Executive Director (V1). The following dates show wound sizes increasing on these documents: Right heel: 08/29/2024 9cm x 9cm x not measurable 09/05/2024 10cm x 9cm x not measurable 09/19/2024 10cm x 8.5cm x not measurable 09/26/2024 10.5cm x 15cm x 0.2cm 10/31/2024 10cm x 15cm x 0.7cm Left heel: 08/29/2024 4cm x 4cm x 0.2cm 09/05/2024 5.5cm x 4.5cm x 0.2cm 10/3/2024 5cm x 4 cm x 0.2cm Sacrum: 10/10/2024 1.8cm x 2cm x 0.2cm 10/17/2024 6cm x 3cm x 0.2cm 10/24/2024 7cm x 2.5cm x 0.2cm Right buttocks: 10/17/2024 - resolved. 10/24/2024 1.5cm x 1.5cm x 0.2cm On Wound Evaluation & Management Summary dated 09/05/2024 and after under plan of care documents: turn side to side in bed every 1-2 hours if able. Order dated 10/30/2024 documents: Please do not get up patient until further order. On 10/30/24, at 02:04 PM, Order for not getting patient up until further order was provided to surveyor dated 10/30/2024 by V1 (Executive Director). V1 explained, that she spoke to wound nurse (V8) that told her it was a verbal order given by wound doctor (V7) and that was transferred from nurse to nurse in report. When V1 was asked why the nurse did not put order in electronic medical record, V1 could not provide an answer and stated, that is what I need to find out. At the same time surveyor was also provided document with this order written on paper and dated 08/29/2024. Order dated 08/29/2024 documents: Reposition every 1-2 hours if able every shift. On 10/29/24, at 09:55 AM, Surveyor went to R24's room. R24 in bed wearing gown positioned on back with head of bed raised to approximately 45 degrees. R24 has fabric incontinence pad underneath buttocks on top of flat sheet over low air loss mattress. Heel protector boots noted on both heels. On 10/29/24, at 10:19 AM, Surveyor went with Licensed Practical Nurse (LPN) V3 and Certified Nursing Assistant (CNA) V4 to observe wounds for R24. R24 noted to be positioned on back with head of bed elevated to approximately 45 degrees. R24 noted to have on heel protectors on both feet and legs on pillows x 2. Right foot noted to have large scab to top left of foot and wound to heel on left foot. V3 stated, it is unstageable and has tunneling. Left heel has stage 3 pressure ulcer. She has not got up out of bed for 1 week. I believe it was the wound nurse (V8) that does not want her to get up. I think she got them less than 3 months ago. Before R24 was propelling in wheelchair to dining room. Maybe from propelling in wheelchair R24 got these. R24 was up every day before this happened. R24 is not on hospice. R24 also has a wound stage 3 on her sacrum and right buttocks. All the resident who have wounds have their position changed every 2 hours. V4 CNA stated, I change her position 2 times on my shift. After breakfast and after lunch. V3 stated, that may be why they are getting worse. V4 stated, I only change R24 two times per my shift unless R24 calls me. R24 knows when she has a bowel movement and can use call light. We do not check every two hours, sometimes we check but it is mainly two times per my shift. My shift is 6 am - 2:30 pm. V3 stated, the wound to the right buttocks is getting worse. I will tell the wound nurse V8. From the last time I seen all her wounds they are all getting worse except the left heel is getting better. The wound nurse (V8) is the one documenting these wounds. R24 noted to have sheet on air mattress and green fabric incontinence pad underneath buttocks area. On 10/30/24, at 09:27 AM, V2 (DON) went in room to give resident fresh water. Surveyor noted R24 was positioned laying on back. Bed covered with flat sheet and folded sheet. Folded sheet was folded in quarters so 4 layers of pull sheet under resident as well as flat full sheet. Pillow noted under knees and pillow under heels with heel protecting boots on. R24 stated they have not changed her position or brief yet this morning. On 10/30/24, at 09:34 AM, V3 (LPN) stated, like yesterday green pull sheet should be not on the air mattress. Surveyor asked V3 what should be on the bed with air mattress. V3 stated, only one flat sheet should be on air mattress. There should be no pull sheet or any other item of material under resident. You lose the benefits of the air mattress if you have more layers. If the CNA's do what they are supposed to do, we will prevent the issues like this of resident having wounds or them getting worse. This is my point of view only. On 10/30/24, at 09:39 AM, V3 LPN went with surveyor into R24's room and showed V3 the resident positioned on back and on a pull sheet folded in quarters on top of flat sheet on air mattress. V3 stated, R24 should not be positioned on back, R24 should not have pull sheet or have a pillow under heels because R24 has boots on already. Do you see how many layers are underneath R24? That is wrong. On 10/30/24, at 09:41 AM, V16 (CNA) stated, I put the pull sheet underneath R24. I also put R24 on her back. I put R24's heels on a pillow as well. V3 and V16 repositioned resident to be on right side and removed pull sheet from underneath R24. V3 also removed pillow from underneath resident heels. On 10/30/24, at 09:48 AM, V3 stated, it is hard when you have different CNA's. I have to remind them all of the time. Poor residents. On 10/30/24, at 09:50 AM, V16 CNA stated, we put pull sheets under residents on air mattresses to help move them. I put the pillow under R24's heels to protect the heels. I position resident every two hours from right side, back and left side. There is nothing in the computer to say what side to position resident. When I go in to reposition R24 I just change to a different position than R24 was in. On 10/30/24, at 10:15 AM, V5 CNA provided incontinence care to R24. V5 did not wear a gown. V5 wore gloves. R24 was positioned on her right side with pillow under knees and back, and heel protector boots on bilateral feet. Call light was attached to blanket covering resident and was in reach. On 10/30/24, at 10:26 AM, V14 Registered Nurse (RN) Supervisor stated, CNAs should check all residents every 2 hours for incontinence and keep them clean and dry. Those who are in bed and at risk for pressure injury should be repositioned every two hours. All these high-risk residents should have a clock on the wall indicating what way to turn them. For residents on the air mattresses there should be only a flat sheet used. No fitted sheet, no pads, no pull sheets just the flat sheet should be on the air mattresses. This allows the air to flow freely. If these items are used the air mattress will be ineffective. Air mattresses are used for relieving the pressure for residents at high risk for pressure ulcers or so pressure ulcers do not get worse. It also helps with healing pressure ulcers. The staff can use pull sheet for additional support if they can't use only the flat sheet to move resident but must pull it out and not leave under resident. On 10/30/24, at 10:42 AM, R24 was still positioned on right side and surveyor maintained visual observation of R24's room from hallway. On 10/30/24, at 11:10 AM, Resident remained positioned on right side. On 10/30/24, at 12:15 PM, V3 (LPN) stated, R24 has been in bed for more than a week now because of her wounds. That came from wound care. Surveyor asked V3 to give surveyor a copy of the order to keep resident in bed due to wounds. On 10/30/24, at 12:21 PM, R24 observed to have not been repositioned since incontinence care was provided at 10:15 AM. Surveyor has been observing R24 in hallway since 9:39 AM. Resident has been positioned on right side since 09:41 AM prior to incontinence care and again after incontinence care. On 10/30/24, at 12:42 PM, R24 remains on right side position in the bed. Surveyor was in direct vision of R24 from 10:15 AM when incontinence care was done until 12:42 PM when surveyor stops observing R24's room. 2 hours and 27 minutes passed with R24 positioned on right side. On 10/30/24, at 01:10 PM, Surveyor returned to R24's room and R24 was noted to be positioned on right side in bed. On 10/30/2024, Surveyor was provided with Treatment Administration Record for R24 for the month October 2024. October 30, 2024, documents V3 (LPN) charting that R24 was repositioned every 1-2 hours if able every shift. On 10/30/24, at 02:20 PM, V2 (DON) stated, nurses document that positioning is done on residents, so they check it off in the electronic medical record. CNAs are checking it off on their tasks as well. I cannot print out the CNA tasks but can print out the nursing documentation showing they are charting on repositioning R24. Surveyor told V2 what observations were for R24 repositioning. Surveyor asked V2, how do you monitor that orders are being followed? V2 stated, we do rounds. Me and the nursing supervisors constantly and we are helping out. Surveyor asked V2 to pull up orders for repositioning for R24. V2 stated, order dated 8/29/24 documents reposition every 1-2 hours if able. Anything over 2 hours would be unacceptable. It should be every 1-2 hours and as needed. This would be a write up and re-education/in-service since the orders were not followed. Yearly evaluations for CNA's are done. We do annual competency which are mandatory on in-services and throughout the year we do falls, safety, peri care, or whatever comes up. We do a minimum of one a month. Surveyor asked V2 what interventions are in place for preventing further worsening of wounds and promote healing. R24 is followed by dietician and staff should be off loading heels. R24 should have heel protecting boots and they should not be propped up on a pillow, if using a pillow, it should be placed under the knees/leg for support but not under heels. R24 has juven ordered daily for wound healing. R24 is getting ensure for protein TID. R24 is on an air mattress. My expectations for staff regarding air mattress should have a flat sheet on keeping it clean and dry. It is not ok to have one pad underneath resident on air mattress with flat sheet. Staff should not have a folded sheet underneath R24 on top of flat sheet. Staff should be using enhanced barrier precautions which is gown and gloves for wound care. Staff should be wearing gown and gloves for incontinence care. Surveyor asked V2 what is causing her wounds to get worse and how did they happen. V2 stated, R24 is wheelchair bound and does not walk anymore. R24 does not wear shoes and only wears socks. R24 was in her wheelchair in her room most of the day. Occasional activity, abnormal posture, and that as well as cardiac health caused her wounds. Surveyor asked V2 how did wounds on heels get that big without anyone noticing? V2 stated, I do not know how to answer that. Surveyor asked what the expectation of staff on skin checks is. V2 stated, daily skin checks should be done by nurses and CNA's while providing care. On shower days CNAs should be doing assessment and letting nurse know of any new skin issues. Surveyor showed V2 the shower sheets provided for October 2024 that document on 8 separate skin checks resident has no skin issues and asked if this was acceptable. V2 stated, the shower sheets you have for October that shows no skin issues are unacceptable. CNAs should be marking any skin areas on shower sheets. I will get you shower sheets from 9/5-10/1/24. Regarding pressure ulcer, CNA's when notice any new skin issues and notify nurses and document. Nurses should be rounding every shift making sure they are doing dressing changes. Wound care is done sometimes daily, and they should be making sure wound care is implemented as ordered. Low air loss mattress should only have one flat sheet. Multiple padding can cause further skin breakdown. CNAs should be rounding every 2 hours and change when needed. No pad just a flat sheet and a diaper on air mattress. CNAs should be doing daily skin assessments on all residents. Surveyor asked V2 to provide these documents for the last month. V2 stated she will look to see what she has to provide to surveyor. On 10/31/2024, at 12:24 PM, V1(Administrator) stated, per V2 (DON) CNAs are monitoring skin daily upon providing care and notifying a nurse if there is a skin change. There is no additional documentation. On 10/30/24, at 03:51 PM, V7 Wound Care Doctor stated, I oversee the wounds in the facility. Surveyor asked V7 what expectations of staff are to prevent wound reopening. V7 stated, offloading, clean patient in timely manner, turning and repositioning. The less layers the better for an air loss mattress is better. Multiple padding on air mattress decreases the functioning of the low air loss mattress. Use of low air loss mattress is supposed to help relieve pressure and heat and moisture. When there are multiple layers, it defeats the purpose of the mattress. My expectation of staff should be following skin protocol. Regarding R24, I am not exactly sure what caused her pressure ulcers. R24 has had wounds on her heels before and they healed and reopened up. R24 recently had an infection pneumonia or UTI that may have contributed to reopening. R24 doesn't really move that much and the wound on heals have scar tissue that I have debrided. Surveyor told V7 of observations of R24 regarding positioning, heels on pillow with heel protectors, and multiple layers on air mattress. V7 stated, multiple layers on low air loss mattress contributes to wound worsening and not healing. Not following the position turning schedule also contributes to wound getting worse and not healing properly. Heel boots should not have a pillow under heels as it defeats the purpose of the boots. Risk and Skin Assessment Policy dated April 2019 documents: Page 5 II. C. Skin check is completed on each shower day by nursing assistant staff. 1. Staff document the skin check 2. If an area is identified, the nurse is notified, and the Stop and Watch tool may be used to communicate this information. 3. Appropriate measures will be instituted. D. The nursing assistant visually inspects the skin daily with care. 1. If an area is identified, the nurses is notified, and the Stop and Watch tool may be used to communicate this information 2. Appropriate measures will be instituted. Pressure Ulcer Prevention Policy dated April 2019 documents: Page 6 Prevention I.A. 1. Residents with sensory deficits will be reminded to turn and reposition at least every 2 hours in the bed ore every fifteen minutes to an hour when up in the chair as appropriate. 2. Residents who are unable to turn and reposition independently will be assisted to turn and reposition every two hours or as appropriate. Page 23 Skin Care and Early Treatment Skin Assessment Complete Skin Assessment - The complete skin assessment is an integral part of the pressure Ulcer Prevention Program. It is through these inspections that early skin problems can be identified, and interventions implemented. Page 25 Mechanical Loading Pressure may develop from positioning as well as the use of medical devices. Pressure may develop form the use of nasal cannulas, casts, braces, cervical collars, positioning boots, or other medical devices. Monitor the device for proper placement to avoid pressure on surrounding tissue. Based on observation, interview and record review, the facility failed to assess and implement interventions to prevent the development and reopening of pressure ulcers; failed to prevent the deterioration of an existing pressure ulcer; and failed to maintain proper functioning of the low air loss mattress for two (R24 and R30) of two residents in the sample of 32 reviewed for skin impairment. This deficiency resulted in R24's pressure ulcers on the left heel, right heel, sacrum, and right buttock reopening, deteriorating and increasing in sizes; and R30's healed Stage 3 pressure ulcer on the left buttock reopening. Findings include: R30 is a [AGE] year old male, admitted in the facility on 11/10/2023 with diagnoses of Hemiplegia, Unspecified Affecting Left Nondominant Side; Unspecified Sequelae of Cerebral Infarction; Pressure Ulcer of Left Buttock, Stage 3 (09/19/24); and Vascular Dementia, Unspecified Severity, without Behavioral Disturbance, Psychotic disturbance, Mood Disturbance, and Anxiety. According to MDS (Minimum Data Set) dated 11/17/23, R30's BIMS (Brief Interview for Mental Status) score was 3, which means severe cognitive impairment. Per MDS also under Sec M Skin Conditions, R30 was admitted with intact skin but at risk for developing pressure ulcers/ injuries. MDS dated [DATE] recorded that he (R30) rarely/never understood during interview for mental status; and had one stage 3 pressure ulcer. R30's POS (Physician Order Sheets) recorded the following: 09/19/24 - provide low air loss mattress 10/03/24 - please provide stage 4 mattress 11/10/23 - follow preventative skin care protocol 11/10/23 - skin monitoring every other day for moderate risk R30's doctor's wound notes recorded the following: 10/03/24 - Stage 3 pressure wound of the left buttock full thickness, measures 2.0 cm (centimeters) x 2.0 cm x 0.1 cm. Treatment was to apply alginate calcium once daily and santyl once daily for 16 days. Mupirocin topical 2% apply once daily for 7 days; and cover with gauze island with border apply once daily for 16 days. 10/10/24 - Stage 3 pressure wound of the left buttock full thickness, measures 1.5 cm x 1.6 cm x 0.1 cm. 10/17/24 - Stage 3 pressure wound of the left buttock full thickness, measures 1.0 cm x 1.0 cm x 0.1 cm. 10/24/24 - Stage 3 pressure wound of the left buttock, resolved. Anatomic location of previously existing wound examine today: epithelialized and resolved. Follow up only as needed. Progress notes dated 10/24/24 documented that R30's pressure ulcer on the left buttock was resolved. On 10/29/24 at 10:45 AM, R30 was in his room, in bed. R30 was able to answer yes and no but could not understand and talk in a full conversation. V18 (Certified Nurse Assistant, CNA) was observed providing morning care on R30. R30 was observed wearing double incontinent briefs and the brief touching his skin was saturated with urine. He was using an air loss mattress. The mattress was covered with a flat sheet. On top of the flat sheet was a cloth incontinent pad. On top of the cloth incontinent pad was a white blanket folded into 4s. A wound dressing, dated 10/29 was observed on his (R30) left buttock. On 10/29/24 at 10:40 AM, V9 (Licensed Practical Nurse, LPN) was asked regarding R30's wound dressing. V9 went to R30's room and checked the dressing, opened it, and stated, the pressure ulcer on the left buttock reopened. The wound appeared open, with pinkish wound bed, as observed. V14, (Registered Nurse, RN Supervisor) was also called. V14 did an assessment, stated R30's healed wound reopened. R30's progress notes dated 10/29/24 recorded: skin checked and observed tiny reopening to the old wound in left buttock. R30's POS (Physician Order Sheet) dated 10/29/24 documented: Calcium Alginate External Miscellaneous apply to left buttock topically as needed for wound care. Calcium Alginate External Miscellaneous apply to left buttock topically every night shift for wound care. Foam dressing pad apply to left buttock topically as needed for wound management after cleansing with normal saline solution. Foam dressing pad apply to left buttock topically every night shift for wound care after cleansing with normal saline solution. On 10/30/24 at 9:30 AM, V10 (CNA) was asked regarding skin assessment on residents. V10 replied, We do skin assessment during shower - head to toe, front to back, side to side. We check the skin for any issues like tears, bruising and any kind of scrapes, sore, whether there is developing skin concern or healing. If there is new skin issue, I have to tell the nurse. I also document it in the shower sheets. For low air loss mattress - there should only be one flat, top sheet on the mattress to avoid friction or pressure on the wound. Incontinence brief should only be one. On 10/30/24 at 9:38 AM, V9 was asked regarding R30's pressure ulcer on the left buttock. V9 stated, I am his regular nurse. He has the pressure ulcer on the left buttock, but it was resolved on 10/24/24. After 10/24/24, I did not receive any report from CNA regarding the reopening of his pressure ulcer on the left buttock. I just learned the reopening only yesterday when I was told by surveyor to check the dressing. There was no treatment ordered since 10/24/24 because it was healed. I spoke with V8 (Wound Care Nurse), and she got the order from V7 (Wound Doctor). He (R30) is supposed to wear a single brief. The low air loss mattress should have one flat sheet, I checked the sheets every morning when I do rounds at the start of my shift. R30's shower skin check sheets dated 10/08/24; 10/11/24; 10/15/24; 10/18/24; 10/22/24; 10/25/24 and 10/29/24 indicated no skin issues. There were no marked areas of skin abnormalities found as documented. On 10/30/24 at 10:18 AM, V12 (CNA) was interviewed regarding R30. V12 verbalized, I am his regular CNA. He is alert to his name calling but unable to converse. He is totally dependent on staff for ADLs (activities of daily living). He wears brief, only one, during changing. He is at risk to develop pressure ulcers because he cannot move himself and unable to turn. We do skin assessment anytime we do shower and changing. Any skin issue is reported to the nurse. We document skin assessment when we do shower in the sheet. Last Monday 10/28/24, he has the wound on the left buttock because there was a dressing placed. He is using low air loss mattress and there should be one flat sheet. On 10/30/24 at 2:51 PM, V2 (Director of Nursing) was asked regarding pressure ulcers. V2 stated, Staff should be repositioning following whatever orders specified for individual residents; report to nurses any skin issues and document; nurses should be rounding every shift making sure wound care is implemented as ordered. There should only be one flat sheet on the low air loss mattress because multiple paddings can cause further skin breakdown. CNAs should be doing daily skin assessments on all residents. Double briefs are not acceptable because it increases moisture enhancing skin breakdown. On 10/30/24 at 3:52 PM, V7 (Wound Doctor) was interviewed regarding R30's pressure ulcer. V7 stated, He had a stage 3 pressure ulcer on the left buttock and was resolved. I was not notified that the wound was reopened yesterday. Still stage 3 when reopened. Expectations on staff in managing and preventing pressure ulcer is to maintain the turning and repositioning; follow facility protocol; clean resident in a timely manner. We don't recommend the use of double briefs on residents because of increasing moisture. The less sheets the better over low air loss mattress, only the top sheet, not the fitted sheet. The use of multiple pads on the mattress decreases the functioning of the low air loss mattress. Air mattress helps relieve pressures, heat and moisture. On 10/31/24 at 7:50 AM, V14 was asked regarding measurements of R30's reopened pressure ulcer on the left buttock on 10/29/24. V14 stated, We did not measure it because we don't know how to do it. V8 said she will measure it when she comes to the facility. Several attempts were made to contact V8 (Wound Nurse), but she is not available during the course of this survey. According to an interview with V2 on 10/31/24 at 10:01 AM, she (V8) comes every Thursday late afternoon during wound rounds. V2 also mentioned, Nurses on the floor are in serviced and trained on how to do wound care and wound measurements. I did the measurements today. R30's wound care progress notes dated 10/31/24 Left buttock, Stage 3 pressure ulcer documented: 1 cm x 1 cm x 0.1 cm. R30's care plan on skin impairment related to 10/03/24 left buttock pressure ulcer, Stage 3 documented: Interventions: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Keep skin clean and dry. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration, etc. (and other similar things) to MD (Medical Doctor) Provide treatment as ordered. R30's low air loss manufacturer's guidelines titled True Low Air Loss operating instructions manual was reviewed. There were no instructions documented regarding use of sheets on the mattress. Facility's policy (dated April 2019) titled; Pressure Ulcer Prevention documented (in part) but not limited to the following: Skin care and early treatment Skin assessment Assessments should continue daily for residents at risk for skin breakdown. Monitor skin condition for color, moisture, temperature, integrity, and turgor with close attention to the bony prominences. Also observe skin areas around medical devices such as oxygen cannulas, catheters, collars and braces. Facility's policy (dated April 2019) titled, Risk and Skin Assessment stated (in part) but not limited to the following: Policy: Intact skin is the body's first line of defense. It is the policy of this facility to assess all residents for factors that place them at risk for developing pressure ulcers. It is also the policy of this facility to monitor the skin integrity of our residents for the development of wound or other skin conditions. These assessments will begin upon admission and continue throughout the resident's stay in our facility. Procedure II. all residents will have a visual inspection of their skin. C. Skin check is completed on each shower day by nursing assistant staff. D. The nursing assistant visually inspects the skin daily and with care. 1. If an area is identified, the nurse and the Stop and Watch tool may be used to communicate this information. 2. Appropriate measures will be instituted. Facility's policy titled Pressure Ulcer Prevention dated April 2019, documented in part but not limited to the following: Policy: It is the policy of this facility to implement measures to protect the resident's skin integrity and prevent skin breakdown whenever possible. Facility's policy (undated) titled; Wound Assessment stated (in part) but not limited to the following: Policy: It is the policy of this facility to complete a systematic, ongoing assessment of all wounds that will provide a consistent means of wound evaluation to determine the response to treatment modalities and to facilitate continuity of care and communication among staff and health care providers on an ongoing basis. Procedure: I. The presence of any wounds, ulcers, and/or skin abnormalities will be identified upon admission and documented on the Nursing admission Assessment. B. Wound documentation is initiated upon admission or identification of a wound.

Based on interviews and record reviews, the facility failed to maintain resident safety during resident transfer from regular bed to bariatric bed using bed sheet. This deficient practice affects one resident (R1) of three residents reviewed for incident and accident. R1 was sent out to local hospital due to right hip pain not relieved by prescribed pain medication. R1's hospital x-ray result shows right hip acute right proximal femoral fracture. Findings Include: R1 was admitted in the facility on 4/19/24. R1 has diagnoses of but not limited to: acute and chronic respiratory failure with hypercapnia, Type 2 Diabetes, Morbid Severe Obesity, Heart Failure, Hypothyroidism, and Obstructive Sleep Apnea. On 5/31/24 at 10AM, interviewed R1 via phone and R1 reported R1 was at the facility for 2 days. R1 said R1 has been refusing to be turned due to pain, and stated R1 has no cartilage left in R1's hips and knees. R1 does not want to be turned due to R1 has certain ways they like to be turned in bed, R1's own preferred way. Five staff were turning R1 to be transferred to bariatric bed. Five staff members assisted with transfer. R1 reported she was transferred to bariatric bed with bed sheet. R1 does not recall names of staff who were assisting. R1 stated that R1's left leg was crossed over in front of R1's right leg and R1 heard a cracked on her right hip. R1 felt pain. The worst pain in the world. R1 does not recall if R1 received pain medication and if R1 did R1 stated the medication did not work and R1 continued to have pain. On 5/31/24 at 12:36PM, V5 (CNA) stated that R1 was transferred to bariatric bed during V5's shift on 4/20/24. V5 was not assigned to R1 but staff needed help because R1 was a big lady. Six staff members were present for transfer. When V5 arrived in R1's room they observed other CNAs and the nurse encouraging her to be transferred, explaining to R1 how the transfer will be done. R1 said NO, you can't I am too heavy, you guys can't do it. My leg is broken. You cannot touch this leg. Staff continued to explain to R1 that they will not touch the leg, explaining to R1 that we just have to slide R1 from one bed to another bed, using the bed sheet. R1 continued to scream No, and finally we are able to convince R1 to be transferred. R1 finally said yes. R1 was lying flat, staff did not reposition the leg. The leg was straight, and staff did not touch it. On 5/31/24 at 2:30PM, V7 (RN) stated that they were not the assigned nurse for R1 but was present in the room during transfer, there were two nurses and four CNAs transferring R1 with bed sheet. Staff offered mechanical lift and R1 refused. Two staff were on one side and three on the other side and one on the bottom. R1 was slide it to the other bed. R1 was in supine position when transferred. Once transferred to the new bed, V7 saw R1 was still laying on the hospital linen with the mechanical pad from the hospital. I was one of the staff that pushed the sheet and noted that my uniform got wet. The linens were soaking wet. Staff talked to R1 that we have to remove the linens and R1 agreed for the removal of linens and was assisting the staff at first by lifting herself up but was not able to continue because R1 was heavy. We suggested that we have to turn her a little bit on her side, and R1 agreed. Staff were holding onto a pad to turn R1 a little on her side and staff pulled the hospital linen out. Staff were able to remove maybe three linens and there were more. R1 yelled to put her back, my legs, my legs are hurting, put me back. R1 was upset, saying that we don't know how to take care of people. We put R1 back to the supine position like the way R1 was before. R1 already was with pain before, and after we did not think the pain was new from the transfer. We did not hear any cracking sound during the care. On 5/31/24 at 1PM, V6 (RN) stated V6 was the assigned nurse on 4/20/24 when R1 was transferred from regular bed to bariatric bed. V6 stated that after dinner, bedtime came and V6 explained to R1 that R1will be transferred to the new bed. R1 was not allowing us to transfer R1 because of pain. R1 was told a mechanical lift will be used and R1 refused. R1 said R1wants to be transferred by sheet instead. Six people assisted with transfer: sliding R1 to another bed. The beds were right next to each other. R1 was laying supine in flat position. After the transfer, R1 had no complaint of pain; but during med pass around 5-530 R1 complained of pain on both legs. 2 Tylenol were given, and they were effective. R1 reported less pain, a little bit of relief. No more complaint of pain. V6 stated V6 reported to Nurse Practitioner, and they started gabapentin and other medication. I do not recall which PRN (as needed) medication was given; but recall giving her PRN, 2 Tylenol. V6 stated that V6 was also the nurse for R1 on 4/21/24 afternoon shift. During med pass R1 complained of leg pain. V6 then called V13 (Nurse Practitioner) and made them aware of more pain and R1 does not want to have care provided. V13 ordered to send R1 to the hospital. I was the nurse that sent R1 out to hospital. We were at the time still waiting for the x-ray result. Result was not yet available when NP was called. On 6/4/24 at 10:40AM, V12 (LPN) stated that V12 worked when R1 was already admitted in the facility. V12 worked 2 consecutive days for R1 in the morning shift. On 4/20/24 end of shift R1 complained of right leg pain. Norco for pain given and was effective. Next day (4/21/24) V12 was the nurse of R1 and R1 complained of right hip pain not relieved by pain medication (Norco). V12 called NP (Nurse Practitioner) and V12 ordered right hip x-ray 2-3 views stat. The X-ray came in before 2pm, close to the end of V12's shift. Progress note dated 4/21/2024 at 1:06PM, reads in part: R1 complaint of pain to right hip with scale of 8/10 and didn't relieve with prescribed pain medicine. Nurse Practitioner made aware with new order for Pelvis and right Femur x-ray 2-3 views Stat (immediately). Progress note dated 4/21/2024 at 10:03PM, reads in part: R1 was complaining that R1 is in lot of pain around the buttock area and R1 was refusing all the care from CNAs. R1 did not want anybody to touch her saying she is in lot of pain. There was a barrier in cleaning R1 and her bed since R1 was constantly refusing all care. Writer informed the situation to NP. NP ordered to send R1 to hospital. Gave report to ER (Emergency Room) nurse. On 6/4/24 at 11AM, V2 (DON), stated that R1 was admitted using a regular bed and reported that the bed was uncomfortable. Facility ordered bariatric bed. Bed was delivered the next day. Staff offered R1 the mechanical lift and R1 refused. R1 okayed the transfer with the bed sheet. There was nothing unusual during the transfer to bariatric bed, and at that time R1 was observed with feces and staff attempted to clean her. Staff lifted R1's left side buttock to remove and wipe the feces. Staff were able to clean some but R1 said she was in pain and staff stopped cleaning R1. On 6/5/24 at 12:38PM, V13 (NP) stated that the nurse called V13 and said that resident was complaining of pain, refusing care, and does not want to be moved. V13 stated she knew R1 was already taking narcotics in the hospital and since admission to the facility; and that this pain is not new to R1. V13 ordered X-ray to rule out fracture, due to R1's pain and refusal to be moved. V13 said that there is a suspected fracture and ordered for R1 to be sent out to local hospital for further evaluation. Proximal femur fracture can happen due to trauma: such as fall, mishandling of the patient during patient care, or the patient herself can cause this fracture. Immobility can lead to osteopenia, osteoporosis and can cause fracture. Hospital record dated 4/21/24, reads in part: Chief complaint: Hip Pain. R1 reports that R1 has chronic pain in R1's hips and knees due to bone on bone osteoarthritis but that last night the SAR staff moved R1 too roughly, they folded me like a pretzel and since then she has 10/10 hip pain on the right. R1 had X-ray and showing right hip diffusely demineralized bones and acute right proximal femoral fracture. Mechanical lift transfer policy not dated, reads in part: purpose: to assist the resident with mechanical lift transfer when clinically indicate, to provide increased security for the resident and staff, and to prevent injury during transfer. Standard: Residents should be assisted to transfer using mechanical list when clinically indicated. Accident/Incident Management and Reporting policy not dated, reads in part: Accident and incident are an occurrence affecting a resident that is not the expected outcome of a resident's condition or disease process. Examples include but are not limited to falls or observed on floor, burns, skin tears, bruises, alterations, injuries of unknown origin, and attempted elopement. An accident or incident is an unexpected, unintended event that can cause a resident bodily injury.