**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to monitor and treat skin breakdown to prevent worsening of ulcers for 2 of 3 resident reviewed, (Resident #3 and #21). Resident #3 had an ulcer on his toe, staff failed to contact the doctor when treatment was ineffective. The toe was eventually amputated. Resident #21 had chronic pressure areas on her bottom and found to not have treatment in place. The facility reported a census of 32 residents. Findings include: The MDS (Minimum Data Set) assessment identifies the definition of pressure ulcers: Stage I is an intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have a visible blanching; in dark skin tones only it may appear with persistent blue or purple hues. Stage II is partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough (dead tissue, usually cream or yellow in color). May also present as an intact or open/ruptured blister. Stage III Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Stage IV is full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (dry, black, hard necrotic tissue). may be present on some parts of the wound bed. Often includes undermining and tunneling or eschar. Unstageable Ulcer: inability to see the wound bed. 1) According to the Minimum Data Set (MDS) dated [DATE], Resident #3 had a Brief Interview for Mental Status (BIMS) score of 13 (moderate cognitive deficit.) The resident had 1, unhealed, Stage 2 pressure ulcer. The MDS dated [DATE], showed that the resident had a diabetic foot ulcer. He was totally dependent on staff for transfers, toileting and hygiene, Diagnosis included type II diabetes mellitus, dysphagia following cerebrovascular disease, hemiplegia or hemiparesis, cerebrovascular accident. The Care Plan for Resident #3, revised on 1/27/25, showed that he was non-ambulatory and non-weight bearing status and required the assist of 2 for mobility. The resident was at risk for skin impairment with a history of pressure to buttock, right toe, plantar aspect of the 5th toe. Staff were directed to follow the skin treatments as ordered by provider, check all of the body for breaks in skin and treat promptly as ordered by doctor. In an observation on 3/4/25 at 6:44 AM, Staff A Certified Nurse Aide (CNA) and Staff B, CNA prepared to transfer Resident #3 from the wheel chair to the shower chair for a shower. The resident was wearing a shirt and brief. They transferred him to the bed with the use of the Hoyer Mechanical Lift. Once he was in bed, they removed the protective boots that covered his feet up to his knees. The resident had a callous on his right foot where the great toe had been. His right shin had three scabbed areas along the top of the bone. When asked about the scrapes, the CNA's said they didn't know if that was being documented or how long he had the skin breakdown. The chart lacked documentation of the scrapes on his shin. On 3/5/25 at 10:43 AM, Staff D, Registered Nurse (RN) acknowledged that she was responsible for documenting weekly skin issues. She said that she was not aware of any skin breakdown on the right shin for Resident #3. She went into the room and looked at the area and asked the resident what happened. He said that it was from crossing his feet in bed. Staff D said that she would start a skin sheet for him and a risk management because it is scabbed. She said she hadn't been told about it, the girls hadn't told her about those spots and that should have been documented. A review of the chart revealed that on 5/6/24 at 11:50 AM, resident had been readmitted to the facility after a hospitalization with three new areas of skin breakdown. The readmission Assessment included: Right foot big toe pressure area 0.3 centimeters (cm) x 0.3 cm open area. Right foot little toe pressure area 0.8 cm x 0.5 cm. Right foot second toe scattered scabs. The following documentation was found in the Nursing Notes (NN) and on the paper documentation titled: Non-Ulcer Skin Assessment (SA) leading up to the amputation of the right great toe: a. (NN) 5/8/24, Encounter note by NP; resident post hospitalization for pneumonia and returned to facility with antibiotic therapy. had scabs on left toes and dressing on right great toe, continue orders paint scabs on toes with betadine daily and right great toe remove old dressing, cleanse with saline, apply povidone-iodine to area, skin prep to surround kin and cover with polymen and meplex tape every 2 days, monitor for worsening signs/symptoms. b. (SA) 6/4/24, 0.3 cm x 0.6 cm, wound bed is scabbed, surrounding skin color pink, surrounding tissue wound edges intact. Progress improved continue treatment plan. c. (NN) 6/5/24 Encounter note by NP; skin on toes improved. d. (SA) 6/11/24 size 0.3 cm x 0.6 cm scabbed, red and pink surrounding. improved e. (SA) 6/18/24 size 0.5 cm x 1 cm. improved treatment continued. f. (SA) 6/25/24 size 0.5 cm x 1 cm. improved treatment continued. g. (SA) 7/2/24 0.8 cm x 1 cm. wound bed scab, pink surrounding skin intact wound edges. deteriorated. (chart lacked documentation of physician contact with change). h. (SA) 7/9/24 0.6 cm x 1 cm scab, pink intact and improved i. (SA) 7/16/24 0.5 cm x 1 cm wound bed yellow, surrounding skin pink surrounding tissue fragile progress is improved j. (SA) 7/23/24 0.5 cm x 0.5 cm. surrounding tissue blanchable progress improved slough (dead tissue) yellow or white. k. (NN) Encounter note from the NP, signed on 7/25/24 at 5:02 PM, did not address foot ulcers. l. (SA) 7/30/24, 0.5 cm x 0.5 cm. yellow wound bed surrounding tissue fragile not changed m. (SA) 8/6/24 0.5 cm x 0.5 cm slough 10%, improved n. (NN) 8/13/24 at 10:59, the doctor was in the facility and antibiotic started related to cellulitis (bacterial skin infection) to right great toe. o. (SA) 8/13/24 0.5 cm x 0.5 cm. yellow wound bed, pink surrounding skin, deteriorated, started on antibiotic. A Physician Progress Note dated 8/13/24, showed that the visit diagnosis included; cellulitis and abscess (collection of pus surrounded by inflamed tissue) of toe of right foot. A breakdown to right big toe, area was wet, purulent (containing pus) with redness spreading up the foot. The patient was placed on antibiotic for 10 days. If no improvement, given his severe debility this likely could result in amputation. He had undergone amputation of previous toes due to similar circumstances. Next visit on 9/10/24 will follow closely p. (NN) 8/18/24 at 10:09 AM, Encounter note by NP, follow up to cellulitis of right toe, erythema top of right foot. q. (NN) 8/19/24 at 2:24 PM, less redness and swelling noted to right toe r. (SA) 8/20/24 not changed granulation 90%, 80% red tissue. s. (NN) 8/21/24 at 2:59 PM, no redness swelling odor or signs of infection. (According to the Medication Administration Record, the last day of antibiotic was given on 8/22/24) t. (NN) 8/23/24 at 5:49 PM, foot is slightly pink and warm, resident stated pain in ankle not foot. u. (SA) 8/24/24 0.5 cm x 0.5 cm condition not changed continue with treatment v. (SA) 9/3/24 size unchanged, wound bed white surrounding tissue pink 80% granulation, and white Progress improved w. (SA) 9/10/24, size unchanged, progress was left blank, continue treatment. x. (SA) 9/17/24, size same, progress not changed treatment continue y. (NN) 9/19/24 Encounter by the NP indicated no acute concerns expressed from nursing the documentation lacked any reference to the foot ulcers. z. (NN) 9/24/24 at 9:32 AM, call out to the Nurse Practitioner (NP) with update regards to right foot. Increased redness and drainage. May we have referral to wound nurse. aa. (SA) 9/24/24 measured 0.5 cm x 0.5 cm yellow discharge, 100% slough. Progress deteriorated. Hand written note to be seen by wound care. bb. (NN) 9/24/24 at 9:54 AM, orders for x-ray and referral to bone and joint surgeon. cc. (NN) 9/26/24 at 2:45 PM, out of facility for appointment dd. (NN) 9/26/24 at 4:17 PM resident admitted to hospital to amputate toe. A note from the NP signed on 9/24/24, showed that she spoke with the nurse about concerns that the wound on the right great toe knuckle, had drainage and redness. The resident was unable to feel his toe when it was touched. Initiated orders for a wound culture, antibiotic, x-ray and referral to wound clinic and bone specialist. According to the notes from the Bone, Joint and Sports Surgeons dated 9/26/24 at 4:32 PM, the X-rays of the right foot of Resident #3 showed erosive changes of the distal aspect of the medial proximal phalanx and proximal aspect (bone located on the bottom row) of the distal phalanx (bone at the end of toe) concerning for osteomyelitis. Sensation is diminished to the great toe, open ulceration noted to the dorsal medial aspect of right great toe at interphalangeal joint (joint between the phalanges of toe) It is covered in fibrotic slough, (yellow, tan or white, dead tissue) serous drainage (clear to yellow) present, full-thickness down to the bone measured 1.5 cm x 1.5 cm and there was visible and palpable bone (able to touch) within the wound bed. The toe was erythematous and edematous (red and swollen). Soupy, serous drainage present coming form the wound. Recommended admit to hospital tonight for Intravenous antibiotics, vascular workup and toe amputation within the next few days as long as vascular status was okay. Discussed risks with the patient, biggest risk included delayed wound healing, continued infections, possible need for further surgery and further loss of foot or limb. According to the hospital History and Physical, dated 9/26/24 at 5:33 PM, the principal presenting problem included acute hematogenous osteomyelitis (inflammation of the bone due to infection) of right foot. Presented as an open ulceration to dorsal medial aspect of the right great toe at the interphalangeal joint of the hallux, covered with fibrotic slough, as well as healthy granular tissue. Some serous drainage present. It was full-thickness down to palpable and visible bone. Measured 1.5 cm x 1.5 cm the surrounding erythema to the right great toe. Soupy, serous drainage present. On 3/5/25 at 10:26 AM, Staff D, Registered Nurse (RN) said that she was conducting skin assessments in May of 2024 and when Resident #3 came back from a hospitalization with pneumonia, he had scabs and other pressure injuries to his feet and legs. She said that they suspected that it had been caused by the foot devices that they were using at the hospital. She said that the doctors didn't ever change the treatments and the scabs kept getting moist. Staff D said that Resident #3 was always having some skin breakdown related to his diagnosis of diabetes. Staff D said that they would try a different treatment if the color, pain or discharge changed. The doctors and NP would visit monthly and they were always looking at the resident's feet but they didn't ever see a need to change the treatments. On 3/5/25 at 11:30 AM, Staff D said that Resident #3 didn't get to the wound clinic on 9/24/24 because he was sent right to the bone specialist and then onto the hospital. Staff D reviewed the skin sheets and said that there hadn't been any changes in the toe that would have alerted them to call the doctor. Even if someone had seen a change, the doctor came in once a month and he or she would have looked at the resident's skin. On 3/5/25 at 2:36 PM, Staff E, Licensed Practical Nurse (LPN) remembered when she called the NP on 9/24/24 with her concerns about Resident #3. She said that she thought it was getting worse and they hadn't changed treatment orders. It was about a week prior to the amputation that she noticed changes. She had been directed to report to the Director of Nursing, which she said she did. She said that as an LPN, she was told she was to report to an RN with skin issues. There were times when she would provide treatment and the residents dressing was not in place, or it was soiled and looked as if it hadn't been changed for a while. On 3/5/25 at 12:10 PM, the NP said she remembered the ulcer on the toe of Resident #3 and that she contacted the primary care physician for culture and a wound care referral. She acknowledged that she saw the resident on 8/15/24 for a follow up after the primary care doctor had seen the resident on 8/13 and started an antibiotic for cellulitis on the right foot. The next visit she had with him was on 9/19 but did not make reference to the foot. When asked if she had looked at the foot on the 9/19 visit, she said that whatever she had in her notes was what she provided. The NP said that when she made monthly visits, she would consult with nursing before and after the visit about concerns and stated I can only address what I'm notified of. She stated that everything that she addressed was in her notes and could not say for sure if nursing should have contacted her sooner with changes in condition or what they may have seen leading up to the amputation that could have helped catch the deterioration sooner. On 3/6/25 at 12:35 PM, the DON said that she was not working at the facility in August of 2024 but she did look at the record on the progression of the toe wound for Resident #3 and acknowledged that it was concerning the nurses hadn't noticed the deterioration sooner. The DON read the report from the bone specialist and said that there would have been some warning signs before the wound was down to the bone. She would have directed the nurses to address and reassess the treatments if there wasn't improvement in healing after two weeks of a treatment. The DON said that they have two different skin sheets, one for non-ulcer and one for when an ulcer had developed. The form to be used after ulcer development, had more detailed documentation to include odor, coloring, size etc. 2) The MDS dated [DATE], showed that Resident #21 had a BIMS score of 14 (intact cognitive ability). She required partial assistance with toileting hygiene, dressing and toilet transfers. Resident #21 was at risk for pressure ulcer, and treatments included application of nonsurgical dressing. Her diagnoses included malnutrition, depression, weakness and pressure ulcer of sacral region, Stage 2. On 3/4/25 at 10:04 AM, Staff L, CNA assisted Resident #21 in the bathroom. When asked if she had any skin breakdown, Staff L said that she didn't know of any. The resident said she did, and when she got up from the toilet the CNA acknowledged that she had some protective cream on her buttocks. Staff L wiped her bottom with a cloth and noted some redness and a small slit near the coccyx. The resident said that it did hurt and she asked the CNA for a patch. Staff L said that she could not do that, that would have to be done by the nurse, so the resident asked for a lot of cream. A review of the Orders tab in the electronic chart revealed an order dated 2/5/25 at 2:58 PM, for Mepilex (foam dressing for acute and chronic wounds) to coccyx to be changed every 3 days and as needed (PRN) until healed. A Nursing Note dated 2/3/25 at 1:33 PM, showed that the resident had an area on the inner buttocks below coccyx measured 2 cm x 0.5 cm. Review of the skin sheets found a new sheet titled: Non-ulcer Skin Assessment, started on 2/3/25, that documented an open area to inner buttock, left. The document lacked any follow up measurements or descriptions of the ulcer. On 3/5/25 at 2:48 PM, Staff E said that she applied the dressing for Resident #21 and at times, the dressing has not been on as ordered. On 3/6/25 at 12:33 PM, the DON said that at times, the wound nurse would get pulled to the floor and it may be difficult for her to get all of the assessments completed. She did not know why there wouldn't have been a follow up to measurements or documentation and staff are directed to complete treatments as ordered. On 3/6/25 at 11:11 AM, the Administrator said that they did not have a specific policy for skin assessments, but staff were directed to refer to the DIMES protocol for skin issues. Debridement Infection, Moisture Balance, Edge and Supportive Products. (DIMES) The Wound Care Guidelines included description of wounds and supportive products, but lacked information on when nursing should contact the doctor and recognize the current treatment regimen consider changing.

Based on record review, interviews and observation the facility failed to use safe transfer techniques for 2 out of 4 residents reviewed (Resident #9 and #21). The facility also failed to ensure the care plan fall intervention of a personal alarm was in place for 1 resident out of 4 residents reviewed for accidents/nursing supervision (Resident #11). The facility reported a census of 28. Findings Include: 1. The Minimum Data Set (MDS) assessment for Resident #9 dated 6/20/22 showed a Brief Interview of Mental Status score (BIMS) of 12 which indicated intact cognition. The MDS indicated Resident #9 required an extensive assistance of 1 person for transfers. The MDS diagnoses included weakness, heart dysrhythmias and hypertension. The Care Plan last revised on 7/1/22 documented Resident #9 required the assistance of 1 person, a gait belt and forward wheeled walker for transfers. The Progress Note dated 8/4/2022 at 10:30 PM for Resident #9 documented nurse summoned by the aide to the residents room. Upon entering the resident was observed face down on the floor with extremities stretched outward. Scant amount of blood noted on the floor upon assessment this nurse finds bone to right arm exposed. The facility called 911 for an ambulance transfer to the emergency room (ER). The Facility Investigation documented on 8/4/22 at approximately 10:40 PM, the Director of Nursing (DON), received a phone call from Staff A, Licensed Practical Nurse (LPN), stating Resident #9 had sustained a witnessed fall resulting in a fracture to her right arm. On 8/4/22 at approximately 10:30 PM, Staff B, Certified Nurses Assistant (CNA), was assisting Resident #9 to bed. Resident had her walker and was turning left to ambulate towards her bed when she lost her balance and fell forward. Staff A, LPN, asked Resident #9 what happened she stated, I fell to the floor. Staff B, CNA, was not using a gait belt at the time of the fall. The facility investigation further documented Resident #9 sustained a comminuted, obliquely oriented fracture of the distal right humeral meta-diaphysis. The distal fracture component is displaced anterolaterally by greater than a shaft width (a severely displaced fracture located at the lower end of the arm bone). The emergency room documentation dated 8/5/22 revealed the ER physician determined via X-ray Resident #9's right arm sustained a severely displaced fracture located at the lower end of the arm bone caused by the fall. The Major Injury Determination Form dated 8/6/22 revealed the ER physician classified Resident #9's right arm fracture to be a Major Injury. The Investigation Questionnaire dated 8/4/22 Staff B, CNA, asked what occurred at the time of the incident. Staff B replied, the resident walked to her bed. Gait belt not in use due to lack of judgment. In an interview on 10/19/22 at 2:53 PM, Staff B, CNA, reported on 8/4/22 she assisted Resident #9 transfer from the recliner using a walker. As Resident #9 stood, she started to fall forward. Staff B attempted to catch the resident but instead kicked the resident's walker causing the resident to fall to the ground. Staff B stated she normally used a gait belt when transferring Resident #9 but for some reason just didn't use a gait belt on this occasion. Staff B confirmed the facility followed up with her regarding gait belt education after the incident. In an interview on 10/20/22 at 7:30 AM, Staff A, LPN, stated she arrived to Resident #9's room immediately after the fall where she observed Resident #9 on the ground not wearing a gait belt. Staff A reported that she would have expected staff to use a gait belt when transferring Resident #9. The facility reported they lacked a policy regarding gait belts or transfers. In an interview on 10/20/22 at 2:36 PM, the DON stated that she would have expected staff to use a gait belt and walker when transferring Resident #9. 2. The MDS assessment for Resident #11 dated 6/6/22 for showed a BIMS of 4 which indicated severe cognitive impairment. The MDS indicated Resident #11 required an extensive assistance of 2 persons for transfers, dressing and personal hygiene. The MDS diagnoses included dementia, anxiety disorder and psychotic disorder. The Care Plan dated 6/6/22 instructed staff to use a TAB alarm on Resident #11 to alert staff when the resident attempted self-transfer. The Progress Note dated 7/18/2022 at 1:30 PM documented Resident #11 found by staff on the floor next to her wheelchair. The resident reported to staff that she fell forward when vomiting from the wheelchair. As a result Resident #11 sustained a hematoma to the left forehead. The Progress Note further documented the CNA stated she forgot to place the TAB alarm back on the resident and CNA educated about the importance of having the TAB alarm on the resident at all times. In an interview on 10/20/22 at 10:11 AM, Staff C, Registered Nurse (RN), reported she responded to Resident #11 's room when Staff D, CNA, reported the resident fell out of her wheelchair. Staff C stated she found Resident #11 on the ground next to the wheelchair with vomit beside her on the floor. Staff C noted a hematoma to the resident's forehead, however did not call for an ambulance at the request of the family. Staff C, RN, reported Staff D, CNA, failed to place the TAB alarm on the resident before the fall. Staff C said the CNAs used the TAB alarm on a consistent basis but this time Staff D forgot to place the alarm after moving the resident back to her room. In an interview on 10/24/22 at 7:25 AM, Staff D, CNA, stated she forgot to place the alarm on Resident #11 because while in the room the resident's neighbor called out for help. Staff D stated she got sidetracked and felt horrible for not placing the alarm on the resident. The facility reported they lacked a policy regarding personal or TAB alarms. In an interview on 10/19/22 at 9:37 AM, the DON explained the TAB alarm works by a pull-string that attached magnetically to the alarm with a garment attachment that clipped to the resident. When a resident leaned too far forward or attempted to stand, the string would be pulled, engage the alarm and alert staff to the resident's movement. When asked if Resident #11 should have a TAB alarm placed when she is not in bed, the DON responded, yes. The DON acknowledged the alarm could have prevented the fall. 3. The MDS assessment for Resident #21 dated 9/26/22 showed a BIMS of 3 which indicated severe cognitive impairment. The MDS indicated Resident #21 was totally dependent on staff for transfers, dressing, toilet use and personal hygiene. The MDS diagnoses included morbid obesity, Alzheimer's Disease, renal insufficiency and cancer. The Care Plan dated 10/10/22 showed transfers are to be done with assistance of 2 persons using a Hoyer (mechanical) lift. Observation on 10/19/22 at 11:14 AM showed Staff E, CNA and Staff F, CNA, prepared to move Resident #21 from the bed to the wheelchair using a EZ Way Smart Lift. The CNAs connected the sling to the machinal lifted and raised Resident #21 from the bed. As Staff F lowered the resident into the wheelchair, Staff E then readjusted the wheelchair without engaging the wheelchair breaks. As the lift shifted and moved forward Staff E struggled to hold the wheelchair in place while pulling and guiding the resident down into the wheelchair. EZ Way Smart Lift Manufacturers Instructions last updated on 8/10/18 instructed when moving the resident from the bed to the wheelchair or toilet on Step 6, #1 Position the wheelchair under the patient and lock the wheels of the wheelchair. In an interview with the DON on 10/20/22 at 3:01 PM, the DON reported that she wasn't sure if the wheelchair locks needed to be engaged when transferring a resident from the bed to a wheelchair using the EZ Way Lift. The DON stated, I don't know. I know I don't lock the breaks.