**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. During an observation on 5/21/23 at 7:34 PM of the facility's long term care floor a medication cart was unlocked. No staff present in the hallway, two residents approximately 10 feet away were observed sitting in their wheelchairs. At 7:36 PM a staff member exited a residents room and went to the medication cart. During an observation on 5/21/23 at 7:40 PM of the facility's skilled unit floor a medication cart was observed unlocked. At 7:44 PM a staff member exited a residents room and went to the medication cart. The Director of Nursing (DON) provided a list of residents via e-mail correspondence on 5/23/23 at 2:10 PM who are cognitively impaired and independently mobile equaling 22 of the 86 residents in the facility. During an interview on 5/24/23 at 12:59 PM the DON revealed she would expect medication carts to be locked at all times when not in use. During an interview on 5/24/23 at 1:20 PM the Administrator revealed she would expect medication carts to be locked at all times when not in use. Based on clinical record review, observations, family and staff interviews, and facility policy review, the facility failed to evaluate and document an assessment and ensure a resident able to utilize a motorized wheelchair while indoors and outdoors safely for 1 of 1 residents reviewed with a motorized wheelchair (Resident #11). The facility staff also failed to follow the facility's fall pathway and properly intervene after a resident had a fall and moved the resident despite the resident complained of pain for 1 of 3 residents reviewed for a fall (Resident #40). The facility also failed to ensure portable oxygen safely stored for 1 of 3 residents reviewed for oxygen use (Resident #16), and failed to appropriately supervise and redirect a cognitively impaired resident from accessing a fire panel with a fire extinguisher inside (Resident #15), and failed to ensure medications carts locked for 1 of 4 medication carts reviewed. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] revealed Resident # 11 had diagnoses of stroke, diabetes, hemiplegia (paralysis on one side of the body), and sarcopenia (a gradual loss of muscle mass, strength and function). The MDS revealed the resident had a brief interview for mental status (BIMS) score of 15, indicating cognition intact. The MDS documented the resident used an electric wheelchair and independent with locomotion and movement on and off the unit. The Care Plan initiated on 12/5/22 revealed the resident had an ADL (activities of daily living) self-care deficit related to physical limitations after a CVA (cerebrovascular accident) (stroke) with hemiplegia and weakness. The Care Plan revealed the resident was independent in a power wheelchair and desired to participate in outdoor weather activities. The electronic health record and paper chart lacked an assessment performed or completed on the resident's capability to use a motorized wheelchair indoors and outdoors safely. The Progress Notes revealed the following: a. On 5/8/23 at 2:54 PM, the Director of Nursing (DON) was summoned outside. Resident #11 found lying on his back in a supine position. The resident stated he got too close to the sidewalk and drove his electric wheelchair partway up on the curb of the sidewalk, tipped the wheelchair over, and landed headfirst. The resident stated he hit his head and complained of head pain. 911 was called. An ambulance arrived and placed a c-collar (around the resident's neck). Resident transported to the hospital for further evaluation. b. On 5/8/23 at 11:19 PM, resident arrived at facility via ambulance at about 11:00 PM. The resident had new diagnoses of acute non-intractable headache and a contusion on his left elbow. The resident rated his pain at a 3 out of 10, and had pain medication administered. c. On 5/9/23 at 2:50 PM the Nurse Practitioner (NP) documented she saw the resident after he had a fall. Resident reported he used his wheelchair outside, got too close to the sidewalk, and tipped his wheelchair. The resident reported he landed on his head. Resident sent to the emergency department and evaluated. The resident reported the left side of his face and head hurt. Pain rated at 5 out of 10. The NP documented had acute left sided headache and jaw pain. The treatment plan included hydrocodone (pain medication) 5-325 milligrams (mg) orally every 4 hours as needed for pain. A Fall Risk Evaluation dated 5/8/23 at 2:35 PM revealed the resident had a low risk for falls. A Post Incident Follow Up dated 5/8/23 at 2:35 PM revealed the resident had a fall incident. The document revealed vital signs and a head to toe assessment completed and a new injury found, but unable to assess the resident's neck due to pain. The resident rated his pain at 10 out of 10. Review of Occupational Therapy Evaluation and Notes 7/15/22- 1/23/23 and Physical Therapy Evaluation and Notes 12/2022 lacked a motorized wheelchair assessment and evaluation for Resident #11 to safely operate a motorized wheelchair indoors and outdoors. A Physical Therapy evaluation dated 5/11/23 revealed Resident #11 referred to therapy for a wheelchair driving assessment due to recent fall outside when his wheelchair tipped over off of the curb. The resident was independent with motorized wheelchair previously. The resident's diagnoses included repeated falls, muscle wasting and atrophy, and sarcopenia. Therapy recommended the resident be modified independent with the electric wheelchair while indoors and outdoors. During an interview on 5/24/23 at 9:55 AM, the DON reported Resident # 11 went outside in motorized wheelchair and while he passed by another resident on the sidewalk, the two wheels got caught between the sidewalk and curb and he tipped over in the wheelchair. An ambulance was called and the resident went to the hospital to be examined. The resident was medically cleared and sent back to the facility. The DON stated a therapy evaluation requested upon resident's return from the hospital to determine if the resident safe to use a motorized wheelchair before he could use the electric wheelchair again. The DON reported she was unsure when the resident had an evaluation for use of motorized wheelchair before this incident. During an interview on 5/30/23 at 9:25 AM, Staff U, Physical Therapy, reported therapy unable to access therapy notes and records after transition to new company because they no longer had access to the records. Staff U stated the surveyor needed to check with medical records for therapy notes and evaluations prior to transition to new company. Staff U reported Resident #11's last and most recent therapy evaluation completed 5/10/23. On 5/30/23 at 10:00 AM, Staff V, medical records assistant, stated she was unable to obtain or provide records prior to switch in company. She would need to fill out a form and submit it to corporate to get the information requested by surveyor. 2. The MDS assessment dated [DATE] revealed Resident #40 had diagnoses of a muscle disorder and weakness, diabetes, and a fracture. The MDS recorded the resident had a BIMS of 6, which indicated severely impaired cognition. The MDS revealed the resident had no behaviors, and required limited assistance of one staff for bed mobility, supervision for transfers, ambulation in the room and corridor, and extensive assistance of one for toileting. The MDS documented the resident had a fall without injury but had no special treatment or therapies. The resident took opiod and diuretic medications during the 7 day look-back period. The Care Plan initiated 6/20/21 revealed Resident #40 had limited mobility related to chronic back pain and a history of a L2 (second lumbar) (lower back) fracture. The Care Plan also revealed the resident had a risk for unavoidable falls due to a history of falls, weakness, dementia, chronic pain, and restlessness. The staff directives included the following: ·Reinforce the need to call for assistance. Anticipate resident needs due to noncompliant with call light and dementia (added 6/20/21). ·Encourage resident to stay in common areas when awake for increased observation (added 6/29/21). ·Provide a room close to the nurse's station (added 6/29/21). ·Scoop mattress on the bed to help identify bed boundaries (added 7/29/21); mattress checked and changed after a fall 8/11/22. ·Keep non-slip and well-fitting footwear on the resident (added 11/10/21). ·Provide and keep walker nearby (added 7/18/22). ·Keep bed in low position (added 12/20/22, cancelled on 1/26/23). ·Send to ED (Emergency Department) for evaluation (added 5/30/23). A Fall Risk Evaluation dated 5/4/23 and 5/29/23 revealed the resident had a high risk for falls. The Progress Notes revealed the following: a. On 5/4/23 at 2:54 PM, a Change of Condition Note revealed the resident found on the floor in front of his bed, and resident stated he wanted to get off the floor. ROM (range of motion) within normal limits. Resident denied hitting his head, and had no skin alterations or bruises. Staff assisted resident off the floor. b. On 5/15/23 at 2:59 PM, resident wandering the hallways without a walker. Resident educated to ask for assistance when ambulated. c. On 5/29/23 at 8:27 PM, Staff II, agency LPN, documented she was called into the resident's room by the Certified Medication Assistant (CMA). Resident found on floor lying on his right side. The resident stated he was walking and lost his balance. Resident complained of increased pain with ROM and unable to bear weight on his right leg. Blood pressure and heart rate elevated. NP notified and order received to transfer the resident to the ED for further evaluation. d. An Incident Note documented on 5/31/23 at 12:34 PM revealed Staff II charted: upon assessment resident had shortening on the right side and increased pain with movement. Resident stated area felt better when lying still. Scheduled dose of pain medication given. d. On 5/31/23 at 7:23 PM, resident readmitted to the facility. Incident Reports revealed the following: a. On 1/21/23 at 1:10 PM, resident found lying on his right side on the floor in the dining room. The resident said the chair moved when he sat down and he fell. Resident assessed for injuries and had a hematoma (bruise) on the right side of his head. Two staff assisted the resident onto his feet. Physician and family notified. b. On 1/23/23 at 3:43 PM, resident found on floor by the bed with walker in front of him. Resident tried to transfer from a lowered bed into a chair. Two staff used a gait belt and assisted the resident up. c. On 2/16/23 at 11:59 PM, resident on floor and had back against the bed. The bed was at ground level. Vital signs obtained. Resident complained of some back pain when lifted back into bed. d. On 2/27/23 at 5:32 PM, resident found on the floor and had increased pain to his right hip. Right foot abducted (moved away from the body) and right leg shorter than the left leg. Resident sent to the hospital. e. On 5/29/23 at 8:03 PM, resident lying on the floor on his right side. Resident stated he was walking and lost his balance. The resident had increased pain with ROM and unable to bear weight onto his right leg. NP notified. Resident sent to the ED for further evaluation. A Facility Investigation File provided to the surveyor on 6/6/23 revealed a self reported incident to the State Department of Inspections and Appeals (DIA) due to an accident with major injury that occurred on 5/29/23 at 8:02 PM. A CMA reported she heard a noise while standing at her medication cart. She found the resident lying on his right side in his room next to the privacy curtain. The resident had gripper socks on. No debris or moisture on the floor. Nurse notified of fall and assessment performed. Rated pain at 8 (on 1-10 scale). Resident incontinent of urine. NP notified due to resident pain and decreased ROM. Order received to transport to the ED for further evaluation. Last seen and last checked on when walked back from dinner at 6:30 PM. The Facility Investigatin File lacked witness statements from staff. A History and Physical dated 5/29/23 at 10:42 PM revealed staff found the resident on the ground and complained of right hip pain. Right foot externally rotated. Oxycodone (narcotic pain medication) received prior to EMS (Emergency Medical Services) arrival. Resident unable to ambulate per usual. History of dementia, recurrent falls, and L2 compression fracture. Resident stated he got up without his usual 1-2 person assistance and got tangled up in stuff and fell forward. Per staff, resident found on the floor. Staff helped him up, however the resident unable to put weight on his right foot. Sent to the ED. Staff reported resident falls more often after his last hospitalization. Diagnosed with an L2 compression fracture at that time (in April). On examination, resident unable to move his right leg, and his left leg shorter than the right and turned outward. A pelvic CT (cat scan) revealed a nondisplaced fracture involving the posterior greater trochanter of the right hip. Ortho surgery consulted. During an interview on 6/7/23 at 9:25 AM, Staff D, CNA, stated Resident #40 confused and tried to get up and walk on his own but forgot to take the walker with him. Staff always had to remind the resident to ask for assistance and to take his walker with him. Staff used a hoyer for transfers since the resident came back from the hospital because the resident fell and had a hip fracture. Staff D stated she was not working on the day the resident fell and fractured his hip. During an interview on 6/7/23 at 9:50 AM, Resident #40 recalled he fell last week and went to the hospital. The hospital kept him overnight and gave him something for pain but he was unable to have surgery on his broken hip. The resident reported on the day of his fall incident he got out of bed, lost his balance, fell, and landed on his right side. The resident unable to recall if he had turned his call light on or not prior to the fall. During an interview on 6/7/23 at 7:10 PM, Staff II, agency LPN, reported she had worked at the facility as agency off and on since 1/2023. Staff II reported Resident #40 had dementia, poor safety awareness, self transferred alot, and noncompliant with using his walker. The resident also had alot of anxiety. Prior to the resident's fall (on 5/29/23) he required assistance of one staff for cares and ambulated with a walker. On the night the resident fell, as she passed bedtime medications for other residents, a CMA on the [NAME] hall yelled a resident on the floor. She went into the resident's room, checked the resident's vital signs, assessed the resident and performed range ROM while the resident laid on the floor, The resident couldn't tell her what hurt. After she assessed the him, two CNA's stood the resident up. The resident said Ow and pointed to his right hip. The staff then pivot transferred him into bed. A CNA stood on each side of the resident and Staff II stood in front of him. She didn't have staff walk him but rather pivoted and transferred him into bed. The staff who assisted during this time were an agency CNA and a facility CNA but Staff II unable to recall their names. As the resident laid in bed, she assessed the resident more. He continued to complain of pain with movement but had no pain while at rest. She called the on-call NP, and transferred the resident to the hospital. Staff II reported adequate staffing on the evening of 5/29/23. She observed a call light clipped to the resident but no call light on when he fell. During an interview on 6/7/23 at 2:30 PM, Staff JJ, CMA, reported she had worked at the facility since 9/2022. Staff JJ reported Resident #40 liked to wander and didn't stay in one place very long. He was constantly on the go and didn't ask for assistance. Resident #40 got up on his own and staff had to remind him to use his walker. Staff JJ reported she didn't think the resident had the mentality to ask for help. The resident recently fell and fractured his hip but still tried to stand up on his own. Staff JJ reported prior to the resident's fall he required assistance of one staff for ambulation and cares. On the day the resident fell and fractured his hip, she stood by the medication cart just outside the resident's room and prepared medications. She had just given Resident #40's roommate medication, walked out of the room, prepared Resident #40's medication, and heard the resident holler out. She turned around and saw the resident on the floor. Resident #40 was lying in bed when she had just gave his roommate medications. She found the resident lying on his right side on the floor by the privacy curtain. The resident told her he wanted to get up. She called for the nurse. The resident yelled Ow when staff started to move him. Staff JJ reported an agency nurse and agency CNA assisted the resident up but didn't know their names. Staff JJ reported the facility had so many staff coming and going, she couldn't keep up on who was who. The nurse entered the room first, then two CNA's came into the room. The nurse obtained the resident's vital signs, then sat him up on the floor. The resident started to yell out in pain. The nurse asked where his pain was, but the resident didn't tell her where he had pain. The nurse and two CNA's proceeded to stand the resident up and placed him into bed. The resident was unable to stand. The nurse tried to do ROM on the resident's legs, but the resident screamed in pain. The resident was sent to the hospital. Staff JJ reported whenever a resident had a fall, a nurse needed to assess the resident and ask the resident if he/she had any pain. If a resident had any pain then needed to leave the resident on the floor and call the ambulance. She isn't a nurse but that's what she had been instructed to do. Staff JJ reported she didn't want any part of moving him off the floor when the resident was in so much pain. Staff JJ reported she looked at the resident's [NAME] to know the cares needed and the interventions in place for the resident. Staff JJ reported interventions for Resident #40 included to ensure the resident had shoes and/or socks on his feet, make sure call light in reach, and remind the resident to use his walker and ask for assistance. Staff JJ recalled Resident #40 had socks on but not non-slip socks. During an interview on 6/7/23 at 8:00 PM, Staff LL, agency CNA, reported Resident #40 had dementia, always on the move and tried to stand up but had poor balance. Staff told him all day long to sit down and kept him by the nurse's station so staff could keep an eye on him. She worked the evening when the resident fell last week but didn't know he had fallen until she saw the ambulance at the facility. During an interview on 6/8/23 at 8:20 PM, Staff K, CNA, reported Resident #40 always tried to stand up or grab the bar in the hallway and stand up. On 5/29/23 evening, she assisted another resident but heard staff say this resident fell onto the ground when he tried to stand up by himself. She didn't help him off the floor. She just saw him when he had left the facility. During an interview on 6/8/23 at 8:40 AM, Staff H, CNA, reported staff tried to keep eyes on Resident #40 during the shift even though not assigned to him. The resident tried to get up on own and in a wheelchair most of the time. He required assistance of one staff and used a walker prior to a fall with fractured hip. Since the resident had prior falls, she placed walker out of reach so he didn't try to get up by himself. On the day of his fall with fracture, she heard someone say Resident #40 lying on the floor. The nurse asked who could help. Staff H reported she was helping another resident at the time but after she assisted that resident she went to see if she could help Resident #40. The nurse did an assessment Staff H reported she recalled she placed a hoyer sling under the resident and moved him back to bed. The nurse asked the resident what part of his body hurt. The resident complained of pain in his leg as the nurse touched him. When the surveyor questioned mode of transfer after resident fell on 5/29/23 evening, Staff H then stated she couldn't remember if she helped stand the resident up or if they used a hoyer. During an interview on 6/8/23 at 10:29 AM, Staff LL, CNA, reported Resident #40 pleasantly confused, used a walker during ambulation but now used a hoyer lift when transferred due to he had a fall and fractured his hip. Staff had to remind the resident to use his walker. She was on break when the resident fell. During an interview on 6/8/23 at 2:50 PM, the DON reported whenever a resident had a fall, she expected the staff nurse conduct a head to toe assessment, get statements from people who witnessed the fall, and complete a pain and fall assessment. The DON stated she expected staff to call the physician if a resident had pain after a fall and not move the resident. The DON stated the resident's care plan reviewed and interventions added after a fall. Resident #40 is a busy body, and walked up and down the hallways but sometimes forgot to use his walker. Staff reminded him to get his walker. On the day of incident when the resident fell, staff told her the resident had just ate dinner, went to his room, and resting in bed. A CMA prepared medications in the hallway and heard the resident holler out. The CMA found the resident on the floor by the curtain. A nurse assessed the resident but said he didn't complain of pain while lying on the floor. When the nurse palpated areas of his body, then able to tell location of his pain. The floor was clean and dry, and he had gripper socks on. Unable to recall if the resident had incontinence. The resident was unable to bear weight, and had hip tenderness when the nurse palpated the area. Resident transported to the hospital. A therapy referral was made after he returned from the hospital. The DON reported she had only talked with the CMA and Nurse but unable to reach the CNA's involved after the resident had fallen. The DON reported the interventions in place for fall prevention included the resident kept in a common area and kept busy, his bed kept in low position, scoop mattress on the bed, and staff checked on him frequently. A document dated 2011 titled Phase 1: Assess- initial plan of care revealed a plan of care developed if a resident at risk for falls or had a history of falls, and individualized interventions initiated. Fall reduction and injury prevention strategies that could be implemented upon admission may include: · Orientation to surroundings and use of call light. · Call light and and personal care items placed within reach. · Provision of environmental modification such as a low bed and cushioned floor mats next to the bed. ·Use of appropriate footwear. · Review of ordered medications for potential fall risk side effects. · Referral to physical and occupational therapy. An Interact Care Pathway for Falls dated 2014 revealed a fall is an unintentional change in position and coming to rest on the ground or onto the next lower surface. The care pathway directive included to perform an initial nursing evaluation for injury but do not move the resident off the floor until a complete exam performed. Contact the physician if a fracture or bone deformity suspected or had new or worsening cognition. 3. Observations revealed the following: a. On 5/16/23 at 8:35 AM, a portable oxygen (O2) tank sat upright on the floor in room [ROOM NUMBER]. The oxygen had a seal over the top which indicated an unused tank. b. On 5/16/23 at 12:20 PM, the portable O2 bottle remained in an upright position by the wall in the resident's room, not secured in a holder or rack. c. On 5/19/23 at 7:20 PM a portable O2 tank sat upright on the floor in the 200 hall across from room [ROOM NUMBER], and not secured in a holder or rack. The facility's Oxygen Storage policy revised 7/28/22 revealed oxygen stored safely and properly. Oxygen tanks needed restrained or secured at all times. During an interview on 5/16/23 at 8:35 AM, a family member reported Resident #16 used oxygen as needed. During an interview on 5/23/23 at 10:51 AM the facility's Maintenance Director revealed dollies used to transport oxygen canisters stored in the lower level and main level oxygen rooms. The Maintenance Director stated staff should use the dolly for transportation and storage of oxygen tanks. The Maintenance Director revealed the facility had plenty of dollies for oxygen canisters and the dollies available for staff to use. During an interview on 5/24/23 at 9:55 AM, the DON reported O2 tanks stored in a roller cart or on the back of the wheelchair in a holder. The DON agreed O2 should not be left unsecured in an upright position on the floor, rather it needed placed in a cart or a holder. 4. The MDS assessment dated [DATE] revealed Resident #15 had diagnoses of hydrocephalus, seizure disorder, and legally blind. The MDS documented the resident had impaired short-term and long-term memory and severely impaired decision making skills. The Care Plan initiated on 6/24/21 revealed the resident had cognitive loss related to hydrocephalus, TBI (traumatic brain injury), and at risk for behavior symptoms related to blindness, hearing deficit, and a potential to place non-edible things in his mouth and injest them. The staff directives included frequent supervision of the resident, not to leave the resident unattended in his wheelchair in his room, and lay the resident down in bed after each meal as the resident allowed and tolerated. On 5/19/23 at 8:45 PM, Resident # 15 sat in a wheelchair facing the wall across from the nurse's station. The resident had the door that stored a fire extinguisher open. The resident reached inside the cabinet and attempted to grab the fire extinguisher. During an interview on 5/23/23 at 10:49 AM, the facility's Maintenance Director revealed he had worked at the facility five years and had never had a resident pull a fire extinguisher from the wall. During an interview on 5/24/23 at 9:55 AM, the DON reported staff needed to redirect a resident if a resident had their hand in the fire extinguisher box/panel or attempted to remove the fire extinguisher.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and policy review the facility failed to administer medications through the correct port on a G-J tube (Gastrostomy-Jejunostomy tube - a tube placed into the stomach with three external ports) for 1 of 1 residents reviewed with a G-J tube (Resident #1). The failure led to the resident's transfer to the hospital due to a Gastric Outlet Obstruction when Staff Q, Registered Nurse (RN) administered medication into the balloon port of G-J tube (the balloon is filled with normal saline and is used as an anchor inside the stomach to hold the G-J tube in place) instead of the correct port that is used to put medication into the body causing the balloon to pop inside the resident. The facility reported a census of 86 residents, with 1 resident receiving enteral feeding tube services at the time of the survey. Findings include: Record review of Resident #1's Minimum Data Set (MDS) log on the facility's Electronic Health Record (EHR) revealed the facility did not complete MDS's for Resident #1 during her stay at the facility. Record review of Resident #1 admission Record dated 5/22/2023 documented an admission date of 4/21/23 and a discharge date of 4/21/23. The Progress Note dated 4/21/2023 at 11:45 AM documented the following admission note: Resident #1 arrived by gurney from hospital. The Progress Note dated 4/21/2023 at 6:42 PM documented the following change of condition note: Resident #1 was sent to the local emergency room (ER) for displacement of her G-tube by ambulance. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for Resident #1 documented one (1) medication given during her stay at the facility; Acetaminophen (Tylenol) 325 milligrams (mg), give three (3) tablets via G-Tube every eight (8) hours, may also give orally for pain with a start date of 4/21/23. Record review of Resident #1 Transfer Form assessment documented she was admitted to the facility on [DATE] for skilled care and was being transferred on 4/21/23 for G-tube displacement. The form also documented she had an enternal feeding tube. Record review of a document titled, Chief Complaint and History of Present Illness, dated 4/21/23 at 8:29 PM documented the following: Daughter reports Resident #1 recently moved long term care facilities. Today one of the nurses put crushed up Tylenol with water down the wrong tube, which caused her G-J tube's balloon to pop. The daughter informed that getting the G-J tube placement was very challenging and had to be done at a larger hospital after multiple other attempts. Resident #1 has not been able to receive her normal medications today and she denies any acute symptoms at this time. Record review of a document titled, Internal Medicine Health and Physical dated 4/21/23 at 10:10 PM for Resident #1 documented the following: At the Skilled Nursing Facility (SNF) Resident #1 was accidentally given a medication via the wrong tube causing mechanical malfunction of the tube. Since this time she has had some intermittent abdominal pain. She has not been able to take any of her medications today. Record review of a document titled, One-On-One In-service Record, dated 4/21/23 for Staff Q, Registered Nurse (RN) documented education he was shown the three different types of ports on residents G-J tube and was educated on the difference between ports. Record review of a document titled, Incident Report - Patient Involved, signed on 4/24/23 by Staff Q, the Director of Nursing (DON) and the Administrator documented the following: Description of incident: Staff Q administered medication through Resident #1 G-tube by pushing medication through the balloon port resulting in the malfunction of the G-tube. Record review of a document titled, Investigation Summary, with a date of investigation of 4/25/23 for Resident #1 documented the following: Summary of Alleged Incident: Malfunction G-J tube in resident with gastric outlet obstruction. The Nurse administered medication per tube with malfunction resulting in a burst of the balloon. Resident sent for evaluation and potential replacement, resulting in surgical intervention. Action Taken During Investigation: a. Train nurse involved immediately b. Train all licensed nurses with continuing education c. Quality Assurance of incident Conclusion: Resident remains hospitalized for other health concerns unrelated Record review of a document titled, Quality Assurance and Performance Improvement Committee Meeting dated 4/25/23 documented a new trend was identified for G-J tube malfunction and follow up is needed with staff education as the new mechanism requires nurse education plan. Record review of a document titled, Attendance, dated 4/25/23 revealed the facility provided reeducation on J-G tubes for nursing staff. Record review of a document titled Self Report, of the facilities report to Iowa Department of Inspections and Appeals (DIA) with a submission date of 4/25/23 documented the following Incident Summary: a. Chief complaint per hospital: Malfunction G-J tube for Resident #1 with gastric outlet obstruction. Nurse administration of medication per G-J tube, tube malfunctioned resulting in burst of balloon. Resident sent out for evaluation, resulting in surgery to replace the G-J tube and surgical intervention with intravenous radiology. Corrective Action: a. Sent to ER for evaluation b. Education provided to nurse Record review of Resident #1 Care Plan on 5/22/23 instructed she had a G-tube. The Care Plan lacked instruction on the type of tube she had, a G-J tube. During an interview on 5/23/23 at 7:05 PM Staff Q, Registered Nurse (RN) revealed he worked for an agency staffing company an recalled Resident #1 had a G-J tube that was a specialty tube and placed prior to her admission to the facility on 4/21/23. He revealed the G-J tube had 3 ports on it, he instructed one of the ports was for draining bile. He recalled he checked placement of the tube by insertion of a little air into the port and he used a stethoscope to listen for a swooshing sound/bowel sounds prior to administration of medication. He then informed he gave Tylenol through another port and the resident had tube displacement. He informed Resident #1 had some pain and that is why he gave her something for pain. He revealed he suspected the tube was displaced and called the doctor because he didn't have an x-ray machine. Resident #1 had pain and the tube had some problems and was difficult to assess. He revealed the doctor said due to the complex nature of the resident and that she has had multiple tubes to send her to the local hospital. He then revealed he didn't flush the port after he gave the medication and later found out the tube was displaced. He then informed he was not used to the type of tube Resident #1 had as it was a special tube. He revealed whenever he was unsure of how to do something or not familiar with a process or procedure he checked the policy and looked up information on what to do by using a policy from a previous company. During an interview on 5/24/23 at 1:00 PM the Director of Nursing (DON) revealed she was notified while Staff Q was talking with the Physician on the phone of the concern with Resident #1 G-J tube. She reported she went and spoke with Resident #1's family to find out what hospital they would like to go to. She revealed she educated Staff Q to make sure to check placement prior to administering medication and also revealed the facility had not had any tubes like that for the past two years. She informed Staff Q typically worked 3 nights a week and no education was provided to Staff Q regarding G-J tubes prior to the incident occurring. She then informed all agency nurses and facility staff nurses got training on enternal feeding tubes prior to working their first shift. During an interview on 5/24/23 at 1:20 PM with the Administrator revealed she would expect education to be requested or provided as necessary to nurses regarding feeding tubes. Record review of the facilities policy titled, Medication Pass, last reviewed on 3/28/23 lacked instruction to staff on how to administer medications to a G-J tube.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident, family, physician, and staff interviews, and policy review, the facility failed to ensure residents provided with routine repositioning to prevent pressure ulcers (Resident #3, #16) and failed to evaluate and provide appropriate sized equipment and initiate hospice orders for 1 resident (Resident #39) out of 4 residents reviewed for pressure ulcers. This resulted in harm to the residents due to residents developing facility acquired pressure ulcers. The facility staff identified 8 residents with pressure wounds at the time of the survey. The facility reported a census of 86 residents. Findings include: MDS Definitions of Pressure Ulcers Stage 1 Pressure Injury: Non-blanchable erythema of intact skin Intact skin with a localized area of non-blanchable erythema, which may appear differently in darkly pigmented skin. Presence of blanchable erythema or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 revealed the resident totally dependent upon 2 person physical assistance for bed mobility and transfer. The MDS documented diagnoses that included sarcopenia (age related progressive loss of muscle mass and strength), diabetes mellitus, dementia, and morbid obesity. The MDS dated [DATE] documented a height of 62 inches and a weight of 386 pounds. The Comprehensive Care Plan for Resident #3 revealed a focus area of impairment to skin integrity with multiple wounds including a Stage 3 pressure ulcer to sacrum. Interventions included off load heels as ordered and turn and reposition routinely and as needed. The Progress Note dated 1/29/2023 at 6:33 pm documented Resident #3 had excoriated buttocks and stated buttucks painful when touched. The Progress Note dated 1/31/23 at 2:57 pm documented staff placed a call to the facility Advanced Registered Nurse Practitioner (ARNP) regarding buttocks excoriation. The Wound Evaluation and Management Summary dated 2/2/23 documented the resident as having a Stage III pressure wound to the sacrum. The documentation reflected this wound at Site #31 for wound evaluation. Prior to this visit, the wound physician had been treating the resident for 30 prior wounds. The Summary documented the wound as etiology of Pressure, Stage 3 and size of 2.0 centimeter (cm) x 0.5 cm x unmeasurable depth, 100% slough covered. The evaluation recorded diabetes and dementia as relevant conditions that contributed to wound healing. Recommendations made during the visit included off-loading the wound site and to reposition per facility protocol. The Wound Evaluation and Management Summary dated 3/30/23 documented the Site #31 as Stage 3 Pressure, size of 2.0 cm x 0.5 cm x 0.1 cm, 100% granulation tissue, noted as healing. Recommendations remained as off-loading and repositioning. On the 3/30/23 visit, additional wounds of numbers 41-47 were all documented as new wounds. The Summary documented Site 41 as etiology of Pressure, unstageable Deep Tissue Injury of the right heel. Sites 42-47 were documented as unstageable deep tissue injury to the fingers of both hands, all documented as pressure in etiology. The Wound Evaluation and Management Summary dated 5/5/23 documented Site #31 as Stage 3 Pressure, size of 1.5 cm x 0.5 cm x 0.2 cm (increasing in depth), 100% granulation tissue, noted as healing. Recommendations remained as off-loading and repositioning. On the 5/5/23 visit, additional wounds of numbers 48-55 were all documented. The Summary documented Site 48 as non pressure, moisture associated skin damage to the right buttocks. Site 49 was documented as a Stage 4, etiology of pressure to the right, dorsal, lateral hand. Site 50 was documented as a venous wound of the left shin. Site 51 was documented as an unstageable deep tissue injury, etiology of pressure, to the left first finger. Site 52 was documented an unstageable deep tissue injury, etiology of pressure, to the left fifth finger. Site 53 was documented an unstageable deep tissue injury, etiology of pressure, to the right fifth finger. Site 54 was documented an unstageable deep tissue injury, etiology of pressure, to the right fourth finger. Site 55 was documented an unstageable deep tissue injury, etiology of pressure, to the right third finger. On 5/15/23 at 9:56 am, a family member of Resident #3 stated every time she was in the facility to visit, Resident #3 was flat on her back. She stated she had never seen the resident turned to her side. She stated she wondered if due to the resident's obesity the facility was not capable of turning her but stated it's not good for the resident to be on her back all of the time. Observeation on 5/15/23 at 11:05 am revealed Resident #3 laid on her back with a low air loss mattress in place on her bed. Observation revealed a treatment dressing in place on the resident's right hand and her left hand had multiple dark scabs on her knuckles. Observation on 5/16/23 at 7:55 am revealed Resident #3 again laid on her back in bed. On 5/16/23 at 10:28 am Staff A, Hospice Case Manager Registered Nurse (RN) and Staff B, Licenses Practical Nurse (LPN), with assistance from Staff C, Certified Medication Aide (CMA) performed wound care on the wounds to Resident #3's sacrum and right buttoks. Following wound care, the staff provided significant repositioning assistance and changed the resident's gown. The staff left the resident positioned on her back following cares. On 5/16/23 at 10:59 am, Staff B, LPN, stated the resident stayed primarily on her back at all times but tilted with pillows. Staff B stated that was due to the resident having pain and due to her bariatric size. Continuous observation occurred on 5/16/23 from 12:30 pm to 1:57 pm. The observation revealed no staff members entered Resident #3's room since wound care completed at 10:59 am. At 12:40 PM, Staff D, Certified Nurse Aide (CNA) dropped a lunch tray off in Resident #3's room and exited the door a moment later. At 12:52 pm, Staff D returned to assist Resident #3 to eat. At 1:06 pm, Staff D exited the room carrying the food tray and placed it in the kitchen cart. At 1:20 PM, Staff D stated that Resident #3 always stayed in bed. Staff D stated the resident required total assistance of 2 staff members to provide all cares except eating which required 1 staff person only. Staff D stated it took 2 people to reposition the resident and if the resident were to get out of bed, that would take 2 staff members using a hoyer lift (mechanical full body lift). At 1:57 PM, no staff members had cared for Resident #1 except for providing lunch; more than 3 hours had passed since the completion of wound cares. Continuous observation occurred on 5/21/23 from 11:41am to 3:40 pm. Observation revealed at 11:41 am Resident #3 laid on her back with her heels floated. At 12:46 pm, Staff E, LPN stated she was unaware of what treatments were ordered for Resident #3 but she would look after she completed medication pass. Staff E stated her work hours were 6:00 am to 6:00 pm. At 1:10 pm, Staff D, CNA, entered the resident's room with a lunch tray. At 1:15 pm, Staff D sat on a bench in the resident's room using her personal cell phone with Resident #3's lunch tray sitting untouched next to her. At 1:35 pm, Resident #3 remained in the same position as at the beginning of the observation At 2:15 pm, Staff E, LPN and Staff F, LPN, Nursing Supervisor, stated they would provide wound care treatments. Staff F responded she expected Resident #3 to be assisted to reposition at least every 2 hours. Staff F stated due to incontinence, the resident would likely need assistance more often than every 2 hours. At 2:20 pm, Staff E stated she was not familiar with the orders for Resident #3 and she was having difficulty getting the computer to work in the room. At 2:25 pm, Staff E administered morphine to Resident #3 prior to beginning wound care. At 2:35 pm wound care was started. This was 2 hours and 54 minutes after the start of continuous observation. Multiple wounds were cleansed and dressed. At 3:20 pm an additional dose of morphine was given to Resident #3 for comfort during the remaining wound care. Wound care was stopped to allow the resident to rest while the morphine had time to take effect. Wound care resumed at 3:30 pm. Two additional staff members, Staff G, CNA and Staff H, CNA entered the room to assist with repositioning. Complete repositioning occurred along with bedding and gown change with continuous observation ending at 3:40 pm. On 5/22/23 at 10:02 the Director of Nursing (DON) stated she expected that any resident who was unable to turn themselves should be repositioned a minimum of every two hours. On 5/23/23 at 11:23 am, the Wound Care Physician stated she had most recently cared for Resident #3 the previous week. She stated the resident did not tolerate lying on her side for very long. She stated the biggest factors in wound healing are off loading the pressure and the use of the low air loss mattress. She further stated the resident had significant moisture associated skin damage. She said the pressure wound to her sacrum has had minimal change or improvement and the most important factor for it to heal was off loading pressure. She stated she felt it was unlikely to ever heal fully but it would be beneficial for the resident to lie on her side. She stated she was not in the building for long enough to know if staff were repositioning the resident every two hours but it was her recommendation that it be done. The policy titled Skin Care Treatment Regimen, Revision dated 7/28/22 documented: Residents who are not able to turn and reposition themselves will be turned and repositioned every two hours unless specified in the Physician Order Summary. Review of the Physician Order Summary has no additional orders for repositioning for Resident #3. 3. The significant change MDS assessment dated [DATE] for Resident #39 identified a Brief Interview of Mental Status BIMS score of 3. A BIMS score of 3 suggested he had severe cognitive impairment. The MDS revealed he quired extensive assistance of two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The MDS indicated he was at risk for developing a pressure sore, had one stage one pressure injury and one stage two pressure ulcer present upon admission/entry or reentry. The MDS documented he had a pressure reducing device for his chair and bed, received pressure ulcer/injury care and received applications of ointments/medications other than to his feet. The MDS documented he required hospice services while a resident in the facility. The MDS documented the following diagnoses for Resident #39: sepsis, heart failure, diabetes mellitus, and depression. The care plan focus area dated 3/14/23 documented he was admitted to the facility with pressure ulcers to his sacrum, right outer ankle, and bilateral heels. The care plan directed staff to apply wound treatments as ordered by the physician. Review of Resident #39's hospice orders reviewed the following hospice physician order dated 5/9/23 at 11:55 AM: cleanse stage 1 right ankle wound with soap and water pat dry. Swab wound with betadine swabs then cover with foam bordered dressing and wrap with kerlix and secure with tape. Wound care is to be done daily and PRN for soilage or dislodgement. Hospice skilled nursing to provide wound care on hospice days and facility to provide wound care on non hospice days. Hospice nurse to educate staff on signs and symptoms of infection and to call hospice nurse with any signs and symptoms of infection. Review of Resident #39's May 2023 Treatment Administration Record (TAR) reviewed it did not contain the order that hospice wrote on 5/9/23 at 11:55 AM to treat his stage 1 pressure ulcer to his right ankle. On 6/2/23 at 8:23 AM the Administrator with the hospice provider indicated when a new order has been obtained the hospice nurse will let the facility staff know verbally but they typically send the order over via facsimile (fax). If the hospice staff is in the building they will ask the facility staff to put the order in their Electronic Health Record (EHR) while they are in house then the physician will sign off on the order. On 6/8/23 at 2:52 PM the Director of Nursing (DON) indicated when hospice writes new order the hospice staff and their A Registered Nurse Practitioner (ARNP) would sit together and put in new orders together. When she was made aware that the order for his right ankle pressure ulcer was not initiated after it was written by hospice, she said ok. The facility's Following Physician Orders/Transcription of orders policy with a revision date of 5/2023 indicated physician's orders will be received by a licensed nurse, therapist, or dietician. Orders may be received through written communication in the resident's chart, verbally or per telephone, via fax, or electronically entered in their charting system. If the order is for a medication or treatment, it should be entered in the MAR/TAR accordingly. Active orders should be followed and carried out as written/transcribed. 2. The admission MDS assessment dated [DATE] revealed Resident #16 admitted to the facility on [DATE] and had diagnoses of diabetes, urinary tract infection, and coronary artery disease. The MDS documented the resident had a Brief Interview for Mental Status (BIMS) score of 12, indicating moderately impaired cognition. The MDS revealed the resident had a risk for pressure ulcer development but had no skin problems or pressure sores. The significant change MDS dated [DATE] revealed the resident required extensive assistance of two for bed mobility, transfers, and toileting. The MDS documented the resident had a risk for pressure ulcer but had no skin problems or pressure sores. The MDS indicated the resident on hospice. The care plan initiated 3/7/23 revealed the resident had a risk for skin breakdown due to a history of dehydration, incontinence, diabetes, and immobility. The care plan documented the resident had a non-pressure wound on his right plantar lateral foot and a Stage 1 pressure sore on his right great toe. The care plan also revealed the resident required assistance with ADL's (activities of daily living) including bed mobility and transfers due to limited mobility and physical inactivity. The care plan directives for staff initiated on 3/7/23 included administer treatments as ordered and monitor for effectiveness, apply bilateral heel protectors as indicated, float heels at all times when in bed, provide a pressure relieving/reducing device on the bed and in the chair, and turn and reposition the resident routinely and as needed. The order summary report revealed the following: . a. Medex boots to heels for protection at all times while in bed started on 3/6/23 b. Body audit every Tuesday for skin observation started on 3/7/23 c. Right plantar foot wound: apply skin prep daily (started on 3/30/23); apply betadine and leave area open to air (started on 4/22/23); cleanse and apply gauze soaked in dakins quarter strength to the wound bed and cover with border gauze every day (started on 5/12/23). d. Left plantar foot wound: apply betadine and leave open to air daily started on 4/22/23 e. Right foot first (great) toe: Apply skin prep daily started on 5/6/23. The nursing admission assessment dated [DATE] revealed the resident had a small pinpoint area on his coccyx. The admission assessment revealed the resident scored 16 on the Braden Scale, indicating he had a high risk for pressure ulcer development however the top right side of the document revealed the category listed as low risk and a score of 7. The admission assessment revealed the following responses marked: the resident responded to verbal commands, but could not always communicate discomfort or the need to be turned, the resident had some sensory impairment which limited his ability to feel pain or discomfort in 1 or 2 extremities, he had exposure to moisture at least once a day, had a slightly limited ability to change and control body position, and had a potential problem with friction and shear. The progress notes revealed the following: a.On 3/21/23 at 7:01 PM, the resident's wife notified Staff W, agency Registered Nurse (RN) the resident had a wound on the bottom of his right foot. Staff W observed a necrotic wound. The wound measured 0.8 centimeter (cm) x 0.6 cm. No drainage noted. The bottom of the left foot had a 0.2 cm x 0.2 cm wound. No drainage noted. Hospice contacted. Hospice staff stated a hospice nurse would come and assess the resident. b. On 3/22/23 at 3:45 PM, the nurse practitioner (NP) documented the resident had a pressure ulcer on the anterior part of his right foot. The resident had pain rated at 4 out of 10, and was educated to elevate his leg. The NP documented the resident had a pressure ulcer present on both feet. The right lower extremity pressure ulcer measured 2.2 cm x 2 cm, and the left lower extremity wound measures 0.7 cm x 0.5 cm. The NP ordered a wound care physician (Dr) consult. c. On 3/30/23 at 3:50 PM, resident seen by the wound care Dr. A non-pressure wound on the right plantar lateral foot measured 2 cm (L)(length) x 1.8 cm (W)(width). No new orders received. d. On 4/7/23 at 7:28 AM, resident seen by the wound Dr on 4/6/23. A non-pressure wound of the right plantar lateral foot measured 2 cm (L) x 1.8 cm (W). No new orders received. e. A late entry progress note dated effective 4/13/23 at 2:12 PM, but created on 4/14/23 at 2:13 PM by Staff X, unit manager, revealed the resident seen by the wound Dr on 4/14/26. The resident's plantar lateral foot measured 2 cm (L) x 1.8 cm (W) and had a scab. New orders received and resident educated at the bedside. f. Another late entry progress note created by Staff X on 4/21/23 at 4:02 PM but effective on 4/20/23 at 4:00 PM revealed the resident seen by the wound Dr. A non-pressure wound of the right plantar lateral foot scab measured 2 cm (L) x 1.8 cm (W). A non-pressure wound on the left plantar lateral foot measured 0.3 cm (L) x 0.3 cm (W). The periwound (tissue surrounding the wound) had purpura (purple spots). New orders received. g. A late entry progress note created on 4/21/23 at 4:06 PM by Staff X but effective 4/20/23 at 10:05 AM revealed an end of bed extender lengthened by maintenance per request of the wound Dr due to the resident had a new foot wound. h, On 4/27/23 at 5:22 PM, wound Dr saw the resident. A non-pressure wound of the right plantar lateral foot measured 2 cm (L) x 1.8 cm (W). The left plantar foot wound had resolved. i. On 5/4/23 at 12:45 PM, a dark area noted to the right lateral foot. No redness or warmth surrounded the wound site. Resident compliant with wearing heel protectors. j. On 5/5/23 at 11:02 AM, wound Dr saw the resident. The resident's right plantar lateral foot wound measured 2 cm (L) x 1.8 cm (W) and had 100% thick adherent black necrotic tissue. The resident also had a wound on the right first toe that measured 0.3cm (L) x 1.1 cm (W). No drainage noted. Skin prep applied daily. k. On 5/11/23 at 3:23 PM, wound Dr saw the resident. The right plantar lateral foot non-pressure wound measured 2 cm (L) x 1.8 cm (W) and had 100% thick adherent black necrotic tissue. The right first toe wound measured 0.1cm (L) x 0.8 cm (W) x 0.1 (D). l. On 5/18/23 at 3:06 PM, wound Dr saw the resident. A non-pressure wound of the right plantar lateral foot measured 2 cm (L) x 1.5cm (W) and had 100% thick adherent black necrotic tissue. The right first toe wound measured 0.1cm (L) x 0.8 cm (W). The specialty physician wound evaluation and management summary revealed the following on the right plantar lateral foot: a. On 3/30/23 a non-pressure ulcer measured 2 cm x 1.8 cm. The physician recommended to offload the wound, reposition per facility protocol, and apply skin prep daily. b. On 4/6/23 the wound measured 2 cm x 1.8 cm. The physician recommended to offload the wound, reposition per facility protocol, and apply skin prep daily. c. On 4/13/23 the wound measured 2 cm x 1.8 cm. The physician recommended to continue to offload the wound, reposition per facility protocol, and apply skin prep daily. d. On 4/20/23, the wound measured 2 cm x 1.8 cm. The physician recommended removal of the bed foot board as the resident had a bed extender but his foot still pushed against the board. e. On 4/27/23, the wound measured 2 cm x 1.8 cm. The wound depth not measurable due to presence of nonviable tissue and necrosis. The physician recommended removal of the bed foot board as the resident had a bed extender but his foot still pushed against the board, reposition per facility, and continue skin prep daily. f. On 5/5/23 and 5/11/23, the wound measured 2 cm x 1.8 cm. The physician recommended removal of the bed foot board as the resident had a bed extender but his foot still pushed against the board, reposition per facility, and continue skin prep daily. The skin alteration record dated 5/11/23 revealed the resident had an eschar wound on the right plantar foot measuring 2 cm x 1.8 cm. A pressure ulcer healing chart used to monitor trends in PUSH scores over time revealed a record only for the right first toe. The document revealed on 5/5/23, a PUSH total score of 3 indicating the wound the size of 0.7 cm x 1.0 cm. On 5/11/23, a PUSH score of 1 indicating the wound less than 0.3 cm. A pick-up/exchange ticket dated 5/18/23 revealed a 36 inch ultracare low air loss mattress picked up on 5/18/23. Observations revealed the following: a. On 5/16/23 at 8:10 AM, resident lying in bed with feet on the mattress. b. On 5/16/23 at 9:15 AM, resident continued to lying in bed on his back and feet on the mattress. No pillow observed under the resident's legs. c. On 5/16/23 10:15 AM, resident continued to [NAME] in bed on his back. On 5/16/23 11:10 AM, resident continued to [NAME] in bed on his back. On 5/16/23 at 12:20 PM, Staff L, CNA, and Staff M, CNA, transferred the resident from the bed to the broda chair. Staff L and Staff M placed the foot platform (attached to the broda chair) in the down position. The top of the broda chair was in a semi-reclining position and the resident's feet extended over the end of the platform, The broda chair wasn't long enough for the height of the resident. Staff L placed a pillow under the resident's legs but the resident's feet and ankles were lying on the metal ridge of the foot platform on the broda chair. On 5/16/23 at 2:46 PM, resident now lying in bed. On 5/17/23 at 10:50 AM resident lying in bed with eyes closed. Bilateral feet lying on the mattress, no pillow under the resident's legs. A bed extender was observed on the end of the bed. On 5/17/23 at 12:29 PM, the DON removed the dressing on the resident's right lateral plantar food. The right lateral plantar foot had a nickel-sized scabbed, necrotic area. At 12:40 PM, Staff E, LPN, donned gloves, cleansed the right lateral plantar foot wound, changed gloves and sanitized hands, then applied a dakin's soaked gauze to the wound bed, and a border dressing to the area. Staff E removed her gloves, sanitized hands donned gloves and applied skin prep to the right great toe. During an interview 5/17/23 at 1:00 PM, Resident #16 reported he got a different bed a couple of days ago (on Monday 5/15/23, the day the surveyor entered the facility). The resident reported he was 6 foot 3 inches tall and the bed he had wasn't long enough. Staff had to put pillows in front of the end of the bed because his feet pressed up against the bedboard. The resident stated sometimes staff put a pillow under his legs to float his heels but sometimes it hurt his knees and unable to tolerate pillow at all times. The resident reported the Broda chair provided by hospice but his feet hung over the footboard because he was too tall. The resident reported staff placed a pillow under his legs whenever he sat in the chair. During an interview 5/17/23 at 4:00 PM, the DON reported documentation on wounds and pressure ulcers in the progress notes, but she also had a skin book with documentation of current wounds. The DON stated a referral made to the wound Dr anytime a resident had a significant wound. The NP came to the facility every Wednesday and evaluated the resident's wound progress. The DON stated the wound Dr's wound documentation located in the resident's paper chart. During an interview 5/18/23 at 3:15 PM, Staff Z, CNA, reported she had worked at the facility 14 years. Staff Z reported hospice staff came to the facility to see Resident #16 four times a week. Staff Z was unsure of the days when hospice visited. Staff Z reported Resident #16 required assistance with positioning in bed. During an interview 5/19/23 at 8:30 PM, Staff J, Registered Nurse (RN), reported lots of residents required two staff for assistance and cares. Staff J reported several residents had developed pressure ulcers because the residents had not been repositioned like they should due to the lack of staffing. During an interview 5/22/23 at 9:00 AM, Staff Q, RN, reported interventions such as positioning the resident put into place for prevention of pressure ulcer if a resident had a risk for pressure ulcer development. Staff Q reported the resident's skin risk level depended on if more specific interventions put into place. During an interview 5/22/23 at 3:00 PM, Staff V, medical records assistant reported a box located at the nurse's station for nurses to put items to go to medical records. Staff V stated the box utilized by staff to place discharged resident records, and staff supposed to file documents in the hard (paper) chart for residents who remained at the facility. Staff V acknowledged she also had a file with some records for residents who remained in the facility. The surveyor looked at Resident #16's file with documents in medical records with Staff V. The medical records file contained a pick-up exchange ticket dated 5/18/23 for a low air loss mattress, and a delivery ticket dated 3/29/23 for a broda chair and a seat lift chair. Staff V stated she believed the resident just needed the mattress because the facility had their own beds and bariatric beds. Staff V reported a certain vendor delivered equipment for residents on hospice. During an interview 5/22/23 at 3:35 PM, Staff AA, LPN, reported she let maintenance know if a resident needed a bed extender added to the bed. During an interview 5/22/23 at 3:45 PM, the DON reported Resident #16 didn't qualify for a bigger bed per hospice. The facility had their own bariatric sized bed and provided the resident a larger bed. The DON was unsure of the date when a bariatric bed provided to the resident but stated the vendor picked up the air loss mattress on date listed on the pick-up ticket. During an interview on 5/22/23 at 3:50 PM, the vendor reported the air loss mattress delivered on 3/20/23 and picked up on 5/18/23. During an interview 5/23/23 at 10:30 AM, the NP reported she had been a NP for 2 ½ years and contracted to work as the NP with the facility for the past 10 months. The NP reported she was unable to speak on the minimum interventions put in place for a resident if a resident had a risk for a pressure ulcer. It depended on the resident. When asked if a resident not repositioned or whenever orders or treatments not done if there would be a decline with a wound, the NP responded she had no knowledge what staff were doing and couldn't speak to the surveyor's question. The NP reported most of the time if a resident alert and oriented she asked the resident if they had any skin issues. Otherwise it depended on the resident whether she performed a head to toe skin assessment when a resident admitted to the facility and during follow up visits. The NP stated no policy or protocol used when a pressure area developed to promote wound healing as they didn't have one. The NP confirmed she was notified of a wound on Resident #16's foot and saw the resident on 3/22/22. The NP stated the wound type was a lower extremity ulcer caused by pressure on his bilateral feet. She directed staff to talk to the wound Dr about wound care. The NP was unable to say if the wound was preventable because each resident was different on the things they liked to do or didn't do. A number of factors played a role in a patient getting a wound. The NP was unable to be more specific on what factors would play a role in development of Resident #16's wound. The NP reported she didn't do anything with a Broda chair so she wouldn't know proper positioning in a Broda chair or what staff do for positioning the resident in the Broda chair. During an interview on 5/23/23 at 10:47 AM, the Maintenance Director revealed the facility had a process in place [TRUNCATED]