The facility identified a census of 26 residents, with three residents reviewed for falls and accidents. Based on record review, observation, and interview, the facility failed to transfer Resident (R) 1 safely with a gait belt, and in the process of the transfer staff lifted R1 by both of her arms and R1 sustained a broken left humerus (upper arm bone). This deficient practice placed R1 at risk for injury, pain, and delayed healing. Findings included: - R1's Electronic Medical Record (EMR) documented R1 had diagnoses of dementia (a progressive mental disorder characterized by failing memory, and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), major depressive disorder (major mood disorder which causes persistent feelings of sadness), and lymphedema (swelling caused by accumulation of lymph). The Quarterly Minimum Data Set (MDS), dated 10/14/24, documented R1 had a Brief Interview for Mental Status score of four which indicated severely impaired cognition. The MDS documented R1 had impairment on one side of her upper extremity and lower extremity. The MDS documented R1 required moderate assistance with eating, and maximum assistance with oral hygiene, dressing, and bed mobility. The MDS documented R1 was dependent on staff for toileting, bathing, and transfer. The Cognitive Loss/Dementia Care Area Assessment (CAA), dated 01/14/24, documented R1 had a diagnosis of dementia. She was oriented to herself but would get confused about situations, times, and dates. The CAA documented that R1 became anxious and would yell at staff to compensate. The Urinary Incontinence/Indwelling Catheter CAA, dated 01/14/24, documented R1 was mostly continent of bladder, was on a toileting schedule during the day and as needed at night. She required extensive assistance with toileting transfers and hygiene from two staff. The Falls CAA, dated 01/14/24, documented R1 was a high risk for falls due to vision loss, weakness, and the non-use of her left arm. The CAA documented R1 required one to two person assist with activities of daily living and transfers for safety. R1's Care Plan documented R1 required extensive assistance from two staff members for transfers (03/23/23). R1 no longer used a walker and relied on a pivot transfer with a gait belt for transfers (03/23/23). The care plan documented R1 complained of pain when a regular gait belt was used so R1 had a green Posey gait belt in her room (01/22/24). The care plan documented R1 was dependent on two staff for toileting transfers and peri care and was not to be left alone in the bathroom (03/10/23). The Incident Note, dated 10/20/24 at 07:50 PM, documented Certified Nurse Aide (CNA) M stepped out into the hallway and called Licensed Nurse (LN) G for assistance. R1 sat on the toilet, barely on the toilet, sideways with her head forward and her body flaccid (limp). R1 was unresponsive and her skin was clammy. She had a slight purple discoloration on her face. LN G lifted R1 off ofoff the toilet and into the wheelchair. R1 had her eyes closed but was making mumbling noises. LN G and CNA M transferred R1 into bed from the wheelchair and LN G heard and felt a loud pop in R1's left arm when they lifted R1 for the transfer. LN G removed R1's shirt and noted R1's left deltoid (upper arm) area bulging out and the left shoulder appeared to be higher than the right. R1 showed no signs and symptoms of discomfort with palpation of the area. The Communication Note, dated 10/20/24 at 07:51 PM, documented staff notified R1's responsible party of the two to three minutes of unresponsiveness, the popping noise heard with the transfer, and the resulting abnormalities of the left upper arm. R1's responsible party agreed to monitor R1 throughout the night unless signs and symptoms of pain and discomfort presented and then wanted R1 to transfer to the emergency room. The Health Status Note, dated 10/20/24 at 08:01 PM, documented that staff notified the on-call administrative staff of R1's unresponsive episode and the popping noise with transfer and subsequent abnormality to the left upper arm. The note documented a plan to monitor the resident throughout the night and send a SBAR (Situation, Background, Assessment, and Recommendation) a structured communication tool used to share information about a patient's condition to the clinic. The Health Status Note, dated 10/20/24 at 09:50 PM, documented R1 rested with her eyes closed. The note documented R1 had no signs and symptoms of discomfort in her upper left arm. The Health Status Note, dated 10/20/24 at 11:43 PM, documented an SBAR with information about the incident to R1's left arm was faxed to the on-call provider at the clinic. CNA M's Witness Statement, dated 10/20/24, documented CNA M put R1 on the toilet. CNA M left the bathroom and came back into the bathroom after pulling down R1's covers. CNA M found R1 unresponsive. CNA M looked out the door and yelled for LN G to come down and help. CNA M and LN G got R1 off the toilet. As CNA M and LN G transferred R1 to bed there was a loud pop. CNA M and LN G got R1's shirt off and R1's arm was swollen. LN G's Witness Statement, dated 10/20/24, documented on 10/20/24 at approximately 07:45 PM CNA M hollered out in the hallway for LN G to come and assist her in R1's room. Upon entering R1's bathroom, R1 was on the toilet. Her face had a slight purple discoloration, and her skin was clammy. R1 was unresponsive and her body was flaccid; she was barely sitting on the toilet. CNA M pushed the wheelchair underneath R1 and LN G lifted R1 off the toilet and into the chair. R1 remained unresponsive. R1 mumbled a few things while being pushed from the bathroom in the wheelchair but still had not opened her eyes. After getting to R1's bed, R1's body was still flaccid. LN G and CNA M assisted R1 with a two-person lift from the wheelchair to the bed. CNA M stood on R1's right side and LN G was on R1's left side. When staff lifted R1, there was a loud popping noise and LN G felt a slight pressure in R1's left upper arm. LN G immediately pulled down R1's shirt and sleeve and noted R1's left deltoid area had slight swelling and R1's left shoulder was slightly raised compared to the right shoulder. R1 did not demonstrate any signs or symptoms of pain or discomfort. R1 slowly became more responsive. The facility's undated Incident Report documented Administrative Nurse D contacted LN G about the incident. LN G explained that CMA M had called for assistance from the hallway and LN G responded. When LN G got to the bathroom, CNA M was in the bathroom with R1 and R1 was unconscious, seated on the toilet. LN G assisted CMA M in transferring R1 to the wheelchair. Administrative Nurse D asked LN G if a gait belt was used and LN G admitted a gait belt had not been used. R1 was taken from the restroom to her bed. R1 still did not respond appropriately so LN G and CNA M transferred R1 to the bed. During the transfer, staff heard a popping noise and LN G felt R1's arm move against her body. After completing the transfer, LN G assessed R1's arm and it had begun to swell. R1 did not appear to be in any pain. LN G and CNA M both admitted they did not use a gait belt when they transferred R1. CNA M stated she was concerned for R1's immediate safety when R1 was unconscious on the toilet and therefore did not apply the gait belt for that transfer and then when they transferred R1 to the bed from the wheelchair, CNA M did not think to use the gait belt. She said she was just thinking of R1's safety. LN G stated she felt like it was an emergent situation and responded to R1's immediate needs which was getting her to a safe position. Administrative Nurse D counseled LN G and CNA M on gait belt use and ensured they were aware of the resident's care-planned need for gait belts and where to find this information. The facility will continue random audits for appropriate gait belt use. The Plan of Care Note, dated 10/21/24 at 08:24, documented that R1's left arm was swollen and discolored. R1 stated she had slight tenderness in her shoulder area but not in the rest of her arm. R1 rested in bed. The Order Note, dated 10/21/24 at 08:26 AM, documented R1's primary care physician, ordered a two-view left shoulder x-ray for pain. The Plan of Care Note, dated 10/21/24 at 10:00 AM, documented staff were able to get R1 up and transferred to her recliner to eat breakfast. R1 continued to have no complaints of pain or discomfort. The Plan of Care Note, dated 10/21/24 at 11:14 AM, documented the facility received a call from the nurse practitioner and she requested to see R1 in the emergency room to splint her left arm which had a fracture. The emergency room Discharge Paperwork, dated 10/21/24, documented R1 had a left humerus fracture. Orthopedics (bone specialist) was consulted and advised R1 was not a surgical candidate and recommended a posterior (backside) or sugar-tongue splint to the left arm. Orthopedics wanted R1 to follow up in the clinic with repeat X-rays on Wednesday. The plan of care was discussed with R1's primary care physician and an appointment was made for R1 to see him on Wednesday, 10/23/24 at 02:00 PM for repeat x-rays to be done prior to the appointment and sent to orthopedics. The left posterior arm splint and sling were to remain in place at all times. R1 was non-weight bearing to her left upper extremity. The Order Note, dated 10/21/24 at 01:36 PM, documented R1 was back from the emergency room and would have another x-ray on Wednesday. R1 presented with a left posterior arm splint and sling that was to remain in place at all times. R1 could use over-the-counter Tylenol or ibuprofen (pain medications) as needed for pain or swelling. The note ordered to apply ice to the affected area three to four times daily for thirty minutes for three days, then discontinue. The Radiology Report, dated 10/23/24, documented R1 had sustained a displaced overlapping proximal humerus fracture with some improved alignment. The Health Status Note, dated 10/23/24, documented R1's left humerus x-ray report showed a proximal humerus fracture with some improved alignment with interval splinting. The Health Status Note, dated 11/06/24, documented R1 complained of pain in her left forearm. The CNAs reported R1 had consistently pointed to that area and complained of pain. The nurse pulled pack the ace wrap and encountered cast padding with a sleeve under it. The nurse contacted the on-call provider for advice on how to position and maneuver the left arm for assessment so as not to move the fracture to the left humerus and was advised to bend the elbow like a bicep curl. Upon assessment, a bruise was found on R1's left forearm with black spots in the middle and reddened areas towards the outside which measured 3 centimeters (cm) by 2.6 cm. The findings were reported to the on-call provider, and he advised to return the casting as it had been and loosely wrap the ACE bandage back around the splint. R1's primary care physician will see R1 tomorrow and address the area of concern. The Order Note, dated 11/07/24, documented R1 had a follow-up appointment with her primary care physician regarding her left arm and the pressure area from the splint; padding was placed on the splint. On 11/14/24 at 10:00 AM, observation revealed, R1 sat in her wheelchair with a left splint and sling to her left arm. On 11/14/24 at 10:00 AM, R1 stated she had pain in her left arm and pointed to her left arm with her right hand. On 11/14/24 at 10:15 AM, CNA N stated she never transferred R1 or any other resident without using a gait belt. CNA N stated R1 had complained of pain in her left arm numerous times since breaking it. CNA N stated R1 had just got done showering and the left splint and sling never came off but was wrapped up in a bag to keep it dry. On 11/14/24 at 10:30 AM, LN H stated she expected all staff to use a gait belt with all transfers because it was the only way to ensure resident and staff safety. On 11/14/24 at 01:00 PM, Administrative Nurse D stated she had talked to CNA M and LN G and they admitted they had not used a gait belt for any of R1's transfers the day of the incident. Administrative Nurse D stated there were other ways R1 could have been transferred besides the way staff had transferred her that day. Administrative Nurse D verified she educated all facility staff regarding gait belt use with transfers and following resident care plans on 10/21/24 and was performing gait belt audits randomly throughout varying shifts for four weeks. The facility's Gait Belts and Transfer Policy, revised 03/19/07, documented that gait belts are provided to assist staff in safely transferring or ambulating residents. Note the use of a gait belt in the resident care plan. The facility failed to transfer R1 safely with a gait belt which resulted in a broken left humerus. This deficient practice placed R1 at risk for injury, pain, and delayed healing. On 10/21/24, the facility identified and completed all corrective actions including staff education on following residents' plan of care, use of gait belt use with transfers, and completed gait belt audits randomly for four weeks. All actions were completed before the onsite survey therefore the deficient practice was deemed past noncompliance and remained at a G scope and severity.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 23 residents. The sample included 13 residents with eight reviewed for falls. Based on observation, record review, and interview the facility failed to ensure an environment free from accidents when staff placed Resident (R) 4's electric lift chair remote in reach, despite a safety evaluation which indicated it was not safe. As a result, R4 fell and required sutures to her head laceration. The facility continued to leave the lift control within R4's reach, which placed her at continued risk for falls, injuries, and associated pain. Findings included: - R4's Electronic Medical Record (EMR) recorded diagnoses of anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, atrial fibrillation (rapid, irregular heartbeat), hypertension (HTN-elevated blood pressure) with heart failure, Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), weakness, and repeated falls. The Quarterly Minimum Data Set (MDS), dated [DATE], documented R4 had moderately impaired cognition. R4 had a functional range of motion impairment on both sides upper and lower extremities. R4 was dependent with toileting hygiene and showering and required substantial to maximal assistance with mobility. R4 had a toileting program and was frequently incontinent of urine and occasionally incontinent of bowel. R4 had one non-injury fall. The MDS further documented R4 received an antianxiety (class of medications that calm and relax people), antidepressant (a class of medications used to treat mood disorders), anticoagulant (medication used to prolong blood from clotting), diuretic (medication to promote the formation and excretion of urine), and opioid (medication used to treat pain) medication; R4 used a bed and chair alarm daily. The Annual Fall Care Area Assessment (CAA), dated 08/08/23, documented R4 had multiple back surgeries, mobility, and pain issues, and was at high risk for falls. R4 walked with a walker and one to two-person assistance for short distances. The CAA further documented R4 had not always called for assistance or wait for staff to help her so an alarm pad in her chair and bed. R4's Care Plan dated 02/09/24 documented R4 had multiple back surgeries with mobility and pain issues related to her back. R4 reported her left leg did not work well. She had multiple falls prior to moving into long term care and she had several since. The care plan instructed R4 had her lift chair from home but could no longer safely operate the chair. R4's Durable Power of Attorney (DPOA) was aware of this and the safety risk of falling. R4's DPOA would like staff to operate the chair for her, and if needed, the DPOA would provide a mechanical recliner in the future. The plan documented an assessment would be done quarterly to evaluate for safety. The Quarterly Lift Chair Safety Assessment dated 11/06/23, 01/29/24, and 04/29/24, documented R4 had not met the safety requirements for a lift chair unless under supervision. The Progress Note dated 05/18/24 at 07:20 PM documented a Certified Medication Aide (CMA) requested immediate assistance to R4's room. Upon entering the room, R4 was laying prone (lying face down) on the floor and shifted more onto the left side. There was a large amount of blood present related to a head laceration (wound to the skin) to R4's left forehead and bruising noted to R4's left eyebrow. R4 stated she was trying to get to the bathroom. R4 was transferred to the emergency room at 07:31 PM. The Progress Note dated 05/18/24 at 07:34 PM documented upon further discussion with the CMA, the resident's chair alarm started going off and staff ran to the room where R4 was found lying on the floor. There were non-slip socks were present, and the lift chair was lifted all the way up. The Progress Note dated 05/18/24 at 11:30 PM, documented R4 returned from the emergency room, and had six sutures to the left forehead laceration. A head and cervical spine (neck/spine) computed tomography scan (CT-imaging to obtain detailed internal images of the body) resulted with no negative findings from the trauma. The Progress Note dated 05/20/24 at 10:39 PM, documented R4 had her call light on but was trying to get out of her easy chair independently at 09:45 PM when staff responded. R4 had dark purple bruising to left side of her face and around her left eye. On 05/21/24 at 02:53 PM, observation revealed R4 sat in her recliner with the footrest elevated. The call light was fastened to the right arm rest of the recliner. The remote controls to the recliner sat on the top of a nightstand to the right of the recliner. R4 reported she was blind in her right eye and that is why she had a dark lens in her glasses. R4 reported she fell the other day trying to go upstairs. She said she fell and hit her head and it bled everywhere. On 05/23/24 at 09:00 AM, observation revealed R4 sat in her recliner with her eyes closed, covered with blankets. The footrest of the lift chair was elevated. The call light and the lift chair control were resting on the right arm rest within her reach. There were no staff present supervising. On 05/22/24 at 11:07 AM, Certified Nurse Aide (CNA) M reported staff keep R4's call light within reach, and staff position themselves close to the resident's room. CNA M said staff place appropriate footwear on R4, elevate her feet due to swelling, and place a walker or wheelchair within her reach in case she tries to get up on her own. CNA M reported the chair remote for the electric lift chair should be placed on the nightstand next to the chair to the right side of the resident due to R4 being blind in her right eye. On 05/22/24 at 11:45 PM, Licensed Nurse (LN) J reported staff try to check R4 frequently to make sure things R4 would want are kept withing reach and where she could see them. LN J stated R4 would get impatient with staff and try to get up and only sometimes used the call light. On 05/23/24 at 09:02 AM, CNA O reported R4 had an alarm because she would try to stand up on her own and required two staff for transfers. CNA O stated R4's last fall was due to the resident trying to get up and she fell into the dresser. CNA O verified at this time the call light and lift chair control were located on the right arm rest of the recliner in reach, while the resident sat in it. 05/23/24 at 09:07 AM, Administrative Nurse D stated R4's DPOA was aware she could no longer safely operate the lift chair and knew the safety risk of falling. Administrative Nurse D said R4's DPOA would like staff to operate the chair. Administrative Nurse D verified the call light and lift chair control was present on the right arm rest of the recliner, and stated staff may have to unplug the electric lift chair to prevent R4 from operating the chair without staff present. The facility's Fall Prevention Guidelines policy, dated 09/26/19, documented the facility to provide a safe environment for residents while helping them maintain an optimal level of independence. To assess to residents and implement interventions to keep them safe and independent. The facility failed to ensure an environment free from accidents when staff placed R4's electric lift chair remote in reach despite a safety evaluation which indicated it was not safe. As a result, R4 fell and required sutures to a head laceration. The facility continued to leave the lift control within R4's reach, which placed her at continued risk for falls, injuries, and associated pain.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 28 residents. The sample included 12 residents with one resident reviewed for foot care. Based on observation, record review, and interview the facility staff failed to provide appropriate foot care in accordance with professional standards of practice, to prevent complications from conditions such as diabetes, when a Certified Nurse Aide (CNA) filed Resident (R) 15's callous on her right big toe, which caused a wound. As a result. R15's wound became infected, required medical treatment including antibiotics, and continued to cause R15 pain. Findings included: - R15's Electronic Medical Record documented the resident had diagnose of type II diabetes mellitus (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin). R15's Quarterly Minimum Data Set (MDS), dated [DATE], documented the resident had a Brief Interview for Mental Status (BIMS) score 14, which indicted intact cognition. The MDS documented R15 required supervision with transfers, was independent with the rest of her activities of daily living (ADLs) and had an infection of her foot. R15's Diabetes Mellitus Care Plan, revised 05/25/22, instructed staff to provide diabetic foot checks on the resident twice weekly on Tuesdays and Fridays. The care plan documented the resident received added protein in her meals three times daily for wound healing, and multivitamin and vitamin C daily for wound healing. The care plan documented R15's right great toe was scabbed over, with signs of healing, and pink skin around area. The plan of care recorded the toe had no dressing and instructed nurses to monitor the wound twice weekly with baths. The Skin/Wound Notes, dated 01/14/22 at 09:23 AM documented R15's skin was intact and both feet had dry skin. The note documented R15 complained of right great toe pain around the callous (thick and hardened area of skin), and had some purple discoloration. The note documented the resident stated CNA M filed it on the resident's last bath day, and R15 had discomfort since then. The Skin Assessment Sheet, dated 01/28/22, documented the wound on the tip or R15's great toe measured 1.2 centimeters (cm) long (l) by 0.9 cm wide (w) with 0.2 cm depth. The area had a pink, soft, mushy pinpoint open area, and a wound dressing identified as Duoderm (wafer type moisture-retentive wound dressing used for partial and full-thickness wounds leaking fluids) to be changed every three days and as needed and instructed the wound nurse to follow and treat the wound. The Skin/Wound Note, dated 01/28/22, documented R15 had a pinpoint open and the resident complained of discomfort to the affected area. Administrative Nurse D discussed wound treatment, applied Duoderm dressing to the affected area and would change and monitor area every three days and as needed. The Skin/Wound Note, dated 01/31/22 documented the area on the tip of R15's right great toe was dried, slightly crusty, tender, and slightly boggy underneath. The dressing was changed to include a small amount of medihoney (wound gel used for debriding (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue) on the area, cover with a corn pad, and secure with tape. The note documented the resident would receive a bath the next day. At that time, Administrative Nurse D would see if the area could be debrided (mechanical removal of dead tissue) by scrubbing it, and the physician was notified regarding the wound. A Skin/Wound Note, dated 02/01/22 documented R15 had a stage three (broken completely through the top two layers of the skin and into the fatty tissue below) pressure ulcer on her tip of right great toe, measured 0.4 cm (L) x 0.5 cm (W) x 0.1 cm (D), which was red and granulating (regrowth of tissue). The note recorded a Promogran (a medicated dressing used for exudation (fluid that leaks out of body vessels and tissues]) dressing was placed on the wound, covered with Medihoney, and secured with tape. A Skin/Wound Note, dated 02/08/22, documented staff completed the diabetic foot check on R15's feet and toes. The treatment was changed to cleanse area, apply Promogran, Polymen (breathable yet tough, protective, water-resistant dressing), and secure with tape. The open wound area measured 0.5 cm (L) by0.6 cm (W). A Skin/Wound Note, dated 02/11/22, documented R15 complained of pain to right great toe wound when walking or pressure applied to end of toe. A Skin/Wound Note, dated 02/11/22, documented R15 had a 0.3 by 0.3 cm wound on the tip of her right great toe, which was dark pink, R15 reported the wound hurt when she walked. The dressing was changed to place a corn pad to protect, Polymen, then secure with tape. A Nurse's Note, dated 02/21/22, documented R15 had appointment the next day with the physician for the wound on her right great toe. The Physician Office Visit Note documented on 02/22/22 at 01:30 PM R15 presented to the clinic for a painful big toe. The note documented Administrative Nurse D reported a certified nurse aide filed a callous too close and irritated R15's toe. The note further stated Administrative Nurse D initially treated the wound like a pressure wound and placed some triple antibiotic ointment with band-aide; R15 had irritation with the toe for approximately six weeks. The note documented the resident had a skin ulcer of the toe on the right foot with the fat layer exposed. The Skin Assessment Sheet, dated 02/28/22, documented R15's tip of the great toe measured 0.5 cm by 0.6 cm, had no depth, was pink, and improving. The Physician Office Visit Note documented on 03/23/22 at 10:30 AM recorded the wound on the end of R15's right great toe had a callous on it that had been filed down and created an open area. The treatment was Medihoney, and cover with foam. The note documented R15's toe was red, swollen, and painful with pressure or palpation. There was no drainage from the area, though the area had increased warmth and the physician diagnosed it with cellulitis (skin infection caused by bacteria characterized by heat, redness and swelling). The physician ordered staff to administer Doxycycline (antibiotic) ,100 milligrams (mg), twice daily for seven days and to call for any new, worsening, or changing symptoms. A Skin/Wound Note, dated 04/08/22, documented R15 had wound trauma, measured 0.5 (L) by 0.5 (W) and 0.1 cm (D) and the treatment was changed to Aqucel (sterile post-operative dressing made of an inner (wound contact) non-woven pad) dressing apply to fit wound bed, cover with Polymen, and secure with tube gauze. The Wound Culture Report, dated 05/02/22, documented R15's tip of the right great toe wound had staphylococcus (bacterial infection) and enterococcus (bacterial infection). A Nurse's Note, dated 05/11/22, documented the nurse received a physician order to start R15 on intravenous (IV-medication delivered directly into the blood stream via a catheter placed in the blood vessel) Vancomycin (broad spectrum antibiotic) 750 mg daily until 06/22/22 for right great toe wound infection. A Hospital Wound Care Evaluation /Re-evaluation Sheet, dated 05/17/22 at 08:15 AM, documented the same dressing was applied to R15's tip of the right great toe wound. The sheet documented R15 continued to receive Vancomycin IV daily for an infection to the right great toe through a peripherally inserted central catheter (PICC-long, thin tube that's inserted through a vein in your arm and passed through to the larger veins near your heart). A Hospital Wound Care Evaluation/Re-Evaluation Sheet, dated 05/20/22 at 01:14 PM, documented R15 received treatment for an ulcer on her right great toe. The sheet noted the physician wanted to perform a procedure to clean out the infection. Administrative Nurse D visited with R15's Durable Power of Attorney (DPOA-appointed person to handle certain matters, such as finances or health care) about the procedure, and the DPOA would schedule an appointment with a different physician. The note documented R15 received Vancomycin through outpatient at the hospital for the wound culture results. The note documented the resident had a lot of callous build up on her toe which Administrative Nurse D peeled off easily, and the plan of care to the wound was to moisturize her toe and leave the dressing off. A Nurse's Note, dated 06/06/22, documented R15 had part of the bone in her infected great toe wound removed by the podiatrist (foot doctor) that day. The note further stated the wound began to ache really bad that afternoon, and the nurse received a physician order to administer to Norco (narcotic pain medication) to R15. A Nurse's Note, dated 06/06/22, documented R15 reported right great toe wound pain rated at a 7 (0-10 scale with 0 being no pain and 10 being the worst pain imaginable) at 06:50 PM. The nurse administered Norco to the resident at 07:15 PM and the resident rated her pain at an 8. The note documented the nurse changed the gauze dressing due to bloody drainage leaking through the dressing, wrapped it with coban, and placed a cool compress over the dressing to alleviate some pain. A Nurse's Note, dated 06/08/22, documented the resident continued to report pain in her right great toe wound and the pain medication she received was enough to help with pain. A Nurse's Note, dated 06/10/22, documented R15 complained of discomfort to right great toe during the night and upon rising in the morning and the right great toe wound had purple discoloration. A Physician Office Visit Note documented on 06/14/22 at 02:30 PM recorded R15 reported that her right great toe still hurt. The note documented R15 had a bone biopsy (sample of tissue is removed from the body to examine more closely) and debridement with podiatry the previous week. R15's incision was healing well, and sutures were to be removed the following week. The bone biopsy showed no osteomyelitis (bone infection) so Vancomycin was discontinued. On 07/13/22 at 09:00 AM, observation revealed Licensed Nurse (LN) G applied gloves, removed the R15's gripper sock on her right foot to reveal an uncovered wound area at the tip of the resident's great toe. The indented wound had pink surrounding tissue, with a pinpoint scab in the middle, no odor or drainage noted. R15 stated it was tender to touch but was finally healing. On 07/13/22 at 09:00 AM, R15 stated she went through hell the last six months with the pain from the wound on the tip of her great toe. R15 stated she felt the wound was a result of the CNA filing the callous. On 07/13/22 at 11:30 AM, CNA N stated the facility did not have a designated bath aide. She said when she came to work, the nurse provided her with a list of residents she was responsible for providing baths on that day. CNA N stated all CNAs could provide foot care on all residents' bath days. CNA N further stated the only training she had was two years ago when she was first employed; she watched another aide provide foot care. On 07/13/22 at 08:59 AM, LN G stated CNAs provided resident foot care, including diabetic residents, on their bath day. LN G stated if the CNA was not comfortable providing it to diabetics, the CNAs would get the nurse. On 07/12/22 08:57 AM, Administrative Nurse D stated she heard that CNA M had filed R15's callous too close, but when she asked CAN M, CNA M responded she did not file R15's callous. Administrative Nurse D stated R15 had a spot on the tip of her great toe, which ended up being an ingrown toenail. Administrative Nurse D stated the podiatrist fixed the ingrown toenail (condition where the corners or edges of a toenail grow into the skin) and the wound was now open to air and was healing. 07/14/22 at 11:20 AM, Administrative Nurse D stated she preferred a nurse to provide residents footcare, but CNAs were permitted to provide foot care. Administrative Nurse D stated if a resident was diabetic, the CNA can only file, not clip, the resident's toenails. On 07/13/22 at 03:24 PM, Consultant GG stated he was unaware R15 had a wound on her tip of right great toe. Consultant GG stated if a resident was diabetic, CNAs should not provide foot care on that resident prior to consulting with the facility wound care nurse. The facility's Bathing Policy, revised on 09/26/19, instructed staff to call the charge nurse to trim calluses and toenails on diabetic residents. The facility failed to ensure R15 received appropriate footcare in accordance with professional standards of practice, when a CNA filed R15's callous, causing her pain, infection and surgery.