**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and document review the facility failed to identify, comprehensively assess, monitor surgical wound changes for 1 of 1 resident (R5). This resulted in harm when the physician was not notified of R5's fall that caused R5's wound to dehisce which delayed healing because of required surgical intervention. Findings include R5's Minimum Data Set (MDS) assessment dated [DATE], indicated R5 admitted to the facility on [DATE] from a hospital with diagnoses including encounter for orthopedic aftercare following surgical amputation, acquired absence of right leg below knee, and type 2 diabetes mellitus. The MDS indicated R5 had a major surgical procedure during her prior inpatient hospital stay that required active care during her stay at the facility and had surgical wounds. R5's care plan included a focus dated 5/31/24, that included I have an alteration in skin integrity related to aftercare following surgical amputation of right lower extremity. Goals with revision date of 6/18/24 included I will be free of complication and minimized pain related to my skin alteration through the review date and My alteration in skin integrity will show signs of improvement in healing by the review date. Interventions dated 5/13/24 included administer my treatments as ordered, assess/monitor the alteration in my skin integrity and document status weekly, prevent trauma, and ensure I have proper fitting footwear. R5's physician note dated 7/3/24, indicated she had a right below the knee amputation (BKA) on 5/22/24 with placement of a wound VAC (negative pressure wound therapy via vacuum assisted closure dressing) placed for postoperative healing. On 6/21/24 R5 was evaluated by orthopedic surgery with the incision in excellent condition per reports and care with the wound VAC was continued. R5's physician order with start date of 7/2/24, instructed staff to complete a weekly skin check every Thursday on the day shift. R5's physician visit note from doctor of medicine (MD)-A dated 7/5/24, indicated R5 was seen in the cast room clinic for orthopedic surgery follow-up. It noted R5 had a right transtibial amputation (BKA) on 5/22/24. Her wound VAC was discontinued, 23 centimeter (cm) incision was noted to be healed, the remining sutures were removed, Steri-Strips were applied and to be removed in two weeks, she was fitted with a compression sock, she had a future appointment with the amputee clinic scheduled on 7/18/24, and further follow-up with orthopedic surgery was to be as needed. R5's Incident Note progress note by licensed practical nurse (LPN)-C dated 7/9/24 at 5:49 p.m., indicated therapy yelled for help and we discovered res[ident] lying face down on her floor and her wheel chair was lying beside her she was trying to reach for something in her drawer she said, we asked her where she hurt and if she hit her head, she said no to head and her stump was hurting and it was also bleeding the bp [blood pressure] machine was not working so we got her up with Hoyer [type of mechanical lift] and then we took her vs [vital signs] 174/70 [blood pressure] p [pulse/heart rate] 75. The corresponding Incident Report #1758, added the injury was located on front left lower leg and was described as a laceration. The report did not include further assessment of the laceration. R5's record did not include a comprehensive assessment of the injury to the residual limb that was identified in the Incident Note and Incident report dated 7/9/24. An SBAR [Situation, Background, Assessment, and Recommendation-physician communication form] progress note by LPN-C dated 7/9/24 at 5:55 p.m., included right hip abrasion and end of stump bleeding but did not include further assessment of the wound. R5's progress note dated 7/10/24, indicated R5 refused her shower that evening, she had one on Saturday. It did not include assessment of R5's skin or identify the wound on R5's right residual limb. R5's FOCUS progress note dated 7/10/24, indicated the reason for review was 7/9 17:10 [5:10 p.m.] unwitnessed fall in room and the skin and wounds section noted surgical incision with routine healing. It did not identify the recent alteration in R5's right residual limb wound or include assessment of the wound. R5's Post Fall assessment dated [DATE], noted the presence of leg pain but did not identify or include assessment of the wound on R5's right residual limb. R5'sWeekly Skin Check dated 7/11/24, noted an other type skin alteration on the front right knee 8 cm long with old blood stain, marked no new skin alterations identified, and the summary included no skin issues noted except old blood stain from recent fall per resident. It did not include further assessment of the wound on R5's right residual limb. R5's Post Fall assessment dated [DATE], did not identify or include assessment of the wound on R5's right residual limb. R5's provider note dated 7/12/24, indicated R5 was seen by the primary care provider team at the facility and did not indicate R5 had a recent fall or had experienced injury and bleeding at the incision site of her right residual limb. The physical exam noted skin is warm and dry and right lower leg: no edema. The physician note did not identify the appearance of the incision. R5's Post Fall assessment dated [DATE], did not identify or include assessment of the wound on R5's right residual limb. R5's second Post Fall assessment dated [DATE], did not identify or include assessment of the wound on R5's right residual limb. R5's Weekly Skin Check dated 7/18/24, noted R5 had a surgical incision on the front of her right lower leg and the summary indicated on the right leg, the removed one when she fell out of wheel chair she landed on her stump and broke it open, she still has an open area that we are now dreeing [sic], also coccyx area has small open area. The measurements section of the skin alteration charting for the wound on R5's residual limb was blank. No further assessment of the wound was included. R5's progress note dated 7/18/24, indicated she had a rbka [right BKA], right now it has an open spot due to fall that we are dressing, the cant fir [sic, they can't fit] the prosthetic until the wound has healed. It did not include further assessment of the wound on R5's right residual limb. Review of R5's Treatment Administration Record (TAR) for dates the month of July 2024, included a treatment ordered 6/26/24 and discontinued 7/23/24 directing staff to monitor for signs or symptoms of bleeding/bruising. Notify provider of any changes every shift. The order was scheduled to be completed on day shift, evening shift, and overnight shifts and charted with a check mark indicating completion on all shifts from 7/9/24 through 7/18/24. R5's physician visit note from MD-B dated 7/18/24, indicated R5 was seen in a clinic for physical medicine and rehabilitation follow-up. The note included unfortunately about a week ago she tells me she fell out of her wheelchair. She was not sure how she fell but she did land directly on her right residual limb and notice bleeding soon after . upon removal of her shrinker sock [compression sock over residual limb site] she had a gauze dressing and Steri-Strips still in place. The Steri-Strips had blood on them. Upon removal of the Steri-Strips there was a superficial dehiscence present with subcutaneous fat visible in the wound bed .unfortunately 1 week ago she slipped out of her wheelchair on her residual limb and has now suffered a superficial dehiscence of her residual limb . I called [MD-A's] service and discuss[ed] the case with them. They may want to see her back in the cast room for further evaluation given that her incision is now dehisced. I will follow the patient closely along with orthopedics and once she was [sic, is] healed have her seen back in the amputee clinic for prosthetic prescription. R5's progress note dated 7/19/24, indicated Resident out to cast room for appointment, cast room had called facility last night and stated resident would be a direct admit following appointment. R5's hospital records included an orthopedic surgery physician note dated 7/19/24, which noted Her [R5's] recovery from her right transtibial amputation was uneventful until this past week when she reportedly fell in her nursing home and developed an area of dehiscence distally over her tibia. She had a follow up appointment with the PM&R [physical medicine and rehabilitation] team yesterday, at which point we were contacted given concern for this dehiscence. Today in the cast room, she was examined and the decision was made to admit her directly to the hospital for right transtibial revision amputation on 07/21/2024. R5's hospital Discharge Planning assessment dated [DATE], included Patient has been residing at [facility] working on rehabilitation. Patient experienced a fall after a PT [physical therapy] session in which she stated she 'saw a lot of blood.' Patient stated she inquired about the status of her leg but was re-assured many times by staff at [facility] that it was 'fine' and 'not to worry about it.' Patient returned for a follow-up outpatient visit and was informed her wound had dehisced and required surgical intervention . The patient stated her current admission could have been prevented had she not had a fall. R5's hospital physician consult note by infectious disease dated 7/21/24, included Patient was initiate on empiric vancomycin and cefepime [intravenous antibiotics] prior to surgery. Patient was [is] currently status post revision and closure of dehisced wound following trauma to right BKA incision. Intraoperative cultures are currently in process. Given the superficial wound as well as source control with debridement, it is reasonable to continue empiric antibiotics for an additional 5 days. Would recommend p.o. [oral] Augmentin and doxycycline to complete course. R5's hospital physician progress note by the orthopedic surgery team dated 7/25/24, included [R5] underwent revision closure of the right leg wound on 7/21/24. The aftercare plan section included nonweightbearing right lower extremity until the wound has healed [and] the residual limb is ready for prosthetic fabrication (typically 6-7 weeks in this situation) . Wound care: incision VAC . Additionally, given the high risk of impaired wound healing, we will recommend extended negative pressure wound therapy to support the 9 cm x 7 mm [millimeter] x 5 mm wound during the first six postoperative weeks and perhaps longer depending on her clinical course . Orders have been placed for three cast room visits. Next vac change on Wednesday 7/31 . She will be seen again on Wednesday 8/7/24 to change the incisional VAC sponge (order placed). We anticipate retaining the sutures for a minimum of four weeks. R5's hospital physician consult note by MD-B dated 7/25/24, included We discussed the healing timeline after revision surgery. I will place an order for follow up in the amputee clinic in 6 weeks. The amputee service will continue to follow her in the hospital. In an interview on 7/25/24 at 3:20 p.m., hospital social worker (SW)-A stated R5 was still in the hospital and would discharge tomorrow, 7/26/24. In an interview on 7/29/24 at 9:12 a.m., MD-B stated he saw R5 at an appointment on 7/18/24 and the purpose of the appointment was to see her and prescribe a prosthesis for her residual limb. R5 had seen orthopedic surgery with MD-A on 7/5/24 and was cleared to get prosthetic fitting after her appointment with MD-B, and MD-B was expecting her residual limb to be healed on 7/18/24 and to begin the prosthetic fitting process. MD-B stated when he saw R5, he noted dried blood on her Steri-Strips and shrinker sock, removed them both and noted her wound was open and dehisced about two to three inches which hadn't been the case at the visit with MD-A on 7/5/24. MD-B stated R5 reported she fell about a week prior and landed on her residual limb and saw bleeding immediately that got on the floor but told him that her limb wasn't really looked at. MD-B stated based on the incision now being an open wound, he contacted orthopedic surgery and R1 was admitted the next day for revision surgery; since the wound was now open it needed to be surgically closed to avoid infection and to improve healing time of the wound. MD-A was not planning revision surgery when he saw her on July 5th as the incision had been completely closed. MD-B stated he was not aware prior to seeing R5 on 7/18/24 that she had fallen and injured her residual limb which had been bleeding and he did not see any evidence that MD-A was notified as he was the one who alerted MD-A. MD-B stated the medical recommendation would be if trauma occurs to a residual limb during the healing process and bleeding is seen the medical teams be alerted for further evaluation. Normally this far after surgery we would not expect bleeding from a residual limb, she was already six weeks past surgery. MD-B stated MD-A had to perform a revision surgery on R5's residual limb and it does delay the time healing, now we have to reset the clock to get her prosthesis and certainly there is going to be heightened emotional impact. MD-B thought R1 was understandably quite disappointed; R1 told him that. MD-B also noted that intraoperative cultures (soft tissue samples taken from the wound) returned positive for a bacterium and the orthopedic surgery team consulted with the infectious disease team who prescribed two antibiotics for treatment. In an interview on 7/30/24 at 12:24 p.m., R5 stated she had to have a second surgery after she fell and hit her residual limb. She stated staff did not seem too concerned about it the bleeding even though R5 told the nurse it's bleeding quite bit. The nurse responded oh, it's not that bad even though R5 told the nurse there was blood on the floor, to which the nurse responded we'll just clean it up later. R5 stated to her knowledge it wasn't ever checked again. R5 exclaimed thank god I had an appointment at the [physical medicine and rehabilitation clinic] already, I saw [MD-B]. R5 indicated MD-B contacted her surgeon, MD-A, who decided she needed to have another surgery and had her admitted to the hospital. R5 stated I could already be in my prosthetic if this hadn't happened and I'm angry. R5 explained it had already been a long healing process and has impacted her a lot. It has been really hard and very emotional. The wound delayed her from getting her prosthesis by maybe four weeks. It's not something I planned on at [AGE] years old, you know, and now I'm in another [rehabilitation] facility. R5 was noted to be tearful and emotional throughout the interview. In an interview on 7/29/24 at 11:00 a.m., LPN-C stated she was working when R5 fell and responded to the situation along with clinical manager (CM)-A. LPN-C stated she remembered seeing a small amount of blood coming from R5's stump, she removed the compression sock and there was blood coming from in-between the Steri-Strips over the incision site. LPN-C stated she cleaned the area with some gauze and put gauze over the Steri-Strips and the bleeding stopped. LPN-C noted that at the time of the fall she assessed the wound dressing, noted the Steri-Strips were intact and that there was blood and would document that in the risk management Incident Report in the injuries section. LPN-C stated she worked the next day and did not recall seeing any further bleeding from the site, the care for the site was just putting the compression sock on and off and we weren't doing anything else with it, just monitoring it and checking it. In an interview on 7/29/24 at 11:36 a.m., CM-A stated R5 had a fall on 7/9/24 and he responded because staff said there was bleeding. CM-A stated he assessed the site and there was bleeding obviously, but cleaning it up and applying pressure resolved the bleeding. There were no visible signs of opening or dehiscence, it sill looked intact, but obviously it was not because it was bleeding, but it wasn't a gaping wound. CM-A stated he did not see the wound after that but should have put an order in for nurses to monitor the wound and change the dressing and check up on it. CM-A had instructed LPN-C of what to include in the incident report. CM-A noted for a fall with injury there is a need for continued intervention from nurses including daily assessment of the site of the injury, should be looked at probably every shift. Nursing would monitor for new or worsening concerns and reporting those concerns to the provider groups if necessary. CM-A stated the findings should be documented in resident record. CM-A noted R5's EHR contained four Post Fall Assessments, dated 7/10/24, 7/12/24, and two on 7/14/24, and confirmed the first assessment should have been completed eight hours after the fall. CM-A stated he expected R5's surgical team to have been notified of the fall with injury to residual limb and the surgical team was not notified to his knowledge. He confirmed the Weekly Skin Check dated 7/18/24 did not include comprehensive assessment of the wound. Facility policy titled Post Fall Policy dated 10/13/23, included Monitoring and Re-evaluation: Document on resident's condition at a minimum of every shift for 72 hours. Staff should document relevant post-fall clinical findings, such as vital signs, pain, swelling, bruising, and changes in function or cognitive status. o Staff will have increased awareness that the resident has recently fallen and report any changes in function, increased pain, and changes in cognition to the nurse for further evaluation . Update MD/NP with evidence of acute changes after a fall. Facility policy titled Pressure Injury Prevention and Wound Care Management dated 3/4/24, included Skin impairments, including pressure injuries, non-pressure injury wounds, surgical wounds, skin tears, abrasions, etc., should be assessed and documented weekly by the Wound Nurse, or designee, using the PCC Weekly Wound Assessment. Weekly documentation will include pertinent characteristics of existing ulcers, including location, size, depth, maceration, color of the ulcer and surrounding tissues, and a description of any drainage, eschar, necrosis, odor, tunneling, or undermining . Daily, the clinicians responsible for caring for the Resident will assess the status of the dressing if present, (intact, soiled, leaking), and evaluate for complications such as infection and/or uncontrolled pain .Nursing staff should update the attending physician immediately of wounds that have developed complications and/or not healing as anticipated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to ensure assessed and care-planned interventions for preventative skin care were consistently implemented; and failed to comprehensively reassess and, if needed, develop interventions after a change (i.e., increase) in pressure ulcer risk for 1 of 2 residents (R11) reviewed for pressure ulcer care. This resulted in actual harm for R11 who developed an avoidable stage III (i.e., full-thickness tissue loss) pressure injury on their heel. Findings include: The Centers for Medicare (CMS) State Operations Manual (SOM) Appendix PP, dated 2/2023, identified definitions for pressure ulcer care and treatment. This included, Avoidable, being outlined as, . the resident developed a pressure ulcer/injury and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define and implement interventions that are consistent with resident needs . monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. In addition, the guidance provided several stages of injury definition which included, Stage 3 Pressure Ulcer: Full-thickness skin loss . subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible . depth of tissue damage varies by anatomical location . Undermining and tunneling may occur . On 3/26/24 at 8:31 a.m., R11 was observed lying in bed while in his room. R11 had a standard hospital-style bed with a non-air mattress in place. R11 had a light-green colored Prevalon boot (used to relieve pressure on the heel) on their left foot, however, under the right foot the linens were stained with visible, dark red-colored drainage. Shortly after, licensed practical nurse (LPN)-A entered the room and stated they had to complete a dressing change to R11's right heel. R11's foot was elevated from the mattress using a folded-over pillow and R11's heel was observed which contained a circular, dark-red area with a visible, black-colored center which appeared like a scab-type texture. LPN-A stated, I think it's pressure [related] when asked about the area and expressed the area, just on physical appearance, was approximately 2.5 centimeters (cm) by 1.5 cm in size when asked. R11 stated the area had developed over time to his recall but was unsure how long it had been present adding it had been a couple weeks or more he believed. LPN-A stated this was my first time seeing the wound so they could not comment on if it was healing or not. LPN-A then completed a dressing change to the area which involved cleansing the site with wound cleanser, patting it dry using gauze, applying a Santyl ointment (used to debride the area) to the site and covering it with a silicone-foam dressing. R11's admission Minimum Data Set (MDS), dated [DATE], identified R11 admitted to the care center from the community, had intact cognition, and demonstrated no behavioral symptoms (i.e., rejection of care, physical behaviors). The MDS outlined R11 had multiple medical conditions including anemia, heart failure, and thyroid disorder; and he consumed anticoagulant (i.e., blood thinners) and diuretic medications. The MDS identified R11 was at risk for pressure ulcer formation, however, had no current pressure ulcers present upon admission; and he used pressure-reducing devices for the chair and bed, however, the space to record a formal turning and/or repositioning program was left unchecked. The completed MDS' corresponding Pressure Ulcer/Injury Care Area Assessment (CAA), identified R11 was at risk for pressure ulcer development but had . no skin concerns at this time. The CAA outlined a care plan would be developed to minimize the risk of development and listed dictation reading, Risk for impaired skin integrity care plan was developed with the overall goal for skin to remain intact without breakdown and be free from pressure related injury . interventions were added for Braden scale score and according to Braden scale flow chart. Additional interventions will be added as needed to maintain skin integrity . will continue to complete Braden scale assessments as scheduled and [as needed]. Staff will monitor for changes in physical and medical conditions and report changes . Care plan will be reviewed and updated as needed. R11's admission Screener - V5, dated 3/1/24, identified multiple sections to be reviewed upon admission to the care center including communication, vital signs, skin condition, oral status, sleep patterns, and elimination systems. The completed screener identified R11 admitted to the care center from the community (i.e., home) and had an admitting diagnosis listed, Neurocognitive disorder with Lewy Bodies. A section labeled, C. Skin Observation, identified R11's skin as normal coloration, warm to touch, and dry with a subsection labeled, Skin Integrity, listing no skin alterations were identified. A subsequent section labeled, Details/Comments, was left blank and no dictation was present. The section was signed as completed by licensed practical nurse unit manager (LPN)-B on 3/1/24. However, the completed screener lacked information on how much, if any, physical assistance R11 required with bed mobility, the medications used by R11 which could affect their skin condition and risk for ulcer development (i.e., steroids, anticoagulants), or if R11 had any previous history of pressure ulcer injuries. R11's corresponding Braden Scale For Predicting Pressure Sore Risk, dated 3/1/24, identified R11 had slightly limited sensory perception, had occasionally moist skin, walked occasionally (i.e., short distances), had slightly limited mobility (i.e., frequent though slight changes in body position), and a potential problem with friction or shearing. The scale scored R11 at a 17 which outlined, Mild Risk. R11's initial Baseline Care Plan/Evaluation - V13, signed 3/1/24, identified multiple sections had been evaluated including communication, allergies, functional status, and skin condition. The care plan outlined R11 had an activities of daily living (ADL) self-care deficit due to neurocognitive deficit and heart failure, and directed R11 needed assistance of one to complete personal hygiene, toileting, dressing, transfers and bed mobility. The care plan outlined R11 consumed diuretic and anticoagulant medications, and he was not diabetic. The care plan included a section labeled, 4. Skin Risk, which identified R11 had no current skin issues; however, a subsequent subsection labeled, 4d. Risk for skin breakdown, outlined R11 was determined to be at risk for an alteration in skin integrity and listed a goal which read, I will be free from skin breakdown through the review date. The care plan listed several interventions to help R11 meet this goal which included floating the heels while in bed, keeping the skin clean/dry, and, Turn and reposition me at least every 2 hours, per my particular tolerance and schedule. In addition, R11's corresponding comprehensive skin care plan, revised last 3/12/24, identified R11 was at risk for an alteration in skin integrity related to incontinence and listed a goal which read, . will be free from skin breakdown through the review date. The care plan listed several interventions to help R11 meet this goal including floating his heels while in bed, positioning his body to protect bony prominences, using a pressure-relieving cushion in his wheelchair, and, Turn and reposition me at least every 2 hours, per my particular tolerance and schedule. R11's subsequent Weekly Skin Check - V3, dated 3/10/24, identified R11 had bilateral edema present but added, No new skin issues. The form provided a human figure in anatomical position and corresponding spaced to record what, if any, skin wounds or irregularities were present. However, this was left blank and no skin issues were identified. However, R11's subsequent Braden Scale For Predicting Pressure Sore Risk, dated 3/15/24, identified R11 remained with slightly limited sensory perception, but he had declined in other areas and now had very moist skin, was chair-fast (i.e., ability to walk severely limited, cannot bear own weight and must be assisted into chair or wheelchair), and had very limited mobility (i.e., unable to make frequent or significant changes independently). The new completed scale scored R11 at 13 which outlined, Moderate Risk. R11's medical record was reviewed and lacked evidence R11 had been comprehensively reassessed for their skin risk, including with any tissue tolerance testing, to determine what, if any, new or modified interventions were needed to reduce the risk of pressure ulcer development despite this increased risk score (via the Braden). Further, the record lacked evidence what, if any, education had been completed with R11 pertaining to repositioning or the importance of such. R11's next completed Weekly Skin Check - V3, dated 3/17/24, identified R11 now had a skin impairment on their right heel which the check recorded as, Pressure Ulcer. The ulcer had recorded measurements of 4.5 (cm) by 3.5 cm with no depth and listed the wound as a stage I ulcer (i.e., non-blanchable redness over a localized area). This was recorded as a new skin alteration for R11 and included dictation, Measurement on RLE by the heel . cleaned with wound cleanser and foam border applied. No other skin concern noted. The completed form lacked any further information on what, if any, actions were immediately taken to re-evaluate R11's risk for ulcer development or what, if any, modifications to the care plan would be made to promote healing and prevent additional ulcers. R11's subsequent progress note, dated 3/19/24 (two days later), identified a Skin/Wound Note was completed which outlined, . has a newly noted pressure sore on right heel, it measures .2 cm deep, 4.3 cm long, and 3.4 cm wide, it is a stage 2 pressure sore, applied calcium alginate and a mepilex border and also will float heels while in. bed and when in recliner, also a mepi border on left heel for protectin [sic] it is soft. A corresponding Skin & Wound Evaluation V7.0, dated 3/19/24, identified the area on R11's heel as, 15. Pressure, and listed it as, 2. Stage 2: Partial-thickness skin loss with exposed dermis. The wound was recorded as in-house acquired, being newly onset, and measured at 4.3 cm X 3.4 cm X 0.2 cm with no tunneling or undermining evident. The wound bed was listed as having 20% granulation tissue (beefy, red-colored tissue) and 80% slough (dead tissue separating from living tissue) with moderate serous (clear to yellow fluid) drainage present. The wound was listed as, Healable, and a dressing option was selected with dictation present, Resident has new pressure ulcer to right heel . added to VOHRA wound rounds. The completed evaluation was signed by LPN-B on 3/19/24. R11's VOHRA Initial Wound Evaluation & Management Summary, dated 3/22/24, was completed via medical doctor (MD)-A and identified R11 as an [AGE] year old male with services being rendered (i.e., provided) at the care center. R11's past medical history and medication use was outlined, and the note directed to a completed Focused Wound Exam which was attached. The Focused Wound Exam (Site 1) identified a determination, STAGE 3 PRESSURE WOUND OF THE RIGHT HEEL FULL THICKNESS, and listed an etiology which read, Pressure, along with a duration listed, > [over] 7 days. The wound measurements were listed as 2.1 X 4 X 0.2 (cm) with moderate purulent drainage (thick, milky drainage which may indicate infection) and the wound bed having 80% slough tissue present. A treatment plan was outlined which included a review or R11's care plan and corresponding recommendations which read, Float heels in bed; Off-load wound; Reposition per facility protocol; Turn side to side in bed every 1-2 hours if able; Prevalon boots: On in am and remove at bedtime; Obtain consent from POA [power of attorney] for debridement. Further, the note outlined R11's dementia as a factor which could complicate wound healing but listed, The best medical estimate of the time required for this wound to heal with continued physician evaluation is 98 days . estimate is made with an 80% degree of certainty. When interviewed on 3/26/24 at 1:09 p.m., nursing assistant (NA)-A stated they had worked with R11 multiple times since they admitted to the care center and described (R11) as needing assistance of one to complete most ADLs. NA-A stated they were aware R11 had a wound on their right heel and explained they had noticed it when working with R11 adding just that morning (3/26/24) it had bled onto R11's linens so they alerted the nurse who dealt with it. NA-A stated they believed R11 had admitted to the care center with the wound as it was a really big wound and not just an overnight wound. NA-A stated the wound seemed to be from pressure on it [heel] for a long time and expressed, as a result, the staff were now using the Prevalon boots for off-loading and helping him reposition. NA-A explained staff were not helping R11 to reposition on a scheduled basis, nor were they floating their heels using the Prevalon boots or other devices prior to R11 having the wound to their recall as they had not been directed to do so. On 3/26/24 at 1:28 p.m., R11 was observed seated in their recliner chair with their family member (FM)-A present. FM-A was interviewed and explained R11 admitted to the care center due to themselves (FM-A) having a planned surgery soon and R11 needing respite care which may end-up being more long-term. FM-A verified R11 had no skin issues to their knowledge when he admitted to the care center and expressed the heel ulcer had developed onsite adding, Not to point fingers. FM-A stated now, since the wound developed, the staff were repositioning him and using Prevalon boots to off-load the heels but added, They weren't doing that before [the wound]. FM-A stated they were unable to recall the exact date R11 developed the wound but added they had been updated about it shortly after they discovered it. Further, FM-A stated R11 did wear shoes when he admitted to the care center but they were old shoes which R11 had for a long time prior without issue. When interviewed on 3/26/24 at 3:50 p.m., NA-B explained they had worked with R11 before and described him needing more physical help with mobility when he first admitted compared to now; however, NA-B explained R11 had trouble moving his legs and added doing so, Takes him a long time. NA-B stated R11 was able to somewhat move himself while in bed but added staff have to tell him as he would not do it on his own. NA-B stated R11 was not currently, or ever, on a repositioning program to their recall as he [R11] can do that himself. NA-B stated they were aware R11 had developed a wound on his right heel and expressed staff, including themselves, had not been floating his heels or repositioning him prior to it developing adding aloud, Not before the wound. NA-B stated they were unaware how R11 developed the wound. NA-B explained resident' repositioning was tracked using a paper sheet which was left at the nursing station but added, A lot of days we don't have that sheet. NA-B reviewed the nursing station and was unable to locate it but expressed, had one been there, the staff use it to track repositioning and the nurse then could review it. NA-B reiterated R11 was not on a repositioning program nor having his heels floated while in bed or the chair prior to the wound developing adding, Not that I'm aware of. R11's POC (Point of Care) Response History, printed 3/27/24, identified R11's bed mobility self-performance since 3/7/24, with spaces provided to record the level of assistance R11 needed from the care center staff. A total of 12 episodes were recorded in the five days prior (i.e., 3/13/24 to 3/17/24) to R11 being discovered with a pressure ulcer on his right heel and, of these episodes, seven of them were recorded as R11 needing, EXTENSIVE ASSISTANCE - Resident involved in activity, staff provide weight-bearing support. However, R11's entire medical record was reviewed and lacked any recorded or documented evidence (i.e., task or POC charting) to demonstrate R11 had been repositioned every two hours as directed by the care plan and despite R11 being recorded as needing extensive assistance with bed mobility on multiple occasions prior; nor was any documented evidence during the recertification survey to demonstrate such repositioning had occurred (i.e., tracking sheets). When interviewed on 3/27/24 at 9:37 a.m., registered nurse (RN)-B stated they had worked at the campus for a few months and worked all over on the various units. RN-B verified R11 had a developed pressure ulcer and explained when a resident admitted to the care center, the nurse will do your [their] intake and review them for skin risks in coordination with the therapy department who completed a slip which the aides used to know someone's transfer status and how much help with mobility they needed. These then were placed onto the care plan which was kept on a sheet the aides could keep with them but, upon looking for them at the nurses' station, RN-B stated they were unable to locate one adding they were not sure where such documents were kept. RN-B stated any assessment or comprehensive evaluation, outside of the completed Braden Scale(s), would be the nurse manager' responsibility to complete. RN-B stated some residents who needed more oversight to ensure repositioning was done had an intervention directing such placed on the Treatment Administration Record (TAR) so-as to prompt the nurse, but reiterated this was not done for all residents and rather only for those who needed closer supervision to ensure it was completed. If no such intervention was listed on the TAR, then RN-B explained the expectation was for the NA(s) to follow the care plan and complete repositioning, as needed, and added they should have a sheet to track such repositioning on, to their recall. Further, RN-B stated they had not worked with R11 prior so they were unable to comment on how the wound looked now versus a week (or more) prior, but expressed when staffing levels were short then some tasks, including repositioning, did suffer and not always got completed timely, if at all. R11's TAR, dated 3/2024, listed R11's treatments along with spaces for staff to record their initials if completed or if R11 refused. However, the TAR lacked any interventions or documentation for heel off-loading or repositioning prior to R11 developing the right heel pressure injury on 3/17/24. On 3/27/24 at 10:32 a.m., LPN-B was interviewed and verified they were the campus' wound nurse. LPN-B explained the process for a comprehensive skin assessment included, upon admission, reviewing hospital documentation and doing a skin observation using the admission screener along with a Braden Scale. If an active skin issue was present, then the floor staff were to notify the nurse manager who would ensure appropriate orders were in place. LPN-B explained the Braden Scale was then completed on a weekly basis for one month (i.e., four total) and then monthly moving forward in coordination with the MDS' schedule. When questioned on if any other skin assessments, including a tissue tolerance evaluation, had been completed for R11 upon admission or since, LPN-B responded, Not really. LPN-B explained if a skin issue, like a pressure ulcer, developed after admission, then a new Braden Scale would be completed which could be done by either the floor nurse or the nurse managers. LPN-B reviewed R11 and his medical record, and they verified R11 admitted to the care center with no active wounds present. LPN-B stated R11's mobility, including bed mobility, remained limited as had been for the entirety of his admission adding R11 was, at times, very weak with transfers. LPN-B stated, to their understanding, R11 was able to make repositioning movements himself while in bed with cues and reminders adding, He still is [today]. LPN-B explained R11's care plans, including the baseline and comprehensive, were developed using R11's completed Braden Scale' scores expressing R11's preventative skin care plan had been last revised on 3/12/24 which was before the pressure injury was noted. The interview continued, and LPN-B acknowledged the medical record lacked evidence R11 had received any education on repositioning and expressed aloud, I didn't go through that with him, adding further they were unaware if anyone else had or not. LPN-B stated completed education with repositioning was also most likely not officially documented even if completed. LPN-B explained repositioning was tracked, at times, using a 'task' within the EMR through the NA POC charting; however, upon review this had not been activated for R11 so there was no documentation to provide to demonstrate what, if any, repositioning had actually taken place prior to the pressure injury developing. LPN-B stated there was not a systematic reason when or when not to activate that task within the EMR but verified repositioning should be completed in accordance with the care plan adding, My expectation is they [residents] are repositioned. LPN-B explained R11 developed the wound, per the documentation, on 3/17/24 but they were not notified of the wound until 3/19/24 (two days later). LPN-B stated their expectation was for the staff to notify the on-call nurse immediately of such a wound but, after their investigation, they had determined that did not happen. LPN-B continued and explained the corporate regional nurse had identified the wound on 3/18/24 and, as a result, emailed the director of nursing (DON) and themselves (i.e., LPN-B) about it but neither of them had seen the e-mail adding, We get so many e-mails, they get lost. LPN-B stated they were unaware the aides had not been floating R11's heels or repositioning him, as care planned, prior to the pressure ulcer developing and expressed, I don't understand why they weren't doing it. LPN-B reviewed R11's medical record and verified R11 was not in a terminal condition and had adequate nutritional intake, and they also verified the Prevalon boots were implemented after R11 developed the wound. LPN-B stated they were unaware exactly how R11 developed the pressure injury and explained they had discussed it with MD-A and the nurse practitioner (NP)-A who observed the wound together on 3/22/24, who expressed it could have been a blister which progressed or due to R11's feet being pressed against his recliner chair. LPN-B stated the facility had completed a mock survey a few months prior and skin issues were identified as a potential issue, however, the resulted audits they implemented focused more on persons with active wounds, not preventative interventions, and LPN-B explained the facility' was still reviewing and trying to form a different program to help prevent ulcers. LPN-B stated a UDA [user defined assessment] was made which the interdisciplinary team (IDT) had not yet completed and, from that document and corresponding investigation, they would complete any needed education (i.e., following the care plan, documentation) with staff. Further, LPN-B stated, in hindsight, R11 likely needed more help with bed mobility than LPN-B originally believed (i.e., the documented extensive assist with bed mobility, worsening Braden Scale score) and expressed the developed pressure ulcer possibly could have been avoided had R11 had his heels floated and been repositioned according to the care plan. On 3/27/24 at 12:57 p.m., the director of nursing (DON), regional nurse consultant (RNC)-A and administrator were interviewed, and the DON verified they had reviewed R11's medical record. DON explained upon admission, a resident's skin was checked for any current issues and the staff review any referrals or hospital documentation to determine what, if any, treatments or supplies were needed. DON stated the admission screener was then completed, including with the skin review, and interventions were placed in the baseline care plan, if needed, such as repositioning or heel off-loading adding they felt the screener encompassed and covered all areas for skin risk, such as continence and nutrition, as outlined under the regulatory expectation just possibly not in one single section [i.e., skin]. DON stated the interventions marked in the care plans, including baseline and comprehensive, then pulled to the NA [NAME] (a tool used to show what assistance a resident needed) with a symbol (i.e., small 'K') demonstrating such in the EMR. DON verified R11 developed the pressure ulcer after admission to the care center, and they explained a resident' mobility, including when considered for their respective skin risk, was evaluated between nursing and therapy and came from hospital notes, nurse-to-nurse report, and the screener completed upon admission adding those items gave staff a starting point and, if needed, a resident could be downgraded. DON verified R11 was listed as needing assist of one with transfers and bed mobility, and expressed the aides should be recording completed repositioning under the tasks in the POC charting. DON reviewed the completed POC charting and verified R11 was often recorded as needing extensive assistance with bed mobility, and there was no completed charting to demonstrate repositioning or heel off-loading had been completed. DON stated there were no sheets used, to their knowledge, to track repositioning, either. DON explained, since the wound developed, staff were using Prevalon boots and elevating his feet adding they believed those interventions had also been indicated on the baseline care plan. DON stated they would often see R11 in the recliner chair but, in hindsight, did not pay particular attention to the boots [if placed or not]. The interview continued, and DON explained resident' education, including with repositioning and the need thereof, was done as part of the initial screener adding, I don't know that we have a specific place [to document it]. DON stated they had early on talked to FM-A about making sure R11's feet were kept elevated but added, I did not put a note in [about it]. DON verified the medical record lacked evidence any education had been completed with R11 on the need to reposition himself while in bed or the chair. DON explained the skin evaluation process, including upon admission, did not routinely include tissue tolerance evaluation or pressure mapping. The administrator expressed there was an outside company whom, at times, would do it, if needed, for various residents at risk though. DON reviewed R11's completed Braden Scales and verified R11 increased in risk on the 3/15/24 evaluation, adding they felt the reason was due to different nurses' completing the evaluation. However, DON verified there was no other corresponding assessment or evaluation of R11's skin risk at the time to determine what, if any, additional interventions were needed to prevent skin injuries or pressure ulcers adding, I don't see anything in the notes. DON reiterated since the wound had developed, the staff were repositioning R11 and ensuring the heels were off-loaded adding, Now we're doing everything. The administrator explained the UDA process was still pending a full, documented review but reiterated R11's immediate needs and treatment once the wound developed had been completed. The administrator expressed they were aware of ongoing issues with staff not always getting cares or repositioning completed and were taking various steps to better ensure cares were getting completed including a planned education with the aides in the near-future. Further, DON explained they were aware MD-A and NP-A had observed R11's pressure injury and expressed they recalled NP-A thinking the wound was potentially unavoidable due to R11's inadvertent non-compliance (i.e., dementia and unable to full understand interventions) and himself being evaluated, but not started or approved, for hospice care prior to admission. However, DON verified R11 was not considered terminal or actively dying at the time of survey or since admission. On 3/27/24 at 2:00 p.m., NP-A was interviewed and verified they helped oversee R11's medical care while at the care center. NP-A stated, to their recall, R11 did not have any skin issues or pressure ulcers upon admission to the care center in early March 2024 adding, None that I know of. NP-A stated if a wound developed, they would then be notified by the nurse manager and added to a weekly wound rounding until it was resolved. NP-A explained they had been notified last week of R11 developing a wound on his right heel and, as a result, they observed the wound with MD-A and LPN-B on 3/22/24 (see VOHRA note). NP-A stated herself and MD-A felt the wound was likely pressure from not off loading, and they had a discussion with the care center to ensure an appropriate sized bed was in place due to R11's height. NP-A reviewed the EPIC (i.e., hospital) charting and stated R11's last albumin (lab value to help determine nutritional status) was in October 2023 and, at that time, was within normal range. NP-A stated they felt the pressure ulcer could have been preventable adding, I think it's healable. NP-A stated R11 had no personal history of wounds or pressure ulcers and expressed, I'm very optimistic that it will heal, adding further, It probably shouldn't have [happened]. A facility' provided Pressure Injury Prevention and Wound Care Management policy, dated 3/2024, identified a purpose which included, To identify factors that placed the residents at risk for the development of pressure injuries and to implement appropriate interventions to prevent the development of clinically avoidable wounds. The policy outlined a resident who admitted without a pressure injury would not develop such injury unless clinically unavoidable, and listed a procedure which included completion of a comprehensive assessment to identify risk factors and, based on such assessment, be addressed using the RAI process and care plan. The policy continued, Residents at risk for the development of a pressure injury will have their individualized care interventions and approaches documented in the resident care plan. However, the policy lacked information or direction on how repositioning would be documented, if at all, within the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to use a gait belt during transfer and ensure facility shower chairs were maintained for safety for 1 of 3 residents (R1) reviewed for falls. The facility's failures resulted in actual harm when R1 sustained a fall while being transferred incorrectly, and received a severe skin laceration after her fall when the shower chair seat fell onto her. R1 required transfer to the hospital and 16 stitches. Findings include: A facility Incident Report dated 12/21/22, at 7:53 a.m. indicated on 12/20/22, at 6:45 p.m. nursing assistant (NA)-A reported to licensed practical nurse (LPN)-C that R1 had fallen in shower room and needed assistance. R1 had completed her shower and was independently transferring from the shower chair to the wheelchair when R1's legs gave out, and NA-A assisted R1 to the floor. During the process of assisting R1 to the floor, the shower chair flipped over and landed on top of R1. When NA-B arrived to assist, he lifted the shower chair off of R1 and the seat cushion detached and fell onto R1's right lower extremity (RLE). A sharp metal piece created a serious skin tear and laceration that appeared quite deep. Due to the large laceration and profuse bleeding, it was deemed necessary to transfer R1 to the emergency department (ED). R1's Face Sheet dated 12/13/22 indicated R1 was admitted to the facility on [DATE], for short term rehabilitation. R1's diagnoses included abnormalities of gait and mobility, severe morbid obesity, and metabolic encephalopathy (delirium: confused thinking and disrupted attention). R1's admission Minimum Data Set (MDS) dated [DATE], lacked identification of R1's cognitive status. The MDS indicated R1 required extensive assistance of one staff member with transferring and toileting. R1's care plan dated 12/13/22, indicated R1 had limited physical mobility related to metabolic encephalopathy, obesity, and functional decline. The care plan identified R1 required extensive assist of one staff member for transfers, required a gait belt, and was at moderate risk for falls. Further identified R1 was at risk for skin/wound infection related to large laceration of right lower extremity (RLE) requiring suture repair and antibiotics. R1's late entry FOCUS Note (interdisciplinary meeting note) dated 12/20/2022, at 6:45 p.m. identified the reason for the Interdisciplinary FOCUS Review was R1 had a fall and subsequent skin tear to the right lower shin on 12/20/22, at 6:45 p.m. R1's skin tear required 16 stitches. The note identified R1 required extensive assistance from one staff. New interventions: all staff educated to not complete transfers in shower room. During an interview on 01/18/23, at 10:45 a.m. NA-A stated she was with R1 when she had the fall. NA-A explained she had finished R1's shower, wheeled her over to the dry area just past the half-wall. She dried R1 off, applied gripper socks, and wiped the floor with a blanket. NA-A assured the wheelchair brakes were locked, held the back of the shower chair and directed R1 to self-transfer to the wheelchair. NA-A stated she had previously directed R1 to independently walk to her bathroom in her room and did not place a gait belt for support. NA-A stated she had not looked in the care plan or medical record to see how R1 transferred, and she was not aware R1 required a gait belt. NA-A stated she was an agency nursing assistant and did not know the residents well. NA-A stated as R1 was standing, the chair started sliding backwards. This caused R1 to sit back down hard toward the front of chair. Because she was not all the way back, she started sliding off the front of the chair. NA-A reported R1 was a large lady, she could not keep R1 from falling off the shower chair, but she assisted R1 to the floor. The shower chair then tipped over and landed on top of R1. When the shower chair was picked up and moved by NA-B, the seat fell off, and a sharp metal piece cut R1's RLE. NA-A stated again she had not put a gait belt on R1 to assist with transfers because she did not know R1 needed a gait belt. NA-A had access to the care plan but did not review it before transferring R1. Attempts to contact NA-B on 01/18/23, at 1:06 p.m. and 01/24/23, at 9:22 a.m. were not successful and no return telephone call was received. On 01/22/23, at 7:56 a.m. the facility provided a picture of the broken shower chair and the bottom of the seat cushion. There was approximately eight jagged holes on the bottom of the seat cushion where the mounting brackets had been. The metal brackets that connected the seat to the PVC pipe frame were not pictured. During an observation on 1/18/23, at 12:00 p.m. bath chairs #47 and #101 observed on the floor in service (but not in use at the time), did not have weight stickers, and labels were not legible. During an interview on 1/18/23, at 12:38 p.m. the director of maintenance director (DM)-A stated the facility utilizes the TELS Building Management software system to schedule and track preventive maintenance tasks. DM-A stated the facility performed monthly visual inspections of the shower chairs. DM-A then logged into the TELS system, and stated monthly shower chair inspections were not included as a task. DM-A stated he would have to enter shower chair inspections as a monthly task, but does not have any documentation of these visual inspections. During an interview on 1/17/23, at 3:05 p.m. family member (FM)-A confirmed R1 was hospitalized and receiving antibiotics. FM-A stated R1 was very confused and did not remember she was in a nursing home when she fell. R1 stated she was at home when she fell. FM-A further stated with R1's confusion, cognitive communication deficit, and being a poor historian, an interview with R1 would not be credible. During an interview on 1/18/23, at 8:50 a.m. DM-A was re-interviewed and stated he had looked at the shower chair after the incident. DM-A stated it looked like there had been rust on the metal mounting brackets of the chair seat. DM-A further stated when R1 fell onto the shower chair, due to her excessive weight, she broke the mounting brackets. DM-A stated the facility did not have manufacturer's user manual due to the shower chair estimated to be greater than ten years old. DM-A stated due to the age of the shower chair and the inability to purchase replacement mounting brackets, the shower chair was thrown away. A new replacement shower chair was just purchased. DM-A identified after the accident, he looked at the other three facility shower chairs but two of the chairs in service did not identify weight restrictions. Due to the age of the two shower chairs, DM-A stated he was not able to identify the name brand or model number to identify what the maintenance schedule was per the manufacturer for these chairs. DM-A identified the facility uses the TELS Preventative Maintenance System for all equipment in the facility; no alerts for repair nor prevented maintenance had been recorded in the system for the shower chair involved in the incident. During an interview on 1/18/23, at 9:54 a.m. the administrator stated an awareness of the R1's fall. The administrator stated NA-A should have used a gait belt for R1's transfers. During an interview on 1/18/23, at 2:30 p.m. LPN-F stated there were no issues with the shower chair prior to R1's fall. LPN-F stated if there was a problem with the shower chair or any equipment concern, the equipment would be removed from service and taken to DM-A's office. LPN-F stated there were other shower chairs in the facility and the nursing assistants would move them around as they needed to so residents received their shower. During an interview on 1/18/23, at 11:10 a.m. the director of nursing (DON) stated it was reported to her that R1 stood up and fell back to the shower chair and began to fall to the floor. NA-A assisted R1 to the floor but R1 did not sustain an injury from the fall. When NA-B picked up the shower chair the cushion fell off and struck R1's RLE and tore her leg open. The DON stated NA-A did not have a gait belt placed and should have. The DON stated R1 was assessed to require extensive assistants to transfer which required a gait belt to be used. DON stated NA-A knew she should have used a gait but did not; NA-A also had access to care plan which directed the proper equipment for transfers. After the accident, the DON did not provide re-education to all staff on following care plans and gait belt usage, however, informed all staff the new policy of not transferring residents in the shower rooms due to small size and slip hazard. The facility policy Gait-Transfer Belt Policy & Procedure dated 8/1/15, directed staff to use a transfer/gait belt with transfers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and document review, the facility failed to complete a comprehensive pressure ulcer assessment, implement care plan interventions, follow physician orders to promote healing and/or reduce the risk of deterioration for 2 of 3 residents (R6 and R12) that had current pressure ulcers. The facility's failure resulted in harm to R6 who developed a stage 3 pressure ulcer after admission. Findings include: Stage 1 Pressure Injury: Non-blanchable erythema (redness) of intact skin Intact skin with a localized area of non-blanchable erythema (redness). Stage 2 Pressure Ulcer: Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. This stage should not be used to describe moisture associated skin damage including incontinence associated dermatitis, intertriginous dermatitis (inflammation of skin folds), medical adhesive related skin injury, or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Ulcer: Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. 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 wound bed, it is an Unstageable PU/PI (pressure ulcer/pressure injury). Deep Tissue Pressure Injury (DTPI): Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 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 ulcer. Once a deep tissue injury opens to an ulcer, reclassify the ulcer into the appropriate stage. Skin Tears: acute wounds that result from a mechanical force such as shearing or friction or a traumatic injury such as from a fall. R6's face sheet dated 11/8/22, identified R6 had diagnoses of diabetes type II, chronic kidney disease, and heart failure. R6's significant change minimum data set (MDS) dated [DATE], indicated R6 was severely cognitively impaired, required extensive 1-2 person assist with most cares. MDS indicated R6 was total dependence on staff for hygiene and toileting, and was always incontinent of bowel and bladder. Further the MDS identified R6 was at risk for pressure ulcers, did not have pressure ulcers and/or any skin impairments. Skin treatments included pressure reducing cushions for chair and bed. No other interventions were identified. R6's progress note dated 10/14/22 indicated the physician was notified of the following: R6 had a new sacral injury that measured 1.3 cm x 1.0 cm., 100% epithelial tissue. Skin surrounding the wound was reddened, fragile with raised edges. Photo was obtained for monitoring. R6's MDS note dated 10/18/22, at 11:28 a.m., indicated R6 was completely incontinent of bowel and bladder, was currently checked and changed in bed. R2 had a stage 2 on his coccyx that had been noted on 10/14/22. R6's skin integrity care plan focus dated 10/27/22, identified R6 had alteration in skin integrity related to impaired mobility and bowel and bladder incontinence. Associated interventions dated 10/14/22 included: -Complete dressing changes as ordered -Position my body with pillows/support devices, and protect bony prominence's -Turn and reposition every two hours per particular tolerance and schedule. On 10/18/22, intervention identified R6 had a ulcer to coccyx (stage not identified) see treatment administration record. On 10/24/22 intervention was air mattress to be added. R6 skin/wound note dated 10/27/22, at 4:32 p.m., Identified R6 had a skin tear to left buttock caused from full body mechanical lift sling removal. New interventions included put an air mattress on R6's bed. The note did not include measurements and/or further assessment of the skin impairment. Corresponding photo dated 10/27/22 identified a pink area on sacral/coccyx area which was identified as resolved. Left buttock had an open wound approximately size of quarter. The wound bed was deep red in color with no skin flap visible in the photo. The skin surrounding the wound was excoriated or consistent with moisture associated skin damage. R6's record lacked a comprehensive wound assessment of the skin impairment identified as a skin tear. Additionally R6's care plan was not revised to reflect the resolution of the stage 2 pressure ulcer. An additional skin integrity focus was added to the care plan that identified the left buttock skin tear. R6's care plan included additional skin integrity care plan focus dated 10/27/22, identified R6 had a skin tear to left buttock. Associated interventions dated 10/27/22 included: -Air mattress -Toileting program initiated : check change approximately every two hours during wake hours and every 3 hours at night. -Turn and repositioning approximately every 2 hours when in bed, approximately every hour when in wheelchair. -Administer treatments as ordered. -Assess/monitor the alteration in skin integrity and document status weekly. -11/3/22 intervention; new dressing change orders received. R6's wound evaluation dated 11/3/22 identified R6 had a new skin tear to left buttock that measured 2.7 cm x 3.0 cm. with attached edges that appeared flush. Wound bed had slough (dead skin), 10% granulation tissue present (new connective tissue that forms on wound surfaces during healing process) and was pink or red. Surrounding wound was red, and fragile. Further identified wound as improving and healable. Interventions used included: mattress with pump, turning and repositioning program, and moisture barrier and control. R6's left buttock wound order dated 11/3/22, directed to clean wound with cleanser, pat dry, apply Medi honey (honey fiber) to wound bed. Then apply Duoderm to buttocks skin tear. The dressing was to be changed on the evening shift on Mondays and Fridays or sooner if it falls off or was soiled. During an observation on 11/8/22, at 8:27 a.m. R6 laid in his bed on his back. R6's mattress was not an air mattress in accordance with the care plan dated 10/27/22 or the skin evaluation dated 11/3/22. At 10:28 a.m. unknown staff members assisted R6 to his wheelchair. During a continuous observation on 11/8/22, that began at 2:02 p.m. and ended at 3:17 p.m. R6 sat in his wheelchair without offers/attempts to reposition/offload R6 in accordance with the care plan. -At 2:02 p.m. R6 sat in his wheelchair, self-propelling down the hallway. -At 2:33 p.m. R6 continued to sit in his wheelchair in the same position in the sunroom at a table with a puzzle. -At 2:55 p.m. administrator pushed R6 back to his room. -At 2:57 p.m. R6 self-propelled his wheelchair out of his room and an unidentified staff member pushed R6 back to the sunroom. -At 3:12 p.m. R6 sat at the puzzle table and unidentified staff member put his glasses on. -From 3:15 p.m. to 3:17 p.m. R6 observed self-propelling around tables in the sunroom. During an interview on 11/8/22, at 3:24 p.m. NA-A indicated after R6 was up in his chair at 10:30, she had repositioned R6 after lunch, it was about two hours ago around 1:30 p.m. (three hours after R6 was up in his chair). NA-A explained she completed the repositioning by moving R6 around a little bit by the mechanical lift sling that he was sitting on. NA-A demonstrated the action with her arms; action was that of moving back and forth or side to side. NA-A's demonstration would not alleviate pressure to R6's buttock area. On 11/8/22, at 3:29 p.m. NA-A and NA-E observed doing personal cares on R6 in bed. NA-A stated she needed to apply barrier cream and stated she would go to the nurse and get the cream and be right back. R6's right sacral area of redness approximately size of quarter. Coccyx was excoriated with superficial open slit. Right outer gluteal fold (buttock) was excoriated /peeling. Left buttock had an open wound between quarter and half dollar sized. Wound periphery was reddened with surrounding excoriation/peeling skin on the buttock/gluteal fold. R6 stated,OWW, OWW! as NA's cleaned the areas excoriation where the skin was peeling and red. When NA-A was done wiping, with same gloves on, she applied barrier cream to the wound. Then with the same gloves on she applied a bordered dressing to the wound. NA-E asked NA-A if she should be applying the dressing rather than the nurse. NA-A replied, yes, the nurse told me to go ahead and put it on, so I am. Staff removed gloves, did not perform hand hygiene, and left room. R6's progress note dated 11/8/22, indicated as of 10/10/22, R6 wounds have resolved except a new wound found to right buttock-will await update to recommend supplementation. Registered dietician (RD) recommends increased magic cup to 4 ounces twice per due to decreased appetite. Discontinue Prostat (sugar free liquid protein often used for wound healing) due to resolved skin tears, pressure injury as of 10/6/22. R6's record did not identify measurements of the wound after 11/3/22. During an interview on 11/8/22, at 4:00 p.m., nurse manager (NM) indicated R6 had a history of wounds on his bottom. NM stated R6's wound on sacrum was first evaluated on 10/14/22 and had measurements 1.27cm x 1.03cm and had resolved on 10/27/22 by the physician. On 10/27/22 the new wound (skin tear) was identified however that measured 3.91 cm x 2.56 cm.; total surface area was 7.06 cm. On 11/3/22 measurements of wound were 2.73cm x 2.95cm; total surface area 6.18 cm. NM stated staff should follow R6's care plan; he should be offloaded every hour when in a wheelchair by using a pillow or such. NM stated it was definitely not appropriate to shift a sling under a resident because it would not remove the pressure from the wound. NM stated nursing assistance (NA) were not to complete dressing changes as they do not have the education on assessing and it was out of their scope. During an interview on 11/9/22, at 9:34 a.m. administrator and director of nursing indicated they had identified the nurse had indeed delegated the task of wound care to the NA and had given the wrong directions. Education to staff was provided. Additionally, facility also provided job description to staff and what to do if they were directed to complete tasks out of their scope of practice. During an interview on 11/10/22, at 1:34 p.m. wound doctor (WD) stated R6 spent a lot of time in his wheelchair and R6 was bony and susceptible to pressure ulcers. WD stated he had not seen R6's wound last week but had seen the wound today; he debrided the wound as much as R6 would tolerate. Wound measured 0.1 and 1.4 cm, width was 1.8 cm. There was 80% slough, 10% granulation tissue, and 10% other with a little drainage. WD stated the wound had gotten smaller in the surface area than what he had seen previously. The skin impairment was caused by skin tear and the bias from that was pressure related as well as he (R6) did have fragile skin (shearing wound caused by pressure). WD stated the wound was (currently) stage III pressure ulcer because it had some depth to it. WD indicated treatment was xeroform (medicated gauze dressing) and mepilex with border (foam dressing). WD explained R6 should be repositioned in his wheelchair every one hour and every two hours while in bed, additionally should have an air mattress. R12 R12's admission record indicated R12 was admitted on [DATE], with diagnoses that included left femur fracture, diabetes with diabetic polyneuropathy (damage to nerves), and stage 3 pressure ulcer of the left heel. R12's admission Minimum Data Set (MDS) dated [DATE], identified R12 to be cognitively intact and had no rejection of cares exhibited. R12 required extensive assistance of two or more staff for toileting, bed mobility, transfers, and required extensive assistance of one staff for hygiene. MDS also identified R12 was at risk for pressure ulcers and had one stage 1 pressure ulcer. Skin and ulcer treatments included: pressure reducing device for chair and bed, along with pressure ulcer care. R12's hospital After Visit Summary (AVS) dated 11/3/22, identified R12 was admitted to the hospital with a femur fracture after a fall that required surgical intervention. Details of hospital stay identified R12 had a history of left heel ulcer from 8/8/22 hospitalization and indicated R12 had current left heel healing stage 3 that was treated with Santyl (enzymatic debrider ointment used for debriding dermal ulcers and aid in wound healing) to area covered with Mepilex (absorbent foam dressing) heel. Addition interventions were Prevalon boots (have a cushioned bottom that floats the heel off the surface of the mattress, helping to reduce pressure) when lying or sitting to help protect. R12's right heel was intact but at risk (for skin breakdown) just like her left. Assessment and plan for pressure ulcer of left heel stage 3 included, unable to assess today, nursing to evaluate upon admission. R12's medical record lacked a comprehensive skin assessment upon admission to the facility as directed by the hospital summary. Further even though the hospital summary directed to use Santyl, R12's physician orders directed to use zinc-based cream, which is not an enzymatic debrider. Physician order dated 11/4/22, indicated apply zinc-based cream to left posterior heel and change daily. R12's record did not identify an order to discontinue the Santyl and/or why there was a change to the treatment as identified by the hospital discharge summary. R12's Baseline care plan, signed 11/4/22, indicated R12 was at risk for alteration in skin integrity related to obesity, decreased mobility and dependence on staff. Interventions: float my heels or use heel suspension boots while I am in bed and keep my skin clean and dry. The baseline care plan indicated current skin integrity issues to include scratches/rash on right wrist, pressure injury left heel, surgical incision of left hip/thigh, and left shin scratches. R12's progress note, dated 11/4/22, at 8:44 p.m. indicated R12 complained of left heel pain. Mepilex applied. Skin dry and intact. R12's record did not include further assessment that identified source of pain, color, and texture (bogg/firm) of skin, and interventions used to relieve pain. During observation and interview on 11/8/22, at 8:55 a.m. R12 laid in her bed on her back with both of her heels directly on the bed. Both heels had a dressing around the bottom wrapped with gauze and secured with tape; the dressings were undated. R12 stated she used to have a pressure ulcer on her left heel that she got in the hospital a while back. R12 explained she thought her dressings were supposed to be changed daily, however, no one had changed her dressing in a few days. She was not aware if the treatment had changed. R12 stated staff did not come in and help her to reposition in the bed and was not aware she was supposed to call for assistance and/or reposition. R12 indicated no one ever offers and/or puts her leg up on a pillow like they did in the hospital. R12 explained she usually just laid in bed; she worked with therapy and sometimes therapy would get her up. R12's November treatment administration record (TAR) identified physician order to apply zinc based cream to heel and cover with mepilex daily. The TAR indicated R12's treatment to heel was completed from 11/5/22 to 11/10/22, however did not include description of R12's heel or wound. Additionally, TAR identified R12 had diabetic foot check completed on the night shift from 11/3/22 to 11/10/22, however, did not address R12's skin integrity to her heel. During an observation and interview on 11/8/22, at 2:13 p.m. R12 laid in bed on her back covered with a sheet. R12 stated she did not get the dressing on her left heel changed yet. R12 stated she had been in bed all day, and no one had offered to reposition her or offer to put a pillow under her leg. R12's heels were directly on the mattress and not floated. R12's pressure relieving boots were observed to be on the shelf at the end of her bed. During an observation and interview on 11/8/22, at 2:21 p.m. licensed practical nurse (LPN)-B stated because they were short staffed last night (11/7/22) she had not changed R12's heel dressing per physician orders. Instead, she reinforced the dressing with a gauze wrap. LPN-B walked to R12's room and verified R12's heels were not offloaded (floated) per the care plan. Further LPN-B did not offer and/or attempt to float R12's heels, place pressure relieving boots on her or offer to reposition. LPN-B indicated R12 refused to wear the pressure relieving boot because she thought it caused the pressure ulcer, no one has followed-up with therapy about the boot, and thought someone should do that. Although, R12's hospital discharge summary and base line care plan dated 11/4/22, directed to offload pressure from R12's heel and use pressure relieving boot, R12's TAR did not identify the directive or order until 11/10/22. The order included offload heel with Prevalon boots and wear Darco shoe outside. Float heel when sitting with pillows to keep heel pressure free every shift for pressure injury (ulcer) of left heel stage 3. A progress note dated 11/5/22 indicated R12 refused interventions, and on 11/9/22 identified R12's heels were offloaded, the facility did not consistently implement interverventions to prevent pressure ulcers. During an observation on 11/8/22, at 3:02 p.m. LPN-B removed R12's dressing to her left heel and verified the dressing was not dated. The back of R12's left heel (Achilles tendon area) was observed; heel had a rectangular butterfly shaped open wound that had small red dots on the wound bed, approximately 1.0 inch by 2.5 inch, no surrounding redness. Above the wound there was an area of dry skin, no areas scabbing were observed over or surrounding the wound. LPN-B looked at the Mepilex and stated, there was a small amount of serous drainage (watery discharge that is pale yellow and transparent) on it. While LPN-B removed the dressing there was a distinct pungent foul odor which LPN-B verified. LPN-B looked at the wound on the back of left heel and stated it was open. LPN-B explained she did not think it was open before, but since there was drainage on the dressing it must have been open. LPN-B measured area on left heel; announced measurements of 5.0 cm x 3.0 cm. Stated she was going to clean the area with soap and water and have the wound nurse look at it prior to applying the zinc and Mepilex. During an observation and interview on 11/8/22, at 3:22 p.m. Nurse manager (NM) verified he was the wound nurse for the facility. NM explained a wound specialist (WD) was at the facility every Thursday. On Thursdays, residents were brought to the treatment room where they used a computer application to take pictures of the wound. WD would complete assessments, obtain measurements, and ensure treatments were appropriate. NM entered R12's room and looked at R12's left heel- Achilles tendon area. NM stated the left heel was definitely open with multiple red pinpoint areas located across the wound base. NM stated the wound was most likely from pressure. NM measured the wound; he reported results of 3.6 cm x 4.0 cm which were inconsistent with LPN-B's measurements. NM explained there was nothing on her heel upon admission on [DATE]. The area had some dry skin around it and was not open. As NM was touching R12's left heel he asked R12 if she could feel his hand. R12 closed her eyes and stated she could not feel it. NM stated for now he would cleanse the area with wound cleanser and apply a Mepilex and call the doctor to see what he wants to do with this. NM then put a pillow under R12's left leg so that the heel was off the bed. R12 allowed this without any rejection and/or refusals. R12's physician notification note, dated 11/8/22, at 4:46 p.m. included background of pressure ulcer to R12's left posterior (back) heel. Assessment included: posterior heel has a hard scab to previous pressure ulcer (documentation of a hard scab was inconsistent with observation at 3:22 p.m.). Upon evaluation on this day, the site measured 4.0 cm x 3.0 cm (Length x Width) to peri wound site appears with multiple pinpoint red areas. Old dressing had light serous drainage. Updated orders requested, currently using zinc barrier cream, site is dry. R12's progress note dated, 11/9/22, at 9:49 a.m. indicated a new order of Arginaid (Powder nutritional supplement drink mix that promotes the healing of pressure ulcers) two times a day to aid in wound healing related to pressure ulcer of the left heel. R12's progress note dated, 11/9/22, at 3:20 p.m. response from physician notification was, continue to follow wound MD. R12's progress note dated 11/9/22, at 7:34 p.m. included Mepilex to bilateral heels in place, left heel pressure injury present at this time. R12's admission MD visit dated 11/10/22, identified history of R12's left heel wound however, however did not identify current staging. The note included the following treatment orders and interventions: cleanse the wound with wound cleanser, pat dry, cover the wound bed with Mepilex. Change daily and as needed if soiled. [R12] to offload heel with Prevalon boots and wear Darco shoe outside. Float heel when sitting with pillows to keep heel pressure free. Nutritional consult with goal to improve nutritional status for wound healing. Any acute changes between visits should be documented and communicated ASAP (as soon as possible) to provider: a new wound or a change, if there is new or worsening drainage from a wound, redness, swollen or painful to the touch, if wound changes from pink or red to a tan or brown or black color, if development of fever or wound odor gets worse. Document and alert provider if patient declined repositioning or dressing change. During an observation and interview on 11/10/22, at 9:56 a.m. R12 laid on her back in her bed, heels were not offloaded/floated. R12's left heel had a Mepilex dressing placed underneath her heel but was not secured. R12 stated a doctor had just looked at her heel and no one has offered/attempted to offload her heel yet today. R12's weekly skin assessment dated [DATE], indicated left heel had blanchable redness measuring 6.5 cm x 4.0 cm. Further identified left heel pressure ulcer was a suspected deep tissue injury (SDTI) measuring 1.9 cm x 1.5 cm. Above blanchable redness surrounds the SDTI. The SDTI area is non-blanchable purple appearance, skin intact. During a phone interview on 11/10/22, at 12:27 p.m. WD stated he had not had a chance to review R12's medical records yet. WD explained R12 had told him she had the pressure ulcer on her left heel since August. WD indicated he had assessed R12's wound today; measured 1.4 cm x 1.9 cm. The new treatment orders will be to apply Betadine (antiseptic liquid, put on minor wounds, cuts, abrasions or burns that helps reduce the risk of developing an infection) and a Mepilex dressing. WD further explained R12 would need to float her heels with a pillow or use the boots. Facility policy entitled, Pressure Injury Prevention and Wound care management, dated 8/26/2018, revised 4/27/21, stated that the policy was created for the facility to ensure that a resident who is admitted without a pressure injury does not develop a pressure injury, unless clinically unavoidable, a resident who has pressure injury will receive care and services to promote healing and to prevent additional ulcers. Policy indicates to refer to dressing change policy and procedure for dressing changes. Education provided to nursing staff on 11/8/22 and 11/9/22, indicated wound care MUST be performed by a licensed nurse. A licensed nurse cannot delegate wound care to certified nursing assistant (CNA) staff. This is outside their scope of practice. Any CNA staff being asked by a licensed nurse to complete wound care on a resident is to notify the Nurse Manager/Charge Nurse/Director of Nursing immediately and not follow the direction of the licensed nurse related to the wound care.