**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three residents (Resident #10, #9, and #13), in a review of 13 sampled residents, were treated with dignity and respect. Certified Medication Technician (CMT) F was rude and rough during care for one resident, (Resident #10) and the resident said it hurt his/her feelings and made him/her feel angry. CMT F was rough and forceful with Resident #9's care and the resident said it made him/her feel like he/she wasn't worth anything. Resident #13 reported CMT F was condescending and liked to show his/her authority; the resident said it made him/her so angry he/she wanted to punch CMT F in the face. The facility census was 76. Review of the facility's policy Resident Rights, revised December 2016, showed all employees should treat all residents with kindness, respect, and dignity. Review of the facility's policy Conduct and Behavior, revised May 2019, showed examples of conduct and behavior that were considered inappropriate and therefore prohibited included failure to treat all residents with kindness, respect and dignity, being discourteous to residents or any behavior that was deemed offensive or unsafe 1. Review of Resident #10's Care Plan, dated 11/12/24, showed the following: -The resident had a self-care deficit related to impaired balance and limited mobility; -Encourage resident to participate in the fullest extent possible with each interaction; -Encourage the resident to use the call bell for assistance; -The resident needs prompt response to each call for assistance; -The resident required partial to moderate assistance with personal hygiene, toileting, transfers, bathing, bed mobility, and dressing. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by facility staff, dated 1/14/25, showed the following: -Moderate cognitive impairment; -Upper extremity impairment on one side of the body; -The resident required supervision or touching assistance moving from a lying position to sitting on the side of the bed; -The resident required substantial to maximum assistance with toileting hygiene, showering and lower body dressing; -The resident required partial to moderate assistance with personal hygiene, moving from sitting to standing position, chair/bed-to-chair transfer, toilet transfer and tub/shower transfer and walking 10 feet; -Mobility devices of walker and wheelchair; -Diagnoses included cancer, heart failure (a chronic condition in which the heart doesn't pump blood as well as it should), arthritis and depression. During an interview on 2/20/25 at 2:45 P.M. the resident said the following: -Certified Medication Technician (CMT) F was very rude during care; -Last week when he/she turned on his/her call light, CMT F said four staff had just been in his/her room and said he/she (the resident) should have asked the other staff instead of turning on the call light again; -CMT F was rough when he/she pulled the resident up in bed and made comments that he/she would push the resident through the wall when the resident complained about him/her being rough with care; -CMT F hurt the resident's feelings and made the resident angry. CMT F acted like he/she was the boss; -The resident was afraid to report CMT F because he/she could retaliate against him/her. 2. Review of Resident #9's annual MDS assessment, dated 11/17/24, showed the following: -The resident was cognitively intact; -The resident was dependent on staff for toilet hygiene and lower body dressing and with transfers; -The resident required substantial to maximal assistance with personal hygiene and bathing; -Partial to moderate assistance needed with upper body dressing; -Always incontinent of bowel and bladder; -Diagnoses included multiple sclerosis (a chronic disease where the body's immune system attacks the protective coating around nerves in the brain and spinal cord, causing damage that disrupts signals and can lead to muscle weakness, vision problems and difficulty walking). Review of the resident's Care Plan, revised 2/20/25 showed the following: -The resident had an activities of daily living (ADL) performance deficit related to multiple sclerosis; -Allow sufficient time for dressing and undressing; -The resident had limited physical mobility related to ataxia (impaired balance or coordination) and multiple sclerosis; -The resident was dependent on a manual wheelchair for locomotion; -The resident refused showers at times. Caregivers to provide opportunity for positive interaction and attention; -Explain all procedures to the resident before starting and allow the resident time to adjust to the changes; -Approach and speak in a calm manner. During an interview on 2/25/25 at 10:18 A.M. the resident said the following: -CMT F was rough and forceful with care; -CMT F wanted to do everything his/her way and if the resident complained about it, CMT F said you just need to fucking get used to it; -This made the resident feel like he/she was not worth anything; -He/She just let it go, because it could get worse if he/she reported CMT F. 3. Review of Resident #13's Care Plan, dated 11/20/24, showed the following: -The resident had an activities of daily living (ADL) self-care performance deficit related to a stroke with hemiplegia (weakness on one side of the body); -The resident required extensive assistance with dressing; -The resident required limited assistance with transfers, bed mobility and toilet use; -The resident was independent with personal hygiene with setup assistance; -Encourage the resident to participate to fullest extent possible with each interaction; -Encourage the resident to use his/her call bell for assistance; -The resident had impaired cognitive function/dementia or impaired thought processes; -With communication, identify yourself with each interaction, reduce any distractions, the resident understands simple directive sentences. Provide the resident with necessary cues and stop and return if agitated. Review of the resident's quarterly MDS, dated [DATE], showed the following: -Moderate cognitive impairment; -Functional limitation in range of motion affecting one side of the body; -The resident required partial to moderate assistance with toileting hygiene, bathing, personal hygiene, upper body dressing and chair/bed-to-chair transfer and the ability to come to a standing position from a sitting position; -The resident required substantial/maximal assistance with lower body dressing; -Mobility device used was a wheelchair; -Diagnoses included a stroke, aphasia (a language disorder that affects how you communicate), hemiplegia and depression. During an interview on 2/24/25 at 8:40 A.M. the resident said the following: -CMT F was rude and talked down to him/her; -CMT F was condescending and liked to show his/her authority; -The resident said CMT F made him/her so angry he/she wanted to punch CMT F in the face! During an interview on 2/24/25 at 10:00 A.M. Certified Nurse Assistant (CNA) C said the following: -Many of the residents said CMT F was rough, hateful, and rude during care; -CMT F said things like, get up yourself, I'm not doing it for you, or you can do it yourself; -CMT F's tone was harsh, and it upset the residents; -He/She had reported the residents' complaints to different charge nurses, but nothing was ever done. During an interview on 2/24/25 at 1:45 P.M. the Director of Nursing (DON) said the following: -CMT F didn't have a gentle approach; -He had received a couple of complaints regarding CMT F in the past couple of years and one recently about his/her tone; -All residents should be treated with dignity and respect. During an interview on 2/24/25 at 3:30 P.M. the Administrator said the following: -CMT F was too gruff and had been written up before for not providing good customer service to one of the residents; -She would expect staff to treat all residents with dignity and respect. MO248667

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure staff adequately documented assessments and monitoring of pressure ulcers (any lesion caused by unrelieved pressure, resulting in damage to underlying tissue that usually occur over bony prominences and are graded or staged to classify the degree of tissue damage observed) for one resident (Resident #333), in a review of 22 sampled residents; failed to maintain documentation of communication with the resident's physician on the changes to the resident's pressure ulcers to ensure appropriate treatment and care of the pressure ulcers; failed to ensure the resident's physician or designee followed facility policy to examine the resident's pressure ulcers upon readmission to the facility and to evaluate and document the progress of the pressure ulcers during resident visits; and failed to re-evaluate the need for ordered interventions, including a low air loss mattress, when the condition of the resident's pressure ulcers worsened. The pressure ulcers on the resident's buttocks, originally developed during hospitalization, worsened while in the facility, resulting in a Stage IV pressure ulcer (a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur). The facility census was 84. Review of the facility's policy, Wound Care, dated (revised) October 2010, showed the following: -Documentation: the following information should be recorded in the resident's medical record: -The type of wound care given; -The date and time the wound care was given; -The position in which the resident was placed; -The name and title of the individual performing the wound care; -Any change in the resident's condition; -All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound; -How the resident tolerated the procedure; -Any problems or complaints made by the resident related to the procedure; -If the resident refused the treatment and the reason(s) why; -The signature and title of the person recording the data; -Reporting: Notify the supervisor if the resident refuses the wound care; report other information in accordance with the facility policy and professional standards of practice. Review of the National Pressure Ulcer Advisory Panel (NPUAP) guidelines, dated September 2016, showed the following definitions: -Stage I pressure injury is intact skin with localized area of non-blanchable (when you press on the area of redness the redness does not go away) erythema (redness). Presence of blanchable erythema changes in sensation, temperature, or firmness may precede visual changes; -Stage II pressure injury is a partial-thickness loss of skin with exposed dermis (the thick layer of living tissue below the top layer of skin that forms the true skin). The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister, and deeper tissue are not visible. Granulation tissue (new connective tissue), slough (dead tissue in the process of separating from the body, which is usually light colored, soft, moist, or stringy), and eschar (dead tissue that sheds or falls off from health skin) are not present; -Stage III pressure injury is a full thickness loss of skin, where adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and eschar may be visible, but do not obscure the extent of tissue loss. The depth of tissue damage varies by the location on the body. Undermining and tunneling may occur. Fascia (a thin sheath of fibrous tissue), muscle, tendon, ligament, cartilage, or bone are not exposed; -Stage IV pressure injury is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and or eschar may be visible, but do not obscure the extent of tissue loss. Rolled edges, undermining and or tunneling often occur. Depth varies by location; -Unstageable pressure injury is a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar; -Deep Tissue Pressure Injury (DTPI) is an intact or non-intact skin with localized area of persistent non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (unstageable, stage III or stage IV pressure injury). Review of the facility policy, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated (revised) April 2018, showed the following: -Assessment and Recognition: -The nurse shall describe and document/report the following: -a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissues; -b. Pain assessment; -c. Resident's mobility status; -d. Current treatments, including support surfaces, and: -e. All active diagnoses; -3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions; -4. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer; -5. The physician will help identify and define and complications related to pressure ulcers; -Monitoring: -1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly healing wounds. 1. Review of Resident #333's undated medical diagnoses record showed the resident's diagnoses included transverse myelitis (a neurological disorder that results in inflammation of both sides of one section of the spinal cord, which can cause pain, muscle weakness, paralysis, sensory problems, or bladder and bowel dysfunction), diabetes mellitus (too much sugar in the bloodstream), and peripheral vascular disease (PVD, a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs-usually the legs). Review of the resident's Care Plan, dated 06/19/24, showed the following: -The resident has potential/actual impairment to skin integrity. The resident refused wound care, turning/repositioning every two hours, and hygiene cares to promote wound healing; -Monitor/document location, size, and treatment of skin injury. Report abnormalities, failure to heal, signs/symptoms of infection, maceration, etc. to the physician; -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. Review of the resident's progress notes, dated 07/14/24 at 2:16 P.M., showed the resident had experienced emesis (vomiting) all day and was discharged to the hospital where he/she was admitted . Review of the resident's progress notes, dated 07/24/24 at 5:53 P.M., showed the resident was readmitted to the facility from the hospital. Review of the resident's Weekly Wound Assessment, dated 07/25/24 at 9:00 A.M., showed Registered Nurse (RN) N documented the following: -Date of onset: 07/25/24; -The resident had an unstageable pressure ulcer located on his/her right buttock that was present on admission to the facility; -The pressure ulcer measured 0.5 centimeters (cm) length by 0.5 cm in width by 0.1 cm in depth; -No undermining (separation of the wound edges from the surrounding healthy tissue, often creating a pocket under the wound surface) or tunneling (a wound that has progressed to form passageways underneath the surface of the skin); -Wound bed color- pink and red; -Granulation (the development of new tissue and blood vessels in a wound during the healing process) 100 percent; -Amount of drainage (exudate) small, less than 25 percent (%); -Type of drainage (exudate) serosanguinous (thin, watery, pale, red/pink drainage); -No odor; -Wound edges- macerated (a softening and breaking down of skin resulting from prolonged exposure to moisture) and red; -Periwound tissue (tissue surrounding a wound) macerated, redness; -No pain related to wound; -Wound healing progression-new. Review of the resident's Weekly Wound Assessment, dated 07/25/24 at 9:00 A.M., showed Registered Nurse (RN) N documented the following: -Date of onset: 07/25/24; -The resident had a Stage III pressure ulcer located on his/her left buttock that was present on admission to the facility; -The pressure ulcer was 3.6 cm in length by 4.3 cm in width by 0.1 cm in depth; -No undermining or tunneling -Wound bed color- red; -Granulation 100 percent; -Amount of drainage: small, less than 25 percent (%); -Type of drainage: serosanguinous; -No odor; -Wound edges- red; -Periwound tissue was macerated, redness; -No pain related to wound. -Wound healing progression-new. Review of the resident's Care Plan, last dated 06/19/24, showed no documentation staff updated the care plan to include the resident had pressure ulcers on his/her left and right buttocks and no goals or interventions to address these areas. Review of the resident's Nursing Progress Notes, dated 7/29/24, showed staff documented the resident was lethargic (sleepy), had a low level of consciousness and confused, with a low blood pressure. He/She was discharged to the hospital on [DATE]. Review of the resident's progress notes, dated 08/05/24 showed the resident was readmitted to the facility from the hospital. Review of the resident's Hospital Discharge Orders, dated 08/05/24, showed the following orders for skin/wound care: -Bilateral sacral gluteal (base of the spine/buttocks) - cleanse with Theraworx (a hygiene and barrier system foam) daily. Apply triad cream (an antibiotic cream) daily dime thick (approximately 2 millimeters (ml)) to open lesions. Apply mixture of triad cream and petroleum jelly to surrounding skin and gluteal/perineal region for barrier cream. Use petroleum jelly as needed with incontinence care after daily application of petroleum jelly. Do not scrub barrier/wound cream away with repeated care, wipe away top (soiled) layer only and then reapply; -Please do the following for the best care of the patient: IsoAir low air loss mattress (a special mattress that helps prevent and treat pressure injuries and manages moisture)-please implement! Review of the resident's physician orders showed an order, dated 08/06/24 at 7:00 A.M., to cleanse the resident's bilateral buttocks with cleanser, pat dry, apply thick layer of zinc/collagen mixture (topical treatment for cell repair) every shift until healed every day for wound healing. (Review showed no evidence staff obtained an order for a low air loss mattress.) Review of the resident's weekly wound assessment, dated 08/06/24 at 7:53 A.M., showed Registered Nurse (RN) N documented the following: -The resident had a stage II pressure ulcer on his/her right buttock that was present on admission to the facility; -The pressure ulcer measured 4 cm in length by 5 cm in width by 0.1 cm in depth. (The size of the pressure ulcer increased from the previous assessment on 7/25/24 when it measured 0.5 cm in length by 0.5 cm in width by 0.1 cm in depth. Staff identified the pressure ulcer on 7/25/24 as unstageable.) -No undermining or tunneling; -Wound bed color- pink and red; -Granulation 100 percent; -Amount of drainage: small, less than 25% -Type of drainage: serosanguinous; -No odor; -Wound edges- macerated and red; -Periwound tissue: macerated, redness; -No pain related to wound. Review of the resident's weekly wound assessment, dated 08/06/24 at 8:01 A.M. showed RN N documented the following: -The resident had a pressure ulcer on his/her left buttock that was present on admission to the facility. He/She classified the wound as a deep tissue injury (DTI); -The pressure ulcer measured 5.5 cm in length by 4 cm in width, by 0.1 cm in depth. (The size of the pressure ulcer increased from the previous assessment on 7/25/24 when it measured 3.6 cm in length by 4.3 cm in width by 0.1 cm in depth. Staff identified the pressure ulcer changed from a stage III pressure ulcer on 7/25/24 to a DTI on 8/6/24.) -No undermining or tunneling; -Wound bed color- red and black; -Necrosis (the death of the cells in your body tissues which can occur due to injuries, infections, or diseases) 100%. (Staff's assessment on 7/25/24 showed the pressure ulcer had 100% granulation tissue.) -Amount of drainage-none; -No odor; -Wound edges- red; -Periwound tissue macerated, redness; -No pain related to wound. Review of the resident's medical record showed no documentation RN N notified the resident' physician or primary care NP of the condition of the resident's pressure ulcers or the changes to the resident's pressure ulcers identified on the weekly skin assessment completed on 08/06/24. Review of the Interdisciplinary Team (IDT) meeting notes, dated 08/06/24 at 9:45 A.M., showed the Social Worker documented the following: -The resident said his/her goal was to work with therapy to go home; -The Director of Therapy explained to the resident that he/she was only able to use the slide board for transfers; -The IDT team discussed with the resident the pros and cons of an air mattress as per the resident's hospital paperwork; -The resident verbalized understanding and said he/she wanted to continue working with therapy to get stronger and go home; -The Director of Therapy explained that in the resident's best interest, therapy would continue to work on slide board transfers, but the resident would remain a mechanical lift for nursing staff until therapy cleared him/her; -The resident was in agreement with goal to go home and to work with therapy to do so; (Review of the IDT meeting notes showed no documentation the primary care NP or resident's physician were in attendance.) During an interview on 10/04/24 at 2:00 P.M., RN N said the following: -A low-air loss mattress was not obtained for the resident when he/she returned to the facility on [DATE]. He/She and the therapy team decided during an IDT meeting that since the resident's goal was to return home and therapy was working with the resident on slide board transfers, they would hold off on the low-air loss mattress for the time being. A slide board could not be used with a low-air loss mattress; -He/She was pretty sure he/she discussed why nursing and therapy decided not to implement a low air loss mattress as ordered on the hospital discharge on [DATE] with the resident's primary care NP and the NP concurred. During an interview on 10/07/24 at 9:45 A.M., the Director of Physical Therapy said the following: -The IDT met regarding the resident's return to the facility on [DATE]; -She recalled the conversation during the IDT meeting about the resident's hospital discharge orders on 08/05/24 for a low-air loss mattress; -The resident's goals at that time were to return home, so the team opted to continue to work with the resident on slide board transfers; -A slide board cannot be used on a low air loss mattress; -She was not aware the resident had any worsening of his/her pressure ulcers on the buttocks from his/her recent hospitalization and upon his/her return to the facility on [DATE]; -If a resident's wound involved the buttocks, a slide board could potentially cause worsening of the wound. Review of the resident's medical record showed no documentation staff notified the resident's physician or primary care NP of the IDT's discussion to not utilize a low air loss mattress on the resident's bed or consulted with the physician to determine if a slide board was appropriate for transfers when the resident had pressure ulcers on his/her buttocks. Review of the resident's progress notes, dated 08/08/24, showed the primary care NP documented the following: -History of present illness (HPI): the resident was seen in follow-up for his/her readmission to the facility from the hospital on [DATE]; -The resident had buttocks wounds; -The resident's assessment included skin: warm and dry; -The resident's diagnosis was wound of buttock, unspecified laterality; -Continue treatment orders. (Review showed no documentation the NP evaluated the pressure ulcers and assisted the staff to identify the characteristics of the pressure ulcers, or identified any complications related to the pressure ulcers, or evaluated and documented the progress of healing per facility policy.) Review of the resident's five-day prospective payment system (PPS) Minimum Data Set (MDS), a federally mandated assessment completed by facility staff, dated 08/11/24, showed the following: -Cognitively intact; -Dependent for toileting; -Partial to moderate assistance for chair/bed-to-chair transfer; -Had an indwelling urinary catheter; -Always incontinent of bowel; -At risk for developing pressure ulcers; -Had one or more unhealed pressure ulcers at stage I or higher; -Skin and ulcer treatments did not include pressure reducing device for bed. Review of the resident's progress notes, dated 08/15/24, showed the primary care NP documented the following: -History of present illness (HPI): Medicare (part) A follow-up; -The resident had buttocks wounds; -The resident's assessment included skin: warm and dry; -The resident's diagnosis was wound of buttock, unspecified laterality; -Continue treatment orders. (Review showed no documentation the NP evaluated the pressure ulcers and assisted the staff to identify the characteristics of the pressure ulcers, or identified any complications related to the pressure ulcers, or evaluated and documented the progress of healing per facility policy.) Review of the resident's weekly wound assessment, dated 08/16/24 at 1:11 P.M., showed RN N documented the following: -The resident had a stage II pressure ulcer on his/her right buttock that was present on admission to the facility; -The pressure ulcer measured 3.0 cm in length by 3.8 cm in width and 0.1 cm in depth. (The size of the pressure ulcer decreased from the previous assessment on 08/06/24 when it measured 4 cm in length by 5 cm in width by 0.1 cm in depth.); -No undermining or tunneling; -Wound bed color- pink and red; -Granulation 100%; -Amount of drainage: small, less than 25% -Type of drainage: serosanguinous; -No odor; -Wound edges- macerated and red; -Periwound tissue: macerated, redness; -No pain related to wound. Review of the resident's weekly wound assessment, dated 08/16/24 at 1:14 P.M., showed RN N documented the following: -The resident had a pressure ulcer on his/her left buttock that was present on admission to the facility; -He/She classified the wound as a suspected deep tissue injury (DTI); -The pressure ulcer measured 5.5 cm in length by 4.0 cm in width and 0.1 cm in depth. (The size of the pressure ulcer stayed the same from the previous assessment on 08/06/24); -No undermining or tunneling; -Wound bed color- red and black, (unchanged from staff assessment on 08/06/24); -Necrosis 100% (unchanged from staff assessment on 08/06/24); -Amount of drainage-none; -No odor; -Wound edges- red; -Periwound tissue macerated, redness; -No pain related to wound. Review of the resident's progress notes, dated 08/19/24, showed the primary care NP documented the following: -History of present illness (HPI): Medicare (part) A follow-up; -The resident had buttocks wounds; -The resident's assessment included skin: warm and dry; -The resident's diagnosis was wound of buttock, unspecified laterality; -Continue treatment orders. (Review showed no documentation the NP evaluated the pressure ulcers and assisted the staff to identify the characteristics of the pressure ulcers, or identified any complications related to the pressure ulcers, or evaluated and documented the progress of healing per facility policy.) Review of the resident's Physician's Orders, dated 8/20/24, showed a new order to cleanse the resident's bilateral buttocks with cleanser, pat dry and apply calcium alginate (a type of dressing that accelerates wound healing) to affected areas, then cover with sacral silicone border foam dressing (an absorbent dressing) daily and as needed for soiling/dislodgement until healed. Review of the resident's progress notes, dated 08/21/24, showed the primary care NP documented the following: -History of present illness (HPI): Medicare (part) A follow-up; -The resident had buttocks wounds; -The resident's assessment included skin: warm and dry; -The resident's diagnosis was wound of buttock, unspecified laterality; -Continue treatment orders. (Review showed no documentation the NP evaluated the pressure ulcers and assisted the staff to identify the characteristics of the pressure ulcers, or identified any complications related to the pressure ulcers, or evaluated and documented the progress of healing per facility policy.) Review of the resident's weekly wound assessment, dated 08/23/24 at 9:53 P.M., showed RN N documented the following: -The resident had an unstageable pressure ulcer on his/her bilateral buttocks that was present on admission to the facility; -The pressure ulcer measured 6.4 cm by 5.4 cm by 0.1 cm; -No undermining or tunneling; -Wound bed color pink and red; -Granulation 100%. (RN N identified the unstageable pressure ulcer had 100% granulation tissue, however, an unstageable pressure ulcer is identified as a full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. RN N did not identify any slough or eschar on the skin assessment.) -Amount of drainage: moderate, 25 to 75 percent; -Type of drainage: serosanguinous; -No odor; -Wound edges macerated and red; -Periwound tissue macerated, redness; -No pain related to wound; -Wound healing progression- worsened. Review of the resident's medical record showed no documentation staff notified the resident's physician or primary care NP of the worsening condition of the resident's pressure ulcer on 8/23/24. Review of the resident's progress notes, dated 08/25/24 at 3:43 P.M., showed facility staff documented the resident's left foot was red and warm to touch and he/she was lethargic (sleepy) and hard to arouse. The resident was discharged from the facility to the hospital where he/she was admitted . Review of the resident's hospital records, dated 08/27/24 (four days after the facility's weekly wound assessment completed on 8/23/24), showed the hospital skin care team (SCT) documented the following: -Sacrum/coccyx and bilateral gluteal unstageable pressure injury measures 11.5 cm by 14.5 cm. (a worsening in measurements from 6.4 by 5.4 cm by the facility). This large wound bed covers the sacrum, coccyx and extends on both the right and left gluteal with greater than 50% of the wound bed covered in adherent yellow-black slough (a specific type of nonviable tissue that occurs as a byproduct of the inflammatory process, it can delay healing and increase the risk of infection). Additionally, there is incontinence associated dermatitis (skin inflammation) noted to the periwound, with generalized bright red erythema with partial thickness skin loss and small areas of erosion; -Recommendations: consult a surgical team to evaluate for debridement (a surgical procedure by which dead skin tissue is removed). Review of the resident's hospital records, dated 08/28/24, showed the SCT documented the resident's sacrum and coccygeal stage IV pressure injury, post-debridement. ACS debrided some of the eschar (dead tissue that forms over healthy skin) and slough today noting this is a stage IV as this probes to bone. During an interview on 10/04/24 at 2:00 P.M., RN N/Wound Nurse said the following: -He/She was the wound care nurse for the facility; -He/She received wound care training from a wound care certified nurse practitioner (NP) who previously cared for the resident at the facility; -He/She was not wound care certified; -The resident's primary care nurse practitioner (NP) oversaw the resident's pressure ulcers after the wound care certified NP left a couple of months ago; -RN N saw the resident and provided wound care to him/her daily and as needed; -The primary care NP did not always see the resident's wounds with RN N, but RN N was always in communication with the primary care NP, either while the NP was in the building making rounds on residents or by phone, about how the wounds were looking and what treatment changes might need to be made. (Review of the resident's medical record showed no documentation of the communication between RN N and the primary care NP); -He/She documented his/her findings on the weekly skin assessment flow sheet and in the nurses' progress notes if he/she needed to; -He/She completed skin assessments weekly unless there was a change in the wound; -If a wound was not improving or worsened, he/she notified the primary care NP. Sometimes he/she spoke to the NP when the NP was making rounds at the facility or he/she could always call the NP; -The resident sometimes refused wound care and to turn; -If a resident refused care, staff should document that in the progress notes. He/She wasn't sure why that had not been documented. (Review of the resident's progress notes showed no evidence the resident refused care.) -He/She did not exactly recall how the resident's pressure ulcers looked on 08/20/24 when the wound care orders were changed to a calcium alginate product for the buttocks, but he/she would have gotten the wound care order from the primary care NP; -His/Her last assessment of the resident's pressure ulcers was on 08/23/24, two days prior to the resident being discharged to the hospital; -He/She could not recall how the resident's pressure ulcers looked on 08/23/24, but remembered the buttocks did not have any depth, and that he/she was still comfortable with the current treatment orders. During an interview on 10/08/24 at 11:00, the primary care NP said the following: -She was not wound care certified; -She oversaw wound care for her residents after the previous wound certified NP left the facility, about two months ago; -She did not make rounds with RN N, who was the wound care nurse, but she was in contact with RN N as she was in the facility at least one to two times each week seeing other residents; -The resident had been in and out of the facility for hospital admissions and had been seen by other specialists while hospitalized and on an outpatient basis; -She thought the resident's pressure ulcers were managed by other specialists, to include infectious disease (ID), vascular (blood flow specialists) and orthopedics (bone specialists), so she would typically not change any wound care orders. (Review of the resident's progress and consultation notes showed no documentation that other medical specialists who saw the resident, including vascular and orthopedics, evaluated or ordered treatment specific to the resident's buttocks/sacral wounds.); -She thought she last saw the resident's pressure ulcers after the resident's vascular appointment, maybe in July; -If the wound nurse did not communicate any concerns about the resident's pressure ulcers not improving or worsening, she would not have changed any orders; -She may have given the order to change the wound treatment for the buttocks to a calcium alginate product on 08/20/24. She was not sure and could not recall what changes had been reported to prompt the new orders. (Review of the resident's progress notes showed no documentation regarding the condition of the resident's pressure ulcers on 08/20/24 or evidence staff notified the NP regarding the resident's pressure ulcers on this date.); -She thought she remembered staff said they were not going to use a low-air loss mattress when the resident returned to the facility on [DATE] because therapy wanted to still work on transfers with the slide board; -Not using a low-air loss mattress could have contributed to worsening of the resident's wounds, however, the resident had several other medical issues that likely also contributed to her lack of wound healing or wound deterioration; -She could not speak to the discrepancy of the pressure ulcer assessment by the wound care nurse in the facility on 08/23/24 to the hospital assessment of the pressure ulcer on 08/27/24 which determined the resident had a stage IV sacral pressure ulcer; -She expected nursing staff to follow the facility policy for wound care; -She expected nursing staff to document wound care, verbal orders, or other communications about the resident with the primary care team (physician/NP) in the progress notes. During an interview on 10/08/24 at 4:15 P.M., the Director of Nurses (DON) said the following: -The facility's wound nurse was trained by the previous certified wound care NP who was no longer at the facility; -The primary care NP oversaw the residents with wounds while the facility looked for a new wound care provider; -The primary care NP was in communication with the wound care nurse at least one to two times weekly as the NP was in the building making rounds on her residents; -He was not sure if the primary care NP saw Resident #333's pressure ulcers when she was in the facility; -He was aware therapy was still working on slide board transfers when the resident was readmitted on [DATE] and that the low-air loss mattress, as ordered on hospital discharge, was not obtained at that time, and that the resident's PCP was also aware; -He was not aware the pressure ulcers on the resident's buttocks had worsened from 08/05/24 through 08/25/24; -He was unable to speak to the discrepancies and worsening of the pressure ulcer on the resident's buttocks from the wound nurse's weekly skin assessment on 08/23/24 to the resident's hospital evaluation of the pressure ulcer on 08/27/24 which showed a stage IV sacral pressure ulcer; -If he had known the pressure ulcer had gotten so bad, they would have done things differently such as stopping the slide board transfers and started using a low-air loss mattress; -He expected nursing staff to follow facility policy for wound care; -He expected the wound care nurse to report and document any changes of a resident's pressure ulcers and any communication or new orders about wound care with the primary care NP or physician in the progress notes; -He expected the wound care nurse to report any changes or worsening of a resident's pressure ulcers to the DON and document those changes and communication in the progress notes. During an interview on 10/08/24 at 5:00 PM, the Administrator said the following: -She expected nursing staff, including the wound care nurse, to report changes or worsening of a resident's pressure ulcers to the DON and the PCP; -She expected nursing staff, including the wound care

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure staff safely transferred two residents (Residents #133 and #21), in a review of 22 sampled residents and one additional resident (Resident #30), who required assistance with transfers. Staff failed to utilize proper transfer technique when transferring Resident #133, when staff did not use a gait belt and did not ensure the resident wore proper foot wear during a transfer which resulted in a fall with injury. The resident sustained a displaced fracture of the tibia/fibula (ankle) as a result of the fall. The facility census was 84. Review of the facility policy, Managing Falls and Fall Risk, revised [DATE], showed the following: -Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling; -According to the Minimum Data Set (MDS), a fall is defined as unintentionally coming to rest on the ground, floor or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode were a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. -Environment factors that contribute to the risk of falls include: wet floors, poor lighting, incorrect bed height or width, obstacles in the footpath, improperly fitted or maintained wheelchairs, and footwear that is unsafe or absent. Review of the facility's policy, Safe Lifting and Movement of Residents, revised [DATE], showed the following: -In order to protect the safety and well-being of staff and residents and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents; -Resident safety, dignity, comfort and medical condition will be incorporated into goals and decisions regarding the safe lifting and moving of residents; -Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following: resident's preferences for assistance; resident's mobility (degree of dependency); resident's size; weight-bearing ability; cognitive status; whether the resident is usually cooperative with staff; the resident's goals for rehabilitation, including restoring or maintaining functional abilities; -Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 1. Review of Resident #133's discharge Minimum Data Set (MDS), a federally mandated assessment to be completed by a previous facility, dated [DATE], showed the following: -His/Her cognition was intact; -The resident required partial to moderate assistance (helper provided less than half the effort, helper lifts, holds, or supports trunk or limbs, but provides less than half the effort), with position changes from sitting to standing and transferring from chair to chair and/or chair to bed; -The resident required supervision/touch assistance with toilet transfers; -The resident required supervision or touch assistance with walking ten feet. Review of the resident's undated discharge documents from a previous facility showed the following: -The resident weighed 415 pounds; -The resident could ambulate and transfer to the toilet. Review of the resident's face sheet showed he/she admitted to the facility on [DATE]. Review of the resident's physician's orders, dated [DATE], showed the resident used a walker and wheelchair. Review of the resident's admission fall assessment, dated [DATE], showed the following: -He/She was at risk for falls; -He/She was not steady and only able to stabilize with physical assistance while standing, sitting, and during transfers. Review of the resident's care plan, initiated on [DATE], showed the following: -The resident had an activity of daily living (ADL) self-care performance deficit related to limited mobility; -The resident required substantial/maximum assist with transfers. -The resident was at high risk for falls related to deconditioning; -Ensure the resident wore appropriate footwear (non-skid socks) when ambulating. Observation on [DATE] at 6:25 A.M. showed the following: -The resident requested to use the bedside commode; -Certified Nursing Assistant (CNA) M assisted the resident to prepare for the transfer from the bed to the bedside commode; -The resident did not wear socks or shoes. CNA M did not assist the resident to put on proper footwear prior to the transfer; -CNA M did not put a gait belt on the resident. The resident held onto his/her walker and stood while CNA M provided stand-by assistance. The resident said the floor was wet. The resident's left foot began to slide. The resident told CNA M to place his/her foot next to his/her (the resident's) left foot to prevent it from sliding. CNA M placed his/her foot next to the resident's foot and the resident started to pivot to the bedside commode. As the resident pivoted, his/her right foot slid, and he/she said he/she was going to fall. CNA M attempted to assist the resident to the floor by attempting to hold onto the resident's arm, but the resident fell to the floor. During an interview on [DATE] at 8:25 A.M., the resident said the following: -He/She stood up and his/her right knee buckled which caused his/her left leg/foot to slide; -Staff never used a gait belt on him/her; -His/Her feet were too swollen for socks and his/her slippers were too big for him/her to wear so he/she did not wear footwear. During an interview on [DATE] at 4:10 P.M., CNA M said the following: -He/She did not use a gait belt when transferring this resident because the resident had told him/her (in the past) that he/she could transfer by himself/herself; -During the transfer, the resident said there was water on the floor, but the floor was usually shiny and cold. He/She did not see anything wet on the floor prior to the transfer. If he/she had noted the floor was wet, he/she would not have transferred the resident; -He/She worked with the resident a couple of times and was directed (did not specify who provided this direction) that the resident required stand by assist with transfers; -The resident had never had any problems with previous transfers; -He/She should have assisted the resident to sit down and asked for assistance when the resident asked him/her to place his/her foot next to the resident's foot to prevent it from sliding. Review of the resident's nursing progress note, completed by Registered Nurse (RN) H, dated [DATE] at 7:15 A.M., showed the following: -The resident had a witnessed fall during a pivot transfer with one assist; -Assessment completed and x-ray of the right ankle/foot ordered. Review of the resident's right ankle x-ray report, dated [DATE], showed an acute displaced fracture of the tibia/fibula (ankle). During an interview on [DATE] at 7:00 A.M., the Assistant Director of Nursing (ADON) said the resident normally required a one person stand/pivot transfer. During an interview on [DATE] at 3:25 P.M., RN H said the resident may only require standby assistance if he/she was having a good day, but staff should always use a gait belt when transferring the resident. During an interview on [DATE] at 3:40 P.M., the Director of Nursing (DON) said the following: -The resident transferred to the facility from another facility; -The discharging facility's staff, who transported the resident to the facility, demonstrated how the resident transferred which was one person pivot transfer with a gait belt; -He expected staff to use a gait belt with transfers; -When the resident said the floor was wet and was sliding, the CNA should have stopped the transfer, sat the resident down, and assessed the situation; -The CNA should not have used his/her foot as a wedge for the resident's foot during the transfer. 2. Review of Resident #30's care plan, dated [DATE], showed the following: -The resident had an activity of daily living (ADL) self-care deficit performance deficit related to weakness; -Staff were to transfer the resident with a mechanical lift; -The resident was a risk for falls related to gait/balance problems. Review of the resident's admission MDS, dated [DATE], showed the following: -Cognitively intact; -Upper and lower extremity impairment on one side; -Required partial to moderate assistance chair/bed-to-chair transfers; -Medical diagnoses included stroke. During an interview on [DATE] at 4:10 P.M., the resident said the following: -He/She had a stroke that left his/her left side weak, so it was hard for him/her to get out of bed without help; -Usually just one staff helped him/her to get out of bed; -Sometimes the staff used a gait belt when they helped him/her up, but not always; -He/She did not always feel steady on his/her feet when he/she was up. Observation on [DATE] at 4:20 P.M. showed the following: -The resident lay in bed and was barefoot; -CNA C did not put a gait belt on the resident; -CNA C assisted the resident to sit on the side of the bed, then assisted the resident to stand at the bedside by lifting up under the resident's left arm/underarm area; -The resident held onto the walker with his/her right hand while he/she attempted to steady himself/herself to stand; -The resident tottered to his/her left side briefly while standing; -CNA C steadied the resident by holding onto the resident's left arm; -The resident put his/her left hand onto the walker and used both hands to hold on and steady himself/herself as he/she stood at the walker. During an interview on [DATE] at 5:00 P.M., the resident said the following: -He/She felt very unsteady when CNA C helped him/her up earlier and did not use a gait belt; -He/She was afraid of falling. During an interview on [DATE] at 9:05 A.M., CNA C said the following: -The resident required stand-by assistance from one staff for transfers; -He/She didn't use a gait belt because the resident usually did pretty well with transfers; -He/She did not realize the resident was barefoot. The resident probably should have worn gripper socks. During an interview on [DATE] at 3:00 P.M., the Restorative Nurse Aide (RNA) said the following: -The resident was on restorative therapy and transferred with assistance from one staff; -He/She was not sure why the care plan indicated the resident needed a mechanical lift; -Staff should always use a gait belt for all transfers. 3. Review of Resident #21's face sheet showed the resident's diagnoses included hemiplegia and hemiparesis (weakness on one side of the body) following a stroke, affecting the left non dominant side, morbid obesity, unsteadiness on feet, cognitive communication deficit, difficulty walking and need for assistance with personal care. Review of the resident's significant change MDS, dated [DATE], showed the following: -The resident had severe cognitive impairment; -The resident had limited range of motion on one side of his/her upper body and lower body; -The resident required partial assistance from bed to chair transfer and for sit to stand assistance. Review of the resident's visual bedside [NAME] report (a facility document that directed staff how to care for a resident) showed the following: -Mobility: The resident was weight bearing; -Transfer: Maximum one staff assist; -Dressing: The resident required extensive assistance; -No documentation of gait belt use. Observation on [DATE] at 12:33 P.M., showed the following: -A gait belt hung on the towel rack in the resident's room; -CNA C assisted the resident to sit on the side of his/her bed; -CNA C did not put a gait belt around the resident; -CNA C placed his/her left arm under the resident's right arm, placed his/her right hand around the resident's waist, and assisted the resident to a standing position. CNA C then pivoted the resident and assisted the resident to sit in a wheelchair; -The resident was able to stand briefly for the transfer. During an interview on [DATE] at 12:40 P.M., CNA C said the resident required one staff to help him/her stand and pivot to his/her wheelchair. Staff did not use a gait belt to assist the resident with his/her transfers. The resident did not like the staff to use a gait belt during his/her transfers. During an interview on [DATE] at 9:06 A.M., Licensed Practical Nurse (LPN) C said the resident was able to stand to transfer. Staff should use a gait belt when helping with transfers. During an interview on [DATE] at 2:34 P.M., the Director of Rehabilitation said the resident had a stroke and had improved with therapy. He/She required one staff to help him/her stand and pivot to his/her wheelchair. Staff had been educated to use a gait belt when doing a one person transfer with the resident. No one had ever mentioned the resident refused the use of a gait belt during transfers. 4. During an interview on [DATE] at 6:00 P.M., the DON said he expected staff to use gait belts with all stand by transfers. During an interview on [DATE] at 6:05 P.M., the Administrator said she expected staff to use gait belts with all stand by transfers.