**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident #157 was admitted [DATE] to the facility, from the hospital, with diagnoses which included sepsis, cellulitis of left lower limb, quadriplegia, and pressure ulcer of right hip. A Braden Scale, dated 03/10/23, documented the resident was at moderate risk for skin breakdown. A Care Plan, dated 03/13/23, documented Resident #157 required assistance with ADLs. There were no documentation in the resident's clinical record related to a wound/skin issue on Resident #157's left great toe. A Skin/Wound Note, dated 03/14/23, documented the skin assessment was completed on 03/13/23 by the WCN. It did not document any wound/skin issues on Resident #157's left great toe. On 03/14/23 at 3:00 p.m., Resident #157's wound care was observed to be completed by the wound care nurse. An undated band aid was observed on the resident's left great toe. The WCN removed the band aid and an unstageable pea sized wound was observed. The resident stated they hit their toes a lot. They stated they think it happened about two weeks ago. Resident #157 stated home health or the hospital had put the band aid on their toe prior to being admitted at this facility. The WCN stated, Going to have to say I didn't see that. On 03/14/23 at 3:25 p.m., the WCN stated charge nurses were to complete skin assessments when the resident admitted and she completed her assessment at a later time. She stated she completed her assessment on 03/13/23 [four days after the resident admitted ]. The WCN stated when she completed her assessment, she did not look under the band aid. There was no documentation of the skin condition to the left great toe on admission. On 03/15/23 at 10:18 a.m., the DON stated they completed skin assessments on admission. She stated if a wound was identified, the WCN would assess them. The DON stated they would implement wound care orders if necessary. She stated she would expect the nurses to assess an extremity if the resident admitted with cellulitis to the extremity. The DON stated she would expect the nurses to remove bandages on admission, unless there were orders to not remove. She stated she would still expect them to lift the bandage and look under it and then put it back if they were able to. The DON was asked if the physician had been notified and interventions put in place to treat the unstageable wound identified on 03/14/23. She stated no interventions had been implemented and the physician had not been notified. The DON clarified there had not been any treatment to the Resident's left great toe since admission [DATE]]. Resident #157's left great toe had not been assessed, monitored, or treatment obtained for five days. A Nurse's Note, dated 03/15/23 at 11:01 a.m., read in part, .Focus assessment related to wound: Band-aid to distal end of Left great toe, upon removal observed, circular area dark brown scabbed area measuring 1cm x 1.5cm x 0cm, surrounding tissue clinically appears dry and flaky, no exudate observed .new order received for Betadine once a day until healed . On 03/15/23 at 12:43 p.m., the DON was asked what the diagnosis was of Resident #157's left great toe. She stated it was an unstageable wound. On 03/16/23, an IJ situation was determined to exist due to the facility failing to ensure: a. Resident #153, who admitted with a blister to their left heel was thoroughly assessed on admission and weekly, monitored for changes, physician notified, and interventions implemented. This resulted in sepsis, osteomyelitis, and left BKA, and b. Resident #157 was thoroughly assessed on admission and an unstageable pressure ulcer was identified four days after admission. On 03/16/23 at 2:30 p.m., the Oklahoma State Department of Health was notified and verified the existence of the IJ situation. On 03/16/23 at 2:48 p.m., the Administrator and DON were notified of the IJ situation. On 03/16/23 at 11:19 p.m., an acceptable plan of removal was provided. The plan of removal documented: .1. Immediate action(s) taken for the resident(s) found to have been affected include: R-153 no longer resides at the facility. R-157 was assessed on 3/15/23 for wound on left great toe. M.D. notified, order obtained, treatment provided, and care plan updated. Appropriate revisions were made to the care plans to reflect all current pressure injury prevention interventions. The MDS nurse reviewed the revised care plans with all staff involved in the care of the resident on 3/16/23. 2. Identification of other residents having the potential to be affected was accomplished by: The facility took the following actions: Head to toe assessments and Braden assessments were completed for all residents on 3/16/23 by the nursing management team. For those residents at risk, care plans were reviewed to ensure appropriate interventions. The MDS nurse reviewed the revised care plans with all staff involved in the care of at risk residents on 3/16/23. Any resident out of the facility for more that 24 hours will have a new head to toe assessment completed. 3. Actions taken/systems put into place to reduce the risk of future occurrence include: The facility policy regarding Pressure Injury Prevention was reviewed to include Braden assessment and head to toe assessment to be completed upon admission. All licensed nursing staff was inserviced by the Director of Clinical Services and or Nursing Management Team on the facility policy for Pressure Injury Prevention and Management, skin assessments and timely reporting of skin concerns on 3/16/23. All licensed nurses who were on leave (2) will be in-serviced prior to returning to work. All non-direct care staff have been in-serviced regarding if any skin issues are observed or have knowledge of must be reported to the nurse at that time. Skin policies (Pressure Injury Prevention and Management, Skin Assessment and Notification Changes) reviewed have been added into thee onboarding process for new hire nurses. Routine skin meetings have been initiated as of 3/16/23 which will then be reviewed by the IDT. 4. How the corrective action(s) will be monitored to ensure the practice will not recur: The MDS nurses and/or designee will review Braden assessments, skin assessments, interventions, and care plans on all new admission on -going. The Director of Clinical Services and/or designee will monitor/audit a minimum of 10 admission per month for three months, then 5 admission per month thereafter unless otherwise determined by the QAPI committee until such time consistent substantial compliance has been achieved as determined by the committee On 03/17/23 at 9:35 a.m., interviews were conducted across all shifts with facility staff. Staff had knowledge of the POR. After the facility conducted skin assessments on all residents, the DON stated they had five additional residents as having skin issues including shears, cellulitis, and unstageable pressure ulcers. On 03/17/23 at 11:32 a.m., the Administrator was informed the immediacy had been lifted. The deficient practice remained at a harm level. Based on record review, observation, and interview, the facility failed to ensure: a. Resident #153, who admitted with a blister to their left heel was thoroughly assessed on admission and weekly, monitored for changes, physician notified, and interventions implemented. This resulted in sepsis, osteomyelitis, and left BKA, and b. Resident #157 was thoroughly assessed on admission and an unstageable pressure ulcer was identified four days after admission. The Resident Census and Conditions of Residents report, dated 03/13/23, documented 59 residents resided in the facility and two had pressure ulcers. Findings: A Pressure Injury Prevention and Management policy, dated 01/03/23, read in parts, .This facility is committed to the prevention of avoidable pressure injuries .and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries . Pressure Ulcer/Injury refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device .Avoidable means that 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, resident goals, and professional standards of practice; monitor and evaluate the impact of the interventions; or revise the interventions as appropriate . The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate . Licensed nurses will conduct a full body skin assessment on all resident's upon admission/readmission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record . Assessments of pressure injuries will be preformed by a licensed nurse, and documented on the EHR. The staging of pressure injuries will be clearly .Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate (if present), presence of pain, signs of infection, wound bed, wound edge and surrounding tissue characteristics . A Skin Assessment policy, dated 01/03/23, read in parts, .It is our policy to perform a full body skin assessment as part of our systemic approach to pressure injury prevention and management . A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission, weekly thereafter. The assessment may also be performed after a change of condition or after a newly identified pressure injury .Documentation of skin assessment .Document observations .Document type of wound .Describe wound . 1. Resident #153 had diagnoses which included pressure ulcers. Resident #153's Physician Order, dated 01/09/23, documented wound consult, evaluate, and treat as needed. A Braden Scale for Predicting Pressure Score Risk, dated 01/09/23, documented the resident was at moderate risk for pressure ulcers. A Weekly Skin Screen, dated 01/10/23, documented staff observed what clinically appeared as a fluid filled blister with 75 percent of the blister deflated. There was no location of the wound, stage, size, exudate, description of wound bed, description of wound edges, or signs of infection identified for the blister. There were no physician's orders to treat the wound for four days. A Physician's Order, dated 01/13/23, read in part, .Apply to BLISTER OF LEFT HEEL topically every day shift related to BLISTER (NONTHERMAL), LEFT FOOT, INITIAL ENCOUNTER .GENTLY CLEANSE W/SALINE WOUND WASH, GENTLY PAT DRY, APPLY XEROFORM GAUZE, COVER W/GAUZE ISLAND DRESSING CHANGE DAILY . An admission Resident Assessment, dated 01/16/23, documented Resident #153 was at risk for pressure ulcers, and had one stage one pressure ulcer present. A Weekly Skin Screen, dated 01/18/23, did not document stage, size, exudate, description of wound bed, and description of wound edges for the blister. A Skilled Progress Note, dated 01/20/23 at 1:53 p.m., did not document stage, size, exudate, description of wound bed, and description of wound edges for the blister. A Care Plan, dated 01/20/23, read in part, .have potential/actual impairment to skin integrity. I was admitted to the facility with a stage 1 pressure ulcer .a blister to my left heel. I am at risk for further impairment to my skin r/t impaired gait/mobility .My Skin injury will remain free from infection/complications by review date and I will have no further impairment to my skin .Follow facility protocols for treatment of injury .Identify and document potential causative factors and eliminate/resolve where possible .Monitor and document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD .Monitor limb for swelling and skin changes. Take pedal pulses every shift . A Late Entry Nurses' Note, dated 01/23/23 at 10:21 a.m., created on 01/27/23, documented the nurse observed a fluid filled blister of left heel which appeared clinically with completely deflated blister, surrounding tissue pink, center with 70% thick black eschar (dead tissue). A Wound Care Telemedicine Initial Evaluation, dated 01/25/23, documented the resident had a stage three pressure wound of the left heel for at least 30 days duration. It documented there was moderate serous exudate present with 70% thick adherent black necrotic tissue present. It documented the resident had no medications found to be affecting wound healing. The left heel wound measured 3 by 6.7 by not measurable. This was the first complete wound assessment since the wound had been identified. A Physician's Order, dated 01/27/23, read in part, .Apply to WOUND OF LEFT HEEL topically every day shift related to PRESSURE ULCER .STAGE 3 [three] .CLEANSE WOUND W/SALINE WOUND WASH, PAT DRY, APPLY MEDI HONEY TO WOUND BED, COVER W/FOAM, WRAP W/ROLLED GAUZE .SECURE W/TAPE ONCE DAILY . A Treatment Administration Record, dated January 2023, for Medihoney and Xeroform to the left heel was blank on 01/30/23. A Treatment Administration Record, dated February 2023, for Medihoney and Xeroform to the left heel was blank on 02/05/23. A Weekly Skin Screen, dated 02/01/23, did not document stage, size, exudate, description of wound bed and surrounding skin, or signs and symptoms of infection. A Weekly Skin Screen, dated 02/03/23, did not document stage, size, exudate, description of wound bed and surrounding skin, or signs and symptoms of infection. A Radiology Results report, dated 02/04/23, documented bilateral ankle brachial index impression was mild blockage. Mild range indicated early stages of peripheral arterial disease. A Progress Note signed by Nurse Practitioner #1, dated 02/04/23 at 11:01 p.m., documented Resident #153's left heel was open to air. Resident #153 had a physician's order for daily dressing changes. Daily Skilled Assessment notes, dated 02/05/23 at 8:11 a.m. and 8:29 p.m., documented signs of infection to the foot and left leg. There was no documentation the physician had been notified. A Physician's Order, dated 02/05/23, read in part, .LEFT AND RIGHT LEG VENOUS ULTRASOUND one time only for 1 Day SWELLING . The Extremity Veins Ultrasound results, dated 02/06/23, documented all interrogated veins demonstrated normal venous flow and no thrombus was seen. A Physical Therapy note, dated 02/06/23, documented the resident was declining in ambulation due to a blister on their left foot. A Nurse's Note, dated 02/07/23 at 10:40 a.m., documented the resident was noted with an altered mental status and unable to state what month or year it was. The resident had a fever of 102.7. It documented the Nurse Practitioner was notified and an order was obtained to send Resident #153 to the emergency room for evaluation and treatment. A Progress Note signed by Practitioner #1, dated 02/07/23, documented Resident #153 was oriented to self only, had a temperature of 102, heart rate of 130, and was complaining of pain to the left foot at a 10/10. Resident #153 was transported to the hospital. Resident #153's clinical record did not contain documentation the left heel wound had been assessed for improvement or deterioration for 12 days. There was no documentation of the stage, size, exudate, and description of the wound bed or surrounding tissue from 01/25/23 through 02/07/23 when the resident had been sent to the hospital due to altered mental status, fever, increased heart rate, and severe pain to Resident #153's left foot. Resident #153's Hospital Records, dated 02/07/23, documented Resident #153 presented with complaints of altered mental status, and had a large pressure ulcer to the heel of the left foot. It documented the resident presented with acute encephalopathy likely secondary to their underlying sepsis. It documented Resident #153 likely had an infected pressure ulcer to the left heel. It documented podiatry would consult for possible debridement and further surgical management. The hospital record documented Resident #153 had a stage IV pressure ulcer to the left heel. A MRI report, dated 02/07/23, documented Resident #153 had osteomyelitis involving a large five centimeter region to the left posterior calcaneus, suspicious for infectious tendinosis and abscess formation. Resident #153's Hospital Medicine admission History and Physical, dated 02/07/23, documented the resident had an ulcer on their left heel with surrounding erythema, was septic, and was being treating with antibiotics. Resident #153's Podiatry Consult Note, dated 02/07/23, documented the resident had nonpalpable pedal pulses It documented the posterior aspect of the left heel was necrotic and draining. It documented the wound probed deep towards the calcaneus with copious drainage noted. It documented if the area were to be surgically debrided, it would render the foot nonfunctional as the resident would no longer have a calcaneus, and the wound would never heal. The Podiatrist recommended a BKA as the best option for both healing and containing the infection. Resident #153's Hospital Discharge Summary, dated 02/12/23, documented the resident was admitted with a diagnoses of MRSA bacteremia due to left calcaneal osteomyelitis. Resident #153 was evaluated by podiatry who felt the foot wounds were nonsalvageable. Resident #153 underwent left BKA. On 03/14/23 at 3:25 p.m., the WCN was asked if Resident #153 had any skin issues on admission. She stated they had a partially deflated, fluid filled blister to the left heel. The WCN stated the wound changed quickly and developed a dark unstageable area to the center of the wound. She was asked to locate skin assessments that documented measurements and wound deterioration. The WCN provided the wound care doctor's progress note, dated 01/25/23. On 03/15/23 at 1:26 p.m., the DON was asked how they ensured residents did not develop pressure ulcers or have pressure ulcers worsen. She stated they looked at bed mobility, turning and repositioning, and Braden scores. The DON stated if a resident had a pressure ulcer, they wound notify the wound care doctor, who would do weekly rounds. The DON stated the WCN would monitor the wounds and do their treatments. The DON was asked when skin assessments should be conducted. She stated on admission, re-admission, weekly and with any significant changes. She was asked if Resident #153 had a pressure ulcer on admission. She stated they had a stage two to their left heel. The DON was asked when the physician had been notified of the stage two pressure ulcer. She stated there were no orders implemented for four days. She was asked when the physician should have been notified and interventions implemented. The DON stated on 01/10/23. The DON stated if a wound had 70% black eschar, it would be considered unstageable. The DON was asked if Resident #153's wound had deteriorated from a stage two pressure ulcer to an unstageable pressure ulcer within two weeks. She stated, Yes. The DON was asked if the weekly skin assessments conducted on Resident #153 had been thorough. She stated, No. She was asked when the physician should have been notified of any skin issues. The DON stated, As soon as they are found. She was ask if the unstageable pressure ulcer was avoidable. She stated, Yes, interventions weren't put in place. On 03/16/23 at 11:01 a.m., the DON was shown the blanks for the wound care on 01/30/23 and 02/05/23. She was asked what the blanks indicated. The DON stated the treatments were not done. The DON was shown the nurses' notes from 02/05/23 that documented signs and symptoms of infection. She was asked if the physician had been notified. She stated no. On 03/16/23 at 2:12 p.m., the DON was asked to locate documentation pedal pulses were monitored every shift per the care plan. She stated it should be in the TARs or daily skilled notes. She was observed to look in the EMR. The DON stated, They weren't doing it.