**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, and policy review, the provider failed to ensure one of one sampled resident's (1) wheelchair was secure in the facilities transport vehicle according to manufacturer's guidelines resulting in the resident's wheelchair tipping backwards and the resident sustained a spinal fracture.Findings include:1. Review of SD DOH FRI that was submitted on 7/15/25 revealed:*At approximately 11:15 a.m. on 7/15/25, resident 1 was being transported from an appointment back to the facility in the facility's transport van by certified nursing assistants (CNA)s G and H and his wheelchair tipped backwards while the van was driving.*It was suspected that the front wheelchair locking mechanisms failed, allowing resident 1's wheelchair to tip backwards.*Resident 1 complained of pain in his back to the staff in the van.*CNAs G and H assisted resident 1 back into his wheelchair after it tipped and transported the resident back the facility.*At the facility, resident 1 was assessed by registered nurse (RN) I and was sent to the Emergency Department (ED) for further evaluation related to his back pain.*On 7/15/25, resident 1 returned to the facility from the ED with a diagnosis of a closed nondisplaced fracture of the sixth cervical vertebra (a break in one of the bones in his neck).*The provider's investigation concluded that lap belt connectors malfunctioned and did not tighten correctly which caused the resident's wheelchair to tip backwards.*The lap belt connectors suspected of malfunctioning were removed from the transport van and replaced with new parts.*CNA G was educated on correctly locking and tightening wheelchair straps in the transport van. 2. Interview on 7/22/25 at 10:55 a.m. with resident 1 revealed:*He recalled the accident that happened on 7/15/25 in the facility's transport van.*He was able to describe the injury he sustained due to the accident.*He stated he had been to several medical appointments in the past while CNA G was driving and had never had any accidents.*He could not recall if CNA G had any changes in her normal routine of securing his wheelchair that day. 3. Interview on 7/22/25 at 1:02 p.m. with CNA H revealed:*She had accompanied resident 1 to his medical appointment on 7/15/25 and rode along in the facility's transport van.*She did not assist with securing his wheelchair in the transport van.*She could not recall watching CNA G securing resident 1's wheelchair in the transport van that day. 4. Interview on 7/22/25 at 2:50 p.m. with administrator A revealed:*After resident 1's 7/15/25 incident in the facility's transport van, she had CNA G demonstrate to her what happened during the transport.*Administrator A checked the wheelchair securing straps and was not able to duplicate the malfunction that happened during the incident that day.*CNA G had been the transport van driver for the past two years and had not encountered an accident like that before.*The wheelchair securing straps were replaced with new ones.*After the incident, there had been a new section added to the van's daily checklist that would have the driver physically check the tension on the wheelchair securing straps for safety.*She felt it was an unfortunate event caused by faulty equipment. 5. Interview and demonstration on 7/23/25 at 10:45 a.m. with CNA G and administrator A in the facility's transport van related to resident 1's incident revealed:*CNA G reported on the day of the incident she loaded resident 1 into the van from the rear wheelchair ramp.*Once resident 1 was in place in the van, she locked his wheelchair brakes, then she attached two hooks to the rear of the wheelchair. She then attached two hooks to the front of the wheelchair. She then fastened resident 1's seat belt.*She then reported leaving the medical provider's parking lot.*After driving for about a block, she heard a loud noise and when she looked back she found resident 1 had tipped backwards in his wheelchair inside the van.*She reported that after pulling over the van, the two hooks attached to the rear wheelchair wheels were still attached. The hooks attached to the front of the wheelchair were no longer attached. It did not appear that the front straps had pulled out of the locking device.*She and CNA H then assisted resident 1 back into his wheelchair.*Resident 1 was taken back to the facility to be assessed by as nurse. 6. Interview on 7/23/25 at 3:30 p.m. with regional nurse consultant/acting director of nursing B revealed that she did not do the staff training for the facility van operation. 7. Interview on 7/23/25 at 4:00 p.m. with administrator A revealed:*Business Office Assistant (BOA) J does the competency testing for staff that drove and operated the facility van.*The current van driver (CNA G) provided training for new van drivers. The new driver would ride with the current driver for a couple days to learn the process.*BOA J used the Driver's Road Test Examination to verify the driver's ability to safely operate the van. 8. Interview on 7/23/25 at 4:47 p.m. with BOA J revealed:*She did not use a specific curriculum for testing a driver's ability to safely operate the van.*She used the facility's Driver's Road Test Examination, which contained a checklist of observed steps.*When asked if she had a checklist for what was specifically observed during the Observed and has competency in securing a wheelchair in the vehicle. step, she stated No, I've just done it so many times. I did it for two years. 9. Record review of education provided to facility van drivers on 7/15/25 revealed:*All safety belts will be checked with each resident transport daily to ensure all locks are secure and lap belts are placed for resident safety. Van Driver will note this on the van log with each transport.*The van driver will notify the resident's nurse of any injury that occurs in the van during transport or loading/unloading resident for appointments. The resident will not be moved until assessment has been made by the nurse or EMS [emergency medical services]. 911 will also be called if the injury assessment is deemed appropriate.*CNA G was educated by administrator A.*Administrator A was educated by nurse consultant B.*BOA J was educated by administrator A. 10. Review of the AMF [NAME] America (wheelchair tie down manufacturer) user manual revealed:*Section 2, A. Daily Inspection Checklist, 1. Check the retractors by quickly pulling out the webbing to ensure proper locking.*Section 3, Wheelchair and Securement Instructions, Step 6. Once you have all four straps attached, release the brakes on the wheelchair and check for movement. Once secured, the wheelchair should not move more than two (2) inches front-to-back or side-to-side. Reapply the brakes. 11. Interview on 7/24/25 at 8:35 a.m. with administrator A revealed:*She was not aware that the manufacturer's instructions were to release the wheelchair brakes to check for movement before driving the vehicle.*She was not sure if following that step could have prevented resident 1's accident because she was not there during the accident.*She felt it was an equipment malfunction that caused resident 1's wheelchair to tip in the van that day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) complaint intake review, record review, interview, and policy review, the provider failed to protect the resident's right to be free from neglect related to assessing and providing skin care to prevent skin necrosis (death of cells or tissue through disease or injury) of both the residents feet and implementing monitoring to potentially prevent a significant weight loss for one of one sampled discharged resident (51) who required hospitalization related to those conditions. Findings include: 1. Review of the 1/9/25 SD DOH complaint intake revealed: *The complainant had a concern regarding the quality of care and treatment for resident 51. *The reported the resident was admitted to the hospital on [DATE]. *The resident's left foot great toe, three other toes, and 3 last toes and part of his foot was necrotic. *The resident's right foot necrosis was between his great toe and the next toe. *The resident had been previously hospitalized in October 2024 and had no skin issues at that time. *The first time the facility had reached out to the doctor about the necrosis on his feet was on 1/1/25 *The resident had dementia (impaired memory and cognition) and thought his foot was broken. *The resident's wife lived at a different facility and his durable power of attorney (DPOA) was his daughter who did not live close by. 2. Review of the 1/16/25 SD DOH complaint intake revealed: *The complainant wanted to remain anonymous. *They reported the resident was admitted to the facility late fall 2024. *The complainant reported the resident's family had not been invited to his care plan meetings to review his current status and allow them to be a part of any changes in his plan of care. *His family had been notified of a fall and skin tear but had not been notified about his toes until 1/1/25. *The resident's family had been informed by the unit manager, licensed practical nurse (LPN) C regarding the necrosis of his toes. *They reported the family had been informed the resident's toes had started to turn black related to his diabetes diagnosis. *They felt the resident should have been sent to the emergency room (ER) but it was decided he would be seen by a podiatrist (foot doctor) instead. *On 1/7/25 the hospital podiatry department informed the family the resident had gangrene (dead tissue caused by an infection or lack of blood flow) in both of his feet related to an untreated infection. *The family had been told his condition Was brewing for months: and could not have been a recent onset. *The complainant reported the hospital staff informed the family that when they took off the resident socks, they had been afraid his toes would peel off with the socks due to the advanced state of the gangrene. *They were aware the resident had been hospitalized in December of 2024 due to Coronavirus disease (COVID -19) and had returned to the facility on [DATE]. *The hospital's podiatry department also informed the family the resident was malnourished (had a nutritional deficiency). *He had lost 23 pounds (lbs.) from 10/23/24 through 1/7/25. *The facility had not informed the resident's family of his extreme weight loss and when discussed with the facility they were informed he had been refusing his medications also. *The complainant reported the family felt like no one was paying attention to the resident and they had been concerned he was being neglected. *The hospital informed the family the only options for him was a double amputation of his legs or Hospice Care (end-of-life care). *The family made the difficult decision for the resident to start Hospice Care and admitted him to a different long term care facility (LTC) for Hospice Care. 3. Review of resident 51's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His diagnoses included: -Chronic Obstructive Pulmonary Disease (a disease that makes it hard to breathe). -Type 2 Diabetes Mellitus without complications. -Type 2 Diabetes Mellitus with Diabetic Neuropathy (decreased sensation in the feet, legs, hands, and arms). -Chronic Kidney Disease Stage 3 (moderate damage to the kidneys, where they are not filtering waste effectively). -Dependence on Renal Dialysis (medical treatment that removes waste products and excess fluid) 3 times per week. -Dementia. -He had been affected by COVID-19 from 12/16/24-1/1/25. *His Brief Interview for Mental Status (BIMS) score was 11 which indicated he had moderate cognitive impairment. *On admit on 10/29/24 he had a skin tear on his left 2nd toe which measured 0.3 centimeters (cm) x 0.3 cm, and it had healed on 11/19/24. *There was a note in his Dialysis report dated 12/20/24 which indicated: -Dialysis education additional information: Nursing Home staff: Please check bilateral feet as they are red. *There was no documentation, progress note, or a Non-Ulcer Skin Assessment form in his EMR to indicate his feet were checked for that redness. *He had an order dated 11/12/24 for daily weights to be checked. -Upon admission on [DATE] he had weighed 158.6 lbs. and by 1/7/25 he had weighed 128.2 lbs. -He had lost 30.4 lbs. within 69 days. *There was no documentation that indicated the weight loss was reported to his doctor or his family to ensure further guidance was provided. 4. Interview on 2/5/25 at 9:20 a.m. with director of nursing (DON) B regarding skin assessments for residents who were in isolation related to COVID-19- revealed: *She would have designated a tub room for residents on isolation to use, the resident could have worn a mask in the hallway when staff transported them to the tub room, or they resident could have received a bed bath in their room. *CNAs would do skin checks on residents when they bathed or showered them. *If a CNA noted a skin concern for a resident, they would have been reported that to the nurse or unit manager *The nurse, unit manager, or wound nurse would have completed the Non-Ulcer Skin Assessment form in the residents' EMR and added the resident and skin concern to their weekly wound rounds for follow up. 5. Interview on 2/6/25 at 11:50 a.m. with wound nurse N regarding resident 51's necrotic skin revealed: *She had been wound nurse since employed at the facility. *She had not received any special training related to wounds. -no special training *She completed the resident's Non-ulcer Skin Assessment on 10/29/24 for weekly wound rounds and had notified the family that the area of concern had been healed by 11/19/24. *The resident had COVID-19 from 12/16/24 through 1/1/25 and had remained isolated to his room, and had not received a shower during that time. -He had a shower after the COVID-19 had been resolved on 1/1/25. -The skin concerns on his feet had been discovered at that time. *The CNA identified the concerns during the resident's shower and had let the nurse know about the new skin issue. *She knew the nurse working that day had called for an appointment to get his foot looked at and he had gone later that week to a podiatry appointment. *She did not do regular diabetic skin checks and was not sure if that had been completed by the nurses. *She expected the CNA's and nurses to let her know when they identified a new skin concern for her to follow up on it. 6. Interview on 2/6/25 at 12:57 p.m. with certified medication aid (CMA)/CNA O revealed: *She had been doing residents' baths for 12 years at the facility. *She stated if she found a skin tear, an open area, an abrasion, a bruise or anything she had not seen before on a resident during their bath she would let the nurse know about it. If it was new to her, she would have reported it even if nurse had seen it. -The nurse would have come in to assess that resident's area, get measurements, and fill out their documentation for wounds if one had not been started. -The nurse would take that information to the wound nurse so she could add it to their list and follow up on their weekly rounds. *She did not know anything about resident 51's feet or skin concerns. *If there was COVID-19 in the building she would have given those not on precautions baths first. -She would take residents on isolation one by one to the bathing room at the far end of the hall that was for those on isolation. 7. Interview on 2/6/25 at 12:04 p.m. with assistant director of nursing (ADON) C revealed: *She had been notified by the nurse on Wednesday 1/1/25 about resident 51's feet by text message. *She read the text that had asked her, Were you aware of pinky toe and next two toes are black? *They had set up an appointment for the resident right away because his toes on both his feet were blackened. *On 1/1/25 they received an antibiotic order from the doctor, and he was given his first dose that day. *The resident was scheduled to see podiatry on 1/7/25 at 3:00 p.m. *He went to his podiatry appointment and was admitted to the hospital from there. She stated, I am assuming because of the feet. *She completed weekly wound rounds on her area of the building with wound nurse N every Wednesday. *On 12/31/24 she had done wound rounds with the wound nurse and resident 51 was not on their list to monitor at that time. *She would not have expected the resident to be on the list that day because he did not have an identified skin issue at that time. *She stated they would have measured a new wound, documented in the resident's EMR and notified the resident's doctor, family, administrator, and DON of the skin concern. *The next step in the process or follow up would depend on what the doctor ordered. *Nurses did not complete or perform regular diabetic skin or foot checks. -The bath aid would let her know if they saw anything. -She would check their feet when she cut their nails if the resident was Diabetic. -Nurses do not complete skin assessments for residents until there is an issue. *Resident 51: -Did not return to the facility. -Tested positive on 12/16/24 for COVID-19 and after he moved over from the rehab unit, she stated he didn't feel good. *She had not received a report from the rehab unit manager prior to his admit to long term care on 12/5/24 but she had done a chart review and had not seen skin issues to monitor for him. *He had been refusing most cares and would not eat much of anything while he was sick with COVID 19. *She was not sure if he had gotten a bath during his COVID-19 isolation, He had been refusing cares and did not want to do much. *She stated his necrotic toes had come on kind of quick and then he was hospitalized on [DATE] and did not return to the facility. 8. Interview on 2/6/25 at 2:25 p.m. with RN E regarding resident 51 revealed: *She had been called to the tub room by the CNA on 1/1/25 to look at his skin. *She recalled his left foot had redness and dark spots on it. *She called the doctor and received orders to start him on an antibiotic and to make him a podiatry appointment instead of going to the emergency room. *She had contacted the resident's family to inform them of this skin concern. *He had been started on an antibiotic for his foot infection. *She did not do skin assessments and had not assessed his skin when he moved over from the rehab unit on 12/5/24. *Bath CNAs checked residents' skin when they gave them a bath and would have let her know if they discovered a skin concern to be checked. *Residents cannot come out of their room for showers when they were on COVID-19 isolation, but they could have gotten a bed bath. *She thought 1/1/25 was the first shower resident 51 had since he had COVID-19 starting on 12/16/24. *Daily weights had not been done while resident 51 was on COVID-19 isolation. *She thought Covid isolation was for 7-10 days. *The resident did not have any treatments for his feet prior to the blackened toes being identified on 1/1/25. *There was no documentation in his EMR for wound care had been provided to his feet between 1/1/25 and when he had gone to the podiatry appointment on 1/7/25. 9. Interview on 2/6/25 at 3:49 p.m. with DON B revealed: *CNA's gave residents their showers and would have performed a head-to-toe skin check and would notify the nurse if skin issues were discovered. *Residents with wounds were added to the weekly wound rounds with the nurse to monitor. *Nurses did not complete or perform regular diabetic foot checks but did check (or trim) their nails weekly or every other week and checked their feet at that time. *The last COVID-19 outbreak had been from 12/16/24 through 1/7/25 and there had been confusion about resident's bed baths. *Residents could have had showers if they wore a mask in the hallway or they could choose a bed bath if they refused to wear a mask. *Resident 51 admitted in October 2024 with a skin tear on his left foot that had healed November 2024. -All he wanted to do was to lay in bed and not receive cares while he had COVID-19. -He refused care and would not go to dialysis while he was sick with COVID-19 *He could have come out of isolation and his room if he had worn a mask for certain activities. 10. Interview on 2/6/25 at 3:49 p.m. with nurse consultant P revealed, he had poor vascular circulation and was frail and fragile when he admitted here. 11. Review of resident 51's care plan dated 10/29/24 revealed: *He had a diagnosis of Diabetes Mellitus and nursing would check his body for breaks in skin and treat promptly as ordered by medical practitioner. *He had potential for impairment to his skin integrity and nursing would observe skin during cares and report changes to the nurse. -Weekly skin inspections and as needed. *Discharge plan was undetermined but resident 51 wished to return home after rehab, staff to assist the resident and family in decision making process based on home situation and resident's needs. *He had the potential for nutritional problems related to type 2 diabetes, kidney dialysis. -His weight would remain stable during the review date with targeted date 1/17/25. -Registered Dietician would evaluate and make diet change recommendations as needed. Provide/serve modified renal diet 1500 milliliter (ml.) fluid restriction as ordered. *He was independent with eating after setting up and preferred meals in his room. A house supplement was ordered. *There was no focus area that indicated he had been refusing to eat and what further interventions had been put in place to promote nutritional health. *There was no focus area that indicated they were aware of his significant weight loss and the interventions put in place to support nutritional health. 12. Review of the provider's January 2024 Person-Centered Care Plan policy revealed: *'Guideline, Person centered care planning is an on-going process which actively encourages the resident and/or the resident's representative to be an active participant in the care planning process and addresses the development and implementation of individualized person care . -2. The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: -(ii) A summary of the resident's medications and dietary instructions. -(iv) Any updated information based on the details of the comprehensive care plan, as necessary. 13. Review of the provider's 10/19/22 Vulnerable Adults policy revealed: *Purpose; Accura Health Care supports Zero Tolerance for resident abuse, neglect, mistreatment, and/or misappropriation of resident property. -Identifying Maltreatment: g) Neglect 1) Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. 14. Review of the provider's 1/20/23 Weekly Skin Assessment and Documentation Process revealed: *Skin ulcers and Non-Ulcers will be assessed and documented weekly by the facility wound nurse. -Assessment and Documentation Process, b) Identifying a Skin Ulcer or Non-Ulcer Assessment; 1) the nurse who initially identifies the Skin Ulcer or Non-Ulcer ulcer will complete the appropriate Skin Assessment (Non-Ulcer or Ulcer Assessment). 15. Review of the provider's 11/13/24 Process for Resident Activity Restrictions During an Outbreak revealed: *a) During an infectious disease outbreak, we may limit resident group activities to prevent the spread of communicable disease within the facility. When a significant number of resident's are exhibiting signs and symptoms of potentially infectious illness, the supervisor will restrict resident activity, after discussion with the IPN [infection prevention nurse] and/or the on-call representative of administration. If the supervisor is unable to reach either of the above, she or he will make a decision about restrictions based on information available. *1. Restrictions may include: -i) Restriction of residents to their units. -ii) Restriction of residents to their rooms. *b) All other restrictions deemed appropriate by the supervisor or the IPN [infection prevention nurse]. *Bathing and skin checks were not listed as resident restricted activities.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Observation on 10/16/23 at 4:03 p.m. revealed resident 25 was lying on her back and sleeping in her bed. Her heel protector boots were lying beside her but were not on her feet. A pressure relieving cushion was in the wheelchair. Observation on 10/17/23 at 1:39 p.m. revealed resident 25 was again lying on her back in her bed after lunch without her heel protector boots on her feet. Observation on 10/17/23 at 1:54 p.m. with RN K providing wound care to resident 25 revealed: *The right (R) heel wound measured 1 centimeter (cm) in length and 1 cm in width. *The R ankle wound measured 1.2 cm in length and 1.8 cm in width. *The R heel and the R ankle were treated with Betadine and then covered with foam dressings. *The sacral pressure ulcer measured 2.5 cm in length, 0.6 cm in width, and 0.5 cm deep and was treated with Betadine and a wet-to-dry dressing. *When asked what other interventions were being done for the resident's pressure ulcers. RN K stated that the resident should have been wearing the heel protector boots while she was lying in bed. Observation on 10/18/2023 at 8:58 a.m. revealed resident 25 was lying on her back in bed without her heel protector boots on. Interview on 10/18/23 at 9:02 a.m. with CNA E revealed resident 25's heel protector boots should have been worn while the resident was lying in bed. Interview on 10/18/2023 at 1:15 p.m. with CNA H and CNA J revealed: *Pocket care plans were used by the CNAs to determine what care needs were required for the residents. *When the pocket care plan was reviewed, the CNAs stated that those pocket care plans were not currently updated with the resident's current pressure ulcer interventions. That included both repositioning and the heel protector boots. The pocket care plan provided no specifics as to when those heel protector boots should have been worn or any repositioning information. CNA H verbalized that resident 25's heel protector boots were to have been worn while the resident was in bed. *Review of the [NAME] on 10/18/23 at 1:30 p.m. with the CNA J revealed: *The [NAME] had not listed the heel protector boots as an intervention and was not included on the resident's current care plan interventions for impaired skin integrity regarding repositioning. The [NAME] stated that the resident should have been repositioned every 4 to 5 hours. CNA J stated that the repositioning every 4 to 5 hours was not correct. *CNA J. stated that pocket care plans and [NAME]'s were updated by the MDS nurse. Interview on 10/18/2023 at 2:57 p.m. with nurse manager D regarding the monitoring of resident interventions revealed the monitoring of CNAs completing care plan interventions was completed by a visual inspection with eyes on the resident and was done randomly. Interview on 10/18/23 at 3:35 p.m. with RN K revealed: *RN K was responsible for documenting interventions in the care plan regarding the current pressure ulcer interventions for resident 25. *A blister that measured 2.5 cm x 2.3 cm was identified on the R heel on 8/17/2023. *A physician order was received to change Adaptic Touch dressing weekly until healed. Review of resident 25's 9/19/23 physician's orders included the following: *Betadine wet to dry dressing daily. *Low air loss mattress *Frequent repositioning every 2-3 hours *R heel - paint with Betadine, cover with foam dressing *Continue the heel protector boots, change foam dressing every 3 days. *R ankle - paint with Betadine, cover with foam dressing, and change every 3 days. *When asked how resident 25's pressure ulcers had developed, she stated, Probably from lying in bed. She does not see well and would run into things with her ankle while in her wheelchair. Wearing her boots probably would have helped. Interview on 10/19/23 at 12:13 p.m. with director of nursing (DON) C and Minimum Data Set (MDS) coordinator L regarding resident pressure ulcers revealed: *DON C. was unable to provide a policy for the prevention of resident pressure ulcers. *She was able to verbalize in detail how the facility prevents pressure ulcers. *She was able to provide a Skin Management Protocol updated on 5/16/23, which included steps for wound notification when a skin alteration or skin ulcer was identified but there was no documentation on how to prevent pressure ulcers from occurring. * She provided a Leadership's admission checklist updated on 6/9/23 the facility used when admitting a new resident that included a comprehensive skin assessment and a Braden scale. *She stated that the interdisciplinary team (IDT) met daily and reviewed any concerns of those residents with pressure ulcers and those residents that were at risk for developing pressure ulcers. *When asked about the discrepancy with the resident care plans, the pocket care plans, and the [NAME], she stated that she would communicate changes with her nursing supervisors, and it was their responsibility to update the direct care staff on those changes. *DON C stated that she has had issues with RN K updating resident care plans. *When asked how nurses monitor to ensure interventions were being completed, she stated the CNAs document using the task tab in Point Click Care. Repositioning and the heel protector boots were not included in those tasks for resident 25. *MDS Coordinator L. admitted that she had at times missed putting interventions in the task tab and that she has had issues with Point Click Care and entering interventions into the resident care plans. Review of resident 25's 10/11/23 care plan revealed the following: *The care plan had not mentioned a R heel pressure ulcer. *The care plan did list interventions related to the residents non-healing chronic Stage II pressure ulcer to the sacrum. *Interventions included: - Encourage resident to reposition/position changes during rounds. -Attempt to turn and reposition off the area every 2-3 hours and as needed and/or not position on that area, when possible. -Float and off-load heels with pillows or offloading boots. *The care plan intervention had not specified when the heel protector boots were to have been used. Review of resident 25's 6/23/23 Quarterly Comprehensive Skin and Positioning Evaluation revealed: *The Braden score was 14 indicating the resident was at moderate risk for altered skin integrity. *Interventions included: -Pressure reducing device in the chair. -Pressure reducing device in bed. -Pressure ulcer/injury care, application of non-surgical dressings (with or without topical medication) other than the feet. -Application of ointments/medications other than the feet, keep the linens dry and wrinkle-free. *Summary included, [Name of the resident] does have a non-healing pressure area on her coccyx, treatment as ordered from MD (medical doctor), does have potential for altered skin integrity r/t her impaired sensory r/t diagnosis of depression, dementia, and diabetes, moisture r/t (related to) her perspiration, has Foley indwelling catheter, impaired activity/mobility r/t use of full mechanical lift and w/c (wheelchair) and general shearing/friction with repositioning and scooting down in bed, air mattress on bed and pressure reducing cushion in w/c, skin inspected weekly. Review of the provider's revised 10/20/17 Care Plan policy revealed: *The resident care plans were reviewed and revised annually, quarterly, with significant change in status and as needed. *The resident care plan should have been consistent with the CNAs pocket care plans. Based on observation, interview, record review, and policy review, the provider failed to ensure:*Preventative interventions and approaches were implemented prior to the development of pressure ulcers for two of two sampled residents (59 and 60). *Interventions and approaches were consistently implemented for three of three sampled residents (25, 59, and 60) who currently had pressure ulcers. Findings include: 1. Observation on 10/17/23 at 10:35 a.m. of resident 59 revealed: *He was seated in his wheelchair outside of the small dining room area near the rehabilitation unit. *He had gripper socks on his feet and both feet were placed on the foot-pedals of his wheelchair. *There was a cushioned footboard placed on the top of the wheelchair foot-pedals that extended up behind his heels and legs. *Heel boot protectors were not on his feet. Observation and interview on 10/17/23 at 11:00 a.m. with resident 59 in his room revealed: *He had been seated in his wheelchair with gripper socks on his feet. *His wife had been with him and talking to him. *She visited him on a daily basis. *He had an area on his left heel that had developed a week after his admission. *The area had been healing but she stated she had not seen it recently because it had been covered with a dressing. *The nurses monitored it daily. *He had heel protectors for his feet. *She had not seen the nursing staff put heel protectors on his feet lately. *She was not sure what had happened to them. *He used to fiddle with the boots and would attempt to remove them. *When he rested in bed, the nursing staff would place pillows under his ankles to relieve the pressure off of his heels. Observation on 10/19/23 at 9:11 a.m. of resident 59 revealed: *He was seated in his wheelchair with the footboard cushion in place at the bottom of his wheelchair. *He had been wearing gripper socks. *There were no heel protector boots on his feet. Review of resident 59's 12/27/22 Comprehensive Skin and Repositioning Evaluations revealed: *His Braden score was 12, that indicated he was at high risk for developing pressure ulcers. -- [Resident] has no pressure areas, does have potential for altered skin integrity r/t [related to] his impaired sensory r/t his diabetes, dementia, moisture r/t his incontinence and perspiration, impaired activity/mobility r/t his use of w/c [wheelchair] and shearing/friction r/t his scooting to [the] edge of [the] bed/chair and general repositioning, pressure reducing mattress on bed and pressure reducing cushion in w/c, skin inspected weekly, does participate in therapy. Review of resident 59's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *A Brief Interview for Mental Status (BIMS) score of zero that indicated he had severe cognitive impairment. *He had diagnoses of the following: congestive heart failure, post Covid-19 condition, atherosclerotic heart disease, atrial fibrillation, type 2 diabetes, and dementia. *A left heel unstageable pressure ulcer that had been discovered after his admission on [DATE]. -It had been a fluid filled blister when it was first identified that measured 4.5 centimeters (cm) by 5 cm. -It currently measured 0.8 cm by 0.8 cm on 10/11/23. Review of resident 59's current [NAME] interventions for CNAs to have followed revealed: *There were no interventions to float his heels by positioning pillows under his ankles while he was in bed. *There were no interventions for staff to follow when he refused or had combative behaviors. Review of resident 59's revised 9/27/23 care plan revealed: *There was no information that his feet were to have been floated and positioned with pillows under his ankles while he was in bed. *His heel boot protectors were still on the care plan and had not been discontinued as an intervention. *Focus: [Resident] has Pressure injury to left heel: Date initiated: 1/14/23 -Goal: Pressure injury will show signs of healing and remain free from infection by/through review date: Date initiated: 1/14/23 -Interventions/Tasks: --Administer treatments as ordered and observe for effectiveness. Date initiated: 1/14/23. --Dakins wet to dry to left heel daily. Date initiated: 10/1/23. --Glucerna 8 oz with meals BID. Date initiated: 1/13/23. --Heel lift boots when in bed. Date initiated: 1/14/23. --Notify family and medical practitioner of any new area of skin breakdown or worsening in status of current area. Date initiated: 1/14/23. --Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration, noted during bath or daily care. Observe skin daily with cares. Date initiated: 1/14/23. --Obtain lab/diagnostic work as ordered. Report results to medical practitioner and follow up as indicated. Date initiated: 1/14/23. --Pumpless air mattress on bed and pressure reducing cushion in w/c. Date initiated: 1/14/23. *The above interventions were added to the care plan after he had acquired the pressure ulcer to his left heel on 1/4/23. *Preventative measures were not put into place even though he had been identified through the Braden scale for being at high risk for developing pressure ulcers. *No information was documented that his feet were to have been floated by positioning a pillow under his ankles when he was in bed. *His heel protector boots had not been discontinued according to the information on the care plan. Interview on 10/19/23 at 9:13 a.m. with certified nursing assistant (CNA) P and CNA Q regarding resident 59 revealed: *The pressure ulcer on his heel was there since he was admitted and had started as a blister from his heel rubbing on the wheelchair pedal. *They used two pillows positioned under his ankles to float his heels when he was rested in the bed. *When he was in his wheelchair he had a footboard cushion that was placed on top of the foot-pedals to cushion his heels and the back of his legs. *His wife visited every day to help him with his needs and to spend time with him. *When he laid down for a nap after lunch staff floated his heels off the bed with positioning pillows under his ankles. *He had used boot protectors for a short time but had not liked them and would take them off. *They no longer put the heel boot protectors on the resident. *He had been resistive of care and at times struck out at staff, but they knew him well and were able to reapproach him when his mood improved. *They used pocket care plans to know what care to provide to the residents. *Interventions were documented on the computer [NAME] system when they had been completed by the CNAs. Interview on 10/19/23 at 9:38 a.m. with RN K revealed: *She had been the nurse that completed wound care for the residents. *The wound was discovered on 1/4/23 and caused by his left heel rubbing against his wheelchair that caused a blister to form. *The area was unstageable (the wound is covered by a layer of dead tissue that might be yellow, grey, green, brown, or black. The base of the wound is not visible and therefore cannot be staged) and had been healing. *The wound was monitored daily by nursing staff. *She completed weekly wound assessments. *He had a pressure reducing mattress. *For anyone with skin concerns it would have been her expectation to have interventions in place to prevent resident skin integrity issues from developing. *He hated the heel protector boots, so they got rid of them and got a cushioned insert for the wheelchair to cover the back and the foot-pedals. *They now placed a footboard cushion on his wheelchair to protect his heels. *His heels were to have been floated with positioning pillows under his ankles while he was in bed. *CNAs were to reposition residents every two to three hours or as the physician had ordered. *The CNAs carried a pocket care plan to follow for the appropriate care to complete with each of the residents. -The CNAs also documented completion of assigned tasks in the computerized [NAME] system. *The care plan was to be updated with resident changes that reflected the resident's current needs. -Interventions were driven from the care plan into the computerized [NAME] system. *When an intervention or a condition would change with the resident's care, the Minimum Data Set (MDS) coordinator L would update the care plan and the pocket care plan. *Staff used a computerized [NAME] program with interventions for CNAs to document when the care was completed for the resident. *All the interventions should have been the same in the resident's current care plan, the [NAME], and the pocket care plan. 2. Observation on 10/17/23 at 1:58 p.m. of resident 60 revealed: *He was lying in his bed on his right side facing the wall. *He had not been wearing heel protector boots. *His body pillow was placed on top of his recliner. *His bed was in the lowest position. *There was a Geri wheelchair next to his closet. *His electric recliner was in the upright position and had a padded cushion in the seat. Observation on 10/18 23 at 2:11 p.m. of resident 60 and his unoccupied room revealed: *He was seated in a Geri wheelchair chair wheeling himself down the hallway. *He had not been wearing the heel protective boots. *His bed was made and he had a pressure reducing mattress. Review of resident 60's 2/3/23 Comprehensive Skin and Repositioning Evaluation revealed: *His Braden score of 17, that indicated he was at risk for developing pressure ulcers. -- [Resident] does have pressure areas to his buttocks, does have cream that is applied to the buttock area, does have potential for altered skin integrity r/t [related to]his impaired sensory r/t his dementia, moisture related to his perspiration, impaired activity/mobility r/t his weakness and use of FWW [front wheeled walker] and general shearing /friction r/t his scooting to edge of bed/chair and general repositioning, pressure reducing mattress on bed, skin inspected weekly. Review of resident 60's EMR revealed: *The resident admitted on [DATE]. *He had been admitted with pressure ulcers on his buttocks that were healed. *His BIMS score was 99 and that indicated he chose not to answer, or had given responses that had not made sense. *He was not able to be interviewed. *His diagnoses included: dementia, benign prostatic hyperplasia, high cholesterol, spinal stenosis, heart disease, and major depressive disorder. *A stage II (an open wound, the skin opens and wears away or forms an ulcer, it is usually an abrasion, blister, or a shallow crater in the skin) pressure ulcer on his right buttock area that was discovered on 3/2/23 that measured 1.5 centimeters (cm) by 0.5 cm. -It currently measured 1.5 cm by 0.8 cm. *A stage II pressure ulcer on his left buttock area that was discovered on 5/30/23 that measured 0.5 cm by 0.5 cm. -It currently measured 1.0 cm by 0.5 cm. *He was placed on hospice care on 7/12/23 for advanced dementia symptoms and increased weakness. Review of resident 60's revised 10/6/23 care plan revealed the following interventions: *Daily wound monitoring in place. Date initiated: 2/19/23. *Float/offload heels. Date initiated: 2/19/23. *Give anti-pruritic medication as ordered by medical practitioner. Observe and document side effects/effectiveness. Date initiated: 2/19/23. *Keep linens dry, wrinkle-free. Date initiated: 2/3/23. *Keep skin clean and dry. Date initiated 2/19/23. Revision on: 10/11/23. *Observe for side effects of antibiotics and over the counter medications: gastric distress, rash, allergic reactions which could exacerbate skin injury. Report changes to nurse/medical practitioner. Date initiated: 2/19/23. *Observe skin during cares. Report changes to nurse. Date initiated: 2/19/23. *Pressure reducing mattress on bed and pressure reducing cushion in wheelchair. Date initiated: 2/19/23. Revision on 10/17/23. -The last two interventions were added to his care plan on 10/17/23 which was during the time of the survey. *Weekly skin inspection and prn (as needed). Date initiated: 2/19/23. Revision on 10/17/23. *The following had been added in the care plan on 10/17/23, which was during the time of the survey: -Focus: [Resident] has potential impairment to skin integrity r/t [related to] impaired sensory r/t his dementia, moisture r/t his incontinence, impaired mobility/activity/r/t his use of w/c [wheelchair] and general shearing/friction r/t his scooting in bed/chair and general repositioning. Date initiated: 10/17/23. -Goal: Will have no complications through the review date. Date initiated: 10/17/23. -Interventions/Tasks: --Encourage reposition/position changes during Rounds and every 2-3 hours. Date initiated: 10/17/23. --Keep linens dry, wrinkle free. Date initiated: 10/17/23. --Keep skin clean and dry. Date initiated: 10/17/23. --Observe skin during cares. Report any changes to nurse. Date initiated: 10/17/23. --Pressure reducing mattress on bed and pressure reducing cushion in w/c. Date initiated: 10/17/23. --Weekly skin inspection and prn (as needed). Date initiated: 10/17/23. Review of resident 60's undated pocket care plan revealed: *The pocket care plan had been received by nurse manager D on 10/19/23 at 2:40 p.m. *He had a wound to his coccyx. *He was on hospice. *He had heel lift boots. -Heel lift boots had not been seen in his room or placed on the resident during the above previously noted observations. Interview on 10/18/23 at 2:17 p.m. with the nurse manager D and certified medication aide (CMA) R regarding resident 60 revealed: *Family members came for daily visits. *His daughter had been a nurse practitioner and was very involved with his care. *He used a Geri chair and was able to wheel himself around the area. *On admission he had used a four wheeled walker to ambulate. *His dementia had worsened and he had been placed on hospice care. *Hospice staff came on a weekly basis to provide him care. *When he needed to use the restroom he would let staff know. *His days and nights were mixed up. *He had a body pillow that they used to position him when he was in bed. Interview on 10/19/23 at 9:59 a.m. with RN K regarding resident 60 revealed: *He had a history of breakdown in that area prior to and at the time of his admission. *The area had healed and redeveloped again on 3/2/23 on the right buttock and on 5/30/23 on the left buttock. *She completed wound assessments on those areas weekly and documented the results on a weekly wound assessment form. *The dressings were changed daily. *She thought those areas had not healed due to his advancing dementia and health decline. *Any resident who had been at risk for skin breakdown should have had interventions in place prior to prevent any breakdown of the skin. *The CNAs had pocket care plans to follow and the [NAME] for interventions to follow. -Those interventions should have all been the same from what was on the resident's care plan. Interview on 10/19/23 at 12:43 p.m. with director of nursing (DON) C regarding residents with current pressure ulcers revealed: *She thought the pressure ulcers they currently had were due to the residents health declines. *They had not had a good process in place to prevent pressure ulcers. *They recognized that the current process was not working. *They added two nurse manager positions recently to attempt to correct the issues with pressure ulcer prevention. *She confirmed there had been a lack of communication and consistency in writing care plans, [NAME] interventions, and pocket care plans and their oversite of those processes had been lacking. *She agreed there had not been a clear policy and procedure in place for pressure ulcer prevention interventions. piece. *They used nursing care standards and the American Healthcare Association for reference and guidance.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of two sampled residents (124) received preventative skin care to prevent acquiring two pressure injuries. Findings include: 1. Observation on 10/25/22 at 12:43 p.m. of resident 124 before and after certified nursing assistants (CNA) E and F had provided personal care revealed: *She required total assistance with a full body lift to transfer from her wheelchair to her bed. *She required total assistance to be repositioned from side-to-side. *Had an incontinent bowel movement (BM) and required her brief to be changed. *The BM was up to her waist in the back and the edges were dried. *No protective ointment was applied after she had been cleansed. *She was positioned on her back and her heels were not elevated. *There were no extra pillows or heel protectors in the room. *She did not have a special cushion in her wheelchair. *Did not have a special mattress on her bed. Review of resident 124's 10/14/22 at 4:45 p.m. admission nursing assessment included: *She was incontinent of bowel and bladder and was to have had a barrier cream or protective ointment applied after each incontinent episode. *Her skin was to have been observed with personal cares and any concerns were to have been reported to the nurse. *She had bruising to her right inner elbow, left elbow, the right side of her back, and a stage two pressure injury to her right third toe. Review of resident 124's 10/18/22 at 11:01 a.m. comprehensive skin and positioning evaluation included: *A Braden (skin risk assessment) score of 14 which indicated she was at moderate risk for skin breakdown. *A nursing summary statement [Resident name] does have pressure area to her toe, does have potential for altered skin integrity r/t [related to] her weakness and use of w/c [wheelchair] and general shearing/friction r/t her scooting in w/c and bed and general repositioning, pressure reducing mattress on bed and pressure reducing cushion in w/c, skin inspected weekly. Review of resident 124's skin ulcer assessments revealed: *On 10/26/22 at 4:16 p.m. a nursing progress note Right heel has fluid filled blister 4.0 x 2.0 cm [physician] updated. *On 10/26/22 at 8:22 p.m. an acquired unstageable pressure injury to her sacrum. It measured 1.5 centimeters (cm) by 1 cm by 0.5 cm. *On 10/26/22 at 8:30 p.m. a stage 2 pressure injury to the bottom of her left third toe. It measured 0.6 cm by 0.5 cm. This had been noted in her admission assessment and a skin ulcer assessment had not been completed until this date. *On 10/26/22 at 8:32 p.m. a stage 2 pressure injury to the top of her second toe on her left foot. It measured 0.7 cm by 0.8 cm. There was no documentation of this area in her admission assessment. Review of a 10/26/22 at 8:22 p.m. nursing progress note regarding resident 124's sacral pressure injury revealed: Documentation is of a new area that is a pressure wound. Wound base has slough [dead skin tissue] present. A scant amount of drainage noted. No odor is present. Drainage is serosanguinous [thin and watery with a light red or pink hue]. Wound edges are intact. Wound edges are pink. MD [medical doctor] notified of new area on Wound is new. Review of resident 124's baseline care plan revealed it had been initiated on 10/14/22. Areas related to skin integrity had been added on 10/26/22 and included: heel protectors/elevate heels, and wound locations. Written on the bottom border of the document was -Repo [reposition] as needed. Interview on 10/27/22 at 11:30 a.m. with clinical coordinator C regarding resident 124's newly acquired pressure injuries to her right heel and sacrum revealed no other inventions were put in place based on a residents risk at admission or during their stay. The interventions were put in place if they developed any areas of concern. Interview on 10/27/22 at 2:30 p.m. with administrator A revealed they had started a skin process improvement plan for pressure areas. They were monitoring to ensure skin audits were forwarded to the wound nurse so they could be monitored and followed up on timely. The bath aides were responsible for the completion of a skin audit for each resident with each bath/shower they received. Those audits were then to have been reviewed by the charge nurse for any interventions needed. The completed bath audits were scanned and attached in the residents electronic medical record (EMR). No bath audits were found for resident 124 in her EMR. Bath audits for resident 124 had been requested on 10/27/22 at 11:30 a.m. from clinical coordinator C. They had not been received by the end of the survey on 10/17/22 at 5:30 p.m. Review of the provider's updated 10/14/22 Skin Management Protocol revealed: *Notify DON (director of nursing) and wound nurse of the new skin alteration or skin ulcer. *Procedures for stage 2, 3, 4, or unstageable pressure injuries had no interventions other than treatment types.