Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who fell from his wheelchair while being pushed by facility staff. Failure to use wheelchair pedals may have contributed to resident 1's fall. This citation is considered past noncompliance based on the corrective actions the provider implemented immediately after the incident. Findings include: 1. Review of the provider's 7/26/24 SD DOH FRI report revealed: *On 7/26/24, occupational therapy assistant (OTA) C was wheeling the resident back to his room. The resident was holding his feet off the floor; wheelchair pedals were not attached to wheelchair. During the transport, resident 1's feet dropped to the floor, causing him to fall forward out of the wheelchair. *He hit his head on the floor during the fall, causing a laceration and bleeding. *He was evaluated in the emergency department at the local hospital. *A chest X-ray revealed he had multiple left side rib fractures. Interview on 8/28/24 at 8:44 a.m. with director of nursing (DON) B revealed: *After the 7/26/24 fall, resident 1's care plan had been updated to always use foot pedals when transporting him in the wheelchair. *A trial was conducted with foot pedal bags attached to resident's wheelchair instead of keeping foot pedals in the resident's closet, making foot pedals easily accessible when needed. *The trial was successful, and they ordered foot pedal bags for all wheelchairs. Review of employee education records revealed staff had been educated on topics related to safe resident transport and workplace safety as part of the provider's annual education for all employees reviewed. The provider implemented actions to ensure that the deficient practice does not reoccur. That was confirmed on 8/28/24 after record review revealed that resident 1's care plan was updated to always have foot pedals on his wheelchair when transporting, education had been provided to employees regarding safe resident transport and workplace safety, and staff were able to verbalize when wheelchair pedals should be used during transports. Based on the above information, non-compliance at F689 occurred on 7/26/24, and based on the provider's implemented corrective actions, the deficient practice confirmed on 8/28/24, the non-compliance is considered past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to: *Ensure environmental precautions were in place to prevent harm to one of one sampled resident (37) who received a burn to her left ankle from a heat register in her room after her bed had been moved. *Implement timely and appropriate bowel management interventions for one of one sampled resident (128) who had been receiving hospice services. Findings include: 1. Observation on 3/21/23 at 8:09 a.m. and again at 10:08 a.m. of resident 37 revealed: *She was lying in bed under the blankets and appeared to be sleeping soundly. *The bed was in the lowest position and a fall mat was on the floor in front of the bed. *She had a full body pillow positioned beside her on the non-wall side. *A call button was clipped to the pillow at the head of her bed. *There was a wheelchair in the corner of her room with a Pommel cushion setting in it. *At 10:08 a.m., she was lying on top of her made bed, dressed and groomed under a throw blanket and appeared to be sleeping soundly. Review of resident 37's medical record revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) score was 12 indicating her cognition was mildly impaired. *Diagnoses included Parkinson's disease, dementia, repeated falls, a burn, pain, limited range of motion, history cerebral infarction, dysphagia, weight loss, and adult failure to thrive. *On 3/3/22 the Wound/Incision -Complex assessment documented an open pink wound measuring 3.5 centimeters (cm) length x 2.5 cm width x 0.1 cm depth with an 8.75 cm wound area. An Optifoam dressing was placed over the wound/burn. *On 3/10/23 the Wound/Incision-Complex assessment documented the burn to the left ankle was 5 cm length x 5.3 cm width x 0.1 cm depth with a wound area 26.5 cm and described as redness surrounding the wound, It had a white open area inside the wound, a fluid-filled blister at the distal end of the wound and a purple area in the center of the wound. *On 3/18/23 the Wound/Incision - Complex assessment documented the burn to left ankle was 4 cm length x 2.5 width, 10 cm wound area with a dark area in center over the ankle bone and a 6 cm x 5 cm red macerated [occurs when skin is in contact with moisture for too long] area surrounding open area. *On 3/15/23 [[NAME] St. Luke's] wound care clinic orders were written as Burn L [left] foot dressing change every three days. 1.) Exoderm/Duoderm to burn site 2.) upon change clean with sterile water, dry well. 3.) Allow any necrotic tissue to peel away. 4.) f/u [follow up] 2 weeks. Ensure bottle x 1 a day. Next appointment on 3/29/23 9:30 am. *There was no documentation in the resident's medical record indicating what type or degree of burn the resident had. Review of resident 37's comprehensive care plan initiated on 10/11/23 and revised through 3/10/23 revealed: *Problem -Skin Integrity --As evidenced by: urinary incontinence, Braden reveals mild risk, requires extensive assistance with bed mobility & toileting ---3-6-23 left outer ankle as a large pink area. Optifoam gentle to left outer ankle-change every 5 days until healed. ---3-10-23 left outer ankle has clear liquid drainage on dressing, odor when taking dressing off, area is worse than on 3-6-23. (see measurements). will update MD to get wound consult. -Nutritional Status --Severely compromised nutrition status D/T [due to]: significant weight loss and needs altered diet texture and staff assistance. ---Meals at assisted table. ---Supplement with noon & supper meals and prn [as needed] Try hot chocolate Boost at breakfast. ---Black enlarged handled silverware and divided plate. -Fall risk --As evidenced by history of falls, impaired balance, Psychotropic drugs, Impaired cognition secondary to Parkinson and dementia. ---1/26/23 pommel cushion in wheelchair per safety huddle and therapy review is to continue restorative therapy and check on resident frequently. Review of the provider incident report dated 3/3/23 revealed: *Resident's injury was due to her left ankle resting against the heat register in her room. *Her room had been rearranged and the bed was moved along the wall next to the heat register. *Once the burn was identified and addressed by staff her bed was moved away from the heat register on the wall. *Education was provided to the staff that before rearranging resident's rooms they were to consult with the resident care coordinator for permission, an email was sent to the staff and the education was reinforced during the staff daily line-up meetings. *The physician and family were notified of the incident. Observation and interview on 3/22/23 at 9:22 a.m. with licensed practical nurse (LPN) Q during the wound care for resident (37) revealed: *The wound was a burn on her left ankle and was a result of her ankle resting on the heat register on the wall while she was lying in bed. *The bed was now moved away from the heat register and was placed against a different wall. *The resident required staff assistance for transfers and repositioning. *Skin assessments of identified wounds were completed on Saturdays and Sundays by staff nurses with measurements completed at that time. *The provider did not have a designated wound care nurse. *If residents wounds were not improving or worsened they were referred to the wound care clinic. *She had no formal wound care training. *The resident had been referred to the wound care clinic after her burn wound had worsened. *The old dressing was removed, the area was cleansed with normal saline, patted dry with gauze and a Exoderm dressing was placed over the residents' burn wound. *The left ankle burn was approximately 4 cm length x 2.5 width, it had a dark black area in the center over the ankle bone and had approximately a 6 cm x 5 cm red macerated area surrounding the dark area in the center of the burn. *The resident moaned, cried out and attempted to move her foot away from the nurse during the wound care process. *LPN Q agreed she was exhibiting behaviors of pain and stated that had been her usual response during the wound care for her burn. *LPN Q stated the resident was able to communicate by answering questions with a yes or no, it took her a while to respond and it was a very soft and quiet whisper when she would speak. *No resident verbal communication was observed during the observations. *The staff had received an email that there was to have been no rearranging resident's furniture in their rooms without the permission from the resident care coordinators. Interview on 3/23/23 at 8:59 a.m. with assistant director of nursing (ADON) C revealed: *Initially resident rooms were arranged per the resident's choice, their needs, and in resident 37's case she was dominant on one side so they would have looked at what was going to work best for her. *Rearranging furniture in resident's rooms was not something that happened in the facility. *Staff had historically not taken it upon themselves to rearrange furniture and that event was a total fluke. *Administrative staff had a meeting and completed the 5 why's. *Staff that had worked that shift were interviewed and two days prior to the identification of the resident's burn was when they had thought the residents bed had been moved. *No staff had come forward or admitted moving the bed and no staff had knowledge of why the bed had been moved. *The provider does not have a designated wound care nurse. *The charge nurse completed the wound care and would send a fax to the physician for communication and to obtain orders. *Nurses had not received any specialized training for burn wound care. *Resident care coordinators would have been consulted if a wound was not healing, they had assigned on line training for wound care along with each staff nurse. *The provider utilized outside referrals to consult for wound care at the hospital with a physician order. *She felt the nursing staff had the education to have known when to reach out for wound care consults with regards to wound changes or decline in the wound status. Interview on 3/23/23 at 9:49 a.m. with registered nurse (RN) P while performing another task revealed: *There was no designated wound care nurse. *The charge nurse was responsible for resident's wound care during their scheduled shift. *Nurses and CNAs completed on-line training and she had not received any specialized wound care training. *If a resident's wound was not improving or worsening the charge nurse would fax the physician and get an order to send the resident to the wound care clinic. *The staff had received an email regarding there was to have been no rearranging resident's furniture in their rooms without permission from the resident care coordinators. Interviews on 3/23/23 between 10:35 a.m. and 11:20 a.m. with CNAs S, R and J revealed: *They had all been employed from six to eight months and had received their training from the provider. *They had each received a work email regarding that there was to have been no rearranging of residents rooms or moving resident's furniture without prior approval from the nurse. *CNA S stated she would not have rearranged a resident's room or moved their furniture without talking to and getting permission from the nurse first. *CNA R stated she would have talked to the resident or a nurse and gotten permission before making any change to a resident's room. *CNA J stated she would visit with the nurse before moving a resident's furniture and also voiced she had not received any other education or shared in discussion residents' rooms and moving furniture. Interview on 3/23/23 at 10:50 a.m. with resident care coordinator (RCC) E revealed: *She had been employed for two months. *She was aware and had been educated on the newly developed protocol for staff to get permission from the resident care coordinators before re-arranging resident rooms or moving their furniture. *Staff were educated on the newly developed protocol and had received an email with continued follow up occurring at the staff's daily line up meetings. *She was not aware of staff rearranging residents' furniture prior to or since the incident occurred with resident 37. Interview on 3/23/23 at 11:41 a.m. with director of nursing (DON) B revealed: *Resident rooms were arranged for resident's choice, convenience and safety. *There had been no set policy for resident's room arrangements as residents were different and it was to have been individualized. *Conversations needed to happen before room adjustments were made to ensure resident safety. *Since the incident involving resident 37 had happened they had developed a new protocol where the standard of practice was staff must visit with the resident care coordinators first and leaders were to have discussed as a team prior to the staff rearranging resident's rooms or moving resident's furniture. *During the survey the newly developed protocol was requested. *DON B stated they had not developed a written policy or protocol, she only had the emails that had been sent to the staff and meeting notes from when meetings had taken place. *DON B stated they had completed many interviews with staff during their investigation and no one came forward during the investigation. *They had reported the incident to the South Dakota Department of Health, educated staff regarding the new protocol that had been developed, sent staff emails, followed up during staff's daily line ups and completed a sweep of the building to ensure resident's room arrangements were safe. *Since COVID nursing staff were completing on-line training's. *She was not aware if there was an on-line skin/wound training program. *Nurses communicated the resident's wound status and received physician orders for wound care by faxing a communication form to the resident's physician. *If a resident's wound was not healing or worsening a nurse would fax the physician and get an order for a wound care consult. 2. Observation and interview on 3/21/23 at 8:45 a.m. with resident 128 in her room revealed she: *Was lying in bed on her side and looked thin in appearance. *Was receiving hospice services and wanted nature to take its course. *Stated her main concern was the inability to get a laxative like Milk of Magnesia which she had used at home. -Had only one bowel movement in the eleven days since her admission on [DATE]. Review of resident 128's medical record revealed: *Her admission date was 3/10/23 and she began receiving hospice services on that same date. *Hospice registered nurse (RN) T's 3/12/23 progress note: Will plan to request prn [as needed] stool softener as patient verbalizes she has always had one in the past. She would like to try prune juice today to assist with bowels. I did update ECF [extended care facility] nurse on this request. *Medication orders signed on 3/13/23 by the resident's medical provider included the following orders: -Daily scheduled and as needed oral oxycodone-acetaminophen related to the resident's history of chronic back, neck, and coccyx pain. --That medication was an opioid with known side effects that included constipation. -Daily as needed oral senna (laxative) and daily as needed bisacodyl (laxative) suppository. *Hospice RN T's progress notes: -3/14/23: She [resident 128] shares the prune juice did help her bowels and she was able to have a bowel movement yesterday. Information was reviewed with the facility nurse. -3/17/23: Patient [resident] shares need for prn stool softener today. ECF nurse updated. Last bowel movement was 3/13/23. She continues to drink prune juice to help with bowels. *RN U's 3/19/23 faxed communication to the resident's medical provider included the following: -Resident is requesting PRN MOM [Milk of Magnesia]. States this has worked the best for her in the past for occasional constipation. She currently only has PRN bisacodyl suppositories and PRN Senna 8.6 mg BID. She has been receiving PRN Senna (once on 3/18/23 and twice on 3/19/23) with no results and she is day six of no bowel movement. She refuses the suppository when offered. *Hospice RN T progress notes: -3/21/23: Conferred with medication aide V ECF. He also updates she [resident 128] has been requesting prn stool softener for constipation. She is also requesting to have a scheduled stool softener to assist with bowels. I will plan to request this from the provider. *RN U progress notes: -3/22/23 at 9:58 a.m.: New orders were received for scheduled Senna 8.6 mg PO BID and PRN MOM. PRN milk of magnesia given this morning .in addition to her scheduled Senna to help promote bowel movement. Resident declined a PRN suppository in lieu of trying the MOM first. 12:49 p.m.: Resident was reapproached about the use of a PRN suppository which she agreed to. Hard stool present at rectum when inserted suppository. Small amount of hard stool removed with digital disimpaction. 1:31 p.m. Extra large results from suppository that was given. Interview on 3/22/23 at 3:45 p.m. with resident 128 in her room revealed: *Her bowel movement earlier that afternoon was the most painful thing and no one should have to go through that. *I just couldn't get them [staff] to understand her need to have regular bowel movements. Interview on 3/22/23 at 4:15 p.m. with resident care supervisor (RCS) D regarding resident 128 revealed: *She knew as a former hospice nurse that residents who were prescribed scheduled opioids were at increased risk for constipation without scheduled bowel management interventions. -Resident 128 should have had scheduled pharmacological and non-pharmacological bowel interventions that were initiated at the time of her admission. *She was the provider's designee and was responsible for working with hospice staff to coordinate care for residents receiving hospice care services. -She had not reviewed resident 128's hospice orders. *Nursing staff had not followed the provider's Bowel Protocol policy that included consistent administration of ordered PRN laxatives and contacting the resident's medical provider on day four if the resident had no bowel movement. *I can't even defend it referring to the reason why the resident had gone nine days without having had a bowel movement. Interview on 3/22/23 at 4:50 p.m. with RN U regarding resident 128 revealed she was aware of the provider's bowel protocol and had followed it on the days she worked by administering ordered PRN laxatives and notifying the medical provider about the resident not having had a bowel movement. Interview on 3/23/23 at 10:15 a.m. with director of nursing B revealed: *Resident 128 should have had a scheduled laxative ordered at the time of her admission. *Nursing staff had not followed the Bowel Protocol policy. *Nursing staff, RCS D, and hospice RN T were expected to collaborate on RN T's visit days to assess symptom management and address in a timely manner any barriers to symptom management to ensure the comfort and quality of life of the hospice resident. Review of the June 2022 revised Bowel Protocol revealed: *Residents at risk for constipation included those who routinely used narcotics. *For resident complaints of constipation and/or no bowel movements for two days: -5.a. Day 2=offer Prune juice. -5.b. Day 3=give ordered PRN Milk of Magnesia or Miralax. -5.c. Day 4=Listen for bowel sounds. Give ordered PRN Dulcolax Suppository. -5.d. If still no results, consider contacting the Physician.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure ongoing and timely skin assessments were conducted and documented by a licensed nurse prior to the development of pressure ulcers for two of two sampled residents (20, and 58). Findings include: 1. Observation and interview on 3/21/23 at 10:38 a.m. with resident 20 in his room revealed he: *Was sitting in a wheelchair on a pressure relieving cushion. There was a pressure relieving cushion in his recliner and a pressure reduction mattress on his bed. *Had a colostomy, was able to empty the colostomy bag independently and the nurse changed the appliance every five days. *Received a shower with staff assistance once a week. *Had a prosthetic for his right lower leg, was able to put it on independently but was not wearing it because he had swelling in his leg and it would not fit at that time. *Had a CROW [Charcot Restraint Orthotic Walker]boot that was used to accommodate and support and keep his left foot from rolling to the outside and reduce pressure, but he was not wearing it because it caused a pressure ulcer to his left lower inner leg, that had healed. *Reported the nurses used a Betadine swab and painted a sore on his backside [buttocks], was going to wound care at the hospital for it, and the nurses had taken a picture of it weekly. *Reported the bath aide drying him off after his shower had seen the sore on his backside and reported it to the nurse. *Had no feeling or pain on his backside. *Had a sore on his backside several times before, they healed up and would come back in a different spot. *Was on a carbohydrate-controlled diet but had not always chosen to follow the diet. *Reported he exercised five days a week in the physical therapy department, but was unable to walk in the parallel bars without his prosthetic and the CROW boot. *Reported his blood sugars ran high, it was 372 when checked by nursing during the interview, his physician was aware and had given the nurses orders for how to deal with his high blood sugars. Review of resident 20's medical record revealed: *He was admitted on [DATE]. *The provider's Roster Matrix [a resident listing of pertinent care categories] indicated he had a facility acquired stage 3 pressure ulcer. *His diagnoses included insulin dependent type 2 diabetes with neuropathy, right below knee amputation, colostomy, pressure ulcer of the sacral region stage 3, limitation of activities due to disability, abnormality of gait and mobility, morbid obesity, muscle weakness, chronic kidney disease, and atherosclerotic heart disease. *The Minimum Data Set (MDS) assessments dated 11/8/23 and 2/7/23 coded him at risk for developing a pressure ulcer and he had a pressure reducing device for his bed and his chair. *His Brief Interview for Mental Status (BIMS) score was 14 on all the above MDS assessments, and indicated he was cognitively intact. *Blood sugars listed four times daily from 3/1/23 to 3/22/23 totaled 88 blood sugars ranging from 143 to 483. -19 blood sugars documented were greater than 400. -38 blood sugars documented were greater than 300. -23 blood sugars documented were greater than 200. -8 morning blood sugars documented ranged from 143 to 197. *All six Braden Scale scores (used to determine the risk of developing a pressure ulcer) completed between 2/15/22 to 2/6/23 indicated he was at mild risk for developing a pressure ulcer. *Wound/Incision - Complex assessments completed by nursing dated 12/24/22 through 3/18/23 revealed resident 20 had a stage 3 pressure ulcer and was seen at the wound clinic weekly. *The wound clinic weekly visit documentation from 9/27/23 to 3/14/23 revealed: -Resident 20's chief complaint was I have a sore on my backside -Surgical History included: coronary stents, mid foot amputation on the right - 11/2/20, right foot surgery - 9/3/2020 (9 times), decubitus surgery buttocks - 9/30/2020 (multiple), Colostomy, BKA [below knee amputation] (right). -9/27/23 Wound Assessment Wound #7 Sacral is an acute Stage 3 pressure Injury Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 0.5 cm length x 0.3 cm width x 0.2 cm depth, with an area of 0.15 sq [square] cm and a volume of 0.03 cubic cm. Necrotic adipose is exposed. No tunneling has been noted. No sinus tract has been noted. No undermining has been noted. There is a moderate amount of serosanguineous [thin watery fluid that is pink in color]drainage noted which has no odor. The patient reports a wound pain level of 0/10. The wound margin is thickened. Wound bed has No epithelial, No eschar, Yes slough, Yes bright red, pink, firm granulation. -2/7/23 Wound Assessment Wound #8 Coccyx is an acute Stage 3 Pressure Injury Pressure Ulcer and has received a status of not healed. Initial wound encounter measurements are 2.5 cm length x 0.3 cm width, x 0.2 cm depth, with an area of 0.75 sq [square] cm and a volume of 0.15 cubic cm. Necrotic adipose [fat tissue] is exposed. No tunneling has been noted. No sinus tract has been noted, No undermining has been noted. There is an moderate amount of serosanguinous drainage noted which has no odor. The patient reports a pain level of 0/10 [a score of 0 meant no pain on a scale of 0 to 10, 10 indicating the worst pain ever felt]. The wound margin is unattached. Wound bed has no epithelialization, No eschar, Yes slough, Yes pink, firm granulation. *The wound care orders dated 3/14/23 read Sacrum essentially resolved, DC [discontinue] dressing. BID [twice daily] Betadine paint for 10 days then DC. DC from routine FUP [follow up] unless new wounds develop or wound persists. Review of residents 20's comprehensive care plan regarding skin integrity was initiated on 10/3/22 and revised through 2/21/23 revealed: *As evidenced by current impaired skin integrity and hx [history] of previous open area to coccyx/buttocks -2/21/23 new area - left inner calf. Resident wears CROW Boot, only wear 1-2 hours first day and slowly increase wear time monitoring skin-should not wear gripper socks-needs long sock over top of brace. -2-21-23 collagen to right coccyx wound bed. cover with Optifoam Gentle. change every 4 days. -2-21-23 to left inner calf, apply Optifoam gentle to open area on inner left calf. change every 5 days and PRN until healed. Keep long socks on when wearing boot. Review of residents 20's comprehensive care plan regarding nutritional status initiated on 10/20/22 revealed: *Moderately compromised status D/T [due to] skin concern, abnormal labs, health risks from obesity, and needs therapeutic diet. -Skin integrity - heal skin concern. Improve hgb/hct [hemoglobin and hematocrit] and A1C [a blood test that measured an average blood sugar level over the past three months] levels. -Arginaid nutritional supplement with breakfast. -'Low Concentrated Carb[carbohydrate], No Added Salt diet. Observation and interview on 3/23/23 at 10:11 a.m. with registered nurse (RN) P while performing wound care for resident 20 revealed: *Resident 20's ulcer to his coccyx was dry and scabbed over. *Orders from wound care were to paint the ulcer with Betadine through 3/24/23 and then stop the wound care. *The pressure reduction measures in place for resident 20 were a pressure reduction cushion in his wheelchair and recliner and a pressure reduction mattress on his bed. *He had an alternating air pressure reduction mattress when he had his last pressure ulcer but he had not had it since the previous pressure ulcer had healed. *Nurses completed a thorough skin assessment when a resident was admitted and then weekly for three additional weeks. *Braden scales for the identification of pressure ulcer risks were completed at admission and quarterly with the MDS. *Nurses had not completed routine skin assessments for residents other than for new admissions prior to the identification of a resident's skin concern. *Certified nursing assistants (CNA's) observed resident's skin during bathing and personal care and reported any concerns of redness, skin tears or open areas to the nurse. *She was not sure if the CNA's had received specialized training for observing resident's skin and identifying skin concerns. *There was no designated wound care nurse. *The charge nurse was responsible for the resident's wound care on their scheduled shift. *Nurses and CNAs completed on-line training's and she had not received any specialized wound care training. *If a resident's wound was not improving or was worsening the charge nurse would fax the physician and get an order to send the resident to the wound care clinic. 2. Observation and interview on 3/21/23 at 10:30 a.m. with resident 58 revealed she: *Was sitting in her wheelchair watching television and her call light was clipped to her shirt. *Had a pressure reduction cushion in her wheelchair. *Had socks and tennis shoes on her feet. *Had her bed in the lowest position. *Had heel protector boots setting on the floor next to her recliner. *Was not responding verbally when spoken to and was determined to be non-interviewable. Review of resident 58's medical record revealed: *She was admitted on [DATE]. *Her diagnoses included Alzheimer's disease, dementia, diarrhea, urinary incontinence, and pressure ulcer of the left heel. *The MDS assessments dated on 11/29/22 and 2/27/23 coded her at risk for developing a pressure ulcer and she had a pressure reducing device for her bed and chair. *Her BIMS score was 1 on all the above MDS assessments, and indicated she had severe cognitive impairment. *The provider's Roster Matrix indicated she had a facility acquired stage 3 pressure ulcer. *All Braden Scale scores completed between 11/30/22 to 1/3/23 indicated she was at mild risk for developing a pressure ulcer. *The 11/30/22 Braden Scale assessment documentation listed activity as ordered, skin care products, hygiene, specialty bed mattress and specialty cushions interventions that were in place. *The 12/20/23 Braden Scale assessment documentation listed activity as ordered, offload bony areas, elbow/heel protectors, skin care products, hygiene interventions that were in place. *Wound/Incision - Complex assessments completed by nursing started on 12/9/22 through 1/6/23 documented the left heel with a deep tissue injury [purple or maroon localized area of discolored intact skin or blood filled blister due to damage of underlying soft tissue from pressure and/or shear], described as purple, black, dark red, and boggy. *The initial Wound/Incision - Complex assessment completed by nursing dated 12/9/22 had the wound measurements as 2.5 cm length x 4.0 cm wide and the wound area as 10 cm. *Physician communication fax dated 1/30/23 were orders for resident 58 to have been seen by podiatry at wound care at hospital. *Progress notes from the wound clinic dated 2/3/23 documented Wound Assessment - Wound #1 Left heel is chronic Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Initial wound encounter measurements are 2 cm length x 4 cm width x 0.1 cm depth, with an area of 8 sq cm and a volume of 0.8 cubic cm. No tunneling has been noted. No sinus tract has been noted. No undermining had been noted. *There was no drainage noted. The patient reports a wound pain level of 0/10. Wound bed has not epithelialization, Yes eschar, No slough, No granulation. *Progress notes from the wound care clinic dated 2/3/23 documented orders for dressing as apply primary dressing - betadine gauze, dry gauze and cloth tape. Change daily. Review of residents 58's comprehensive care plan regarding skin integrity and nutrition dated 11/28/22 with a revision date of 2/20/23 revealed: *She had a pressure ulcer to her left heel. *She received Boost Breeze at breakfast and chocolate Boost Plus a supplement at the noon meal. *Nursing staff were applying topical iodine, gauze and tape daily. *No other interventions were listed on the skin integrity care plan. Observation and interview on 3/23/23 at 9:49 a.m. with registered nurse (RN) P while completing wound care for resident 58 revealed: *Resident 58 was sitting in her recliner with no pressure reduction cushion and she had heel protector boots on both feet. *Her wheelchair was next to her bed and it had a pressure reduction cushion on it. *There was a pressure reduction mattress on her bed. *Resident 58's pressure ulcer to her left heel was intact, black/brown, firm dry area, dry and scabbed over. *Orders from wound care were to apply topical Betadine, cover with gauze and tape in place daily. *The pressure reduction measures in place for resident 58 were a pressure reduction cushion to have been used in her wheelchair and her recliner, a pressure reduction mattress on her bed, and heel protector boots, *Nurses completed a thorough skin assessment when the resident was admitted and then weekly for three additional weeks. *Braden scales for the identification of pressure ulcer risks were completed at admission and quarterly with the MDS. *Nurses did not complete routine skin assessments other than for new admissions, prior to the identification of a resident's skin concern. *CNAs observed resident's skin during bathing and personal care and reported any concerns of redness or open areas to the nurse. *She was not sure if CNAs had received specialized training for observing skin and identifying skin concerns. *There was no designated wound care nurse. *The charge nurse was responsible for the resident's wound care on their scheduled shift. *Nurses and CNAs completed on-line training and she had not received any specialized wound care training. *If a resident's wound was not improving or was worsening the charge nurse would fax the physician and get an order to send the resident to the wound care clinic. Interview on 3/22/23 at 9:22 a.m. of licensed practical nurse (LPN) Q while performing another task revealed: *Braden scales were completed for residents at the time of admission and then quarterly with the MDS. *Skin assessments were completed by nursing for residents at the time of admission and then weekly for an additional three weeks. *Skin/wound assessments for the residents with identified skin wounds were completed on Saturdays and Sundays by the charge nurse working that shift and wound measurements were completed at that time. *If residents wounds were not improving or worsening they were referred to the wound care clinic. *Skin observations were done by CNAs during resident personal care and bathing and they notified the nurse if they saw any skin concerns such as redness, bruises, skin tears etc . *She denied being aware of CNAs receiving any additional skin/wound training other than what they received during their CNA course. *She denied that nursing completed routine skin assessments for residents at risk for pressure ulcers prior to the identification of a pressure ulcer. *She completed on-line training's and had not received any specialized wound care training. Interview on 3/23/23 at 8:59 a.m. with assistant director of nursing (ADON) C revealed: *Head to toe skin assessments were completed in the evening by the night shift charge nurse when a resident was admitted . *The charge nurse worked a twelve hour shift. *Braden scales were completed for residents at the time of admission and then quarterly with the MDS by the resident care coordinators. *Pressure ulcer prevention measures put into place for residents at risk for developing a pressure ulcer were repositioning schedules, specialty mattresses for pressure reduction, wheelchair/recliner cushions and some of the residents had pressure reducing boots. *CNAs completed skin observations during resident's personal care and bathing and reported any skin concerns of redness or open areas to the nurse. *She was not aware if there had been a procedure or protocol set up and in place for nurses to complete routine skin assessments for residents at risk for developing a pressure ulcer. *The charge nurse completed residents wound care and sent a fax to the resident's physician with communication of the wound status and for new orders. *The resident care coordinators were consulted if a resident's wound was not improving or was worsening. *The resident care coordinators were assigned and completed the same on-line training's as the other nurses. *The would have utilized outside referrals to consult with the wound care clinic. *She felt the nursing staff had the education and knowledge to obtain a physician order for a wound care consult for residents with wound changes, non-healing wounds or a decline in the wound status. Interviews on 3/23/23 between 10:35 a.m. and 11:20 a.m. with CNAs S, R, and J revealed: *They had all been employed from six to eight months and had received their on-line training and training from the provider. *In their roles, they were to observe residents skin during bathing and personal cares and report any skin concerns such as redness, skin tears, or open areas to the nurse. *They had not received any additional training for observing skin concerns other than what was included during their training. *They were aware pressure ulcer prevention interventions utilized for residents identified as at risk for skin breakdown were: repositioning, toileting schedules, applying barrier cream, cushions, heel boots, and pressure reducing mattresses. Interview on 3/23/23 at 10:50 a.m. with resident care coordinator (RCC) E revealed: *She had been employed for two months. *She had received training for completing admission, discharges, care conferences, the MDS assessments, and helping staff that worked with residents. *Braden Scale assessments were completed with residents at the time of admissions, and then quarterly with the MDS assessments. *Resident skin assessments were completed at the time of admission, then weekly for an additional three weeks, quarterly, and annually with the MDS assessments. *She had not received any specialized wound care training. *CNAs completed skin observations while providing residents personal cares and bathing and reported any skin concerns such as redness or open areas to the charge nurse. *She was not aware if the CNAs received any skin care education beyond the CNA certification program. Interview on 3/23/23 at 11:41 a.m. with director of nursing (DON) B revealed: *Nurses completed head to toe skin assessments for residents at the time of admission, then one time weekly for 3 additional weeks, and then quarterly and annually with the completion of MDS assessments. *Braden Scale assessments were completed at the time of admission, quarterly and annually with the MDS assessments. *Residents found to have been at risk for pressure ulcers were discussed at interdisciplinary (IDT) team meetings, therapy would have been involved and interventions were put in place such as a restorative program, repositioning, good nutrition, pressure reduction mattresses, cushions, and the family and physician were updated. *CNAs were observing resident's skin during bathing, personal care, repositioning and reporting skin concerns to the nursing staff and that was how resident skin concerns or issues were identified. *There was no process in place for nurse skin assessments to have been completed, for residents identified at risk for pressure ulcer development. *Prior to COVID they had nursing staff attend wound workshops and had wound care training events with wound care. *She was not aware if there was an on-line skin/wound training program or if CNAs had received additional training for completing skin observations outside of what they had received in their CNA certification course. Review of the provider's 6/2021 Skin Assessment policy revealed: *It is the policy of this facility that all residents will be routinely monitored for impaired skin integrity. Measures will be taken to predict residents at risk and implement individualized preventive interventions as needed. In the event impaired skin integrity unavoidably develops, individualized interventions will be implemented to promote rapid healing. -5. Weekly assessments will be completed by a licensed professional and updated on the weekly skin assessment sheet. Review of the provider's 10/2021 Pressure Ulcer Prevention Policy and Procedure revealed: *A pressure ulcer risk assessment (Braden scale) will be done on admission and repeated at defined intervals. Skin assessments will be done on admission and repeated at defined intervals. Interventions will be implemented to reduce the risk of developing pressure ulcers by managing moisture, optimizing nutrition and hydration, and minimizing pressure. all related assessments and interventions will be documented. -A. Assessment --1. Perform Braden Scale risk assessment to identify pressure ulcer risk --2. Perform skin assessment --5. Identify all individual risk factors -B. Interventions --1. Implement interventions based on Braden Scale score ---At Risk: Braden score 15 to 18 ---Moderate Risk: Braden Scale score 13 to 14 ---High Risk: Braden Scale score 10 to 12 ---Very High Risk: Braden Scale score 9 or below *This policy applies to personnel responsible for skin assessments, risk assessments and interventions to reduce the risk of developing pressure ulcers by managing moisture, optimizing nutrition and hydration, and minimizing pressure. All nursing personnel are expected to inspect and protect their patient's skin. Nursing is responsible for assessment and plan of care; the LPN and non-licensed personnel are responsible for skin inspection, implementation of plan of care and reporting any changes in skin condition to the RN. *Leadership is responsible for ensuring there is a system-wide awareness of the patient safety performance goal of providing pressure ulcer prevention measures. Leadership is responsible for making the investment in resources required to meet the goal, analyzing performance gaps, and reporting the performance gaps as indicated by metrics to corporate level. *Appropriate staff must be competent in use of the Braden Scale, skin assessment, proper repositioning techniques and proper use of related equipment.