**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, closed record review, and policy review, the provider failed to ensure environmental precautions were in place to prevent harm to one of one sampled resident (147) who received an injury to her right foot from a heat register on the wall in her room where her bed was located. 1. Observation and interview on [DATE] at 10:12 a.m. with associate maintenance mechanic F in the room where resident 147 resided while she was in the facility revealed: *The room was currently not occupied by any residents. *The room measured 15'6 by 12'4 and had been built to accomodate two residents. *Opposite the door entering the room was a large window with a heat register under the windowsill. *The heat register was cool to touch. *One of the heat registers metal vents was broken and had a jagged edge. *There was one bed in the room, and it was pushed up against the wall with the heat register next to it. *Associate maintenance mechanic F stated the heat register was a working register and was the main heat source for the room. *There had been a different bed in the room when resident 147 was in the room and her bed was moved 3 to 4 inches away from the wall/heat register after staff had found her second right toe/foot injury. *There had been two residents residing in that room until approximately 2 to 3 weeks ago and he was unsure of how the beds were positioned. *He was unaware of the broken jagged edge on the heat register and was sure it had not been that way when resident 147 had resided in that room. *He was not sure why that room was the only room in the facility without a wooden cover built over the heat register and stated the wooden covers over the heat registers in all the other rooms in the facility were there before he started working at the facility approximately 10 to 12 years ago. Review of resident 147's medical record revealed: *She was [AGE] years old and was admitted to the facility on [DATE] from another nursing home. *Her [DATE] admission Minimum Data Set (MDS) assessment revealed she was rarely or never understood and had short-term and long-term memory problems. *Diagnoses included dementia, osteoarthritis, history of falls, insomnia, pain/discomfort, and a traumatic wound/skin tear on the right toe/foot. *She was admitted to hospice care on [DATE]. *She died at the facility on [DATE]. *[DATE] nursing progress note documented Note Text: Res [resident] has been getting her legs off of the bed during the night and at times while she rests in the afternoon. Nurse requested an order for a repositioning pillow to lay alongside res while in bed to help keep feet and legs in bed. PCP [primary care provider] has agreed with this and sent order. *[DATE] nursing progress note documented Note Text: Resident was found sitting beside bed, R [right] lateral side of leg were red from sitting on it. Looks like res [resident] slid out from her bed. No injuries noted. Vitals taken. Resident was noted to be restless and/or anxious on day of incident. Body pillow added for re--positional device, as resident has been hanging her leg off side of bed. No suspicion of abuse/neglect suspected. *[DATE] nursing progress note documented Note Text: Heard res [resident]screamed help RN went and res [resident] stated my toes are killing me upon assessment noticed that res [residen] epidermis fell off unsure how she obtained a skin tear while laying in bed. Flaps unable to approximate. Send fax to provider to ask for treatment. For now, area is cleansed and Mepilex applied. Tried to give Tylenol to res [resident] however spitted medication out *[DATE] nursing progress note documented Note Text: At approximately 0500 CNA [certified nursing assistant] reports dressing is missing from resident's right lateral toe. Upon observation, noted that the resident now has a wound that is approximately 7cm [centimeter] x 3cm [centimeter] in size. This is larger than the previous measurement on 1-29-23 of 3cmx3cm. The wound bed is very red in color with some darker areas noted, the foot was resting on heater vent beside her, also has an intact blister to the fourth right toe. Covered blister in betadine, hydrogel applied and wrapped in gauze wrap, informed Dr. [residents physician name] of the condition of the foot. *On [DATE] the wound RN (registered nurse) assessment and wound data collection documented a 3 centimeters (cm) length by 3 cm width skin tear wound with full thickness tissue loss and a red wound bed at the 5th toe and surrounding area of the right foot. The physician and family were notified, and wound care orders were obtained. The wound was cleansed with normal saline, a hydrogel dressing was placed over the wound and wrapped to secure in place with a bandage roll. Acetaminophen and morphine sulfate was to have been administered as needed with dressing changes. *On [DATE] the wound RN assessment and wound data collection documented a new full thickness traumatic wound to the right lateral foot stating that it had increased in size, with increased redness and swelling and there was a blister to the right fourth toe measuring 2 cm length by 1.5 cm width. The physician and family were notified of the new wound and the new treatment orders were obtained for Betadine to the area twice daily. Review of resident 147's comprehensive care plan initiated on [DATE] and revised through [DATE] revealed: *Impairment to skin Integrity R/T [related to] dementia, osteoarthritis, and now has a traumatic wound/skin tear on the right toe/foot. *Pain/discomfort R/T osteoarthritis and traumatic wound right toe/foot. Review of the provider incident report dated [DATE] revealed: *Resident's injury was due to her right foot resting on the heat register in her room. *Her room had been arranged with the bed along the wall with the heat register next to the bed. *Once the injury was identified and addressed by staff her bed had been moved away from the heat register on the wall. *The physician and family were notified of the incident. *Staff were educated at stand-up meetings during shift changes. Interview on [DATE] at 5:08 p.m. with director of nursing (DON) B revealed: *She stated resident 147's feet were always moving back and forth, she had foot and heel protector booties, but they had not stayed in place with her feet moving all the time. *She stated room [ROOM NUMBER] had been the hospice room with only one bed in it until residents were moved to the facility from another nursing home in the area due to a fire. *At that time, they had to have two residents in room [ROOM NUMBER], and she had thought that was why the bed was positioned against the wall with the heat register. *She was unsure why room [ROOM NUMBER] was the only resident room in the facility that had no wooden cover built over the heat register. *Her expectation would have been that the bed should have been moved away from the heat register on the wall when resident 147 was identified as kicking her feet off the bed between the bed and wall with the heat register in addition to the implementation of the body pillow. *She would have expected the bed to have been moved away from the heat register when the resident obtained the skin tear on her toe before the wound from laying her foot on the heat register occurred. *There had been two residents residing in room [ROOM NUMBER] until recently and the resident that had been in the bed by the wall with the heat register was cognitive. *The two nurses that had worked the morning of [DATE] were not currently working at the facility. One nurse had resigned and the other was a contract travel nurse. Interview on [DATE] at 10:48 a.m. with administrator A regarding resident 147 revealed: *The resident's bed was moved away from the wall with the heat register after she had obtained the right toe/foot injury. *Her expectation was that beds were not to have been positioned against a wall with a heat register. *After the incident they completed staff education regarding safety, and positioning of resident beds away from heat registers. *During her investigation she had completed audits that revealed room [ROOM NUMBER] was the only resident room in the facility without a wooden cover built over the heat register. *She was unsure why room [ROOM NUMBER] had not had a wood cover built over the heat register but stated they were working with a contractor in town to complete that. *Prior to residents moving to the facility from another nursing home after the fire it had not been an issue as that had been the hospice room that had only one resident and bed in it. *Her audits included checking the heat register in room [ROOM NUMBER] at different times of day for several days and revealed that the heat register alternated between cool and warm to the touch but was never hot enough that it would have caused a burn. *She was sure the broken vent with the jagged edge had not been there when resident 147's injury occurred. She had checked the register several times daily for several days and ran her hand along the register. She would have noticed it. She attributed the broken vent to when staff moved the head of the bed against the heat register. Interview on [DATE] at 11:05 a.m. with CNA I regarding resident 147 revealed: *She had worked with resident 147 the morning of [DATE] after the injury had been discovered. *She had not seen the injury on the right toe and foot as it was covered with a dressing when she arrived but had been told it was a burn from her foot laying on the heat register. *Resident 147's bed was positioned against the wall with the heat register until it had been moved that morning, staff found a burn on her right toe and foot. *Staff were educated at a meeting regarding repositioning residents and safe bed placement after the incident with resident 147. *Resident 147 was very stiff, not very mobile, and had a body pillow to assist with positioning. *The other three CNAs working on [DATE] were no longer working for the provider. Interview on [DATE] at 11:20 a.m. with registered nurse (RN) G regarding resident 147 revealed: *She was not working the day the residents' injury happened. *She had never seen the wound as dressing changes were completed by the treatment nurse. *She knew the wound was from trauma, but it was never clear as to whether it was a burn or from her foot rubbing against the heat register after her foot had fallen off the side of the bed between the bed and wall with the heat register. *The resident's bed was positioned against the wall with the heat register. *Her bed had been moved away from the wall with the heat register after the injury was discovered. Interview on [DATE] at 11:35 a.m. with licensed practical nurse (LPN) H regarding resident 147 revealed: *The resident's bed was positioned against the wall with the heat register until her injury and then the bed had been moved. *The resident was very stiff, moved her feet, and had a body pillow to assist with positioning. *She worked as the treatment nurse and completed dressing changes for resident 147's right toe and foot wound along with the hospice nurse. *The wound was called a burn and it appeared as a burn. The redness went away but then the area turned black. *She was told the burn occurred after the resident's right foot had laid against the heat register. *The wound treatments were painful for the resident. The resident had been given morphine that had helped with the pain. They applied betadine to the wound and then wrapped it with a dressing. *She could not remember any meetings regarding the incident, safety, or bed placement. *There had been residents in that room since but the bed was not placed up against the heat register. Review of the providers [DATE] Resident Environment policy revealed: *Purpose -To ensure an appropriate resident environment *Policy -The center will provide a safe, clean, comfortable and homelike environment -Resident rooms will be designed and equipped for adequate nursing care, safety and comfort

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the provider failed to ensure one of fourteen sampled residents (186) received the necessary care and services to: *Ensure staff had been aware of non-weightbearing orders for a newly admitted resident 186. *Ensure resident 186 had not experienced pain related to transfers and cares. *Ensure staff had implemented an appropriate pain rating scale for resident 186. *Ensure resident 186's care plan had been updated to inform staff how to care for her needs. Findings include: 1. Review of resident 186's medical record revealed: *She had been admitted from the hospital on 1/17/22. *Her diagnoses included displaced bimalleolar fracture of the left leg, with a subsequent encounter for a closed fracture with routine healing, Alzheimer's disease with late onset, Dementia without behavioral disturbances, other specified disorders of bone density and structure, bilateral primary osteoarthritis of the knee. *The care plan initiated at that time did not include a plan for non-weight bearing status or effective pain management. *Physician orders for Tylenol 325 milligram (mg) two tablets by mouth scheduled four times daily and non-weightbearing. Medical predictability is to begin intense therapies on or around 1/24/22 to rehab bimalleolar fracture. Physical therapy and occupational therapy to evaluate and treat. 2. Observation and interview on 1/18/22 at 5:56 p.m. of resident 186 in the facility dining room revealed she: *Was sitting in a wheelchair at a dining table alone facing a wall and crying. *Stated she was unable to walk and had not wanted to eat because her leg hurt. *Requested to go back to her room and wanted to call her son. *Ate none of her meal and drank a small amount of her coffee. -A facility staff member was obtained by this surveyor and asked to assist her. -The staff member spoke to her briefly and then pushed her out of the dining room in her wheelchair. Observation on 1/18/22 at 6:18 p.m. of resident 186 revealed: *She was sitting in a recliner in her room with both of her legs elevated, no longer crying, and watching TV. *There was a chair side table with a water mug and straw. *A call light was clipped to the arm of the recliner. *She had a pink cast to her lower left leg. 3. Observation and interview on 1/19/22 at 9:36 a.m. of resident 186 revealed she: *Was dressed, her hair combed and was sitting in a recliner in her room with both of her legs elevated watching TV. *Continued with complaints of left leg pain and rated her pain as miserable. *Reported she had fallen at home; her family took her to the hospital and a cast was put on her leg. *Did not know about her pain management plan and stated I don't know, I get very few pain pills. I can't even lift my leg up and, I don't know if I will be doing therapy. *Was hungry and I don't know if I went to breakfast or they brought it to me. 4. Observation and interview on 1/20/22 at 11:24 a.m. with registered nurse (RN) M, certified nursing assistant (CNA) P, and resident 186 revealed: *RN M asked resident 186 how she transfers. -Resident 186 shrugged her shoulders to indicated she had not known. *RN M asked CNA P, who stated pivoting with one assist. *RN M transferred resident 186 to her wheelchair: -He stood in front of her, stood her up from her recliner, and pivoted her into her wheelchair. -She was observed having weight on both legs. -He had not used a walker, gait belt or any other kind of assistive device. *Resident 186 was crying out in pain during the transfer and afterwards. *Surveyor asked if RN M could look in her electronic medical record (EMR) to see how she was supposed to transfer. *While looking in her EMR he: -Was unable to identify her needs based on her care plan. -Looked under orders and noted that she had an order for non-weight bearing status. *Surveyor asked how they usually transfer residents who are of non weight bearing status and he stated: -With a lift. -CNA P told me she was a stand pivot transfer. 5. Phone interview on 1/20/22 at 2:07 p.m. with orthopedics surgery (RN) N regarding resident 186 and her weight bearing status revealed: *Resident was seen by orthopedic provider on 1/12/22. *The surgeon was performing surgery and unavailable for interview. *A short leg cast was placed on the residents left lower leg. *Non weight bearing of the left leg was ordered by the physician. *No pain medications had been prescribed by the orthopedic surgeon. -A two week follow up appointment was scheduled for 1/24/22 at 11:00 a.m. *RN N verified that resident 186 should not be placing any weight on her left leg nor doing any pivot transfers. 6. Interview on 1/20/22 at 2:26 p.m. with RN O, a nurse from the hospital resident 186 was discharged from revealed: *On 1/7/22 after a fall, resident 186 had been brought from her assisted living facility to the emergency room. *She was transferred to hospital acute status for pain management on 1/10/22. -Hydrocodone/Acetaminophen one to two tablets every six hours as needed for pain was prescribed. *She was discharged from the hospital acute status on 1/12/22 for an outside appointment and transported to the Orthopedic provider by family. -She returned to the hospital following her orthopedic clinic appointment on 1/12/22 and was again, admitted as custodial care (care and services to assist her with her activities of daily living). -An order for transfer with walker and assist of two to wheelchair with pivot and front wheeled walker to maintain non-weight bearing to left extremity was placed. -The Hydrocodone/Acetaminophen 5/325 mg medication order was decreased to one tablet every four hours as needed for pain on 1/13/22, with the last dose received on 1/17/22 at 8:30 a.m. *She was discharged from the hospital and admitted to the long-term care facility on 1/17/22. -The hospital discharge orders did not include pain medication. Interview on 1/20/22 at 2:55 p.m. with administrator A and RN M regarding resident 186 revealed: *RN M agreed: -The resident did not understand how to rate her pain using the number pain scale and the staff should have used the faces pain scale. -The ratings of a two on her pain scale were likely inaccurate. -The pivot transfers had been causing her pain. -The physician order for non-weight bearing was not included in her care plan. -To notify the physician for new pain medication orders. -The orthopedic physician should be notified that she had been transferred with pivoting and weight bearing of the left lower extremity. *The administrator was not aware she was being pivot transferred with weight-bearing of the left extremity and agreed that would be contributing to her pain. Interview on 1/20/22 at 3:50 p.m. with minimum data set coordinator (MDS) G regarding resident 186 revealed: *The administrator and director of nursing had completed a screening process prior to accepting new facility admissions. *The social worker had been responsible to obtain new admission orders. -The administrator fulfilled the social worker role until a new social worker was hired and trained. *The daytime charge nurse reviewed and entered new resident admission orders on the day of admission. -The new resident admission orders were left on the nurse station computer keyboard for the night charge nurse to review. *A request for Ibuprofen or Tylenol was faxed to the hospital discharging physician assistant and received back with a signed order for Tylenol 650 mg scheduled four times daily. *The charge nurse was responsible to monitor for the effectiveness of pain medication and follow up with the provider for any needed adjustments. Observation and interview on 1/20/22 at 4:12 p.m. with resident 186 revealed she: *Was sitting in a recliner in her room with both legs elevated. -The call light clipped to the arm of the recliner. *Stated It hurts a lot, I can't walk on it. Continued review of resident 186's pain ratings on her medication administration record revealed: *While surveyor had observed her on 1/18/21 at 5:56 p.m. in the dining room crying with pain, her documented pain rating was a 2. Review of the [NAME] admission documentation policy reviewed/revised on 1/18/21 revealed: * Purpose -To obtain appropriate initial information regarding the resident and family. -To provide the initial documentation needed on admission. * Procedure - 13. The care plan is initiated through triggered UDAs as the Nursing Admit/Readmit Data Collection is completed. ADL and dietary information must be completed within the first 24 hours. Review of the provider's december 2021 Pain Managemen policy revealed: * Purpose -To provide residents assistance in pain management. -To promote well-being by ensuring that residents are as comfortable as possible. -To consistently collect data related to pain, -To determine what pain relief interventions specific to the resident can be used to aid in maintaining a comfortable level of function and quality of life. -To use non-pharmacological interventions for pain relief before starting any new medication. -To use non-pharmacological interventions as identified by the resident to promote comfort. *Responsible Staff -RNs -LPNs *Policy -All residents will receive interdisciplinary consultations on assistance in managing pain. Individualized approaches will be developed to address the resident ' s pain management needs in a holistic manner. -The registered nurse will assess current pain levels and develop with the physician and interdisciplinary team interventions that may be non-pharmacological, as well as pharmacological. The registered nurse will review response to medication intervention and work closely with the physician to assist in the individualized pain management plan. -The nurses working directly with residents must continually monitor and observe the resident for success of the pain management plan and report to the nurse manager and prescriber as necessary to keep the resident comfortable. *Procedure - 2. Develop care plan including pain focus, goal, and interventions, including non-pharmacological interventions that allow documentation. Once these interventions are care planned, a pain management plan should be person centered and can include, but not be limited to, a medication regimen. The plan should help determine what other methods or alternatives to pain control/relief may be implemented prior to contacting a physician. The interdisciplinary team and nurses must have ongoing communication with the resident and monitor and evaluate the pain management plan, Include the resident ' s goal for control of his or her pain. Update care plan as needed to reflect current effective interventions. - 6. Pain documentation by the CNA is ideally entered using the interventions from the care plan. This is the most efficient and resident-specific way to allow documentation of pain and response to interventions. If a pain plan is not yet care planned, employees can use the Pain task (Numeric or PAINAD) and/or Vital Signs tasks in PCC[point click car]-POC[point of care]. Any time a resident is in pain, the nursing assistant should make the resident as comfortable as possible and verbally communicate with the nurse on duty, as well as send a New Alert from PCC-POC using the eINTERACT Stop and Watch Alert for pain.