**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents. Specifically, for 1 out of 18 sampled residents, a resident that required extensive assistance of two or more persons for bed mobility and toilet use had a brief change performed by one Certified Nursing Assistant (CNA), rolled out of the bed, and fractured their right hip. Resident identifier: 34. Findings included: Resident 34 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, Multiple Sclerosis, atrial fibrillation, type 2 diabetes mellitus, mood disorder due to known physiological condition with major depressive like episode, nondisplaced intertrochanteric fracture of right femur, reduced mobility, repeated falls, and chronic pain syndrome. Resident 34's medical record was reviewed on 2/6/24. A care plan Focus initiated on 7/27/17 and revised on 11/12/21, documented [Resident 34] needs assist with ADL [activities of daily living] self-care performance. [Resident 34] has Multiple Sclerosis. The interventions initiated on 10/26/17, included: a. Discuss with resident, family, and Power Of Attorney any concerns related to loss of independence and decline in function. b. Encourage resident to discuss feelings about self-care deficit. c. Encourage resident to participate to the fullest extent possible with each interaction. d. Monitor, document, and report as needed any changes, any potential for improvement, reasons for self-care deficit, expected course, and declines in function. A quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 34 required extensive assistance of two or more persons for bed mobility, transfers, toilet use, and personal hygiene. The MDS assessment documented that resident 34 had a Brief Interview for Mental Status (BIMS) score of 8. A BIMS score of 8 to 12 would suggest moderately impaired cognition. On 4/19/23 at 5:46 PM, a Nursing Note documented LATE ENTRY Note Text : Weekly Note: Resident has been in bed most of the day. Requires assistance with all ADLs. Can eat and drink with set-up and some coaxing. Takes snacks but often refuses to eat them. 2 person assist for transfers. Dependent on staff to change brief. Skin is intact, redness beneath breasts is resolving. On 5/24/23 at 6:23 PM, a Nursing Note documented Note Text: Weekly NN [Nurses Note]- Resident is alert and oriented to self and place. She ambulates with the use of a wheelchair pushed by staff. She is dependent on staff for bed mobility, showering, dressing, and grooming. Her meals are set up and monitored by staff. She has a fair appetite. On 6/7/23 at 9:50 AM, a Nursing Note documented Note Text : Weekly NN- Resident is alert and oriented to self, otherwise confused. She is able to verbalize her needs and wants. She ambulates by wheelchair pushed by staff. She requires 1 staff extensive assist with bed mobility, brief changes, transfers, showering, dressing and grooming. Her meals are set up and monitored by staff. She has a good appetite. On 6/10/23 at 5:26 AM, a Nursing Note documented Note Text: At approximately 0512 [5:12 AM] hrs [hours] the CNA was in the process of changing the resident's brief and providing peri care, she rolled off the opposite side of the bed and onto the floor. The resident hit her head on the night stand and her back landed on the floor. The CNA then called for the nurse who found the resident on the floor with the CNA holding her head. A through [NAME] [neurological] check of the resident did not identify any noticeable injuries at the time. With the assistance of an additional CNA, the nurse and the attending CNA placed the resident back onto her bed where another complete body check was conducted by the Nurse with the assistance of the CNA. The results were negative in finding any additional wounds. At approximately 0520 [5:20 AM] hrs, a voice mail was left for the resident's sister to call back so she can be informed of the incident. At approximately 0525 [5:25 AM] hrs the [NAME] [sic] [Assistant Director of Nursing] was notified of the incident. The PA [Physician Assistant] was notified via text. Information was passed on to the oncoming Day shift staff. [NAME] checks and checklist was started at the initial [NAME] check. Will continue to monitor for safety. On 6/10/23 at 8:16 AM, a Nursing Note documented Note Text : FALL CHARTING: Resident had a witnessed fall this morning just before the start of my shift. Neuro checks continuing, no change noted from her baseline. Generalized mild pain noted, Tylenol given. No immediate concerns at this time. WCTM [will continue to monitor] closely. On 6/10/23 at 10:58 AM, the Radiology Report documented CT [computed tomography] right hip. IMPRESSION: Fracture of the base of the freater [sic] trochanter, with mild distraction/displacement. No definite fracture line is seen through the intertrochanteric region or femoral neck, though that possibility is not excluded given the diminished bone mineral density. Further evaluation with MRI [Magnetic Resonance Imaging] is suggested. On 6/10/23 at 11:29 AM, a Nursing Note documented Note Text : FRACTURE: This resident started complaining of right hip pain this morning at approximately 0930 [9:30 AM]; I assessed the patient and found that her right hip is swollen and painful to the touch. VS [vital signs]: BP [blood pressure]: 150/90, HR [heart rate]: 96, Spo2 [oxygen saturation]: 91% on RA [room air], RR [respiratory rate]: 22. PA notified, new order received for an XR [x-ray] of the right hip and pelvis. Family notified at 0953 [9:53 AM]. Resident taken over to the hospital and the XR was inconclusive for a fracture, so the MD [Medical Doctor] at the hospital put an order in for a CT scan. CT scan showed the following: 'Fracture of th [sic] base of the grater trochanter, with mild distraction/displacement. No defginite [sic] fracture line is seen through the intratrochanteric [sic] region or femoral neck, though that possibility is not excluded given the diminished done [sic] mineral density. Further evaluation with MRI is suggested' Even though MRI was suggested, there are no staff available today at the hospital to do an MRI. The Dr [doctor] Physician, [name removed], consulted with ortho [orthopedics] and ortho found her fracture to be non-operable and suggested treating her pain and following up with Dr. [name removed] next week. Family was updated with this information, however they were also concerned about her right knee (slightly swollen and abrasions present); Dr. [name removed] put an order in for an xr of the right knee; results still pending. Family updated again. PA updated with all the above information and new order received for Tramadol 50mg [milligrams] PO [by mouth] q6h [every six hours] PRN [as needed] pain. Resident to be returned to facility via staff transportation shortly. On call nursing management also notified. WCTM patient closely. On 6/10/23 at 1:42 PM, a Nursing Note documented Note Text : XR RESULTS RIGHT KNEE: Spoke to Dr. [name removed] in the ER [Emergency Room]; he said that there is no fracture to her right knee. Family and patient made aware as well. On 6/10/23 at 1:43 PM, a Nursing Note documented Note Text : NEW INJURIES NOTED POST FALL: In addition to her right hip fracture, a couple other wounds have been noted from her fall that occurred just before day shift started today: 1) right hip edema & right hip fracture (see previous nursing note for details) 2) right knee bruising and edema 3) right knee abrasions: two small abrasion present to the anterior aspect of her knee; . , no need for a bandage at this time. 4) small lump on the right side of her posterior head, but no changes or concerns noted with her neuros. On 6/10/23 at 8:10 PM, a Nursing Note documented Note Text : Resident s/p [status post] fall from this morning. Upon going in to give her PM meds [medications], resident appeared to be in pain. HR and BP elevated. O2 [oxygen] at 80. PRN med given as ordered, prn albuterol neb [nebulizer] given. Residents family is concerned about shunt to R [right] side of head not beingassessed [sic]. SN [Skilled Nurse] called and notified [name removed], resident sent over to ER at 2000 [8:00 PM] to get shunt checked out. Family with resident at the hospital at this time. On 6/11/23 at 1:25 PM, a Nursing Note documented Note Text : Resident arrived back from hospital. CT scan of head came back clear. UA [urinalysis] was done, resident has UTI [urinary tract infection]. Resident given naloxone at the hospital and rocephin via IV [intravenous]. Tolerated well. MD at hospital ordered levaquin 750mg QD [daily] x7D [days]. [Name removed] made aware, waiting call back. Resident resting in bed asleep. VS WNL [within normal limits]. Continue to monitor. On 6/11/23 at 11:54 PM, an Alert Note documented Note Text : WITNESSED FALL - Resident had a WF [witnessed fall] yesterday. She is resing [sic] /sleeping at this time. She was given tylenol for pain. Her bed is at the lowest point and she is being monitored by staff for safety. On 6/14/23 at 7:33 PM, a Nursing Note documented Note Text : WEEKLY: . Pt [Patient] did have a fall and fractured her pelvis. s/s [signs and symptoms] of pain observed due to her hip fracture. Resident is unable to sit up or ambulate due to her fracture and the pain she experiences. On 6/14/23 at 7:39 PM, a Nursing Note documented Note Text : DOCTOR VISIT: Pt visited Dr. [name removed] (ortho) today. The following are the clinic notes and orders from the Dr: 'Weight bearing as tolerated on right low extremity. Pillows in between legs in bed for abduction and external rotation of right leg. Continue with current pain meds. On 2/6/24 at 12:22 PM, an interview was conducted with CNA 1. CNA 1 stated if a resident could help to roll or there was a grab bar on the bed the resident was usually a one person assist. CNA 1 stated if a resident could not roll or the CNA felt like they needed help for safety she would request another CNA to help with a resident brief change. CNA 1 stated that most residents at the facility were a two person assist. CNA 1 stated that she would radio for another CNA if she needed help and unless they were short staffed a CNA would assist. CNA 1 stated that the facility was not short staffed often. CNA 1 stated that resident 34 towards the end of her stay at the facility went from a one person assist to a two person assist. CNA 1 stated that the last two years resident 34 required a two person assist. CNA 1 stated that resident 34 would get up but resident 34 was only able to move her hands and arms. CNA 1 stated that resident 34 was able to transfer her self when she was first admitted to the facility and the last two years resident 34 required more help. CNA 1 stated that resident 34 was a smoker and required supervision. On 2/7/24 at 10:10 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 34 required full assistance with cares. LPN 1 stated by the time resident 34 left the facility she could not walk at all. LPN 1 stated that resident 34 required two people for a brief change. LPN 1 stated that earlier on there was not a problem with resident 34 rolling in bed and resident 34 had been at the facility for several years. LPN 1 stated if resident 34 rolled out of the bed resident 34 should have had two people assisting with cares. LPN 1 stated that yes resident 34 should of had two people to assist with a brief change. On 2/7/24 at 11:33 AM, an interview was conducted with CNA 2. CNA 2 stated she had worked at the facility since June 2023. CNA 2 stated resident 34 was full cares with ADLs. CNA 2 stated that resident 34 required a brief change and it would depend on how resident 34 was that day if resident 34 required two CNAs. CNA 2 stated if resident 34 was fully aware then one CNA would be able to assist resident 34, if resident 34 was tired then two CNAs were required to assist resident 34. On 2/7/24 at 1:18 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 34 had been at the facility for a very very long time. The DON stated that resident 34 required extensive assist with most ADLs since the DON had been at the facility since June 2021. The DON stated that resident 34 liked to stay in her bed but would go out occasionally to smoke. The DON stated that resident 34 ate most meals in her room and was content and happy. The DON stated that resident 34 had a fall where the CNA went in alone to do a brief change. The DON stated that the CNA thought she was good and when she rolled resident 34 the CNA tried to grab resident 34 but resident 34 fell out of the bed. The DON stated there were no injuries noted from the initial nurse assessment. The DON stated that resident 34 was alert and oriented and neuro checks were started. The DON stated the on coming nurse came into the facility about 10 minutes after resident 34 fell and resident 34 was complaining about her hip. The DON stated an xray was done, resident 34 was shipped out of the facility, and there was a fracture. The DON stated there should have been two CNAs for the brief change with resident 34 and the incident should have been reported to the State Survey Agency. On 2/7/24 at 2:55 PM, a telephone interview was conducted with LPN 2. LPN 2 stated that he was at the main nurses station in the center of the facility with another CNA the evening of the incident. LPN 2 stated that the CNA that was helping resident 34 came out to the hallway and yelled that resident 34 just fell on the floor. LPN 2 stated when he entered resident 34's room the bed was at a pretty high level and resident 34 had fallen between the bed and the window. LPN 2 stated that he did an assessment and neuro checks were immediately started. LPN 2 stated if he remembered right resident 34 had a bump on her head and maybe a scrape on her knee. LPN 2 stated that resident 34 told him that she was hurting but LPN 2 figured it was from the fall and there was nothing out of the ordinary. LPN 2 stated that resident 34's legs at the time were at the same length. LPN 2 stated he brought resident 34's bed down to the lowest position and with the CNAs they got resident 34 back in bed. LPN 2 stated the CNA was changing resident 34 and stated to him that she had done it that way for years. LPN 2 stated the CNA had resident 34 laying on her side on the far end of the bed from the CNA and the CNA was doing a bed strip. LPN 2 stated the CNA was positioned on the left side of the bed opposite of resident 34 and resident 34 was on the right side of the bed. LPN 2 stated when resident 34 started to fall the CNA tried to grab resident 34's gown but resident 34 fell off the bed. LPN 2 stated oh yes the CNA should of had two staff in the room to assist. LPN 2 stated resident 34 was not obese but resident 34 was not that mobile and required a Hoyer lift to move to the wheelchair. LPN 2 stated that resident 34 required two people and the CNA at the time knew that. LPN 2 stated the CNA worked agency and since the incident she had not been back to the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review it was determined, for 2 of 22 sample residents, that the facility did not ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers received necessary treatment and services, to promote healing, prevent infection and prevent new ulcers from developing. Specifically, a resident that was determined to be at risk for developing a pressure ulcer did not have interventions in place to prevent pressure ulcers from developing. The resident developed pressure ulcers that enlarged and one became infected. In addition, another resident's wound was enlarging in size and was not offered to be turned and repositioned. The resident's admission physician's orders were not followed. Resident identifiers: 21 and 45. Findings include: 1. Resident 45 was admitted to the facility on [DATE] with diagnoses which included dementia without behavioral disturbance, chronic obstructive pulmonary disease, acute kidney failure, atherosclerotic heart disease, peripheral vascular disease, mood disorder, and muscle weakness. On 1/6/20 at 11:40 AM, resident 45 was observed sitting in a wheel chair with bilateral heel protectors. Resident 45's medical record was reviewed on 1/8/20. A Braden Scale for Predicting Pressure Sore Risk dated 9/10/19, documented that resident 45 was at risk for pressure sores with a score of 18. [Note: A resident at mild risk for pressure ulcers would have a total score of 15 to 18.] A Care Plan focus initiated on 9/10/19, documented [Resident 45] has potential for impairment to skin integrity. The goal developed was [Resident 45] will maintain or develop clean and intact skin by the review date. The following interventions were developed: a. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. b. Educate resident 45, family, and caregivers of causative factors and measures to prevent skin injury. c. Encourage good nutrition and hydration in order to promote healthier skin. d. Identify and document potential causative factors and eliminate and resolve where possible. e. Keep skin clean and dry. Use lotion on dry skin. An admission Minimum Data Set (MDS) assessment dated [DATE], documented that resident 45 was at risk of developing pressure ulcers. The MDS further documented that resident 45 had a pressure reducing device for chair and bed. The Care Area Assessment section of the MDS documented that Pressure Ulcer was a triggered care area and was addressed in the care plan. [Note: The skin integrity care plan initiated for resident 45 did not include interventions to prevent pressure ulcers including the pressure reducing device for the chair and bed.] Additionally, resident 45 was documented as having a Brief Mental Interview Status (BIMS) score of 3. [Note: A resident that was severely impaired cognitively would have a BIMS score of 00 to 07.] Resident 45 was also documented as requiring extensive one person physical assistance with bed mobility and transfer. [Note: Bed mobility was defined as how a resident moves to and from a lying position, turns side to side, and positions body while in bed or alternate sleep furniture.] A Nutritional Screen dated 9/13/19 at 3:22 PM, documented that resident 45 was at Normal nutritional status. [Note: A Nutritional Evaluation calculating resident 45's nutritional needs including calories and protein was unable to be located in the medical record.] A Nursing Progress Note dated 12/2/19 at 3:05 PM, documented Resident has a blister on each heel. New order to keep heels floated while in bed. Apply skin prep to heels BID (two times daily). A Nursing Progress Note dated 12/3/19 at 10:42 AM, documented Resident is alert and oriented to self only. she has been spending most of her time in bed over the last few weeks. she will sleep most of the day and can be difficult to arouse. A Nutrition/Dietary Progress Note dated 12/3/19 at 11:11 AM, documented Resident with BMI (body mass index) of 28.4, overweight. Current weight of 150.2# (pounds). Resident is on a regular diet, mechanical soft texture, thin liquids, small portions. PO (by mouth) intake is 50-75% of meals. Resident has blisters to left heel and right medial malleolus. Recommend adding vitamin C and multivitamin/mineral to aid in skin integrity at this time. Will continue to observe. A Nutrition/Dietary Progress Note dated 12/3/19 at 1:58 PM, documented New order obtained for MVI (multivitamin) with minerals one po QD (every day), Vit (vitamin) C 500 mg (milligrams) po BID. CBC (complete blood count) CMP (complete metabolic panel) scheduled 12/16/19. Will also add to weekly weight monitoring. A Nursing Progress Note dated 12/3/19 at 2:00 PM, documented New order to increase Skin Prep to Bilat (bilateral) Heels from BID to QID (four times daily). A Nursing Skin and Nutrition Review dated 12/3/19 at 3:30 PM, documented that for the last 7 days [Resident 45] had an ER (emergency room) visit dt (due to) lethargy. Diagnosed with Hypoxia and UTI (urinary tract infection). New orders for O2 (oxygen) to keep sats (saturations) > (greater than) 90%. Antibiotic ordered. MD (Medical Doctor) later dc'd (discontinued) abx (antibiotic) dt no active UTI noted on UA (urinalysis). Bilat heel blisters noted. Skin Prep and vitamin supplements ordered. A Braden Scale for Predicting Pressure Sore Risk dated 12/3/19, documented that resident 45 was at risk for pressure sores with a score of 16. [Note: A resident at mild risk for pressure ulcers would have a total score of 15 to 18.] A Care Plan focus initiated on 12/3/19, documented [Resident 45] has a pressure ulcer (R (right) heel). Additionally, a Care Plan focus initiated on 12/3/19, documented [Resident 45] has a pressure ulcer (L (left) heel). The following interventions were developed for both of the initiated Care Plan focuses: a. Administer medications as ordered. Monitor and document for side effects and effectiveness. b. Administer treatments as ordered and monitor for effectiveness. c. Assess, record, and monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. d. Follow facility policies and protocols for the prevention and treatment of skin breakdown. e. Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate. A Nursing Progress Note dated 12/9/19 at 4:08 PM, documented WCC (wound care consultant) Wound nurse in to see resident today and to assess the wounds on both heels. Resident was in bed with heels floating. WCC stated that one of the wounds is miss classified and should be staged as a deep tissue injury rather than a blister. Floor nurse informed and will update the change in classification during her documentation. SW (Social Worker) bought some soft slippers for resident to wear while she is up in her wheelchair to keep her shoes from adding pressure and causing pain, but the slippers are too small and are being taken back for a larger pair. A Nutritional Screen dated 12/10/19 at 9:05 AM, documented that resident 45 was at Normal nutritional status. [Note: On 12/2/19, resident 45 had developed blisters on bilateral heels. On 12/10/19, resident 45's right medial malleolus blister was reclassified as a right heel pressure deep tissue injury. Resident 45's Weight Summary was reviewed. On 12/3/19, a weight of 154.2# was recorded. On 12/10/19, a weight of 146.8# was recorded. Resident 45 had a 4.80% weight loss in one week. A Nutritional Evaluation calculating resident 45's nutritional needs including calories and protein was unable to be located in the medical record.] A MD visit note dated 12/11/19, was reviewed. [Note: The MD did not document in the visit note that resident 45 had pressure ulcers to both heels. The MD did not document any treatment orders implemented for resident 45's pressure ulcers.] A Braden Scale for Predicting Pressure Sore Risk dated 12/13/19, documented that resident 45 was at risk for pressure sores with a score of 16. [Note: A resident at mild risk for pressure ulcers would have a total score of 15 to 18.] A Nursing Progress Note dated 12/24/19 at 10:44 AM, documented [Resident 45] has deep tissue injuries to bilat feet. Her recent labs show albumin is normal. Her weight is stable. 0.41% gain this week. RD (Registered Dietitian) recommends Zinc 220 mg po QD times 14 days. Order obtained. A Nursing Progress Note dated 12/25/19 at 4:44 PM, documented Resident is alert with confusion. She c/o (complains of) pain to bilat heels. She receives extensive assist with adls (activities of daily living). A Nursing Progress Note dated 12/31/19 at 4:46 PM, documented Resident is alert with confusion. Nurse noted that wounds to heels are smaller but the right heel has purulent drainage noted from it. Area is tender to touch. MD notified of the drainage to the wounds. Clindamycin 300 mg tid (three times daily) times 7 days ordered. Skin prep applied to heels with dry dressing to cover. Son notified of infection. Resident receives extensive assist with adls and transfers. She takes her meals with set-up assist. Her appetite is fair. A physician's order dated 12/31/19, documented clindamycin 300 mg three times daily for infection in heels for 7 days. A Nursing Progress Note dated 1/1/20 at 4:45 AM, documented Resident had c/o pain when right heel wound was touched at dressing change. Purulent drainage and foul odor noted. Resident kept rubbing her feet on each other, then dressings were noted to be off. She was encouraged to leave the dressings to both heels alone. Abx therapy ongoing. Will continue to monitor. A Nursing Progress Note dated 1/1/20 at 9:58 AM, documented Infection note: resident is on abx therapy for wounds on heels. the (sic) is slight purulent drainage that is foul smelling to right heel. dark callusing present. left heel is not draining at this time and has the dark callusing. fluids encouraged. heels floated. A Nursing Progress Note dated 1/2/20 at 9:18 AM, documented Infection note: Resident has dark callusing to bilateral heels. right heel has some slight purulent drainage. it has a foul odor. abx admin (administered) as ordered. dressing done as ordered. heels floated. A Care Plan focus initiated on 1/2/20, documented [Resident 45] has an infection to deep tissue injury on right heel. The goal initiated was [Resident 45] will be free from complications related to infection through the review date. The following interventions were developed: a. Administer antibiotic as per MD orders. b. Maintain universal precautions when providing resident care. c. Monitor, document, and report to MD signs and symptoms of delirium. d. Podiatry consult. e. Treatment per order. Monitor often and notify MD if no improvement. A Nursing Progress Note dated 1/3/20 at 11:07 AM, documented MD also ordered Podiatry consult. [Resident 45] will be seen 1/6/20 at facility. A Nursing Progress Note dated 1/3/20 at 5:02 PM, documented Resident had c/o pain to right heel wound at dressing change. Purulent drainage and foul odor noted. Abx therapy ongoing. Will continue to monitor. A Nursing Progress Note dated 1/3/20 at 10:44 PM, documented Alert charting: Purulent drainage and foul odor noted to right heel. Abx therapy ongoing. dry dressing applied to bilat heels. Will continue to monitor. A Nursing Progress Note dated 1/4/20 at 3:17 PM, documented Residents right heel has a small amt. (amount) serosanguineous drainage. Abx continues as ordered and tolerated well. A Nursing Progress Note dated 1/5/20 at 3:00 PM, documented Resident continuous on abx for right heel infection. There is a moderate amount of purulent drainage on dressing removed. Wound is painful to the touch. Dry dressing with Kerlex for drainage. A Nursing Progress Note dated 1/6/20 at 2:36 PM, documented Resident continues on abx for right heel infection, which seems to be tolerated well. Resident saw [Podiatrist] today for her heels, see referral for new orders. A Podiatrist visit note dated 1/6/20, documented that resident 45 was brought over by the care center for evaluation, treatment, and recommendation of bilateral heel ulcers. The duration of the ulcers was several weeks. The care center had been treating with various topical treatments and off weighting heel boots were in place. The ulceration of the left posterior lateral aspect was measured at 1.5 centimeters (cm) x 1.8 cm, granulating, stage 2. The ulceration of the right heel posterior lateral aspect was measured at 2.2 cm x 3 cm, unstable fibrin. Upon debridement of the right heel the subcutaneous tissue was exposed. A Nursing Progress Note dated 1/7/20 at 1:06 AM, documented Alert charting: Resident continues on abx for right heel infection. There is a moderate amt of purulent drainage on dressing removed. Wound is painful to the touch. Dry dressing applied as ordered. Will continue to monitor. A Nursing Progress Note dated 1/7/20 at 9:22 AM, documented Infection note: Resident has dressing in place to heels. there is no drainage noted to be coming through the dressing. she does c/o pain to the right heel. abx admin as ordered. fluids encouraged. heels floated. A Nursing Skin and Nutrition Review dated 1/7/20, documented that resident 45 eats meals in the Journeys unit. Resident 45 feeds herself with set up and appetite continues to be fair. Resident 45's weight is up 0.14% from last week but significant loss for one month 6.49%. RD recommends no dietary changes at this time. Resident 45 had no ordered snacks or supplements. Resident 45 had a Zinc supplement times 14 days. [Note: The last Nutritional Screen for resident 45 was completed on 12/10/19. On 12/31/19, resident 45's right heel developed purulent drainage and an antibiotic was initiated. Resident 45's Weight Summary was reviewed. On 12/3/19, a weight of 154.2# was recorded. On 1/7/20, a weight of 144.2# pounds was recorded. Resident 45 had a 6.49% weight loss in one month A Nutritional Evaluation calculating resident 45's nutritional needs including calories and protein was unable to be located in the medical record.] A review of the Wound Evaluation forms documented the following measurements for the left heel blister: a. On 12/2/19, 1.51 cm x 1.86 cm. The wound bed was an intact serum filled blister. Treatment included heel suspension protection device. b. On 12/10/19, 1.62 cm x 1.45 cm. The wound bed was a scab. c. On 12/17/19, 2.18 cm x 2.6 cm. d. On 12/24/19, 3.18 cm x 2.86 cm. e. On 12/31/19, 1.81 cm x 1.38 cm. f. On 1/9/20, 1.49 cm x 1.43 cm. A review of the Wound Evaluation forms documented the following measurements for the right heel: a. On 12/2/19, right medial malleolus blister 3.35 cm x 3.04 cm. The wound bed was an intact serum filled blister. Treatment included heel suspension protection device. b. On 12/10/19, 3.6 cm x 3.81 cm. The wound bed was pink/red. c. On 12/10/19, right heel pressure deep tissue injury 3.09 cm x 3.16 cm. The wound bed was pink/red. [Note: The right medial malleolus blister was reclassified as a right heel pressure deep tissue injury.] d. On 12/17/19, 3.13 cm x 1.81 cm. e. On 12/24/19, 4.93 cm x 3.51 cm. f. On 12/31/19, 1.21 cm x 2.42 cm. g. On 1/9/20, 2.4 cm x 2.19 cm. A review of physician's orders documented the following entries: a. On 12/2/19, Skin prep to both heels BID. Float heels while in bed. two times a day for Prophylaxis related to ANEMIA. Order was discontinued on 12/3/19. b. On 12/3/19, Apply Skin Prep to Left heel would QID four times a day for L heel wound. Order was discontinued on 1/3/20. c. On 12/3/19, Apply Skin Prep to R heel wound Four times daily four times a day for R heel wound. Order was discontinued on 1/3/20. d. On 12/3/19, Ascorbic Acid Tablet 500 MG Give 1 tablet by mouth every shift for Supplements. e. On 12/4/19, Multiple Vitamins-Minerals Tablet Give 1 tablet by mouth one time a day for Supplement. f. On 12/25/19, Zinc-220 Capsule (Zinc Sulfate) Give 220 mg by mouth one time a day for Altered skin integrity for 14 Days. g. On 12/31/19, Clindamycin HCl (hydrochloride) Capsule 300 MG Give 1 capsule by mouth three times a day for infection in heels for 7 Days. h. On 12/31/19, cover left heel with dry dressing every shift for to promote healing. Order was discontinued on 1/6/20. i. On 12/31/19, cover right heel with dry dressing every shift for to promote healing. Order was discontinued on 1/6/20. A Clinic Visit and Progress Note from the Podiatrist dated 1/6/20, documented the following orders: a. Right heel: Medihoney with gauze bandage. Change every 2 to 3 days. b. Left heel: Hydrogel with collagen powder. Change every 2 to 3 days. c. Continue to protect heels from pressure. On 1/8/20 at 4:01 PM, an interview was conducted with Certified Nursing Assistant (CNA) 2. CNA 2 stated that resident 45 had been more confused since admission. CNA 2 stated that resident 45 required assistance with going to the bathroom. CNA 2 stated that resident 45 was able to eat and drink on her own. CNA 2 stated that resident 45 wore oxygen at night and required that her feet were elevated while she was in bed. On 1/8/20 at 4:04 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that resident 45's heel pressure ulcers started the beginning of December. LPN 1 stated that skin prep was initially started on resident 45's heels because the skin was closed. LPN 1 stated that when the skin started to open and had a foul smell resident 45 was started on an antibiotic. LPN 1 stated that the MD did not order cultures of the heel. LPN 1 stated that the facility MD ordered the consult with the podiatrist and the antibiotic on December 31. LPN 1 thought the heel protectors were ordered the middle of December. LPN 1 stated that resident 45 required to have her legs elevated while in bed, skin care with lotion, and repositioned. LPN 1 stated that she had noticed the wounds on resident 45's heels and the shoes that resident 45 was admitted with did not fit right due to resident 45's legs swelling. Resident 45 stated that the heel area of resident 45's shoes were hard. LPN 1 stated that a staff member got resident 45 some slippers. On 1/9/20 at 7:45 AM, an interview was conducted with CNA 4. CNA 4 stated that turning and repositioning of a resident would be charted under the bed mobility task. CNA 4 stated that she would try and get resident 45 to reposition but resident 45 liked to sleep on her back. CNA 4 stated resident 45 would keep the heel protectors on now that the wounds hurt. CNA 4 stated that prior to the wounds hurting resident 45 would kick the heel protectors off. CNA 4 stated that resident 45's heels were slightly red on admission. CNA 4 stated that it had been the last month and a half that she had tried to put the heel protectors on resident 45. CNA 4 stated that she would try and float resident 45's heels because resident 45 would not float them on her own. On 1/9/20 at 8:25 AM, an interview was conducted with the Assistant Director of Nursing (ADON). The ADON stated that resident 45's wounds started as blisters on both heels and they were found on a skin check. The ADON stated that resident 45 had gotten sick and was spending more time in bed. The ADON stated that skin prep was being used on the heels to help toughen up the skin and that would usually work to resolve the blisters. The ADON stated that resident 45's wounds got progressively worse. The ADON stated that the wound specialist had been working with the DON on orders for resident 45's wounds. The ADON stated that resident 45's right heel became infected. The ADON stated that the staff were floating resident 45's heels and slippers were obtained for resident 45 after the blisters were discovered. The ADON stated that a multivitamin with minerals and vitamin C were started. The ADON stated that the RD wanted to wait for resident 45's Albumin prior to making any further recommendations. The ADON stated that when resident 45's laboratory results were received the RD did not recommend a protein supplement but a 14 day course of Zinc was recommended. The ADON stated that a new treatment order was received from the podiatrist on 1/6/19. The ADON stated that the facility MD was at the facility weekly. The ADON stated that the facility MD was made aware when the skin prep was ordered and he was made aware when resident 45's wounds got worse. On 1/9/20 at 8:30 AM, an interview was conducted with CNA 4. CNA 4 was in the dining room with resident 45 during the breakfast meal. CNA 4 stated that resident 45 ate 100% of her breakfast meal. CNA 4 stated that resident 45 had 1 slice of french toast, oatmeal, sausage, milk, and juice. CNA 4 stated that resident 45 did not drink supplements. CNA 4 stated that resident 45 was able to feed herself independently. CNA 4 stated that resident 45 liked coffee with 2 tablespoons of sugar. CNA 4 stated that resident 45 ate snacks like fig bars and crackers. On 1/9/20 at 8:52 AM, a phone interview was conducted with the RD. The RD stated she completed a nutritional screen on all residents after admission. The RD stated that if the resident was at risk for malnutrition or had malnutrition then she would complete a nutritional evaluation. The RD stated that resident 45 was not at nutritional risk so she did not complete a nutritional evaluation. The RD stated that since resident 45 was eating good and her cognition was not hindering her oral intake then she did not mark that area of the nutritional screen. The RD stated that if she did not perform a nutritional evaluation then calories and protein needs were not calculated for a resident. The RD stated that a small regular meal provided 1500 to 1800 calories and 88 grams of protein. The RD stated that resident 45 was eating 75 to 100% of meals so she did not feel that resident 45's diet needed to be changed. The RD stated that she calculated resident 45's calorie needs based on resident 45's current weight of 144.2 pounds. The RD stated that she would use 25 to 30 calories per kilogram (kg) of body weight for a total of 1636 to 1963 calories per day. The RD stated that she would use 1.2 to 1.4 grams (g) per kg of body weight to calculate protein needs of 78 to 88 g of protein per day. The RD stated that since resident 45 had a deep tissue injury (DTI) she would not increase resident 45's calculated need to 1.5 to 2.0 g until the DTI was staged high like a stage 3 or 4 pressure ulcer. The RD stated that resident 45 had a DTI and it was not staged at a 3 or 4 pressure ulcer. The RD stated that resident 45 was admitted at a higher weight so she was not concerned that resident 45 had a significant weight increase and then a significant weight decrease because her BMI was considered overweight. The RD stated that weight loss was desirable but did not have a physician's ordered weight loss program in place. The RD stated that she depended on the staff to inform her of resident 45's cognition and eating. The RD stated she was not aware of how much protein resident 45 was eating because she took the percent of meal intake and divided it by how many grams of protein the meal offered and used that to determine resident 45's protein intake. The RD stated she did not know if residents were eating protein foods or not and it was all based on the percentages that the CNAs document. On 1/9/20 at 9:40 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the RD came into the facility twice weekly and the RD would look at the residents percentage weekly intake. The DON stated that the skin and weight meetings were conducted weekly and the RD was in attendance. The DON stated that the RD would email her recommendations and a conference call would be scheduled weekly with the RD. The DON stated that a resident's nutritional evaluation was done weekly and the RD made recommendations. The DON stated that the WCC nurse was a resource for wound care products. The DON stated that the WCC nurse would come to the facility monthly and give order suggestions. The DON stated that if a pressure ulcer got worse she would expect to get as many eyes on the wound as possible. The DON stated that the facility MD and the WCC nurse saw resident 45's wounds. The DON stated that the WCC nurse resided in Washington State and was not an employee of the facility. The DON stated that the facility had a contract with the company that the WCC nurse worked for. The DON stated that the WCC nurse assessed resident 45's wounds but the WCC nurse would not have notes on resident 45. [Note: The contract was reviewed for the company that employed the WCC nurse. The contract was titled a Business Associate Agreement. A Business Associate Agreement was a written arrangement that specifies each party's responsibilities when it comes to Protected Health Information.] On 1/9/20 at 11:00 AM, an observation of resident 45's dressing change was conducted with LPN 1. LPN 1 was observed to remove the dressings from resident 45's left and right heel. LPN 1 was observed to take pictures of resident 45's wounds on the left and right heel. LPN 1 stated that the camera images were uploaded into the Wound Evaluation section of the resident medical record. LPN 1 stated that the camera image would automatically do the measurements. LPN 1 stated that once the image was captured she would trace around the wound image on the camera screen and the program would determine the measurements of the wound. LPN 1 stated that the measurements were dependant on the angle the image was captured. 2. Resident 21 was admitted to the facility on [DATE] with diagnoses which included gangrene, urinary tract infection, hypotension, major depressive disorder, psychosis, obsessive-compulsive disorder, sepsis, and dehydration. On 1/6/20 at 2:50 PM, an interview and observation was conducted with resident 21. Resident 21 stated that she had a wound on her backside that was almost healed. Resident 21 was observed to be sitting in a high back wheelchair in her room. Resident 21 was observed to have a regular mattress. The facility matrix revealed that resident 21 had a stage 2 pressure ulcer on her buttocks. Resident 21's medical record was reviewed on 1/8/20. An admission MDS assessment dated [DATE], revealed that resident 21 was admitted with a stage 2 pressure ulcer. The MDS further revealed that resident 21 had a pressure relieving device to chair and bed, pressure ulcer care, and ointment or medications applied. A care plan dated 10/23/19 and revised on 10/25/19, revealed [Resident 21] has potential for impairment to skin integrity. [Resident 21] has a wound to her coccyx and surgical wounds to bilat great toes. The goal developed was [Resident 21] will maintain or develop clean and intact skin by the review date. The interventions developed were [Resident 21] will not sustain thermal burn injury related to hot beverage consumption through the next review. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Educate [resident 21]/family/caregivers of causative factors and measures to prevent skin injury. Encourage good nutrition and hydration in order to promote healthier skin. Identify/document potential causative factors and eliminate/resolve where possible. Keep skin clean and dry. Use lotion on dry skin as needed. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. Resident 21's admission Discharge Orders from the local hospital dated 10/23/19, revealed Discharge Wound Care Instructions to cleanse with NS (normal saline), apply medihoney and a PUP (pressure ulcer pad) pad. Resident 21's October, November, and December 2019 Treatment Administration Record (TAR) was reviewed and revealed the following treatment ordered on 10/27/19 and discontinued on 12/8/19, Duoderm to right buttocks every day shift every 3 days for open wound. The December 2019 TAR revealed on 12/4/19, a physician's order for, Cleanse wound with safe cleanse, pat dry apply collagen and hydrogel mixed together and cover with adhesive bordered foam one time a day for wound to right buttocks. A Nutrition Screen dated 10/26/19, revealed that resident 21's most current weight was 157.8 pounds which was obtained on 12/4/18. The RD documented PO intake is varied with an average of 50-75% of meals. Pressure wound to right buttock, surgical incisions to right and left 1st toes. Recommend adding multivitamin/mineral and vitamin C to aid in wound healing. Protein status is WNL (within normal limits), Alb (albumin) 4.0. A care plan on the form reveled a Focus of The resident has nutritional problem or potential nutritional problem. The care plan goals on the form were [Resident 21] will maintain adequate nutritional status as evidenced by maintaining or gradually losing weight, no s/sx (signs or symptoms) of malnutrition through review date. The interventions dev[TRUNCATED]