**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, and review of facility documents, the facility staff failed to ensure one resident (Resident #38) entering the facility did not develop pressure ulcers unless they were unavoidable. For Resident #38, the facility failed to identify two pressure ulcers prior to being found at an advanced stage (unstageable), which constituted in harm. For Resident #58, the facility staff failed to provide care and services to prevent pressure ulcer development and to identify a left heel pressure ulcer prior to progression to an advanced stage (stage 3) which constituted harm. For Resident #88B, a new stroke victim who required total care for all activities of daily living (ADL), the facility staff failed to provide care and services to prevent development of an unstageable deep tissue injury (DTI) of the right buttock. The survey sample consisted of 38 residents. The findings included: 1. The staff failed to identify Resident #38's pressure ulcer to his left and right heel prior to being found at an advanced stage (unstageable) which constituted in harm. The first wound was to the left heel, identified on 11/15/21 as an unstageable pressure ulcer measuring 3 cm x 3.5 cm; appearance necrotic/black. The second pressure ulcer was to the right heel, identified as an unstageable pressure ulcer measuring 3 cm x 2.7 cm; appearance necrotic/black. Resident #38 was originally admitted to the facility on [DATE]. Diagnoses for Resident #38 included but are not limited to Tracheotomy, absent of a larynx, Peripheral Vascular Disease (PVD) and Protein-Calorie Malnutrition. Resident #38's admission Assessment (14-day) with an ARD of 09/21/21 coded Resident #38 a 15 out of a possible score of 15 indicating no cognitive impairment. Resident #38 was coded extensive assistance of one with toilet use, personal hygiene, dressing, toilet use and bathing, limited assistance of one with bed mobility and transfer and supervision with eating for Activities of Daily Living (ADL). Under section H - (Bladder and Bowel) was coded for frequently incontinent of bladder and bowel. Under section G0400 - Functional Limitation in Range of Motion (ROM) coded Resident #38 with no impairment to his upper and lower extremity. Resident #38 was coded as having no mood, rejection of care or behavioral problems. Resident #38's admission Assessment (14-day) with an ARD of 09/21/21 under section M; (Skin Condition - M0100) was coded no for Resident #38 having a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device. Under section (M0150) at risk for developing pressure ulcers was coded yes, under section (M0210) for unhealed pressure ulcers was coded no and under section (M0300) for having current number of unhealed pressure ulcer at each stage for admitted with or facility acquired was coded as none under section (0130), number of venous and arterial wound present coded with one. Under section (M1040), other ulcers, wounds, and skin problems (foot) problems were coded for none present and under section (1200) for skin, ulcer treatments were coded for having pressure reducing device for chair and bed, and applications of ointments/medications other than feet. Resident #38's quarterly MDS with an ARD date of 02/22/22 coded Resident #38 a 15 out of a possible score of 15 indicating no cognitive impairment. Resident #38's MDS coded Resident #38 requiring supervision with all ADLs except for bathing which requires extensive assistance of one for Activities of Daily Living (ADL) care. Under section G0400 - Functional Limitation in Range of Motion (ROM) coded Resident #38 with no impairment to his upper and lower extremity. Resident #38 was coded as having no mood, rejection of care or behavioral problems. Under section M; (Skin Condition - M0100) was coded for the using a Formal Assessment Instrument/tool (e.g., Braden, [NAME] or other) for the determination of Pressure Ulcer Risk. Under section (M0300) the resident was coded as having two (2) facility acquired unstageable pressure ulcers. Resident #38's person-centered care plan initiated on 11/17/21 identified a pressure ulcer to left and right heel. The goal set for the resident by the staff was that the resident will show signs of healing. Some of the interventions/approaches the staff would use to accomplish this goal is to turn and reposition every 2 hours, keep the physician and Responsible Representative (RR) updated, treatment as ordered and weekly wound documentation. Resident #38's person-centered care plan with a revision date 12/01/21 identified the resident at risk for impaired skin integrity related to current wounds, occasional bladder incontinence and diagnosis of PVD. The goal set for the resident by the staff was that the resident will be free of further skin breakdown. Some of the interventions/approaches the staff would use to accomplish this goal is to elevate heels off mattress per routine and/or as needed, inspect skin during routine care daily, treatments as ordered, help to reposition resident for comfort per routine and as needed, and skin assessment per routine and as needed. A Braden Risk Assessment Report was completed on 10/06/21 with the following coded under sensory perception slightly limited and responds to verbal commands, but cannot always communicate discomfort or the need to be turned or has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. The clinical record revealed the weekly skin assessment to be completed by the license nurse for the week of 11/07/21, but it was not completed for Resident #38. Review of Resident #38's Weekly Wound Assessment completed by License Practical Nurse (LPN) #1 (wound nurse) revealed the following documentation: -11/15/21 - an unstageable pressure ulcer to the left heel measured 3.0 cm x 3.5 cm; appearance necrotic/black with no drainage or odor. The treatment on 11/16/21 is to paint left heel with Betadine Solution every day shift. -11/15/21 - an unstageable pressure ulcer to the right heel measured 3.0 cm x 2.7 cm; appearance necrotic/black with no drainage or odor. The treatment on 11/16/21 is to paint right heel with Betadine Solution every day shift. A phone interview was conducted with the VOHRA wound care specialist/physician on 04/14/22 at approximately 9:04 a.m., who stated the left and right heel were both identified at an unstageable stage. The wound specialist (VOHRA) initial assessment made on 11/17/21 documented an unstageable Deep Tissue Issue (DTI) to the right heel but it should have been documented unstageable pressure ulcer because the area was noted with thick black necrotic tissue (eschar). The wound care specialist documented the following: -11/17/21 - unstageable DTI to right heel (partial thickness) etiology of wound (pressure) area measured 1.5 cm x 1.5 cm with no drainage. Chief complaint: resident has multiple wounds. Treatment: continue betadine daily. Recommendation: Off-load wound, reposition per facility protocol and float heel in bed. The resident appears to have associated pain evidenced by restless and grimacing. -11/17/21 - unstageable to left heel due to necrosis, etiology of wound (pressure) area measured 2 cm x 2 cm with no drainage. Chief complaint: resident has multiple wounds. Treatment: continue betadine daily. Recommendation: Off-load wound, reposition per facility protocol and float heel in bed. The resident appears to have associated pain evidenced by restless and grimacing. -12/27/21 - unstageable to the right heel (due to necrosis - full thickness), area measured 0.7 cm x 0.6 cm with 50 % thick adherent black necrotic tissue and 50% thick adherent devitalized necrotic tissue. This wound is in an inflammatory stage and is unable to progress to a healing phase because of the presence of a biofilm. Treatment plan: apply Dakins solution moistened gauze with Santyl ointment daily. Debridement refused. Recommendation: Off-load wound, reposition per facility protocol and float heel in bed. -12/27/21 - unstageable to left heel due to necrosis, area measured 1.5 cm x 1.5 cm with no drainage with 20 % thick adherent black necrotic tissue and 50% thick adherent devitalized necrotic tissue and 30% granulation tissue. This wound is in an inflammatory stage and is unable to progress to a healing phase because of the presence of a biofilm. Treatment plan: apply Dakin's solution moistened gauze with Santyl ointment daily. Debridement refused. Recommendation: Off-load wound, reposition per facility protocol and float heel in bed. -01/17/22 - unstageable to the right heel (due to necrosis - full thickness), area measured 1.1 cm x 1.0 cm with 20% thick adherent black necrotic tissue and 50% thick adherent devitalized necrotic tissue and 30% granulation tissue and light serous drainage. This wound is in an inflammatory stage and is unable to progress to a healing phase because of the presence of a biofilm. Treatment plan: apply Dakins solution moistened gauze with Santyl ointment daily. Recommendation: Off-load wound, reposition per facility protocol and float heel in bed. -01/17/22 - unstageable to left heel (due to necrosis) area measured 1.8 cm x 1.5 cm with light sero-sanguinous drainage with 50% thick adherent devitalized necrotic tissue and 50% granulation tissue. This wound is in an inflammatory stage and is unable to progress to a healing phase because of the presence of a biofilm (wound has improved). Treatment plan: Treatment plan: apply Dakin's solution moistened gauze with Santyl ointment daily. Recommendation: Off-load wound, reposition per facility protocol and float heel in bed. The clinical record revealed Resident #38 had a wound evaluation from (name of podiatry center) on 01/26/22 with the following new orders: apply Santyl to Right and Left foot wound daily and offload lower extremities in prevalon boots while in bed. Recommendation: Off-load wound, reposition per facility protocol and float heel in bed. During the initial tour on 04/12/22 at approximately 1:30 p.m., and again on 04/13/22 around 9:30 a.m. During each observation, Resident #38 was observed lying in bed with prevalon boots in place to bilateral heels. On 04/13/22 at approximately 9:30 a.m., an interview was conducted with Resident #38. Resident #38 is without his voice box which made him not able to communicate verbally but is able to point to areas on his body with concerns and nodded his head when asked simple and direct questions. When asked if he had sores to his heels, he nodded his head yes but was not able to identify when the areas occurred. On 04/13/22 at approximately 10:05 a.m., wound care observation was conducted with LPN #1. Resident #38 was lying in bed, positioned in a supine position with prevalon boot in place to both heels. The left heel pressure ulcer wound bed noted with necrotic tissue with a moderate amount of serosanquineous drainage with no odor present. The right heel pressure ulcer noted with yellow/red wound bed with a small amount of serous drainage with no odor present. Wound care was conducted per wound care orders and infection control precautions maintained. A phone call was placed to Resident #38's Resident Representative (RR) on 04/14/22 at approximately 1:35 p.m., who stated, My brother, Resident #38 FaceTimed me complaining of severe pain to both of his heels. I called the facility and spoke to his nurse, LPN #1, who stated she would assess Resident #38 and call me back. On the same day, not sure of the time, LPN #1 called me and said my brother had an unstageable pressure ulcer to both of his heels. On 04/14/22 at approximately 3:25 p.m., an interview was conducted with LPN #1 who was assigned to Resident #38 on 11/15/21 (7-3 shift). The LPN stated she spoke with Resident #38's (RR) on 11/15/21 who said Resident #38 had called her and reported having severe pain to his heels. The LPN said a skin assessment was completed and observed an unstageable pressure ulcer to both heels. When asked, if the CNA's had reported any skin issues with Resident #38 heels, she replied, No. A phone call was placed Certified Nursing Assistant (CNA) #4 on 04/14/22 at approximately 1:40 p.m. The CNA was assigned to provide care and services to Resident #38 on 11/15/21 (7-3 shift). A message was left, the CNA never returned the call. A phone call was placed CNA #5 on 04/14/22 at approximately 1:40 p.m. The CNA was assigned to provide care and services to Resident #38 on 11/15/21 (7-3 shift). A message was left, the CNA never returned the call. An interview was conducted with the Director of Nursing (DON) and Regional Director of Clinical Services on 04/14/22 at approximately 10:37 a.m. The DON stated, (Resident #38's Name) FaceTimed his sister and showed her the areas located to his bilateral heels. She said the sister called and spoke to LPN #1 who was Resident #38's nurse. The nurse assessed Resident #38 heels and observed an unstageable pressure ulcer to his left and right heel. The DON was asked, at what stage should pressure ulcer to be first identified, she replied, Preferably at a stage one. The DON stated, The CNA's are to do skin checks while providing care daily on every shift and on their shower days. She (DON) said, the CNA 's are looking at all pressure point areas including the resident heels and if they identify any changes in the resident skin condition such a redness, bruising or an open area, the changes are to be reported to the nurse right away who will document the findings in the resident clinical record and notify the physician. When asked if there were preventative measure put in place prior to the development of Resident #38's unstageable pressure first identified on 11/15/21, she replied, No, none that I could find. Another interview was conducted with the DON on 4/14/22 at 3:46 p.m. When asked if the weekly skin assessment was completed the week of 11/07/21, she replied, I did not see where a skin assessment was completed. The DON said she expect for the nurse nurse's to do their skin assessments on a weekly basis. When asked, What was the purpose of weekly skin assessment and why are they important, she replied,It's imperative that weekly skin assessments are being done and that way we could have found Resident #38's pressure ulcers prior to being found at an unstageable pressure ulcer. A debriefing was held with the Administrator, Director of Nursing, [NAME] President of Operations and Regional Director of Clinical Services on 04/14/22 at approximately 4:32 p.m., who were informed of the above findings; no further information was provided prior to exit. The facility policy titled Pressure Ulcer Prevention and Treatment policy revised on 09/18/20. Residents admitted with existing pressure injuries will receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection. New pressure injuries will not develop unless the individual's clinical condition demonstrates that they were unavoidable. Definitions: -Tracheotomy is a surgical procedure to create an opening through the neck into the trachea (windpipe). A tube is most often placed through this opening to provide an airway and to remove secretions from the lungs. This tube is called a tracheostomy tube or trach tube (https://medlineplus.gov). -Absence of larynx - your voice box (larynx) is made of cartilage, muscle and mucous membranes located at the top of your windpipe (trachea) and the base of your tongue. Your vocal cords are two flexible bands of muscle tissue that sit at the entrance of the windpipe. Sound is created when your vocal cords vibrate, without your larynx, sound cannot be created (https://www.mayoclinic.org/diseases-conditions/voice-disorders/symptoms-causes). -PVD is the narrowing or blockage of the vessels that carry blood from the heart to the legs. It is primarily caused by the buildup of fatty plaque in the arteries, which is called atherosclerosis. PAD can occur in any blood vessel, but it is more common in the legs than the arms (Source: http://www.cdc.gov/DHDSP/data_statistics/fact_sheets/fs_PVD.htm). -Protein-Calorie Malnutrition refers to a nutritional status in which reduced availability of nutrients leads to changes in body composition and function (https://www.ncbi.nlm.nih.gov/pmc/articles). -Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed (http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-injury-stages/). -Betadine Solution a topical antiseptic used to prevent and treat minor wounds and skin infections. This medicine works by killing germs and preventing the spread of infection (a topical antiseptic (www.betadine.com/firstaid). -Dakin's solution is a type of hypochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria and viruses (http://www.webmd.com/drugs/2/drug-62261/dakin's-misc/details). -Santyl is used to help the healing of burns and ulcers. Collagenase is an enzyme. It works by helping to break up and remove dead skin and tissue. This effect may also help to work better and speed up your body's natural healing process (http://www.webmd.com). -Prevalon boots give patients the most advanced protection against heel pressure ulcers and foot drop. Prevalon helps minimize pressure, friction and shear on your patient's feet, heels and ankles. By elevating the foot and separating the heel from the mattress, it delivers total heel pressure relief (http://www.sageproductsglobal.com/en/prevalon.cfm). 2. The facility staff failed to provide care and services to prevent pressure ulcer development and to identify a left heel pressure ulcer prior to progression to an advanced stage (stage 3) measuring 0.4 centimeters by 0.4 centimeters by 0.2 centimeters (cm), for Resident #58) which constituted harm. Resident #58 was originally admitted to the facility 11/12/21 after an acute care hospital stay. The resident has not been discharged from the facility. The current diagnoses included; coronary artery disease, peripheral vascular disease and congestive heart failure. The quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 3/15/22 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 15 out of a possible 15. This indicated Resident #58's cognitive abilities for daily decision making were intact. In section G (Physical functioning) the resident was coded as requiring extensive assistance of one person with personal hygiene, dressing, toileting, limited assistance of one person with bed mobility, transfers, walking and locomotion, help with the bathing activity, and supervision after set-up with eating. On 4/12/22 at approximately 12:15 p.m., Resident #58 was observed in bed lying on her left side. The resident stated my left foot hurts. She stated she hadn't told her nurse but the nurse knew it was painful that's why she puts a bandage on it. The resident stated she knew of nothing that helps her left foot feel better. Beneath the bed linens, bilateral feet were observed to be elevated by some type of device. Review of the facility's matrix revealed Resident #58 had a current pressure ulcer staged at a stage IV. Review of the clinical record revealed a progress note dated 4/6/22 which revealed Resident #58 was identified with a stage 3 pressure of the left heel which measured 0.4 cm by 0.4 cm by 0.2 cm. The stage 3 left heel pressure ulcer's wound bed was red, the periwound was pink there was scant drainage, and no odor. The treatment order was Santyl ointment and Dakins solution. The 3/12/22, 3/19/22, 3/26/22, 4/2/22, and 4/9/22 Weekly Skin Evaluation were coded for no current skin issues. The Nutrition Monitor and Nutrition Evaluation dated 2/15/2022 revealed Resident #58's weight was 127.6 pounds and the Resident showed significant weight gain soon after admission to the facility but had a significant weight loss over the past 30 days at 5.5%. Resident is currently within her ideal body weight range. Weight maintenance within 5 pounds of current weight is planned at this time. Po intake of Regular consistency diet is typically 26 to 100% with most meals at 50%. Nutritional needs for wound healing and weight maintenance are currently being met. Daily use of multiple laxatives. Fluids should be strongly encouraged during waking hours. Added to the weekly weight schedule for close monitoring. The 4/6/22 Braden Scale Pressure Ulcer Risk Assessment revealed Resident #58 was a low risk for pressure ulcer development because she had no sensory deficit which would limit her ability to feel or voice pain or discomfort, her skin is only occasionally moist, her ability to walk is severely limited or non-existent, she makes frequent though slight changes in body or extremity position independently, rarely eats a complete meal and generally eats only about half of any food offered and moves feebly or requires minimum assistance. Further review of the clinical record revealed a wound assessment report by the wound care physician dated 4/11/22 which read, Resident presents with a wound on her left heel. At the request of the referring provider, a thorough wound care assessment and evaluation was performed today. She has a stage 3 pressure wound of the left heel. There is light sero-sanguinous exudate. There is no indication of pain associated with this condition. The left heel pressure ulcer measured 0.3 x 0.3 x 0.2 cm and presented with 100 percent granulation tissue. The dressing treatment plan was documented as Iodosorb gel followed by a gauze island with border every two days for 30 days. The active care plan was reviewed on 4/12/22. It revealed a potential for a skin integrity problem with a revision date of 11/16/21 but there wasn't a left heel pressure ulcer problem. On 4/15/22 a care plan problem was developed for the stage 3 pressure ulcer to the left heel which was identified on 4/6/22. The goal read; Area to the left heel will show signs of healing through next review 5/19/22. The interventions included; treatments as per physicians/designee order, monitor for signs and symptoms of infection and weekly wound documentation Review of the physician order summary revealed there wasn't a treatment order in place for Resident #58's left heel pressure ulcer until 4/12/22. There was no evidence in the clinical record that an active treatment was in place and care and services were rendered to the resident's left heel pressure ulcer from 4/6/22 through 4/11/22. The physician order summary's revealed an order dated 04/12/22, which read Iodosorb Gel 0.9 % (Cadexomer Iodine); Apply to the left lateral heel topically every day shift for wound care. This order was not what the wound care physician ordered. The wound care physician order was for every two days not daily. Completion of the left heel pressure ulcer treatment was documented on the TAR for 4/12/22, 4/13/22 and 4/14/22. An interview was conducted with Certified Nursing Assistant CNA) #2 on 4/14/22 at approximately 5:57 p.m. CNA #2 stated Resident #58 is fully alert and oriented and capable of making her needs known. She stated the resident likes one pillow at her back, one under each arm and one under her legs when in bed and she wears boots in bed Crocs when out of bed. CNA #2 stated the resident is unable to self turn since she wears the boots therefore she is fully dependent upon staff when wearing them. She stated she wasn't aware of what was wrong with Resident #58's left foot but she knew a dressing was on it. CNA #2 stated the resident is always compliant with care and feeds herself usually 50% of the dinner meal. An interview was conducted with Certified Nursing Assistant CNA) #3 on 4/15/22 at approximately 9:55 a.m. CNA #2 stated Resident #58 is out of bed about three days per week and she can walk from the bathroom door to the commode in the room. She stated when the resident is out of bed she wears Crocs, does a lot for herself and feeds herself approximately 50% of meals. An interview was conducted with MDS Coordinator #4 on 4/15/22 at approximately 11:30 a.m. MDS Coordinator #4 stated Resident #58's care plan wasn't updated with the left heel pressure ulcer because she was off and didn't get the update until 4/15/22. An interview was conducted with the wound care nurse on 4/15/22 at approximately 10:45 a.m. The wound care nurse stated she couldn't explain how the resident obtained the pressure ulcer for the resident has always been so particular about relieving pressure with multiple pillows propping her body. The wound care nurse also stated she assessed the resident's pressure ulcer on 4/6/22 but failed to document the results timely. The wound care nurse stated it is not good to find a pressure ulcer at stage 3 or above. She stated they should be identified early, where there is redness, ideally. An observation was made of Resident #58's left lateral heel pressure ulcer on 4/15/22 at approximately 11:05 a.m., with the wound care nurse. The resident was again lying on the left side, wearing bilateral pressure reducing boots and there were pillows beneath her knees and bilateral arms. The previous dressing was undated and the gauze next to the pressure ulcer was medium brown and dry. The wound was without odor or drainage and the resident didn't express pain when the wound care nurse touched the left foot pressure ulcer. On 4/15/22 at approximately 1:00 p.m., the above information was shared with the Administrator, Director of Nursing, Regional Director of clinical Services and Regional Director of Operations. The Director of Nursing and the Regional Director of Clinical Services stated they knew they had pressure ulcer problems therefore they developed an in-house plan of correction but it failed January 2022 and they didn't revise or develop an new plan for pressure ulcers. They also acknowledged they had more recent pressure ulcer concerns as well. The Regional Director of Operations stated they tried to manage the pressure ulcers, they just weren't successful. A stage 3 pressure ulcer is a full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling. (CMS RAI Version 3.0 Manual, Chapter 3 page M-14). The information below was obtain from the following website on 4/19/22. Iodosorb Gel is a sterile antimicrobial dressing formulation of Cadexomer Iodine. When applied to the wound, Iodosorb absorbs fluids, removing exudate, slough and debris and forming a gel over the wound surface. As the gel absorbs exudate, iodine is released, killing bacteria and changing color as the iodine is used up. (https://www.[NAME]-nephew.com/professional/products/advanced-wound-management/iodosorb--iodoflex/iodosorb-gel/) The information below was obtain from the following website on 4/19/22. Iodosorb Gel speeds up the healing process and reduces pain. Can be used for up to 3 months in a single course of treatment. 1. IODOSORB Paste should be changed when saturated with wound fluid, indicated by a loss of color, usually 2-3 times a week or daily if the wound is discharging heavily (https://www.[NAME]-nephew.com/documents/canada/canada%20english/iodo-ag-1601en%20(ca11740)%20-%20application%20and%20usage%20guide%20(1).pdf). 3. The facility staff failed to provide care and services to prevent development of an unstageable deep tissue injury (DTI) of the right buttock measuring 6.5 cm by 5.5 cm by 0., for Resident #88B; a new stroke victim who required extensive assistance to total care with all activities of daily living (ADL). Resident #88B was originally admitted to the facility 5/26/21 after an acute care hospital stay and discharged home 6/15/21. The resident's diagnoses included; a stroke, aphasia, dysphagia, right hemiparesis, and coronary artery disease. The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 6/1/21 coded the resident as completing the Brief Interview for Mental Status (BIMS) and scoring 0 out of a possible 15. This indicated Resident #88B's cognitive abilities for daily decision making were severely impaired. In section G (Physical functioning) the resident was coded as requiring total care of one person with personal hygiene, dressing, bathing, toileting and locomotion, extensive assistance of one person with transfers and eating, and extensive assistance of two people with bed mobility. Section H0100 Bowels and Bladder; the resident was coded as utilizing an indwelling catheter. In section M0100 (Skin Disorders) the Resident was coded as having no pressure ulcer, a scar over bony prominence, or a non-removable dressing/device. M0150 - Resident was coded as at risk of developing pressure ulcers. A deep tissue injury is a Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. A deep tissue injury may precede the development of a stage 3 or 4 pressure ulcer even with optimal treatment. (CMS RAI Version 3.0 Manual, Chapter 3 page M-24) During investigation of a complaint, information was gleamed revealing Resident #88 B acquired skin impairments including an unstageable DTI. An interview was conducted with Resident #88B's daughter on 4/14/22 at approximately 2:05 p.m. The daughter stated the mother's husband visited the resident daily at her window because the facility was not allowing visitors inside the facility. The mother's husband told the daughter the staff wasn't repositioning the resident or consistently assisting her with meals and she wasn't capable of feeding herself. The husband stated often the meals were placed far away from the resident. The 5/26/21, 5/27/21, and 6/3/2, 6/10/21 Weekly Skin Evaluation revealed no skin problems. The 6/10/21 Weekly Skin Evaluation revealed a right buttock area. The 6/11/21 Weekly Wound Assessment revealed an unstageable deep tissue injury (DTI) of the right buttock, etiology pressure. The DTI measured 3.0 centimeters (cm) by 4.0 cm by 0 cm., and presented with maroon discoloration on intact skin. The assessment stated Triad cream was ordered as the treatment. The Treatment Administration Record (TAR) revealed and order dated 6/11/21 for Triad Hydrophilic Wound Dress Paste (Wound Dressings) Apply to right buttock topically every day and evening shift for unstageable DTI. The treatment wasn't signed as completed on 6/11/21. The care plan had a problem dated 6/11/21 which read; wounds to right buttock on 6/11/21, left medial buttock on 6/11/21, right medial buttock on 6/11/21. The goal read; Area to right buttock with show signs of healing through next review 6/15/21, Area to left medial buttock will show signs of healing through next review 6/15/21, and Area to right medial buttock will show signs of healing through next review 6/15/21. The Interventions included;[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, facility document review and clinical record review, it was determined that facility staff failed to practice safe bed mobility for one of 39 residents in the survey sample, Resident #26, resulting in an avoidable fall with a head laceration, that lead to an acute transfer to the hospital which constitutes harm. The findings include: Resident #26 was admitted to the facility on [DATE] with diagnoses that included but were not limited to dementia without behavioral disturbance, high cholesterol, type two diabetes and adult failure to thrive. Resident #26's most recent MDS (minimum data set) assessment was a quarterly assessment with an ARD (assessment reference date) of 7/16/19. Resident #26 was coded as being severely impaired in cognitive function scoring 04 out of possible 15 on the BIMS (Brief Interview for Mental Status) exam. Section G (functional status) coded Resident #26 as requiring extensive assistance from one staff member for bed mobility. Review of Resident #26's clinical record revealed that she was had a fall on 9/3/19 and was transferred to the hospital. The following note was written: The CNA (certified nursing assistant) stated that she was changing her brief. The CNA stated that when she turned her, the resident fell out of bed, hitting her head on the corner of the night stand. Immediate intervention: The resident was sent out to the emergency room for evaluation. Vitals: BP (blood pressure): 139/81, Position: Lying l (left) arm. P (pulse) 81 Pulse Type: regular. Resident cooperative. Resident has full range of motion to all extremities. Neurological checks are within normal limits. Evidence of pain noted. Pain to her head. Pain is throbbing Pain level is 6 out of 10. The pain is constant Pain persistent daily. Pain medication .This writer was called down to the residents room by the CNA, the resident was observed laying on her right side side between the bed and night stand, the resident was observed bleeding from a laceration to the front of her head. 911 was called and the paramedics were here minutes later to (sic) without difficulty. The resident is complaining of pain to her head. 911 was called and paramedics were here minutes later to transport the resident to the ER (emergency room) .report was given to the ER nurse. Review of the fall incident report dated 9/3/19 documented the following : Incident Description: The resident was observed laying on the floor in her right side, bleeding from a laceration to the front of her head. Resident was assessed and sent to the hospital. There was no additional information documented on the incident report. Review of Resident #26's ADL (activities of daily living) care plan initiated on 5/12/16, documented Resident #26 as requiring Bathing/Hygiene assist of: 1 (one person). Resident #26 was also documented as requiring an assist of 2 with turning and repositioning/bed mobility with assist of 2. Review of Resident #26's current nursing [NAME] (Resident care guide for nursing aides) documented Resident #26 as requiring one person physical assist with bed mobility. Review of Resident #26's clinical record revealed the most recent fall risk assessment prior to her fall on 9/3/19 was conducted on 4/15/16. Resident #26 was coded at a level 10.0 indicating she was at high risk for falls. Further review of Resident #26's clinical record revealed that Resident #26 arrived the same day (9/3/19) with a laceration to her forehead. The following was documented: 9/3/19 at 19:23 (7:23 p.m.) Resident returned from the hospital @ (at) 1640 (4:40 p.m.). Stitches noted to right forehead covered with dry drsg (dressing). No drainage noted. Resident has no c/o (complaints) of pain. No s/s (signs and symptoms) of acute resp (respiratory) or cardiac distress noted. Review of Resident #26's weekly wound assessment dated [DATE] documented the following: Wound Type: Laceration .Wound Location: Forehead. Length (cm) (centimeters): 3.5 Width (cm): 0.1 .Presents with 100% granulation tissue and 5 intact sutures. Edges well approximated. No s/s (signs/symptoms) of infection or dehiscence. Review of an IDT (interdisciplinary note) dated 9/6/19 documented the following: Par (sic) meeting [NAME] today. All I.D.T. present. Resident noted to have s (sic) laceration to forehead with 5 sutures. Resident is table (sic). No ne (sic) intervetions at this time. Further review of Resident #26's clinical record revealed her laceration had healed on 9/17/19. Review of Resident #26's assessments revealed that Q (every)15 (minute), Q30, Q1 (hour), Q4 hr and Q8 hr neurological checks were conducted until 9/6/19. Further review of Resident #26's assessments revealed an updated Fall Risk assessment conducted 9/3/19. This assessment documented Resident #26 as being at high risk for falls, scoring a level 16.0. On 10/3/19 at 9:14 a.m., an interview was conducted with LPN (Licensed Practical Nurse) #1, the nurse who was assigned to Resident #26 at the time of her fall. When asked how many people it required to provided incontinence care to Resident #26, LPN #1 stated it only took one person. When asked what she could recall about Resident #26's fall on 9/3/19, LPN #1 stated that she was called down to the room by the CNA and found Resident #26 on the right side of the bed, laying on her right side. LPN #1 stated that the resident had fallen while the nursing aide was turning her during incontinence care. LPN #1 stated that Resident #26 was sent out to the hospital for a laceration to her head. LPN #1 stated that the nursing aide was a new employee at the time but she wasn't certain of her name. LPN #1 was asked to get this nursing aide's contact information. On 10/3/19 at 9:31 a.m., an interview was conducted with LPN #7, the MDS nurse. When asked who was responsible for developing care plans, LPN #7 stated that she was responsible. When asked how many assist Resident #26 was with incontinence care, LPN #7 stated that Resident #26 was extensive assistance with one staff member. When asked why Resident #26's care plan documented an assist of one with bathing/hygiene but assist of two with turning and repositioning and bed mobility, LPN #7 stated that Resident #26 was an assist with one for turning but that it required to staff members to lift her up in bed (slide back up). On 10/3/19 at 12:04 p.m., incontinence care was observed for Resident #26 with CNA #4, her assigned nursing assistant that shift. There were no concerns related to bed mobility and turning and respositioning. On 10/3/19 at 1:12 p.m., an interview was conducted with CNA #3, the aide who was present during Resident #26's fall on 9/3/19. When asked how she provides incontinence care to a resident who is extensive assistance, CNA #3 stated that when she is providing incontinence care for a resident who is extensive assistance, she will first undo the brief, turn the resident toward her (with her standing in front of the resident), pull the brief out, wash the resident, tuck a new brief underneath, place the resident back on their back and then she will walk around the bed, turn the resident to the other side of the bed (with the aide in front of her), and then she will secure the brief. When asked how many assist Resident #26 was with incontinence care, CNA #3 stated that she extensive assist with one staff member. When asked what she could recall on 9/3/19 with Resident #26's fall, CNA #3 stated that she didn't pull Resident #26 to the center of the bed prior to turning her on her side. CNA #3 stated that she didn't realize how close Resident #26 was to the edge of the bed prior to turning her. CNA #3 stated that she tried to stop the fall but that Resident #26 was too heavy and fell off the bed. CNA #3 stated that Resident #26's head went down and hit the nightstand. When asked if any education was provided to her after this incident, CNA #3 stated that administration did an in-service with her and other staff about proper turning and respositioning. On 10/3/19 at 2:42 p.m., a concern for harm was addressed with ASM (administrative staff member) #1, the administrator, ASM #2, the DON (Director of Nursing), ASM #3, the Regional Director of Clinical Services, and RN (registered nurse) #1, the ADON (assistant director of nursing). Education that was provided to staff after the incident on 9/3/19 was requested. On 10/3/19 at approximately 4 p.m., signature sheets dated 9/4/19 were presented. CNA #3's signature was on this sheet as well as 16 other nursing assistants. The following was documented on the signature sheet: Subject: Repositioning residents while in bed. Participants: Nursing Staff. The content of this education was requested from RN #1. On 10/4/19 at approximately 10:00 a.m., RN #1 presented the content of the education provided on 9/4/19. The following was documented: 9/4/19 Proper positioning of resident while in bed .1. Before providing care be sure to have the appropriate amount of staff assisting, (i.e. 1 or 2 person assist, per plan of care). 2. When assisting a resident up in bed, lower the head of the bed, elevate the feet and have the resident use their legs to push up. Lowering the head of the bed and elevating the feet, will allow gravity to help. 3. When turning a resident from side to side, be sure that the resident is toward the center of the bed and using the draw sheet roll the resident on their side. Pillows or wedges can be used to maintain resident in side position. 4. Please remember that it is ok to ask for help if needed. On 10/4/19 at 11:45 a.m., review of the facility's incident and accident log revealed no falls with major injuries since 9/3/19. On 10/3/19 at approximately 10:45 a.m., ASM #2, the DON and ASM #3, the Regional Director of Clinical Services were made aware that this concern would be past non-compliance.