**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure other alternatives were tried prior to installing/utilizing side rails. The facility failed to identify and recognize that the use of side rails with an air mattress increases the risk for entrapment for 12 of 12 residents in the facility (R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12) who use a side rail and an air mattress. On 9/23/22, the facility implemented the use of a side rail for R1. The facility failed to ensure other alternatives were tried prior to installing/utilizing side rails/enabler device for R1. On 1/8/24, the facility changed R1's mattress to a Panacea Convertible Mattress with powered alternating-pressure therapy (a pump); the facility failed to complete an assessment for entrapment at this time. On 1/7/25, R1 became entrapped in the siderail resulting in the following three (3) fractures: 1. Left proximal humerus fracture (broken arm), 2. Right periprosthetic distal femur fracture (a break in the thigh bone just above the knee) and 3. Left prosthetic distal femur fracture (a break in the thigh bone just above the knee). R1 expired the next day. The facility currently has 11 residents (R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12) utilizing a Panacea Convertible Mattress with powered alternating-pressure therapy (a pump) together with side rails/enabler devices. The facility did not evaluate alternatives prior to installing the side rails The facility did not provide new risks and benefits to R2, R4, R5, R8, and R12 or their Health Care Power of Attorney when the facility changed their mattress and added an alternating air mattress to their bed with side rails. The facility's Bed System Measurement Device for measuring gaps caused by the use of bed rails is not recommended to be used with alternating air mattresses for R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12 and these forms did not specify a date, a bed identification, or a resident name on them. Director of Maintenance F did not complete quarterly bed/side rail measurement tests per facility policy and procedure. The facility failed to ensure other alternatives were tried prior to installing/utilizing side rails/enabler device. The facility failed to identify that the use of side rails with an air mattress increases the risk of entrapment and failed to ensure a risk and benefit is discussed with the resident or their responsible party when risks/benefits change such as adding an air mattress. The facility failed to properly assess the gaps created by the combination of an air mattress with a side rail. These failures created a finding of immediate jeopardy that began on 1/7/25. Surveyor notified the facility of the finding of immediate jeopardy on 1/27/25 at 2:30 PM. The Immediate jeopardy was removed on 1/27/25; however, the deficient practice continues at a severity/scope of E (potential for more than minimal harm/pattern) as the facility continues to implement its action plan. This is evidenced by The Center for Devices and Radiological Health Guidance for Industry and FDA (Food and Drug Administration) Staff, Hospital Bed System Dimensional and Assessment to Reduce Entrapment, dated 3/10/2006, documents, in part, as follows: Pressure Reduction Therapeutic Products Framed flotation therapy beds, powered air mattress replacements, and similar pressure reduction products that have therapeutic benefits such as reducing pressure on skin are easily compressed by the weight of a patient and may pose an additional risk of entrapment when used with conventional hospital bed systems. When these types of mattresses compress, the space between the mattress and the bedrail may increase and pose an additional risk of entrapment. While entrapments have occurred with the use of framed flotation therapy beds (specialty air beds built into a hospital bed frame) and air mattress replacements, these products are excluded from the dimensional limit recommendations, except for those spaces within the perimeter of the rail. This partial exemption is due to the highly compressible nature of these mattresses, which poses technical difficulties with measuring certain dimensional gaps in these types of products. We will continue to work with the IEC (The International Electrotechnical Commission issues standards for the safety and performance of medical electrical equipment including air mattresses) to develop and refine test methods to address the risk of entrapment in bed systems using these products. Additional caution should be taken when using these products to ensure a tight fit of the mattress to the bed system. If a powered air mattress is replacing a mattress on a bed system that meets the recommendations in the guidance with the original mattress, the resulting bed system with the new air mattress may still pose a risk of entrapment. When these products are used, we recommend that steps are taken to ensure that the therapeutic benefit outweighs the risk of entrapment. NOTE: FDA continues to recommend the dimensional limits in this guidance for bed systems using mattress overlays. We recommend that steps be taken to assess the therapeutic benefit to the patient when applying a mattress overlay to a bed system that does not meet the recommended dimensional limits. The clinical benefit should outweigh the risk of entrapment presented by use of such a system. Potential Zones of Entrapment This guidance describes seven zones in the hospital bed system where there is a potential for patient entrapment. Entrapment may occur in flat or articulated bed positions, with the rails fully raised or in intermediate positions. The seven areas in the bed system where there is a potential for entrapment are . Zone 1: Within the Rail Zone 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support Zone 3: Between the Rail and the Mattress Zone 4: Under the Rail, at the Ends of the Rail Zone 5: Between Split bedrails Zone 6: Between the End of the Rail and the Side Edge of the Head or Foot Board Zone 7: Between the Head or Foot Board and the Mattress End Entrapment at the Bed Deck or Frame Many of the entrapment event reports FDA received involved entrapment between the rail and the bed ' s frame. It is unclear from the event descriptions whether this refers to the mattress deck, the bed frame, or even the hardware attaching the bedrail to the bed system. While this guidance does not recommend dimensional limits on the space at the deck or frame locations, FDA believes that meeting the other recommended dimensional limits would reduce the possibility of entrapment at the deck or frame locations. The manufacturer guidelines for the Panacea Convertible Mattress with powered alternating-pressure therapy, documents, in part, the following: Alternating-Pressure cycle - provides 10-minute loading and unloading cycles designed to relieve peak interface pressures. Warnings: Failure to comply with all directions and warnings may result in injury or death; use only as directed. Note - This product is designed to assist in the prevention and treatment of pressure ulcers and may require other equipment. This may include but is not limited to bedrails for repositioning and fall prevention. Note - This product is only one element of care in the prevention and treatment of pressure ulcers by medical professionals and skilled caregivers to assist in the treatment and prevention of up to Stage IV (4) decubitus ulcers (pressure injuries) for residents under their care. This product is not designed to and cannot replace good care giving practices and treatment, including but not limited to: .Adequate training for a precaution by staff personnel for bed entrapment. The facility policy, Devices and Device Assessment, reviewed 1/2025, documents, in part, as follows: Due to risk of injury related to the use of physical devices, such devices will only be used after an assessment has been completed to determine the risks and benefits of this use. The resident/responsible party will be educated regarding the risk and benefits of physical devices. Physical devices will be reviewed for safety and used according to manufacturer's recommendations. Continued use of physical devices will be assessed at least every 90 days or with significant change to determine if the device is still needed to enhance the resident's safety and/or bed mobility. Devices will be installed as appropriate for the type of bed: For hospital beds: Device will be installed per FDA (Food and Drug Administration) guidelines. For non-hospital beds: Devices will be installed according to the device manufacturer's instructions. Documentation will be entered in the resident's record to include Results of the assessment; Discussion with resident/responsible party regarding risks and benefits and alternatives considered/recommended; Decision made/outcome of discussion. Information from FDA Regarding Side Rails: In 2006 the Food and Drug Administration (FDA) released its recommendations for reducing entrapments. The FDA identified seven zones of entrapment and recommended maximum dimensions for four of the zones. Zone 1: Within the Rail (4.75); Zone 2: Under the Rail, Between the Rail Supports or Next to a Single Rail Support (4.75); Zone 3: Between the Rail and the Mattress (4.75) 1.R1 was admitted to the facility on [DATE] with diagnoses including, dementia-severe without behavioral disturbance (an advanced stage of cognitive decline where significant impairment in memory, language, reasoning and daily functioning occurs), reduced mobility (reduced ability to move), osteoporosis (a condition in which bones become weak and brittle), cerebrovascular disease (a condition that impacts the brain's blood vessels and blood supply). R1 was incapacitated on 7/5/2020. R1's has an APOAHC (Activated Power of Attorney). On 9/23/22 R1's initial APOAHC signed Half Side Rail/Bed Bar Informed Consent that document as follows: An assessment was conducted to determine the appropriateness and need of either a half side rail or bed bar for you. A half side rail or bed bar is a metal or plastic bar that is attached to the side of the bed. A half side rail is approximately one quarter of the length of the bed and a bed bar is approximately one eighth of the length of the bed. Potential benefits of a half side rail or bed bar includes Facilitates turning and repositioning within the bed; Facilitates access to bed controls and personal care items. In some instances, half side rails or bed bars present an inherent safety risk. Potential risk include: *Strangulation, suffocation, entrapment or death when a resident or part of his/her body is caught between the bedrail or between the bedrails and the mattress and the opening of the rails *Serious bodily injury from falls if a resident climbs over the half side rail or bed bar; *Bruising, abrasions, contusions, skin tears; and *Negative psychological effects and altered resident self-esteem There was no evaluation of alternatives to the use of a side rail at this time. R1's Minimum Data Set with an ARD (Assessment Reference Date) of 11/22/24, documents a BIMS (Brief Interview of Mental Status) score of 3, indicating R1 is severely cognitively impaired. R1 is totally dependent on staff for ambulation, transferring, bathing, dressing, and toileting. Section P, Restraints, documents R1 does not use a bedrail. R1's comprehensive care plan, dated 3/1/24, documents the following: Focus: Devices - Safety/Mobility: At risk for injuries/complications R/T (related to) use of 1/4 Side Enabler Bar on Top; Both sides; to help promote independence with bed mobility and to aid in holding sitting position at side of bed. (Date Initiated: 11/16/23; Date Revised: 1/8/25) Goal: Will be free of serious injuries/complications r/t device use through next review. (Date Initiated: 11/16/23; Revised 1/8/25) Intervention: Device Assessment upon application/admission, quarterly, SCC (Significant Change) and/or PRN (as needed); Monitor/Observe/Document application of device, device use, behavior r/t (related to) device and review observations/concerns with MD (Medical Doctor).; IDT (Interdisciplinary Team) review of Device placement for continued appropriateness per facility protocol. (Date Initiated 3/1/24). The facility has a Resolved Care Plan entry: Uses upper 1/4 rail to enable bed mobility. (Date Initiated: 11/16/23; Revision on: 3/1/24; Resolved Date: 3/1/24). Note, it is unknown why the facility discontinued the comprehensive care plan entry of 1/4 siderails to R1's bed on 3/1/24 when the side rails were still in place at the time of the entrapment. R1's comprehensive care plan, dated 11/16/23, documents as follows: Actual/At Risk/and/or Potential for Complications with OR fall R/T (related to) current medical/physical status. Has med's/[NAME] (medications/diagnosis) that can/may affect fall risk. Resident transfers with EZ lift (Note, staff confirmed EZ Lift is total body lift) (Date Initiated: 11/16/23; Goal: Will be free of falls, but if does, will be free of serious injuries r/t falls through next review date. (Date Initiated: 11/16/23, Target Date: 3/13/25); Interventions: Bed in low position; Call light positioned for easy access; Check for unmet needs: pain, toileting, hunger, thirst, temperature; Ensure environment is free of clutter On 1/8/24 the facility put a Panacea Convertible Mattress with an optional alternating-pressure pump in use for R1. It is important to note, this is the same air mattress and pump the facility puts in place for all residents that require an air mattress. The facility failed to identify that the use of side rails with an air mattress increases the risk of entrapment; subsequently, the facility did not complete a new assessment at the time a powered alternating-pressure air mattress was utilized for R1. The side rail in use since R1's admission is Invacare Model IHCSRLAS. This side rail has three (3) vertical bars and two (2) horizontal bars. On 8/12/24, facility staff (this staff member has since retired) completed Bionix Safety Technologies (Food and Drug Administration Approved) for R1's air mattress and bedrail in use together. On 8/12/24 the inspection documents the air mattress with a pump together with a bedrail Passed safety inspection. It should be noted based on the FDA Staff, Hospital Bed System Dimensional and Assessment to Reduce Entrapment, Pressure Reduction Therapeutic Products Framed flotation therapy beds, powered air mattress replacements, and similar pressure reduction products that have therapeutic benefits such as reducing pressure on skin are easily compressed by the weight of a patient and may pose an additional risk of entrapment when used with conventional hospital bed systems. When these types of mattresses compress, the space between the mattress and the bedrail may increase and pose an additional risk of entrapment. While entrapments have occurred with the use of framed flotation therapy beds (specialty air beds built into a hospital bed frame) and air mattress replacements, these products are excluded from the dimensional limit recommendations, except for those spaces within the perimeter of the rail. This partial exemption is due to the highly compressible nature of these mattresses, which poses technical difficulties with measuring certain dimensional gaps in these types of products. On 11/27/24 R1's Fall Risk Screening documents: R1 is at Slight risk due to intermittent confusion On 11/27/24 R1's Enabler/Safety Device Use Tool documents the following: Reason for review: Quarterly Type of Device: Rails Reason for use: Safety Status -Cognitive Status: Confusion -Behavioral Status: Other -Additional Information: No behaviors -IDT (Interdisciplinary Team) Potential Benefits: Increased feeling of safety Potential Risks: Increased-Falls Device Use - Is the device considered a restraint: No *Device Use - Considered beneficial to individual: No IDT (Interdisciplinary Team) Discussion: Uses the side rail for bed mobility Of note, R1's most recent fall prior to the entrapment (below) was in May 2024. No injuries. On 1/7/25 around 4:07 AM, R1's Progress Notes document the following: CNA C (Certified Nursing Assistant) heard yelling from R1's room. R1 was yelling as she was on the ground. Her roommate was yelling because she heard R1 yelling. Upon entering their room, CNA C found R1 on the floor on her fall mat. R1 was facing the wall. Her right arm was holding onto the assist bar, while her left arm was between the mattress and the assist bar. (Note, R1's left arm that was entrapped sustained a left proximal humerus fracture.) Her legs were under her on the mat. R1 had her foam boots on. Her blankets were on the floor and her arm protectors were off. It was also noted there was blood on the floor near her nightstand. CNA C immediately called for the nurse on duty. LPN D (Licensed Practical Nurse) assessed R1 and noted, that R1 had a large mole on her right upper arm that was ½ off and bleeding. It was also noted that there was bruising on the top of her left hand. LPN D then called for an ambulance to send R1 to the emergency room for further evaluation. R1's family member (name) and NP (Nurse Practitioner name) were notified. X-rays were completed at the hospital indicating a nondisplaced proximal left humerus fracture, a slightly displaced fracture of the right distal femoral metaphysis and a significantly displaced fracture of the left distal femoral metaphysis. R1 reported, I was trying to get up. I've been laying in this bed since 10:00 PM and I want to go home. Immediate Action Taken: Call placed to family member. Resident sent to ER (Emergency Room) for further evaluation and treatment. Resident taken to hospital: Y (Yes) Injuries Observed at Time of Incident Fracture Right thigh (front) Fracture Left thigh (front) Fracture Left Upper Arm Hematoma Left hand (palm) Skin Tear (Right Upper Arm Level of Pain: 1 Level of Consciousness: Alert Mobility: Wheelchair bound Mental Status: Baseline for Individual emergency room Visit/Hospitalization Notes: Has a large mole on her right outer arm that is ½ off and is bleeding. Bruising on the top of her left hand. Resident is unable to tell pain. Injuries Reported Post Incident: Other: Right antecubital Level of Pain: Blank (R1 is unable to voice) Level of Consciousness: Alert Mobility: Wheelchair bound Mental Status: Oriented to Place, Oriented to person Predisposing Environmental Factors: None Predisposing Physiological Factors: Confused, Gait imbalance, Impaired Memory Predisposing Situation Factors: Ambulating with Assist; Side Rails up Other Info: Staff are unaware of why or how she got out of bed as she has not self-ambulated in multiple years. Agencies/People Notified: Family Member and Nurse Practitioner R1's hospital ED (Emergency Department) report documents, in part, as follows: R1 arrived to the hospital at 4:51 AM. Skilled nursing facility resident who sustained an unwitnessed fall at her skilled nursing facility. The patient was found to have rolled out of bed, and she was propped between the bed and her nightstand. (Note, NHA A, stated, per staff interviews, this information is incorrect.) The patient was brought to the ED for evaluation. Imaging studies were obtained, which indicated a right periprosthetic distal femur fracture, a left periprosthetic distal femur fracture (a break in the thigh bone just above the knee), and a left proximal humerus fracture (broken arm). Orthopedic Surgery was consulted for further evaluation and treatment of the patient. The patient is currently noncommunicative due to neurocognitive disorder. No other problems are reported. Assessment: 1. Left proximal humerus fracture 2. Right periprosthetic distal femur fracture 3. Left prosthetic distal femur fracture Plan: R1 is a skilled nursing facility resident who sustained an unwitnessed fall with resultant bilateral periprosthetic distal femur fractures and a nondisplaced left proximal humerus fracture. Per report, the patient is relatively bedbound. In addition, the patient has very significant neurocognitive disability. After discussion with the patient's family member, who is also the patient's power of attorney, the family wishes to pursue nonoperative intervention for the patient's lower extremity fractures and provide comfort measures only. Given the patient's overall medical condition, this is completely acceptable. Both lower extremities will remain in knee immobilizers, and left upper extremity will remain in a sling. Comfort measures will be provided. On 1/7/25 at 11:35 AM, R1 was discharged back to the facility. On 1/7/25 (after the incident), the facility completed Bionix Safety Technologies testing for R1's air mattress and bedrail in use together. On 1/7/25 the inspection documents the air mattress with a pump together with a bedrail Passed safety inspection. However, the facility made the decision to remove the side rail from R1's bed upon her return from the hospital ED. On 1/8/25 at 6:00 AM, LPN D (Licensed Practical Nurse) documented the following Progress Note: CNA had turned her at 4:20 AM. Night CNA asked day to help turn her and they walked in her room. They called nursing to her room as she had no pulse, no BP (blood pressure). On 1/8/25 at 6:30 AM, LPN D (Licensed Practical Nurse) documented the following Progress Note: Situation: Found with no BP or pulse Background: Had a fall 24 hours ago and came back comfort care On 1/8/25 at 6:10 AM, LPN D (Licensed Practical Nurse) documented the following Progress Note: R1's family members were called and told about her passing away. The daughter wants us to hold off calling funeral home until she processes all of this. On 1/14/25, Physician/Medical Director E documented the following information to NHA A (Nursing Home Administrator) via email: Case Review 2025.01 Sources: Epic; references; PCC (Point Click Care/Electronic Health Record) chart inaccessible- *The fracture was pathologic (significantly due to osteoporosis) *The fracture was traumatic (significantly due to a fall from bed height) *The fracture had other causes (there were no signs the resident asked for help) *The fracture was a cause of death (were it not for the fracture .) *The fracture was not the only cause of death (were it not for the dementia and frailty .) *The alarm, mats, and side rail did not clearly contribute to the fracture. *Opinions expressed are to a reasonable degree of medical certainty and subject to revision if additional information becomes available. On 1/23/25 at 11:15 AM, Surveyor spoke with CNA C (Certified Nursing Assistant). CNA C stated she was completing rounds at approximately 4:15-4:20 AM when she heard R1 hollering, and she immediately went to check on R1. CNA C stated, she observed R1 on the red floor mat next to her bed with her legs under her. CNA C added, R1 was facing the wall (in front of her) with one arm stuck (entrapped) in the railing and the other arm was holding onto the railing. CNA C stated, she cannot recall which arm was tangled (entrapped). CNA C stated, she hollered for LPN D (Licensed Practical Nurse). CNA C stated, LPN D came to R1's room right away. CNA C stated, we got a pillow and laid R1 down on the mat. CNA C stated, R1 was crying in pain, stated she was hungry wanted to get up out of bed because she has been in bed since 10:00 PM. CNA C stated, the facility put the fall mat intervention in place in 5/2024 when R1 last fell. Surveyor asked CNA C, is R1 able to make movement on her own. CNA C stated, no, not for a long time since she last fell on 5/2024, and we put the fall mat in place as an intervention. Surveyor asked CNA C if she had noticed R1 acting differently recently over the past week or so. CNA C stated, no. CNA C stated, R1 would use siderails when staff would check and change her. On 1/23/25 at 1:15 PM, Surveyor spoke with LPN D (Licensed Practical Nurse). Surveyor asked LPN D to describe what happened when R1 was found on the floor on 1/7/25. LPN D stated, CNA C (Certified Nursing Assistant) had just finished rounds on 1 wing when LPN D and CNA C both heard R1 start calling out. LPN D stated, CNA C immediately responded to R1 calling out. LPN D stated, it is not uncommon for R1 to yell out that she wants to go home or to go see her mother. LPN D stated, CNA C found R1 on the floor mat on her knees and called out for LPN D. LPN D stated, R1's left arm was stuck down about 1 inch in between the siderail and the mattress with her right arm in front of her holding onto the side rail. LPN D stated the side rail was in the up and correct position. LPN D stated, she needed to move the bed up (as it was in the lowest position) in order to disengage the side rail. Emphasis Intended. LPN D stated, she was then able to get R1's arm out from being entrapped in between the mattress and side rail. LPN D stated, when she asked R1 if she has any pain. R1 pointed to her left shoulder. LPN D stated, R1 looked like she had a little pain. LPN D stated, she and CNA C laid R1 down on the mat to assess. LPN D stated, a different nurse contacted R1's APOAHC (Activated Power of Attorney for Health Care) while she stayed with R1. LPN D stated, R1 was then immediately sent to the hospital ED (emergency department). LPN D stated, she heard R1 yell when the EMT's (Emergency Medical Technicians) put her on the stretcher. LPN D stated, all of R1's care plan interventions were in place at the time of this accident. LPN D stated, she observed R1 to be sleeping when she passed water just a short time before the fall. LPN D was also working at the time R1 passed away on 1/8/25, 24 hours after the entrapment and fall with fractures. LPN D stated, on 1/8/25 R1 was found pulseless and not breathing. LPN D stated, this experience has been very traumatic for her as well. On 1/23/25 at 4:45 PM and 5:00 PM, Surveyor spoke with NHA A (Nursing Home Administrator) and DON B (Director of Nursing). Surveyor asked NHA A, what date was R1's side rails put in place. NHA A stated, R1's side rails were likely in place since admission to the facility. NHA A added, the facility previously did not remove side rails when residents discharged . Therefore, any newly admitted residents automatically have a side rail(s) that was in place for the previous resident. The facility identified this as a deficient practice and is addressing it in QAPI (Quality Assurance Process Improvement). Surveyor asked NHA A and DON B, what alternatives were attempted prior to utilizing a bedrail. NHA A stated, the facility has no prior alternatives documented. NHA A stated, alternatives attempted should have been documented and the facility is working to correct this for other residents via the Therapy Department. NHA A stated the Therapy Department is about 2/3rds of the way through screening all 48 residents. Surveyor asked NHA A and DON B, when the air mattress was put in place on 1/8/24, should an assessment have been completed at that time. (Note, the assessment was not completed until 3/8/24.) NHA A stated, yes. 2. R2 admitted to the facility on [DATE] with the following diagnoses: malignant neoplasm of the prostate, encounter for palliative care, age related osteoporosis, and polyneuropathy. R2's most recent MDS (Minimum Data Set) with ARD (Assessment Reference Date) of 10/17/24 indicates R2's cognition is moderately impaired with a BIMS (Brief Interview for Mental Status) score of 10 out of 15. R2's MDS also indicates he is dependent on staff to meet his needs in toileting, rolling from left to right, going from lying to sitting, going from sitting to lying, and transfer bed to chair or chair to bed. R2's informed consent for bed rails, signed 7/12/23, includes potential benefits of a half side rail . in some instances half side rails or bed bars present an inherent safety risk. Potential risks include strangulation, suffocation, entrapment, or death when a resident or part of his or her body is caught between the bed rail or between the bed rails and the mattress and the opening of the rails . serious bodily injury from falls if a resident climbs over the half side rail or bed bar . Bruising, abrasions, contusions, skin tears, and negative psychological effects . and altered resident self-esteem . (It is important to note the facility did not provide evidence of alternative interventions being tried prior to the installation of the bed rails.) R2's Comprehensive Care Plan, includes revision date 3/1/24 bed mobility- independent, assist of 1 to 2 if weak . R2's Medical Record indicated an alternating air mattress was added to R2's bed on 11/24/24. (It is important to note adding an alternating air mattress to a bed with side rails changes the risks and a new informed consent form describing the new risks and benefits of using the side rails with the alternating air mattress was not given to R2 or his activated Health Care Power of Attorney.) R2's Bed System Measurement Device Test Results Worksheet, undated, includes Bed ID: (blank) . Bed make- (blank) . Model-(blank) . Barcode- (blank) . Mattress make- (blank) . Mattress Model- (blank) . Left zone 4- pass, zone 2 pass, zone 4 pass . Right zone 4 pass, zone 2 pass, zone 4 pass . (It is important to note there is no resident name, no bed identification and no date on this form. It is also important to note this system of testing is not recommended to be used with alternating mattresses as the air in the cells shifts when weight is applied.) On 1/23/25 at 8:43 AM Surveyor observed R2's room including his bed. R2's bed had an alternating air mattress and bedrails that reached ¼ of the way down his bed. 3. R3 admitted to the facility on [DATE] with the following diagnoses: unspecified dementia, abnormality of gait, open wound . R3's informed consent for bed rails, signed 2/21/24, includes potential benefits of a half side rail . in some instances half side rails or bed bars present an inherent safety risk. Potential risks include strangulation, suffocation, entrapment, or death when a resident or part of his or her body is caught between the bed rail or between the bed rails and the mattress and the opening of the rails . serious bodily injury from falls if a resident climbs over the half side rail or bed bar . Bruising, abrasions, contusions, skin tears, and negative psychological effects . and altered resident self-esteem . (It is important to note the facility did not provide evidence of alternative interventions being tried prior to the installation of the bed rails.) R3's Medical Record indicates an alternating air mattress was added to her bed on 2/21/24 (on admission). Bed System Measurement Device Test Results Worksheet, undated, includes Bed ID: 251 . Bed make- (blank) . Model-(blank) . Barcode- (blank) . Mattress make- (blank) . Mattress Model- (blank) . Left zone 4- pass, zone 2 pass, zone 4 pass . Right zone 4 pass, zone 2 pass, zone 4 pass . (It is important to note there is no resident name and no date on this form. It is also important to note this system of testing is not recommended to be used with alternating mattresses as the air in the cells shifts when weight is applied.) R3's most recent MDS with ARD of 11/22/24 indicates R3's cognition is severely impaired with a BIMS score of 7 out of 15. On 1/23/25 at 8:48 AM Surveyor observed R3's room including her bed. R3's bed had an alternating air mattress and bedrails that reached ¼ of the way down her bed. 4. R4 admitted to the facility on [DATE] with the following diagnoses: Type 2 Diabetes Mellitus and unspecified mental disorder. R4's most recent MDS with ARD 10/25/24 indicates R4's cognition is severely impaired, and he never or rarely makes decisions. R4's

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not implement professional standards of practice to ensure that a resident did not develop a pressure injury (PI) and that the resident received necessary treatment and services to promote healing and prevent infection of the pressure injury for 1 of 4 residents sampled for pressure injuries (R2). R2 had a history of pressure injuries and was at risk for PI development. The facility failed to implement aggressive measures upon admission, failed to update R2's MD timely when a new pressure injury developed, failed to re-evaluate interventions that were not working, failed to update the care plan timely, failed to complete diabetic foot checks per current standards of practice, and failed to use R2's offloading boots per manufacturer's guidelines. The facility did not consider changing course of action when 3 of R2's Medical Doctors noted the wound to be caused by pressure. R2 developed an infected stage IV PI. It should be noted thoroughout R2's medical record there is conflicting documentation regarding the causative factor of R2's wounds. R2 had a diagnosis of diabetes and some providers called the heel ulcers diabetic ulcers where others called it pressure ulcers. Interviews suggest there is likely a component of both. Obesrvations and interviews during the survey support a pressure related causative factor thus determining citation under 686. The failure of the facility to prevent the development of a PI for an at-risk resident, failure to conduct diabetic foot checks per current standards of practice, failure to implement R2's offloading boots per manufacturer's guidelines, failure to re-evaluate the use of pillows for offloading when they were not working, failure to update R2's care plan timely, and failure to update R2's MD with a new open wound resulted in R2 developing a Stage 4 PI, which became infected requiring antibiotic therapy and surgical intervention. This created a situation of Immediate Jeopardy which began on 1/3/23 when R2's stage 4 PI became infected. NHA A (Nursing Home Administrator) and DON B (Director of Nursing) were formally notified on 2/22/23 at 4:25 PM that an Immediate Jeopardy situation existed. The immediate jeopardy was removed on 2/21/23. The deficient practice continues at a scope/severity of D (potential for more than minimal harm that is not immediate jeopardy/isolated) as the facility continues to implement its action plan. Evidenced by: The facility policy titled Wound Care Guidelines, dated 2/05, includes, in part: .Each resident will be assessed on admission and will have a personalized skin care plan to address skin care needs including preventative care. Weekly assessments and documentation of all wounds will include: the specific location of the ulcer the stage of the ulcer the presence of exudate or drainage or odor, the length width and depth of wound in centimeters, the frequency of dressing changes and what products are being used to treat the wound, the progress, deterioration, or the development of new problems . for heels: apply topical agent to toughen the skin . goal is to keep skin dry . offload heels with foam boots or pillows under ankles . Stage 2 pressure ulcer / partial thickness / skin tear / blister: loss of skin involving the epidermis and possibly the dermis, May see blistering: protect area from undue stress and or pressure, keep the surrounding skin dry, soft, and supple. For ankle or foot wounds: prompt attending physician for Podiatry consult . If necrotic or covered with 20% or greater slough . stage 3 pressure ulcer/full thickness: tissue loss involving subcutaneous tissue but not muscle or bone . stage 4 pressure ulcer/full thickness: deep tissue destruction involving muscle, bone, and fascia. May see draining and necrosis . . (It is important to note the outdated information found in this policy, including slough under the definition of stage 2 as in current standards slough in wound bed indicates stage 3 wound.) Genesis 111 Mattress Manufacturer's Information, undated, includes: 5 inch-Pressure reducing support surfaces are a type of medical equipment used for the care of pressure sores, also known as pressure ulcers or injuries. Pressure ulcers are lesions caused by constant pressure on areas in contact with the mattress, resulting in damage of skin and deep tissues. Some pressure reducing mattresses are powered by electricity (known as powered pressure-reducing air mattresses) and others are not. They replace a standard hospital or home mattress and are either integrated to or placed on a hospital bed frame. Powered pressure reducing mattresses have a surface designed to reduce friction and shear through technologies know as alternating pressure, low air loss, or powered flotation without low air loss. They have a pump or blower which provides either sequential inflation and deflation of the air cells or a low interface pressure throughout the mattress. They are indicated for persons with deeper pressure ulcers (stage II, III or IV) or after surgery, for persons who received a flap or skin graft to cover a wound. Weight Capacity: 350 Pounds Heel Lift Classic Suspension Boot Manufacturer's Information, undated, includes: . suspends the heel to prevent pressure injuries with superior customizability . Application Instructions - Place the foot inside of boot with the heel resting above the opening . Thread straps through the D-rings and secure straps back together . Test the fit under heel opening. Ensure no straps touch the skin . Heel Lift Classic Suspension Boot Customization Instructions Video includes: .Make sure the heel is positioned directly above the opening . To avoid Achilles tendon irritation: cut a v shape into the fixed pad . Carefully place foot in boot making sure the heel is properly centered above the heel opening. The National Pressure Ulcer Advisory Panel's Pressure Ulcer Prevention Points, updated 2007, include: Use devices that eliminate pressure on the heels. For short-term use with cooperative patients, place pillows under the calf to raise the heels off the bed. Place heel suspension boots for long-term use . Use a written repositioning schedule .Perform a head-to-toe skin assessment at least daily, especially checking pressure points such as sacrum, ischium, trochanters, heels, elbows, and the back of the head . Implement pressure ulcer prevention educational programs that are structured, organized, comprehensive, and directed at all levels of health care providers, patients, family, and caregivers. Include information on use of support surfaces . Ensure that the heels are free from the bed . R2 was admitted to the facility on [DATE] following a 10-day hospital stay that included surgical repair of a displaced spiral fracture of the shaft of R2's left femur. R2's medical diagnoses included Type 2 Diabetes Mellitus with diabetic polyneuropathy and nephropathy, reduced mobility, abnormality of gait and mobility, postprocedural complications and disorders of the circulatory system, and age-related osteoporosis. R2's Hospital Discharge Worksheets, dated 10/19/22, include, in part: R2 lives at home with his wife . uses a walker . He tripped, fell at home, and suffered left distal femur displaced periprosthetic fracture. On 10/11/22 an open reduction and internal fixation of left periprosthetic fracture was performed. Elevate surgical leg while resting . post-operative medical devices to be removed daily for head-to-toe skin assessments . if alterations in skin integrity is found, notify R2's MD, document, clean, and dress per standing wound orders . Offload pressure always. He tolerated procedure well . Gluteal cleft wound . Coccyx has sore dark area, un-blanchable 12cm x 9cm with 1cm x 2cm open area . R2 was found to be medically and orthopedically stable but inappropriate to return home independently, therefore, is being transferred to nursing home for short term care and therapy. R2's Norton Plus Skin Risk Assessment Scale includes, in part, the following: Key - 10 or below is high risk 10/19/22 - R2's Norton Score 5 - at high risk for skin breakdown R2's Closet Care Plan, dated 10/19/22, includes Offload heels with boots or pillows under ankles . Document refusals . Turn/Reposition Schedule: Turn and reposition on night rounds . Naps as needed . float heels . elevate left lower extremity but do not place pillow directly under knee . CNAs Check heels/feet AM and PM . (It is important to note the facility did not provide evidence of diabetic foot checks being completed.) R2's Initial Skin Assessment, dated 10/21/22, includes Skilled Nursing observation completed for entire body with focus over bony prominences. The following skin problems noted: open areas by coccyx, surgical incisions, bruising abdomen, needs panacea mattress in the morning. R2's MD Progress Note, dated 10/25/22, includes, in part: . seen today for follow up for coccyx wound and anal pain . continue offloading and daily wound care until healed . likely pain from pressure on coccyx wounds while seated. Reposition and is using a foam cushion on chair. R2's Norton Plus Skin Risk Assessment Scale includes, in part, the following: Key - 10 or below is high risk 10/26/22 - R2's Norton Score 5 - at high risk for skin breakdown R2's Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/26/22 states R2 is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15. R2's MDS also indicates R2 requires the extensive physical assistance of two or more staff to meet his needs in bed mobility, toileting, dressing, and personal hygiene. R2's MDS indicates he is totally dependent on two or more staff to meet his needs in transfer. In addition, the MDS indicates R2 is frequently incontinent of urine, always incontinent of stool, and is at risk for pressure injury development. R2's MDS indicates he did not have any unhealed pressure injuries, venous, or arterial injuries and needs a pressure reducing device for chair and bed and a turning/repositioning program. (It is important to note the stage 2 pressure injury of the coccyx that R2 admitted with is not captured on this MDS.) R2's Nurse Note, dated 10/27/22, include large clear fluid filled blister . right heel . Blue boot applied. The heels have been floated on the PM shift when nurse checked over the past few days. On 2/20/23 at 2:01 PM, Surveyor interviewed RN L (Registered Nurse) regarding R2's pressure injuries (PI.) RN L stated, R2 had pillows to float heels until 10/27/22, but I put a blue boot on the right heel when I was made aware of the first blister. He was on pressure relieving foam mattress on 10/21/22 and I worked late so I left a note for morning shift and housekeeping to replace it with a low air loss mattress. I did not update R2's Care Plan. I should have. (Of note, RN L only placed the heel lift boot on the right heel. Approximately 2 weeks later R2 developed a PI on the left heel.) On 2/21/23 at 10:19 AM, Surveyor interviewed CNA Q (Certified Nursing Assistant) regarding R2's pressure injuries to the heels. CNA Q stated, We were using pillows at the beginning, but his feet were sliding off onto the mattress and he got heel ulcers. Now we use boots. Surveyor asked CNA Q if he notified anyone the pillows were not effective in offloading the heels. CNA Q stated he was sure nursing staff were aware the pillows were not keeping R2's heels off the mattress. R2's Norton Plus Skin Risk Assessment Scale includes, in part, the following: Key - 10 or below is high risk 11/2/22 - R2's Norton Score 7 - at high risk for skin breakdown R2's Nurses Notes, dated 11/8/22, include fluid filled blister on left heel R2's Nurses Notes, dated 11/9/22, include left heel 2.5cm (centimeters) x 3.0cm, intact serous filled blister on left heel . right heel blister is now fully absorbed. Resident has been wearing boots in bed - unsure of cause of blister . Calvon applied. Boots remain in place at all times . Will monitor . R2's Nurses Notes, dated 11/14/22, include left heel blister 4.7cm x 5.5cm x superficial . roof of blister came off . small amount of serous exudate . MD (Medical Doctor) updated. (It is important to note this is the first time R2's MD is updated regarding new open areas on heels.) R2's MD Progress Note, dated 11/22/22, includes Active problems - gluteal cleft wound present on admission, blister on right heel (R2) has had edema to both lower extremities. (It is important to note, R2's MD does not mention R2's open wound to his left heel in this note.) R2's Nurses Note dated 11/22/22, includes left heel blister 4.3cm x 4.6cm continue same treatment . right heel blister - 4.0cm x 4.9cm, blister is resolving . foam boots to offload heels . (It is important to note the wounds are measured but there is no other description of the wounds.) R2's MD Progress Note dated 11/25/22-11/28/22, includes, in part: .was recently hospitalized [DATE]-[DATE] for a left distal displaced periprosthetic fracture which required surgical intervention. Unfortunately, during his stay, he was found to have an acute on chronic congestive heart failure exacerbation with elevated tropin levels and acute post procedural atrial fibrillation . final diagnosis - . wound on left and right heel, wound on left leg, recent femur fracture with surgical repair . Blister of left and right heel: evidence of delayed healing, with likely component of pressure injury and edema skin break down. No surrounding erythema or evidence of infection. Leg eschar loosened 11/27/22. Wound emphasis . included offloading the area, and keeping it clean and covered with mepilex . R2's MD Progress Note, dated 11/29/22, includes Blister of left and right heel: evidence of delayed healing, with likely component of pressure injury and edema skin breakdown. No surrounding erythema or evidence of infection. Leg eschar loosened on 11/27/22. Wound care emphasis . included offloading the area and keeping it clean and covered with mepilex . Left heel ulcer - not hurting unless handled. He is wearing his offloading boots . Bilateral heel ulcer per wound team Left - 6cm x 4cm dry blister with 2cm x 2cm dark central small bleeding . Right - 2 cm x 2cm blister opened with small bleeding. Wounds dressed with Aquacel Ag and Mepilex and offloaded. Assessment/Plan - blister of left heel subsequent encounter: continue offloading and daily wound care . R2's Nurses Notes, dated 11/29/22, include has dark spot within left heel blister 1.8cm x 1.8cm. R2's Closet Care Plan, dated 12/12/22, includes Offload heels with boots or pillows under ankles . Document refusals . Turn/Reposition Schedule: Turn and reposition on night rounds . Naps as needed . float heels . elevate left lower extremity but do not place pillow directly under knee . Foam boots bilateral when in bed . Foam boots on for protection except with transfers . CNAs Check heels/feet AM and PM . (It is important to note this is the first time R2's boots show up on his Care Plans (12/12/22). Also, important to note the facility did not provide evidence of diabetic foot checks being completed.) Nurses Note dated 12/13/22, includes: .left heel peripheral neuropathic wound . DON B (Director of Nursing), ADON C (Assistant Director of Nursing) and Dietician all present. Left heel 2.6 cm x 3.5 cm, eschar plate 95% . left heel again 3.0cm x 3.5cm eschar plate measures 2.5 cm x 2.0 cm . Updated NP (Nurse Practitioner) R2's MD Progress Note dated 12/14/22, includes: .alert and oriented x 4 . alert, cooperative, and pleasant . open wound of left heel (primary encounter diagnosis) . the eschar plate was about 95% covering the wound. Necrotic odor was noted . I debrided the wound . No pain during procedure and very minimal bleeding was observed. The majority of the plate was removed, and the remaining residual was scored . Change wound orders to apply Santyl, cover with Aquacel, followed by Mepilex. Change wound dressing daily . R2's Nurses Notes dated 12/19/22, include: 4.0cm x 4.8cm eschar necrotic odor noted . Updated NP . R2's MD Progress Note, dated 12/23/22, includes: .seen today for follow up for nonhealing left heel ulcer, for possible debridement and wound culture as reported by staff. Skin: left heel ulcer is approximately 5cm in diameter, is completely covered by dry eschar, surrounded by scale . Procedure: Removal of dry eschar revealed more than ¼ inch of slimy brown slough/necrotic foul-smelling tissue. A 1/4-inch layer was removed, but there remains further depth of this tissue across wound bed. Raw wound is reached at the 2 o'clock position, with scant bleeding. Wound culture is obtained there. Procedure: Secondary confirmation of the site was identified by patient and staff. Verbal consent was obtained by patient. Size 5 cm . Description: necrotic eschar covered ulcer located on left heel . the lesion was anesthetized . Sharp excision was performed of the dry eschar plate and ¼ inch depth of the underlying soft slough/necrotic tissue. Bleeding was largely absent, stopped gauze pressure. Wound was dressed with Santyl, Aquacel, and gauze wrap . Continue offloading, daily wound care . Treat infection if presence noted on culture. Podiatry consultation. R2's Nurses Notes, dated 12/24/22, include: .still necrotic with darker gray area surrounding wound . R2's Nurses Notes, dated12/27/22, include left heel wound: 3.3cm x 4.0cm, eschar plate measuring 2.4cm x 2.9cm . strong odor . Updated MD R2's Nurse Notes, dated12/28/22, include MD added oral antibiotics R2's MD Progress Note, dated 12/28/22, includes: . staff report again that eschar plate has re-covered, and ulcer has had persistent foul odor. No surrounding erythema, no purulent drainage. He agrees to further debridement and wound culture if possible. He is reminded of upcoming evaluation with MRA and podiatry. He denies pain unless deeply handled . Has maintained offloading. Skin: 5-6 cm left heel ulcer, eschar covered, has extended laterally now 2-3 cm open area with slough covering. Foul smelling, slimy brown necrotic tissue remains below eschar plate. ¼ inch depth is excised again, with more attention to wound borders. Minimal tunneling is noted, approximately 2 mm (millimeters) around wound edge, worst superiorly . Secondary confirmation of the site was identified by patient and staff. Verbal consent was obtained by patient. Size 5 cm to 6cm . Description: necrotic eschar covered ulcer located on left heel . the lesion was anesthetized . Sharp excision was performed of the dry eschar plate and ¼ inch depth of the underlying soft slough/necrotic tissue. Bleeding was largely absent, stopped gauze pressure. Wound was washed with Dakins 50%, rinsed, and dressed with Santyl, packed ¼ depth and 2mm surrounding tunnels with Santyl saturated packing gauze, and covered with gauze pad and gauze wrap. Debridement has been conservative in setting of pending vascular imaging. Deeper debridement of necrotic tissue is needed to access healthy tissue and stage wound . Eschar plate will likely continue to re-cover. Imaging for osteomyelitis assessment pushing out 6 weeks from wound opening . Antibiotic therapy is initiated in setting of likely diabetic ulcer, necrotic foul-smelling tissue, and positive culture. Wash with Dakin's and rinse. Continue Santyl gauze for packing and covering. If worsens . he may need escalation to inpatient services with parental antibiotics. Follow up . routinely or sooner if worsening/not improving . R2's Closet Care Plan, dated 1/1/23, includes Offload heels with boots or pillows under ankles . Document refusals . Turn/Reposition Schedule: Turn and reposition on night rounds . Prevalon boots bilateral when in bed. Left femur fracture near knee, elevate left lower extremity but avoid pillow directly under knee. Float heels . foam boots on for protection except with transfers. CNAs check feet . R2's Podiatry Visit Note, dated 1/3/23, includes Examination of his feet reveals nonpalpable dorsalis pedis and posterior tibial pulses bilaterally. Feet are warm to touch. Hair growth is absent. Skin is thinning. Epicritic sensations grossly diminished bilaterally. No [NAME] or clonus present. No paresthesia anesthesia, dysesthesias could be elicited. He has necrotic, full thickness through subcutaneous ulceration to the plantar/posterior left heel measuring approximately 35 mm x 30 mm in dimension with 2-3 cm of periwound erythema to follow odor. There is no purulence. There is an intact, noninfected blister to the plantar/posterior right heel . The ulcer appears infected and likely deep, possibly down to the bone. Concerns for osteomyelitis. Does not appear improved from a few days ago. Recommend admission for IV antibiotics, debridement, and further testing . podiatry consultation: resulting in pressure ulcer left heel, blister of right heel . measurements full thickness to calcaneus 4 cm x 3 cm x 1 cm with anullar base . pressure ulcer left heel stage 4 . osteomyelitis left heel . R2's Closet Care Plan, dated 1/11/23, includes Offload heels with boots or pillows under ankles . Document refusals . Turn/Reposition Schedule: Turn and reposition on night rounds . float heels with foam boots on both feet for protection at all times . left heel wound vac . CNAs check heels/feet am and pm . (It is important to note the facility did not provide evidence of diabetic foot checks being completed.) R2's Nurses Note, dated 1/11/23, includes: . left heel surgical wound 2.3cm x 3.1cm R2's Nurses Note, dated 1/13/23, includes: . left heel wound has exposed tendon . R2's Hospital Note, dated 1/13/23, includes Patient presented for direct admission from Podiatry clinic due to worsening left heel ulcer in setting of type 2 diabetes . It started as a blister on the posterior left heel 4-6 weeks ago and progressively worsened . blister also on the right heel at this time. Exam consistent with suspected necrotic ulcer approximately 3 by 3 cm in size with full thickness penetration and fat layer exposed with surrounding erythema and tender to palpation, nonpalpable dorsal pedal and posterior tibial pulses. Concern for cellulitis with possible osteomyelitis by evaluation by Podiatry, recommended imaging including MRI (a test to view muscle and bone), ABI (a test to check lower extremity circulation), and x ray of left foot. X ray left foot shows subtle cortical irregularity suspicious for possible osteomyelitis. MRI also showed changes consistent with osteomyelitis. Patient previously had wound culture on 12/23/23 that showed =light MRSA, light Citrobacter, freundii, started on oral antibiotic Augmentin and Bactrim. IV antibiotics started on admission. On 1/4/23 had surgical debridement of the wound by Podiatry. Initial culture positive for MRSA. Discussed options going forward with patient, who wants to try antibiotic treatment to save his foot. ABI's completed on 1/6/23 were within normal limits. Infectious Disease saw the patient on 1/5/23 in person, recommended blood cultures and changing antibiotics to Cefepime, Vancomycin, and Metronidazole. PICC placement 1/9/23 . Nutrition consulted given multiple wounds and recommendations were given. Today, he is up in his wheelchair, heels offloaded, wound vac to left heel. He states he is doing ok. He wants to know when he can go home. We discussed how difficult this would be since he currently cannot stand on his feet, and his wife could not transfer him. He verbalized understanding. He says Tramadol is helping his heel pain . Left heel ulcer with wound vac, status post-surgical debridement, right heel blister . He is non weight bearing to left foot . Left heel is bandaged with wound vac . 2.5cm x 3.0 cm intact, reducing/drying blister to right heel without surrounding erythema . acute osteomyelitis of left calcaneus . R2's Nurses Note, dated 1/16/23, includes new wound right inner buttock 1.0cm x 0.5cm . left heel surgical site 2.0cm x 3.0cm . R2's most recent MDS with an ARD of 1/17/23 states R2 is cognitively intact with a BIMS score of 15 out of 15. R2's MDS also indicates R2 requires the extensive physical assistance of two or more staff to meet his needs in bed mobility and R2 requires the extensive physical assistance of one staff to meet his needs in transfer, toilet use, dressing, and personal hygiene. In addition, the MDS indicates R2 is frequently incontinent of urine, always incontinent of stool, and is at risk for pressure injury development. R2's MDS indicates he did not have any unhealed pressure injuries, venous, or arterial injuries and needs a pressure reducing device for chair and bed and a turning/repositioning program. (It is important to note R2's MDS does not capture the heel wounds at all, under any category.) R2's Infectious Disease MD Progress Note, dated 1/19/23, includes asked to see patient for infected left heel . after fracture . he had decreased mobility . developed bilateral heel blisters. These got progressively worse. Was following with wound care, left blister developed necrosis, cultures 12/23/22 MRSA and Citrobacter freundii . underwent debridement on 1/4/23 . Podiatrist felt necrosis was all the way to the periosteum. My exam there was only a small area that was very close to the bone . started on a combination of antibiotics . MRI calcaneal osteomyelitis . antibiotics changed on 1/5/23 . wound vac was placed 1/6/23 . 1/11/23 Patient was discharged to nursing home . Exam done via video, with assistance of nursing staff on patient's bedside, with limitations of not examining patient in person . left heel status post debridement of necrotic heel, reported by nursing staff as significant improvement, no reported exposed bone limited visualization on video, wound vac was removed for exam . right foot poorly visualized, blister reported as superficial by nursing staff . Radiology: MRI left foot 1/4/23- large soft tissue ulcer at the posterior medial aspect of the calcaneus with abnormal marrow edema, marrow replacement, and marrow enhancement of the adjacent posteromedial calcaneus with an overall diameter of about 2.5 cm. Findings are highly suspicious of osteomyelitis. Decreased enhancement of the soft tissue around the ulcer suggesting devitalized soft tissue. Longitudinal splitting of the tibialis posterior tendon as well as the proneus brevis tendon. No drainable soft tissue abscess is evident. Assessment: Pressure Injury to left heel led to necrosis, and underlying osteomyelitis, status post debridement 1/4/23 . Pressure injury to right heel appears superficial. Cultures from left heel MRSA and Citrobacter freundii . intraoperative cultures MRSA and E faecalis. R2 developed a pressure injury to left heel, after being immobile from the left side femoral fracture in October. He also has a pressure injury that appears to be superficial on the right heel . Unfortunately, calcaneal ulcers are very difficult to heal, and the success rate is rather low. We are trying to treat underlying osteomyelitis with antibiotics, along with wound vac. Hopefully wound will eventually granulate . will granulate over. With limited exam on video, it appears wound is improving. Will leave antibiotics open ended minimum of 6 weeks . R2's Podiatry Visit Note, dated 1/20/23, includes: . approximately 2 weeks ago R2 underwent a debridement of the severe diabetic/pressure ulcer to the posterior/plantar left heel. He has been recuperating at hospital. He has been receiving IV antibiotics. They have been changing wound vac. He is accompanied today by his wife and son. Physical exam: . resolving blister to the plantar/posterior right heel without sign of infection. The dressing to the left foot is intact and upon removal the wound measures approximately 30 mm x 25 mm x 5mm in depth. It does appear to be down to the calcaneal periosteum. There is increased granulation tissue. There is no purulence. There is no periwound erythema. There is no odor. Neurovascularly he's unchanged. R2's Nurse Notes, dated 1/23/23, include left heel 1.8cm x 3.0cm R2's Infectious Disease MD Progress Note, dated 1/25/23, includes admitted to skilled nursing facility after hospital stay on 1/11/23 for acute osteomyelitis complicating the previously identified left heel ulcer, with multiple comorbidities. Antibiotics and a negative pressure wound treatment were prescribed with some skepticism the infection could be healed . impaired mobility and activities of daily living due proximately to acute left heel osteomyelitis complicating the facility acquired left heel wound .right heel wound reportedly just a blister, under observation with pressure relief . Visit diagnoses: Pressure wound of left heel 11/22, Pressure Wound of right heel 1/23 . (It is important to note this is the third MD to call these heel wounds pressure injuries. R2's primary MD, R2's Podiatrist, and R2's Infectious Disease MD have diagnosed R2 with heel pressure injuries.) R2's MD Progress Note, dated 1/30/23, includes Patient slid out of bed on 1/28/23 with no injury . a bit more confused than last care . He is transferred to bed via Hoyer for wound team management of heel ulcers, left with wound vac, right stage 1 since this hospitalization. He denies feeling ill or otherwise confused. He is oriented today . frail but alert . left heel ulcer measures 2 cm x 3 cm with 1-2 cm depth, with clean edges and granulation tissue, slough center . Right heel ulcer with 3cm blanchable stage 1 wound, skin is intact but appears fragile. Pressure wound left heel 11/22: continue offloading, wound vac, change 3 times a week and antibiotics course per Infectious Disease. Pressure wound of right heel 1/23: continue protective topical and offloading, close monitoring to prevent breakdown . Visit diagnoses: Pressure wound of left heel 11/22, Pressure Wound of right heel 1/23 . R2's Nurse Note, dated 1/31/23, includes coccyx- slough noted in center of wound . 2.5cm x 1.0cm . R2's Nurse Notes, dated 2/1/23, include left heel1.9 cm x 2.9 cm. R2's Infectious Disease MD Progress Note, dated 2/2/23, includes exam done via video with assistance of nursing staff on patient's bedside, with limitations of not examining the patient in person. Left heel status post debridement of necrotic heel, reported by nursing staff as continues to improve, no reported exposed bone limited visualization on video, wound vac was removed for exam, right heel appears superficial. Right foot, poorly visualized, blister reported as superficial by nursing staff . Radiology: MRI left foot 1/4/23- large soft tissue ulcer at the posterior medial aspect of the calcaneus with abnormal marrow edema, marrow replacement, and marrow enhancement of the adjacent posteromedial calcaneus with an overall diameter of about 2.5 cm. Findings are highly suspicious of osteomyelitis. Decreased enhancement of the soft tissue around the ulcer suggesting devitalized soft tissue. Longitudinal splitting of the tibialis posterior tendon as well as the proneus brevis tendon. No drainable soft tissue abscess is evident. Assessment: Pressure Injury to left heel led to necrosis, and underlying osteomyelitis, status post debridement 1/4/23 . Pressure injury to right heel appears superficial. Cultures from left heel MRSA and Citrobacter freundii . intraoperative cultures MRSA and E faecalis. R2 developed a pressure injury to left heel, after being immobile from the left side femoral fracture in October. He also has a pressure injury that appears to be superficial on the right heel . Unfortunately, calcaneal ulcers are very difficult to heal, and the success rate is rather low. We are trying to treat underlying osteomyelitis with antibiotics, along with wound vac. Hopefully wound will eventually granulate . will granulate over. With limited exam on video, it appears wound is improving. Will [TRUNCATED]