**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility did not ensure the prevention, and healing of pressure injuries. This was discovered in 2 (R33 and R2) of 3 residents reviewed with pressure injuries. * R33 developed a fissure above the sacrum on 3/24/21. There was no further assessment of this area until 4/22 and 4/29/21. On 5/13/21, the fissure became larger and the MD was contacted for new treatment. On 6/10/21 the assessment indicated slough in fissure. On 7/17/21, R33 was admitted to the hospital where it was noted upon admission, R33 had a stage 3 pressure injury on the sacrum. The facility had not identified the fissure as a stage 3 pressure injury. Upon readmission from the hospital on 7/23/22, the facility did not notify the physician of the hospital discharge wound treatment recommendations for the use of 2 X 2 with Dakins, cover with wet to dry keep frequently turned. The facility continued to use the treatment to apply Santyl ointment until 7/29/21. There was no wound assessment of R33's stage 3 pressure injury upon readmission on [DATE], even though the hospital identified R33 as having a stage 3 pressure injury. On 10/4/21, the sacrum pressure injury was noted to be larger and deeper and on 10/7/21 the pressure injury was noted to have declined with tunneling. There was no MD consultation or change in R33's care plan with the deterioration of the wound. On 10/14/21 slough was noted in the wound with no MD consultation. On 10/27/21, the MD progress note indicated the wound is declining, encourage nutrition and continue with wound specialist. On 10/28/21, the pressure injury assessment indicated the area was noted to be a stage 4, with no MD consultation, no notification of the POA and no care plan revisions. The physician did not see R33's pressure injury. On 4/13/22, during a dressing change surveyor noted no date on the dressing. R33's care plan was not revised timely as the wound deteriorated. On 4/18/22, R33 was observed seated on a gel cushion when according to RN-G R33 is not to have a cushion with the Broda chair. Additionally RN-G indicated the removal of heel boots from R33's care plan. * R2 is a risk for pressure injuries. A weekly wound assessment for 3/31/22 indicates R2 had a suspected deep tissue injury to the left lateral foot. This weekly wound assessment for 3/31/22 was conducted 6 days after the podiatrist discovered the area on 3/25/22. On 4/12, 4/13 and 4/14/22, Surveyor observed R2 in bed with heels resting directly on the mattress. The facility did not implement the floating of R2's heels prior to the development of the suspected deep tissue injury. Findings include: The facility's policy and procedure for Skin Care Management dated 8/21 was reviewed by Surveyor. The policy indicates to provide skin care to residents that include assessment, prevention of skin breakdown, and management of pressure injury and other skin integrity concerns. The procedures include: A skin and body assessment form will be completed with admission; readmission; significant change in condition; acuity and alterations in skin. 1. On 04/11/22 at 09:43 AM Surveyor observed R33 sitting in a Broda chair in their room. R33 has gripper socks on with pillow under feet. R33 has a seat cushion in the Broda chair. On 4/11/22 at 12:15 PM Surveyor observed R33 eating their pureed lunch in their room. R33 was sitting in a Broda chair and had a seat cushion. On 04/13/22 at 08:03 AM Surveyor observed R33 in bed watching T.V. There was an air mattress on the bed. R33 was laying on their back. R33's medical record was reviewed as R33 had developed a facility acquired stage 4 pressure injury on the sacrum. R33 has a plan of care for skin impairment starting on 10/15/19. The identified concerns with correlating interventions; On 11/1/19 the interventions are; To use a lift sheet, Reposition every 2 hours, Float heels off bed. On 12/9/2020 R33 was identified as having a stage 2 ulcer to coccyx and ulcer to right heel with no corresponding revisions to the care plan. On 2/25/21 the interventions indicate to ensure the Convertible Alternating pressure mattress is on; Broda chair; elevate heels; prevalon boots to feet at all times. R33's Quarterly MDS (Minimum Data Set) assessment completed 6/13/21 indicates at risk for pressure injury and no current pressure injuries. R33 requires total assist from staff for bed mobility/positioning. The Brief Interview for Mental Status (BIMS) documented 00 indicating R33 was not able to complete the interview. The Quarterly MDS assessment completed on 9/10/21 indicates 1 stage 3 pressure injury and total assist from staff for bed mobility/ positioning. R33 has an activated POA (Power of Attorney) for healthcare. The Brief Interview for Mental Status (BIMS) documented 00 indicating R33 was not able to complete the interview. The wound assessments were reviewed. A Wound/Skin assessments dated 3/24/21 indicates fissure above sacrum reopened, MD (Medical Doctor) and POA updated. measured 2 cm (centimeter) x 0.5 cm depth 0.1 cm 25% epithelial tissue. The fissure sacrum wound was not assessed again for 3 weeks, it was not assessed the week of 3/27- 4/2/22, 4/3-4/9, and 4/10-4/16/22. There were no care plan revisions when the fissure reopened. The fissure above the sacrum was not assessed again until 4/22/21 and on 4/29/21. The 4/29/21 assessment documents 0.9 cm by 0.2 cm with a depth of 0.2 cm and 100% epithelial cells. On 5/13/21 an assessment indicated the fissure became larger measuring 1.5 cm by 2.8 cm by 0.1 cm importance of offloading and MD was called for new treatment. The new treatment was for foam dressing to be changed daily rather than every 3 days. On 5/27/21 the care plan identified fissure to sacrum; blister to left anterior foot; reddened areas and pressure ulcers. There are no care planned interventions that correlate with this date. On 6/10/21 an assessment indicated slough in fissure started. On 6/17/21 the Fissure continues to the superior sacrum. On 7/4/21 a care planned intervention of a cushion in the Broda chair was added. R33 had a hospital visit from 7/17/21 - 7/23/21 for an unresponsive episode. R33 received fluids and had a stage 3 pressure injury on the sacrum. The Hospital Discharge Summary on 7/23/21 indicates cleanse sacral wound 2 x 2 with Dakin's and cover with wet to dry keep frequently turned. Upon readmission into the facility on 7/23/21, the Nurses Notes do not indicate the MD was notified of the hospital discharge wound treatment recommendations. The facility continued using the previous treatment until 7/29/21. There was no wound assessment upon readmission into the facility on 7/23/21. On 7/29/21, the facility's wound assessment indicates the fissure evolved to a stage 3 pressure injury. The change in the wound assessment to a stage 3 pressure injury correlates with a hospital stay (7/17-7/23/21). The hospital documents a stage 3 pressure injury upon admission into the hospital on 7/17/21. Surveyor noted R33's pressure injury was not assessed appropriately from a fissure that was actually a pressure injury. Upon return from the hospital stay on 7/23/21, R33 had a stage 3 pressure injury to the sacrum. The hospital discharge instructions had a treatment order. This treatment order was not relayed to the physician at the facility upon readmission on [DATE]. R33 did not have a wound assessment upon return from the hospital. The Treatment Administration Record for July 2021 has a MD order starting on 7/1/2021. This order indicates to clean fissure to buttocks with normal saline, pat dry, apply skin sealant peri-wound, apply Santyl ointment topically nickel thick to wound bed, cover with foam dressing daily until healed. This was documented as being administered, except during the hospital stay, until discontinued on 7/29/21. A new treatment order started on 7/29/21 to cleanse open area to sacrum with normal saline, pat dry, apply skin sealant to peri-wound, apply Santyl ointment topically nickel thick to wound bed only, cover with foam dressing daily. This was administered and then discontinued on 9/3/21. On 8/10/21 there is a care plan intervention to limit time up to 60 minutes during meals. Wound/Skin assessments with changes from a stage 3 to a stage 4 pressure injury were noted on the following: On 10/4/21 the wound/skin assessment indicated sacrum pressure injury is a stage 3 measuring 3.0 cm by 1.5 cm by 1.5 cm wound worse becoming larger and deeper. On 10/7/21 the wound/skin assessment indicated pressure injury declined with tunneling noted. There is no correlation with MD notification or change in plan of care. On 10/13/21 the care plan identified fissure has evolved into a pressure injury to the sacrum. On 10/13/21 an intervention of a protein supplement was added. On 10/14/21 the wound/skin assessment indicated slough in wound, no MD notification The MD progress note dated 10/27/21 indicates wound declining. Encourage nutrition and continue with wound specialist. There is an MD order for a nutritional supplement twice a day for wound healing. The MD progress note indicate stage 3 afterwards. On 10/28/21 the sacrum progressed to a stage 4 pressure injury from a stage 3 pressure injury. The medical record does not contain any care planned intervention revisions, MD or POA notifications when on 10/28/21, the wound declined to a stage 4 pressure injury. On 2/8/22 the care plan identified a fissure evolved into a pressure injury to the sacrum. On 2/11/22 an intervention of a nutritional supplement was added. On 4/12/22 the care plan identified a chronic stage 4 pressure injury to sacrum. There is no updated intervention. On 4/12/22 the care plan identified non-compliance with repositioning at times; dependent on staff for repositioning; incontinent of bowel and bladder. There are no updated interventions. On 4/13/22 at 2:02 PM RN-G provided Surveyor with the CNA (Certified Nursing Assistant) plan of care. The plan of care indicates the following for Skin Care: CCC mattress with pump. Broda chair. Float heels off bed. Offloading boots to be worn in chair. Reposition every 2 hours and as needed. Avoid direct pressure to sacrum as much as possible using slip sheet. Encourage R33 to keep the maximum amount of time in their chair to 60 minutes during meals to promote healing. For Toileting R33 is a check and change every 2 hours for incontinence of bowel and bladder. R33 is a 2 person Hoyer lift for transfers. On 04/13/22 at 01:25 PM Surveyor spoke with RN-G (Registered Nurse). RN-G indicated [R33] has declined overall in nutrition and physical activity which has contributed to the pressure injury RN-G reported [R33] does not have pain with treatment to the pressure injury. RN-G does not know why there is a cushion in the Broda chair. The Broda chair has its own pressure relief. Surveyor observed R33's pressure injury at this time with RN-G. RN-G removed the dressing from the sacrum. There was no date on the dressing. RN-G indicated they have talked with MD-P about nutrition and possible bladder catheter. RN-G indicated R33 has not had any infection in the wound. R33 has barrier cream placed around the surrounding skin. Surveyor observed the surrounding skin to appear macerated and R33 is incontinent of bladder. R33's pressure injury has not been assessed /visualized by any physician or nurse practitioner since their hospital stay from 7/17-7/23/21. RN-G indicated this area started as a fissure (the fissure was not assessed accurately as a pressure injury) and has been in communication with R33's POA . The POA indicated they want R33 managed here in the facility. R33 has limited mobility and there are struggles with moving R33 for transportation. R33's stage 4 pressure injury has no odor or drainage. During the observation of treatment, RN-G applied Santyl with a q-tip to the wound bed, followed by calcium alginate. RN-G then covered the area with a foam dressing. RN-G could not find barrier cream in the room and indicated they will find some later. RN-G indicated R33 uses a heel manager and does not wear pressure relief boots. RN-G indicated they will verify why there was a seat cushion. RN-G indicated R33 does not like to be on positioned on their side. On 04/13/22 at 02:02 PM, RN-G spoke with Surveyor who stated [R33] is not supposed to have a cushion in the Broda chair. RN-G indicated they will remove the cushion. RN-G also stated they will remove the (2/25/21) heel boots from the care plan. RN-G stated [R33] should be using the heel manager or off-loaded device. RN-G stated she would look for when the pressure injury changed to a stage 4 pressure injury and what revisions were made (to the care plan). RN-G will find out more information related to wound changes and interventions. On 4/13/22 at 3:20 PM, Surveyor shared R33's wound concerns with Administration at the facility exit meeting. On 04/14/22 at 02:29 PM Surveyor spoke with RN-G. RN-G indicated on 10/13/21 (she), spoke with Wound NP (Nurse Practitioner) about worsening of the wound, vitamins and nutritional supplements. (There is no documentation of this discussion.) RN-G indicated the plan of care was revised to avoid pressure to sacrum; monitor intakes; encourage to be up un chair for just 60 minutes for mealtimes; protein and nutritional supplement. On 04/14/22 at 10:37 AM, RN-G told Surveyor they did communicate to MD-P the stage 4 change. However, the conversation is not documented reflecting any changes in the plan of care. On 4/14/22 at 3:30 PM Surveyor shared the concerns with R33's wound with Administration at the facility exit meeting. On 04/14/22 at 03:46 PM Surveyor spoke with MD-P who reported they did not see the wound and does not recall if they knew resident had a stage 4 (pressure injury). MD-P's progress notes do not indicate a stage 4 pressure injury. MD-P did not see the pressure injury. There is an MD order on 10/26/21 to switch the nutritional supplement from Prosource to Arginaid, twice a day for wound healing. The MD progress note dated 10/27/21 indicates wound declining. Encourage nutrition and continue with wound specialist. Surveyor observed there was no indication in the record that R33 was being seen by a wound specialist. The wound assessment indicates on 10/28/21 the sacrum progressed to a stage 4 pressure injury from a stage 3 pressure injury. The medical record does not contain any intervention revisions, MD or POA notifications when wound deteriorated to a stage 4 pressure injury on 10/28/21 On 04/18/22 at 09:05 AM Surveyor observed R33 up in a Broda chair with a gel cushion on the seat. R33 also has a Hoyer sling behind R33's back while R33 was seated on the gel cushion. R33 was in the lounge area on unit. On 04/18/22 11:09 AM Surveyor spoke with DON-B (Director of Nurses) regarding R33 seat cushion in the Broda chair, R33's pressure injury concerns with the change of wound, and no care plan revisions/interventions with changes identified through the assessment. DON-B indicated the weekly wound assessments get reviewed by Corporate for interventions. The gel cushion information was provided to Surveyor. The gel cushion manufacturer indicates it is designed for users at moderate RISK for skin breakdown. On 04/18/22 at 03:27 PM, RN-G stated there should be no gel cushion in the Broda. RN-G reported the (pressure injury) area was originally assessed as a fissure. RN-G continued calling it a fissure. On 4/19/22 at 9:00 AM RN-G provided Surveyor with a fax to MD-P. The fax was dated 4/19/22 at 8:30 AM and requests a wound consult and a Foley catheter for bladder. This was just sent and no response noted from MD-P at this time. 2. R2's diagnoses includes Diabetes Mellitus, Atrial Fibrillation, Chronic Obstructive Pulmonary Disease, Hypertension, sleep apnea, and morbid obesity. The CNA (Certified Nursing Assistant) Assignment Sheet not dated under skin care includes Float feet off of bed with heel manager or equivalent device every shift. and DTPI (deep tissue pressure injury) to left lateral foot. The Impairment of skin integrity care plan dated 2/6/20 has the following approaches: * Assess skin condition daily and note any changes, Treat as ordered, Keep clean and dry, apply tubigrips per MD (medical doctor) order, monitor feet daily notify MD of any changes dated 2/6/20. * Assist with hygiene and general skin care, Reposition every two hours, and PRN (as needed) remove tubigrips at HS (hour sleep), elevate legs whenever possible Keep skin clean and dry, Use lift sheet when moving resident in bed dated 2/6/20 & 4/9/21. * Provide ordered diet, Offer replacement food, Determine food likes dated 2/6/20. * 1:1 visits, Encourage activity participation dated 2/6/20. * P.T. (physical therapy) Evaluate, Treat as indicated 2/6/20. * O.T (occupational therapy) Evaluate, Treat as indicated 2/6/20. * S.T. (speech therapy) Evaluate, Treat as indicated 2/6/20. * Assess skin condition daily and note any changes, Treat as ordered, Keep clean and dry, apply tubigrips per MD order, monitor feet daily notify MD of any changes skin assessment weekly due to at risk for skin breakdown due to immobility, diabetes, PVD (peripheral vascular disease), HX (history of) cellulitis Braden scale completed every quarter dated 4/9/21. * Complete tx (treatment) per MD order dated 9/17/21. * Encourage [Resident's first name] to wear shoes when in his w/c (wheelchair) dated 12/1/21 * Administer oral ABT (antibiotics) per MD order dated 2/4/22. * Encourage [Resident's first name] to elevate BLE (bilateral lower extremity) while in bed, assist in trimming finger nails on shower days and PRN dated 2/4/22. * Assist with hygiene and general skin care, Reposition every two hours, and PRN float heels off of bed, tubigrips at HS, elevate legs whenever possible Keep skin clean and dry, Use lift sheet when moving resident in bed dated 3/8/22. * Report shower refusals to nurse promptly dated 3/8/22. * Tubi grips on in am (morning) off at HS, encourage [Resident's first name] to elevate his BLE while in bed dated 4/1/22. * Complete tx per MD order, update MD of any s/s (sign/symptoms) of infection dated 4/1/22. * Float feet off of bed with heel manager or equivalent device every shift NOC (night) AM (day) PM (evening) dated 4/1/22. * Encourage to reposition every 2 hours and PRN, report refusals to nurse dated 4/12/22. The annual MDS (Minimum Data Set) with an assessment reference date of 12/28/21 documents a BIMS (brief interview mental status) score of 15 which indicates cognitively intact. R2 requires extensive assistance with two plus person physical assist for bed mobility & transfer, does not ambulate and is dependent with two plus person physical assist for toilet use. R2 is occasionally incontinent of urine and bowel. R2 is at risk for pressure injuries and is coded as not having any pressure injuries. The podiatry consult dated 3/25/22 under progress notes documents He states feet are mostly numb. Noticed a blood blister still full of blood lateral left foot I told his nurse to monitor, The weekly wound assessment dated [DATE], late entry for 3/31/22 documents Foot problem/care: **NEW AREA** Has 1+ foot problem eg. corn, callous, bunion, hammer toe, overlapping toe, pain structural problem. Suspected Deep Tissue Injury: Appearance of blood-filled blister, intact skin, Location: left lateral foot. Length: 0.5 cm (centimeters), Width: 0.5 cm, Depth <(less than) 0.1 cm, Drainage: none present clean and dry No odor present, Surrounding Tissue: edema +3, Healing process: new area discovered during podiatry visit per nurse interview, Teaching done: importance of floating feet off of bed, Skin Treatment: Receives turning/repositioning program. float heels off of bed with heel manager or equivalent. Receives application of dressings (with or without topical medications) other than to feet. Procedure done: area cleaned examined measured area off loaded from bed. Action: tx order pending. Surveyor noted this assessment is 6 days after the area was discovered during a podiatry consult on 3/25/22. The physician orders dated 4/1/22 documents skin treatment apply skin sealant to intact blood blister to right (should be left) lateral foot daily AM (day) followed by elevation of BLE (bilateral lower extremity). This order was discontinued on 4/2/22. The physician orders dated 4/2/22 documents Skin treatment: Apply skin sealant to intact blood blister to right (should be left) lateral foot three times a day AM (day) PM (evening) NOC (night) followed by elevation of BLE. The weekly wound assessment dated [DATE] documents Suspected Deep Tissue Injury: Purple/maroon colored, localized area, intact skin, Appearance of blood-filled blister, Location: left lateral foot Length: 2.0 cm, Width: 1.0 cm, Depth: <0.1 cm Tissue Type: Closed, Wound Tissue: NA (nonapplicable), Drainage: none present clean and dry No odor present, Surrounding Tissue: edema Healing Progress: no change, Description: no s/s of infection present Teaching Done: importance of diet and edema control on skin condition Skin Treatment: skin sealant applied to area q (every) shift, edema control, diabetes management Procedure Done: area cleaned examined measured Skin tx done per order Procedure Result: treatment effective. On 4/11/22 at 1:25 p.m. Surveyor reviewed the Facility's pressure injury list and noted R2 is listed for a left foot DTPI. On 4/11/22 at 2:00 p.m. Surveyor observed R2 sitting on the edge of the bed. Surveyor asked R2 if he has any skin impairments on his feet. R2 replied they said while ago had a couple of blisters but I can't see them. R2 also informed Surveyor the Podiatrist said had a couple of bumps. R2 stated I don't know why I'm not walking and I have black velcro shoes which are not on my feet. R2 informed Surveyor he has diabetes. On 4/12/22 at 11:09 a.m. Surveyor observed R2 in bed on his back with the head of the bed elevated. Surveyor observed R2 heels are resting directly on the mattress and there is not a heels up device on the bed. Surveyor asked R2 if staff ever floats his heels. R2 replied no. On 4/13/22 at 1:01 p.m. Surveyor observed R2 in bed on his back with two transfer bars up. Surveyor observed R2's heels are resting directly on the mattress and there is not a heels up device on the bed. On 4/13/22 at 1:06 p.m. Surveyor observed treatment for R2's left lateral foot pressure injury with RN (Registered Nurse)-D. RN-D with gloves on removed R2's tubi grips & gripper sock from his left lower extremity, removed her gloves, washed her hands, and placed gloves on. RN-D opened the skin prep package and applied skin prep on R2's left lateral foot pressure injury. RN-D then completed the treatment for R2's left shin stasis ulcer. At 1:12 p.m. RN-D asked R2 where his pillows are. R2 informed RN-D they are in the box. RN-D removed her gloves telling R2 the pillows are for under his feet. RN-D placed gloves on, placed R2's tubi grips and gripper sock back on and placed a pillow under R2's legs to float his heels. RN-D removed her gloves and washed her hands. On 4/13/22 at 1:18 p.m. Surveyor spoke with RN-D regarding R2's deep tissue pressure injury. RN-D informed Surveyor the blood blister was caught by the podiatrist. Surveyor asked RN-D how this area developed. RN-D informed Surveyor R2's feet lay out like a frog and assumed the pressure injury developed from the bed. RN-D informed Surveyor R2 doesn't get up very often just for showers or doctors appointments and very rarely attends activities. Surveyor asked RN-D prior to R2 developing this pressure injury were staff floating his feet. RN-D replied I don't believe so. On 4/14/22 at 7:54 a.m. Surveyor entered R2's room with RN-D to observe RN-D administer insulin to R2. Surveyor observed R2 in bed on his back. After RN-D administered R2 his insulin, Surveyor asked RN-D if Surveyor could look at R2's feet. RN-D removed the bedding off R2. Surveyor observed R2's right foot is resting directly on the pillow and the left foot is on the mattress. RN-D informed Surveyor R2 must of kick off the pillow and readjusted the pillow so R2's feet were being offloaded. On 4/14/22 at 10:54 a.m. Surveyor met with MDS/Wound RN-G to discuss R2's pressure injury. Surveyor asked MDS/Wound RN-G what should be under R2's feet when he is in bed. MDS/Wound RN-G informed Surveyor they encourage R2 to use heel manager as long as R2's feet are offloaded and elevated. Surveyor informed MDS/Wound RN-G most of the time Surveyor observed R2 sitting on the edge of his bed but when R2 was laying in bed the only time Surveyor observed anything under his feet was with RN-D when she placed a pillow. Surveyor asked MDS/Wound RN-G how did R2's pressure injury develop. MDS/Wound RN-G informed Surveyor it's the strangest thing, the podiatrist saw it, thought maybe it was from his shoes being too tight but R2 barely wears them. MDS/Wound RN-G informed Surveyor R2 denied any injury to his foot, R2 does have diabetes and he could of bumped his foot on something. MDS/Wound RN-G informed Surveyor R2 has been wearing tubi grips to help manage edema and float heels off bed when possible. Surveyor asked where Surveyor would be able to find diabetic foot checks. MDS/Wound RN-G replied on the TAR (treatment administration record). Surveyor informed MDS/Wound RN-G Surveyor did not note diabetic foot checks on R2's TAR. MDS/Wound RN-G then looked at R2's electronic record and informed Surveyor she's not seeing it. MDS/Wound RN-G stated Usually diabetics have it, I'm still shocked. On 4/18/22 at 10:35 a.m. Surveyor asked CNA (Certified Nursing Assistant)-I if she knew how R2 developed the pressure injury on his left foot. CNA-I replied I sure don't. Surveyor asked if they float R2's feet. CNA-I informed Surveyor lately they have been putting them up on a pillow. Surveyor asked if they started floating R2's feet after he developed the pressure injury. CNA-I replied yes. Surveyor asked if they were floating his feet prior. CNA-I replied no.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R38's diagnoses include epilepsy, chronic atrial fibrillation, diabetes mellitus, schizophrenia, hypertension, and Parkinson's disease. R38's Annual MDS (minimum data set), with an assessment reference date of 1/21/22, documents a BIMS (brief interview mental status) score of 15 which indicates R38 is cognitively intact for daily decision making. R38 requires limited assistance and one person physical assist for bed mobility, transfer & toilet use. R38 requires supervision with set up only for ambulating in room and requires extensive assistance with one person physical assist for ambulating in corridor. R38 is incontinent of urine and continent of bowel. R38 is coded as not having any falls since prior assessment period. On 4/11/22, at 12:16 p.m. Surveyor observed R38 sitting in a wheelchair in his room. R38 showed Surveyor a scar on his right inner forearm. R38 informed he received this last year in May. Surveyor asked R38 what happened. R38 explained there was a piece of wood sticking out on his footboard and begged maintenance for a long time to fix it, but they said they didn't have time. R38 informed Surveyor he also asked for tape to cover the wood sticking out. R38 informed Surveyor one time he got up and ran into it and had to have stitches. R38's nurses note dated 5/8/21, documents incident type: resident reported a fall, date of incident: 5/8/21, location: resident's room; resident's condition prior: orientated; activity at the time: walking; equipment involved: wheelchair (was not using); injury: laceration; injury location: left forearm (should be right), injury; measurement: 10 cm (centimeters) x (times) 2.5 cm; first aid: DSD (dry sterile dressing) and kerlix; first aid: wrap to forearm transferred to emergency room vitals blood pressure 122/74, pulse 70, respiratory rate 18, temp (temperature) 98.0, neurochecks right hand grasp weak (r/t (related to) pain from laceration) left hand grip firm staff involved: nurse; witnesses: none R38's nurses note dated 5/8/21 documents Resident returned from ER (emergency room) accompanied by 2 paramedic staff. Hospital sutured lac (laceration) on right forearm. Has order for suture removal on 5/18/21 [name of hospital] in emergency department. Resident drowsy but able to answer/ask questions. The after visit summary from hospital dated 5/8/21 documents laceration care. R38's nurses note dated 5/8/21, includes documentation of measurements right arm of 10.0 cm, 2.5 cm, 0.1 cm well approximated with 13 sutures. R38's nurses note dated 5/11/21 includes documentation of skin problems: laceration, drainage: none present no odor present, description: no s/sx (signs/symptoms) of infection noted, sutures intact. On 4/11/22, at 12:17 p.m., Surveyor asked R38 why he doesn't have a foot board on his bed. R38 informed Surveyor maintenance took it off. Surveyor asked why they didn't give him another one. R38 informed Surveyor they were afraid something would happen because he's so tall. R38 informed Surveyor they angled his bed so he could see the TV. R38 stated to Surveyor They haven't apologized for what happened referring to the scar on his right forearm. On 4/14/22, Surveyor reviewed R38's incident investigation for date of 5/8/21 at 1:10 a.m. Under description of incident for what resident stated regarding incident I slipped on the way from the toilet. For root cause identified documents resident not using w/c (wheelchair) For resident injury/outcome documents Laceration to right forearm; resident sent to ER for possible stitches or staples to area. There is a handwritten notation attached to R38's incident investigation which documents Return from hospital, resident stated he cut arm on footboard. Maint (maintenance) immediately addressed. On 4/14/22, at 11:04 a.m., Surveyor asked MDS/Wound RN (Registered Nurse)-G if she was involved with R38's fall on 5/8/21. MDS/Wound RN-G replied no and explained she wasn't the nurse for either fall but does recall the laceration and sutures. Surveyor asked MDS/Wound RN-G how R38 received the laceration. MDS/Wound RN-G informed Surveyor R38 wasn't using his wheelchair and was walking. Surveyor asked what R38 cut his forearm on. MDS/Wound RN-G informed Surveyor she thinks it may have been the footboard. On 4/14/22, at 11:14 a.m., Surveyor asked MS (Maintenance Supervisor)-E if he was involved with R38's fall on 5/8/21. MS-E informed Surveyor R38 fell on the weekend and he wasn't here. MS-E informed Surveyor he removed the footboard because it was cracked. Surveyor asked if R38 mentioned to him his footboard had sharp edges before the fall. MS-E replied I don't recall. On 4/18/22 at 12:07 p.m. MT (Maintenance Tech)-H informed Surveyor he saw R38's footboard after the incident. MT-H informed Surveyor he didn't see anything on their log regarding R38's footboard and does walk around Resident's room. Surveyor inquired if there are any maintenance logs when Resident's beds including headboard or footboards are inspected. MT-H informed Surveyor they do a walk around the room, has glanced in R38's room and doesn't recall anything on the footboard. MT-H informed Surveyor R38 does close his door. On 4/19/22 at 9:08 a.m. Surveyor asked R38 who in maintenance he spoke to regarding his footboard. R38 informed Surveyor last night after supper MT-H came to speak to him. R38 informed Surveyor he had spoken to MS-E. R38 informed Surveyor he told MT-H a piece of wood was sticking out of the footboard and MT-H told him it was a piece of plastic. R38 stated he told MS-E every day for a week before the accident but not on the weekend as there is no maintenance here on the weekend. MS-E told him he was too busy and the day before the accident he asked MS-E for tape to do it himself but MS-E said he had to do it but was too busy. R38 informed Surveyor his right arm got in contact with the object sticking out, must of hit his head as there was blood everywhere and a gash in his skin. R38 again showed Surveyor the scar on his right inner forearm and stated his sister hasn't seen it yet. 3. R31 was admitted to the facility on [DATE] with diagnoses that include dependence on renal dialysis, acute & chronic respiratory failure, anoxic brain damage, and schizoaffective disorder bipolar type. R31's potential for trauma-falls care plan, dated 12/1/18, includes the following approaches: * Observe, record, and report all unsafe conditions and situations, Anticipate fall times, Instruct on safety, dated 12/1/18; * Call light in reach, Toilet every 2 hours and as needed, Anticipate needs, Floor mat on floor beside bed when resident is in the bed, (the right side of bed), dated 12/1/18; * Call light in reach, Toilet every 2 hours and as needed, Anticipate needs, floor mat on both sides of [first name] bed, dated 12/12/18; * Observe, record, and report all unsafe conditions and situations, Anticipate fall times, Instruct on safety, dated 4/28/21; * Call light in reach, Toilet every 2 hours and as needed, Anticipate needs, floor mat on both sides of [first name] bed, dated 4/28/21. The last fall assessment was completed 11/30/20. The CNA (Certified Nursing Assistant) Assignment Sheet, not dated, under the safety Equipment section documents Floor mat on right side of bed in lowest position. Enabling bars on bed. R31's quarterly MDS (minimum data set), with an assessment reference date of 1/26/22, documents a BIMS (brief interview mental status) score of 5 which indicates severe impairment related to daily decision making. R31 is dependent with two plus persons for bed mobility, transfer, & toilet use and does not ambulate. R31 is always incontinent of bowel and bladder and is coded as not fallen since prior assessment period. On 4/12/22, at 11:06 a.m., Surveyor observed R31 in bed on his back with the head of the bed elevated and two transfer bars up. Surveyor observed R31's call light is on the floor and not within reach. Surveyor also observed there were no mats on the floor next to R31's bed. On 4/12/22, at 12:23 p.m,. Surveyor observed R31 in bed on his back with two transfer bars up. Surveyor observed R31's call light is now within reach. Surveyor observed there are still no mats on the floor next to R31's bed. On 4/14/22, at 8:01 a.m., Surveyor observed R31 in bed on his back with the head of the bed elevated with two transfer bars up. Surveyor did not observe a mat on the floor next to R31's bed. On 4/14/22, at 8:56 a.m., Surveyor observed R31 continues to be in bed on his back with the head of the bed elevated and two transfer bars up. Surveyor did not observe a mat on the floor next to R31's bed. On 4/14/22, at 1:30 p.m., Surveyor observed R31 in bed on his back with his eyes closed. Surveyor did not observe a mat on the floor next to R31's bed and R31's bed is not at the lowest position. On 4/14/22, at 1:32 p.m., Surveyor asked RN (Registered Nurse)-D if she knew which CNA (Certified Nursing Assistant) was assigned to R31. RN-D asked Surveyor if Surveyor needed something. Surveyor explained to RN-D Surveyor wanted to ask if R31 is suppose to have mats on the floor next to his bed. RN-D replied I believe he is. RN-D then reviewed the CNA assignment sheet, printed on 4/7/22, and informed Surveyor R31 is to have a mat on the right side of the bed, bed in lowest position and has enabling bars on the bed. At 1:34 p.m., Surveyor informed RN-D there is not a mat on the floor next to R31's bed and the bed is not at the lowest position. RN-D stated she will get right on it now. On 4/14/22, at 3:56 p.m., during the end of the day meeting Administrator-A and DON (Director of Nursing)-B were informed of the above. On 4/19/22, at 9:15 a.m., Surveyor observed R31 in bed on his back with the head of the bed up. Surveyor observed R31's bed is not at the lowest position and there is no mat on the floor next to R31's bed. Surveyor did observe a gray mat along the wall as you enter R31's room on the right side. Based on observation, interview, and record review, the facility did not ensure that 3 (R32, R38, R31) of Residents reviewed for accidents had adequate assistance devices and interventions in place to prevent accidents and that the environment was free of accident hazards. * R32 was assessed as being unsafe with smoking 8/25/21. On 4/10/22, R32 was outside smoking with a family member. R32 sustained a second or third degree burn to the left anterior knee. R32 stated he did not mean to burn himself. R32 was allowed t smoke without staff supervision. *On 5/8/21, R38 fell in his room sustaining a laceration that required 13 sutures. R38's interviews reveals prior to the fall he had informed maintenance about a piece of wood sticking out from bed footboard. He asked for this to be fixed or for tape to fix it himself. R38 informed Surveyor he was told they (maintenance) were too busy. There is no evidence maintenance inspected R38's footboard prior to 5/8/21. R38 received the laceration when he fell against the protruding wood on the footboard. * R31 was observed without a mat on the floor next to the bed and the bed not in the lowest position according to R31's care plan interventions. Findings include: The facility smoking policy with revised date of 6/2020, indicates: . Protocol: 1. The facility prohibits smoking and tobacco use on all company premises in order to provide and maintain a safe and healthy environment for all. a. Company premises is defined as up to the property boundaries of all facilities. *with the exception of the southeast corner of the courtyard on the east side of the building . 3. The smoke and tobacco free policy applies to: a. All areas of buildings occupied by residents and employees. b. All vehicles owned or leased by the facility. c. All visitors (customers, vendors and volunteers) on facility premises. d. All contractors and consultants and/or their employees working on facility premises. e. All residents. f. All employees, including temporary employees. g. All student interns. 5. Employees are not allowed to assist residents in smoking or chewing as they are not allowed to leave the campus property while working. Families that wish to assist residents may do so after signing the resident out on the Resident Sign Out Form and leaving campus property. 1. R32 was admitted to the facility on [DATE]. R32's smoking assessment, dated 8/25/21, indicates R32 memory impaired oriented to person, has difficulty making decisions in new situations, makes decisions which are poor; requires cues and supervision when making decisions. Lights/extinguishes cigarette safely: no: someone to assist him Physically capable of managing smoking: needs assistance. Level of assistance required: needs assistance with: lighting cigarette. R32's quarterly MDS (minimum data set), dated 1/26/22, indicates R32 has cognitive impairment, is dependent with bed mobility, transfers, locomotion on and off the unit, and has mobility issues with his upper and lower extremities. R32's nurses note, dated 4/10/22, indicates open area on left knee. 1 by 0.5 granulation tissue no drainage or odor. Applied dressing to left knee. R32's nurses note, dated 4/11/22, indicates New area has second or third degree burn (s) .superior to left anterior knee 1.0 cm (centimeter) by 0.5 cm by < (less than) 0.1 cm UTA (unable to assess) wound bed to 100% dry tan exudate in place. Area circular in shape. resident stated I didn't mean to burn myself. R32's incident investigation, dated 4/11/22, indicates writer discovered area of skin impairment at time of assessment. Other causal factors: resident smokes primarily with daughter. Physician and POA (Power of Attorney) notified. R32's April 2022 MAR (medication administration record), indicates on 4/11/22 an order was obtained to Cleanse open area to left anterior knee with NS (normal saline) pat dry apply skin sealant to periwound apply silvadene ointment to wound bed topical daily f/b (followed by) dry gauze secure with kerlix AM (morning) R32's smoking assessment, dated 4/13/22, indicate: Holds cigarette safely: no; burn discovered to left anterior left, resident admits he had burned himself with a cigarette, but didn't mean to. Level of assistance required: Needs assistance with entire smoking process. Resident noted to be an unsafe smoker. The above information reviewed with NHA (Nursing Home Administrator), DON(Director of Nursing), and SSD (Social Service Director). POA is aware of findings and agrees that resident is an unsafe smoker due to his ability to fall asleep quickly and frequently. pending further investigation. On 4/13/22, at 3:30 PM, during the daily exit meeting with DON-B, Wound Nurse-G and NHA-A, Surveyor asked how R32 burned himself with a cigarette when R32 is assessed to be dependent and cognitively impaired. Wound Nurse-G stated R32 goes out to smoke with daughter when she visits. Wound Nurse-G stated R32's daughter is not sure how the burn happened. R32's POA (Power of Attorney) stated R32 doses off while smoking. On 4/14/22, at 10:02 AM, Surveyor interviewed Wound Nurse-G. Surveyor asked if the cigarette burn was assessed and treated on 4/10/22. Wound Nurse-G stated when she came in on 4/11/22 she discovered the cigarette burn and obtained orders for treatment from the physician. On 4/14/22, at 3:30 PM, during the daily exit meeting with DON B, Wound Nurse G and NHA A, Surveyor explained the concern R32 sustained a cigarette burn on 4/10/22 while he was outside with his daughter. A treatment for the burn was not obtained until 4/11/22. Surveyor also explained the concern R32 is dependent for most ADLs (activities of daily living) yet was not monitored while outside smoking. As of 4/18/22, Wound Nurse G had no additional information.