**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of Resident Identifier (RI) #44's medical record, the facility failed to develop an individualized care plan for RI #44, a resident totally dependent on staff for all Activities of Daily Living (ADLs), to address RI #44's right leg that was turned outward laterally and rested on the bed, when the resident was placed on bedrest on 10/4/18. The facility further failed to ensure RI #44's use of bilateral heel booties (Posey Heel Pillows), worn daily for the protection and prevention of pressure ulcers, were addressed in RI #44's care plans. These failures to develop and implement interventions to address RI #44's positioning and pressure relief caused RI #44 to develop a facility-acquired Stage IV pressure ulcer on the right outer (lateral) ankle on 11/26/18 that measured 1.8 centimeter (cm) by 1.4 cm with 0.4 cm of depth. The pressure ulcer was assessed as having minimal drainage, no odor and exposed bone. These deficient practices affected RI #44, one of 16 sampled residents and placed RI #44 in immediate jeopardy, as these failures were likely to cause serious injury, harm or death. On 1/22/19 at 8:40 PM, the Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing, Social Service Designee and Secretary were notified of the findings of immediate jeopardy in the area of Comprehensive Resident Centered Care Plans, F656. Findings include: RI #44 was admitted to the facility on [DATE], with a medical history to include diagnoses of: Alzheimer's disease, Dementia, Rheumatoid Arthritis and Chronic Venous Stasis Disease. RI #44's Quarterly Minimum Data Set (MDS) with an assessment reference date of 9/27/18, revealed RI #44 was totally dependent on staff for all ADLs and had range of motion limitation in the upper and lower extremities on both sides of his/her body. According to this MDS, RI #44 did not have any unhealed pressure ulcers but was at risk for developing pressure ulcers. RI #44's care plan titled Potential Alteration in Skin Integrity R/T (related to) thin, fragile skin, decreased mobility, incontinence . last reviewed 10/1/18, did not include an approach for the use of the Posey Heel Pillows used by the resident or approaches to address pressure relief for RI #44's right leg that was turned outward and rested on the bed. In an interview on 1/17/19 at 12:57 PM, Employee Identifier (EI) #8, a Certified Nursing Assistant (CNA) who routinely cared for RI #44 during the first shift (7:00 AM to 3:00 PM), stated when she was assigned to care the resident, she would keep the heel protectors (Posey Heel Pillows) on RI #44. On 1/18/19 at 9:17 AM, RI #44 was observed wearing heel protectors on both feet. On 1/18/19 at 9:40 AM, EI #5, a Registered Nurse (RN)/Treatment Nurse, was asked to describe RI #44's right leg. EI #5 explained RI #44's right leg was turned which caused the right leg and ankle to lay on the lateral side. When asked how long RI #44's leg has been that way, EI #5 stated for as long as she had known the resident, about five to six years. When asked how long RI #44 has been wearing the heel booties, EI #5 stated the heel booties were on RI #44 when she (EI #5) started working at the facility. In an interview on 1/18/19 at 12:52 PM, EI #21, a Licensed Practical Nurse (LPN) was asked if there was any guidance in RI #44's care plans related to how the resident's legs were positioned. EI #21 stated she was not familiar with that. In an interview on 1/18/19 at 1:37 PM, EI #2, the Director of Nursing (DON) stated RI #44 has a care plan for skin integrity but the heel booties were not addressed on that care plan. When asked if the care plan should have addressed RI #44's use of bilateral heel booties, EI #2 said yes. When asked to describe RI #44's leg and how it was positioned, EI #2 stated RI #44 had feet contractures and the resident use to do leg lifts all the time but then one day, the resident stopped. An x-ray was ordered and a Computed Tomography (CT) scan confirmed a fracture. EI #2 was asked why RI #44 was placed on bed rest on 10/4/18. EI #2 replied, when the final report was received that confirmed RI #44 had a fracture, the physician, EI #1, wanted to see if bed rest would give the fracture a chance to heal. When asked why bedrest was discontinued on 11/27/18, EI #2 replied, because of the presence of the pressure ulcer. RI #44's PHYSICIAN'S ORDER for November 2018 documented . Bed rest 10/4/18 . RI #44's NURSE'S NOTES dated 11/27/18, written by EI #2, the DON documented 3p (3:00 PM) - DON spoke (with) (EI #1) & he agreed to D/C (discontinue) bedrest. In an interview on 1/18/19 at 4:22 PM, EI #13, a LPN was asked what preventative measures were in place before a pressure ulcer was identified on RI #44 on 11/26/18. EI #13 stated, (heel) booties. When asked how long RI #44 had worn the heel booties, EI #13 stated a long time. EI #13 was asked if there was any guidance in RI #44's care plans related to how the resident's legs were positioned. EI #13 said she didn't know of any. In a follow-up interview on 1/19/19 at 9:50 AM, EI #8, a CNA was asked to describe RI #44's and how they are positioned. EI #8 stated RI #44's feet are turned in and the resident presses his/her feet down into the bed. When asked why RI #44's wore the bilateral heel booties (Posey Heel Pillows), EI #8 said RI #44 wore them to keep from getting pressure sores on his/her feet while in the bed. During an interview on 1/19/19 at 10:33 AM, EI #6, a CNA who routinely cared for RI #44 during the first shift, was asked how often RI #44 wore the heel booties. EI #6 stated, every day for the protection from sores and wounds. In an interview on 1/19/19 at 11:08 AM, EI #9, a CNA who routinely cared for RI #44 during the third shift (11:00 PM to 7:00 AM), was asked why RI #44 wore heel booties. EI #9 stated to protect the resident's feet from pressure sores. When asked who often RI #44 wore the heel booties, EI #9 stated every night she worked with RI #44, the resident had them on. On 1/19/19 at 11:53 AM, EI #22, a LPN stated RI #44 always had the heel booties on while in bed. According to EI #22, in November 2018, EI #8, a CNA came to her and informed her RI #44 had a place on his/her ankle. EI #22 stated she told EI #8 to let EI #2, who was at the time, the Assistant Director of Nursing (ADON) know. EI #22 stated EI #2 later informed her the place on RI #44's ankle was a Stage IV pressure ulcer. RI #44's WOUND RECORD revealed a Stage IV pressure ulcer on the resident's right outer (lateral) ankle was first observed on 11/26/18 by EI #2, the DON. The pressure ulcer measured 1.8 centimeter (cm) by 1.4 cm with 0.4 cm of depth. The pressure ulcer was assessed as having minimal drainage, no odor and exposed bone. During a telephone interview on 1/19/19 at 1:17 PM, EI #12, a CNA who routinely cared for RI #44 during the 2nd shift (3:00 PM to 11:00 PM), stated RI #44 used to be able to lift both legs but after an x-ray, the resident could not move his/her right leg anymore. According to EI #12, she reported it to a nurse but didn't know if anything was done about it. When asked how often RI #44 wore the heel booties, EI #12 stated, every day. In an interview on 1/19/19 at 2:07 PM, EI #2, the DON was asked why RI #44 wore heel booties. EI #2 said for protection; RI #44 had a history of stasis ulcers. When asked how long RI #44 had worn the heel booties, EI #2 said she was not sure. When asked why the heel booties were not care planned, EI #2 said she just overlooked them. EI #2 was asked should the heel booties have been care planned. EI #2 replied, yes they should have been. When asked what information should have been included on RI #44's care plan related to the heel booties, EI #2 said when and how often to apply and check for skin integrity. EI #2 explained RI #44 used to do leg lifts but after September (2018), the resident stopped moving the right leg. When asked what was done after RI #44 stopped moving the right leg to relieve pressure, EI #2 said nothing new. When asked who was responsible to ensure interventions were implemented, EI #2 stated it was all of our responsibility. EI #2 was asked why nothing was implemented and she replied, nobody did anything. When asked if RI #44's care plan related to the resident's fracture addressed any approaches for positioning and/or pressure relief, EI #2 said no. EI #2 was asked why there was no individualized approaches for positioning and/or pressure relief. EI #2 replied it was overlooked. When asked should there have been any individualized approaches to address RI #44's leg positioning and/or pressure relief, EI #2 said yes. During an interview on 1/20/19 at 3:49 PM, EI #14, a LPN familiar with RI #44's care, was asked what interventions should have been included to RI #44's care plans to address pressure ulcer development, EI #14 said to keep something under RI #44's feet so that the resident's feet were off the bed. On 1/20/19 at 5:05 PM, RI #44 was observed in bed with bilateral heel booties on. RI #44's right leg was turned out laterally with the right ankle resting in the heel pillow on the bed. On 1/20/19 at 5:05 PM, RI #44 was observed in bed wearing bilateral heel pillows. RI #44's right leg was turned out laterally with the right lateral ankle resting on a heel pillow on the bed. There was a pillow between the resident's legs with the left lower leg on top of the pillow and the right lower leg under the pillow. In an interview with RI #44's sponsor on 1/21/19 at 10:47 AM, she was asked how long had RI #44 wore the heel booties. RI #44's sponsor the whole time RI #44 had been in the facility. RI #44's sponsor explained RI #44 wore them all the time, whether in or out of bed. In a follow-up interview with RI #44's sponsor on 1/22/19 at 2:59 PM, she was asked what position was RI #44 in when she visited. RI #44's sponsor stated RI #44 was in bed on his/her back, with the head of bed elevated, heel booties on with the right lateral ankle laying on the bed. RI #44's sponsor explained that when RI #44 was found to have a fracture, the facility placed the resident on bed rest to not strain the fracture. During an interview on 1/22/19 at 1:09 PM, EI #2, the DON was asked what was done to prevent pressure ulcer development when RI #44 was placed on bed rest on 10/4/18. EI #2 replied, nothing new; there was no change in the resident's care plans. EI #2 explained there was a care developed for the fracture but it didn't address any new interventions. When asked who was responsible for updating RI #44's care plans with interventions after 10/4/18, EI #2 stated it would have been her. On 1/22/19 at 3:35 PM, RI #44 was observed in bed wearing heel booties. RI #44's right lateral ankle was positioned on the bed. RI #44 was observed lifting his/her left leg up and down. ************************* On 1/24/19 at 5:20 PM, the facility submitted an acceptable Allegation of Compliance (AOC), which documented: Allegation of Compliance-Care Plan Resident #44 Plan of Care was updated to include 6 inch Skil-Care Standard Foot Elevator to right lower leg and Posey Heel Pillows/Foot Positioner to left foot. Skin integrity checks are to be performed every two hours and documented on TAR by charge nurse that completed the check. Completed 01/23/2019 All Care Plans on Skin integrity to be evaluated by Care Plan team to assure all adaptive equipment for pressure relief is care planned for appropriate use of equipment including q (every) 2 hours skin integrity checks. Care Plans are to be revised as needed. Oversight to be completed by DON. Completed on 01/24/2019 All members of the MDS/Care Plan Committee are to be re-educated by DON regarding the necessity of formulating care plans to be specific to residents and that the Care Plan address the resident's individual needs. Completed on 01/24/2019 ************************* After reviewing the facility's information provided in their AOC and verifying the immediate actions had been implemented, the scope/severity level of F656 was lowered to a D level on 1/25/19, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of Resident Identifier (RI) #44's medical record, the facility's policy titled Prevention of Pressure Ulcers/Injuries and the manufacturer's information for the Posey Heel Pillows/Foot Positioner WOUND PREVENTION, the facility failed to address pressure relief for RI #44's right leg that was turned outward and rested on the bed. RI #44, a resident totally dependent on staff for all Activities of Daily Living (ADLs) and at risk for pressure ulcer development, was placed on bed rest on 10/4/18. When placed on bed rest, there were no changes in RI #44's treatment plan to address the resident's right leg. According to staff interviews, RI #44 wore bilateral heel booties (Posey Heel Pillows) every day. The facility further failed to follow the manufacturer's recommendations to remove the Posey Heel Pillow every two hours and check for skin integrity. On 11/26/18, RI #44 develop a facility-acquired Stage IV pressure ulcer on the right outer (lateral) ankle on 11/26/18 that measured 1.8 centimeter (cm) by 1.4 cm with 0.4 cm of depth. The pressure ulcer was assessed as having minimal drainage, no odor and exposed bone. These deficient practices affected RI #44, one of five sampled residents reviewed for pressure ulcers and placed RI #44 in immediate jeopardy, as these failures were likely to cause serious injury, harm or death. On 1/22/19 at 8:40 PM, the Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing, Social Service Designee and Secretary were notified of the findings of immediate jeopardy in the area of Quality of Care - Treatment/Services to Prevent/Heal Pressure Ulcer, F686. Findings include: The facility's policy titled Prevention of Pressure Ulcers/Injuries with a revised date of July 2017, documented Purpose The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors . Risk Assessment 1. Repeat the risk assessment . upon any changes in condition . Prevention . Monitoring 1. Evaluate, repot and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis . RI #44 was admitted to the facility on [DATE], with a medical history to include diagnoses of: Alzheimer's disease, Dementia, Rheumatoid Arthritis and Chronic Venous Stasis Disease. RI #44's Quarterly Minimum Data Set (MDS) with an assessment reference date of 9/27/18, revealed RI #44 was totally dependent on staff for all ADLs and had range of motion limitation in the upper and lower extremities on both sides of his/her body. According to this MDS, RI #44 did not have any unhealed pressure ulcers but was at risk for developing pressure ulcers. In an interview on 1/17/19 at 12:57 PM, Employee Identifier (EI) #8, a Certified Nursing Assistant (CNA) who routinely cared for RI #44 during the first shift (7:00 AM to 3:00 PM), was asked what preventative measures were in place for RI #44 prior to pressure ulcer being identified on the resident's ankle. EI #8 stated when she was assigned to care the resident, she would keep the heel protectors (Posey Heel Pillows) on RI #44. EI #8 stated she didn't know how the pressure sore happened (developed). According to EI #8, RI #44 stayed real wet from sweating and the resident pressed his/her leg down on the bed. In an interview on 1/17/19 at 1:58 PM, EI #6, a CNA who routinely cared for RI #44 during the first shift, was asked if she saw RI #44's skin prior to the pressure ulcer being identified on 11/26/18. According to EI #6, there were times the resident's ankle was red and she informed a nurse, but didn't know which nurse she told. During an observation of wound care on 1/18/19 at 9:17 AM, EI #5, a Registered Nurse (RN)/Treatment Nurse described RI #1's pressure ulcer on the ankle as a healing Stage IV wound. At 9:40 AM, EI #5 was asked to describe RI #44's right leg. EI #5 explained RI #44's right leg was turned which caused the right leg and ankle to lay on the lateral side. When asked how long RI #44's leg has been that way, EI #5 stated for as long as she had known the resident, about five to six years. When asked how long RI #44 has been wearing the heel booties, EI #5 stated the heel booties were on RI #44 when she (EI #5) started working at the facility. In an interview on 1/18/19 at 11:11 AM, EI #10, a Licensed Practical Nurse (LPN) was asked what preventative measures were in place before RI #44 was identified as having a Stage IV pressure ulcer on 11/26/18. EI #10 replied, we would turn the resident side to side and kept (heel) booties on the resident's feet. When asked how long RI #44 had worn the heel booties, EI #10 said the resident was supposed to always have them on. When asked what caused the wound on RI #44's ankle, EI #10 said pressure. In an interview on 1/18/19 at 4:22 PM, EI #13, a LPN was asked what preventative measures were in place before a pressure ulcer was identified on RI #44 on 11/26/18. EI #13 stated, (heel) booties. When asked how long RI #44 had worn the heel booties, EI #13 stated a long time. When asked what may have cause RI #44 to develop a pressure ulcer on the right lateral ankle, EI #13 stated the way the leg was positioned, with the ankle pressed down on the bed. EI #13 was asked how often the skin should be checked of a resident who wore heel booties. EI #13 replied, every shift. When asked who was supposed to check the resident's skin, EI #13 said the nurses. In a follow-up interview on 1/19/19 at 9:50 AM, EI #8, a CNA was asked to describe RI #44's and how they are positioned. EI #8 stated RI #44's feet are turned in and the resident presses his/her feet down into the bed. When asked why RI #44's wore the bilateral heel booties (Posey Heel Pillows), EI #8 said RI #44 wore them to keep from getting pressure sores on his/her feet while in the bed. When asked when skin checks were to be done, EI #8 stated the CNAs didn't do them, that body audits were done by the nurses. When asked what she had been told about checking a resident's skin, EI #8 said she hadn't been told anything but if there is breakdown to let someone know. During a follow-up interview on 1/19/19 at 10:33 AM, EI #6, a CNA was asked how often RI #44 wore the heel booties. EI #6 stated, every day for the protection from sores and wounds. When asked what she was supposed to do for residents who wore heel booties, EI #6 said take them off during the bath, wash the feet and put them back on. EI #6 acknowledged that she was assigned to care for RI #44 in the days prior the pressure ulcer being found. When asked if she looked at RI #44's ankles during care, EI #6 said she did and saw there was some redness and reported it to a nurse but couldn't recall the name of the nurse she reported it to. In an interview on 1/19/19 at 11:08 AM, EI #9, a CNA who routinely cared for RI #44 during the third shift (11:00 PM to 7:00 AM), was asked why RI #44 wore heel booties. EI #9 stated to protect the resident's feet from pressure sores. When asked who often RI #44 wore the heel booties, EI #9 stated every night she worked with RI #44, the resident had them on. EI #9 was asked if she checked RI #44's skin when she was assigned to care for the resident. EI #9 replied that she only checked the resident's skin when she bathed RI #44. In an interview on 1/19/19 at 2:07 PM, EI #2, the DON was asked why RI #44 wore heel booties. EI #2 said for protection; RI #44 had a history of stasis ulcers. When asked how long RI #44 had worn the heel booties, EI #2 said she was not sure. EI #2 explained RI #44 used to do leg lifts but after September (2018), the resident stopped moving the right leg. When asked what was done after RI #44 stopped moving the right leg to relieve pressure, EI #2 said nothing new. When asked who was responsible to ensure interventions were implemented, EI #2 stated it was all of our responsibility. EI #2 was asked why nothing was implemented and she replied, nobody did anything. When asked if RI #44's care plan related to the resident's fracture addressed any approaches for positioning and/or pressure relief, EI #2 said no. EI #2 was asked why there was no individualized approaches for positioning and/or pressure relief. EI #2 replied it was overlooked. When asked should there have been any individualized approaches to address RI #44's leg positioning and/or pressure relief, EI #2 said yes. EI #2 was asked why the facility was not following the manufacturer's recommendations for the Posey Heel Pillows. EI #2 replied that she had not read it. When asked who was responsible for ensuring nursing products utilized in the facility were used according to the manufacturer's specifications, EI #2 replied she was. When asked why she had not read the manufacturer's recommendations, EI #2 stated because she didn't have it in the facility. The manufacturer's information for the Posey Heel Pillows/Foot Positioner WOUND PREVENTION documented HEEL PILLOW Posey Heel Pillows help protect heels and ankles from skin irritation and friction burns . MONITORING WARNING Be sure to follow your facility's policies and guidelines for frequency of patient monitoring. Posey recommends that this product be removed at least every two (2) hours to check for skin integrity, proper circulation and range of motion . During an interview on 1/19/19 at 3:05 PM, EI #1, the facility's Administrator and Medical Director, also RI #44's physician, was asked how long did it take for a Stage IV pressure ulcer to develop on RI #44. EI #1 replied, as debilitated as RI #44 was, probably only a few days. When asked why the wound was not discovered it was a Stage IV, EI #1 stated there was not a Treatment Nurse and RI #44's leg turned out laterally and the staff were afraid to move it. EI #1 was asked how the facility-acquired Stage IV pressure ulcer could have been prevented. EI #1 answered, if the staff had followed the manufacturer's guidelines and inspected RI #44's ankles frequently. EI #1 explained it would have been ideal for the nursing staff to follow the manufacturer's recommendations. In a follow-up interview on 1/21/19 at 1:40 PM, EI #1, the facility's Administrator and Medical Director, also RI #44's physician, stated RI #44's Stage IV pressure ulcer was avoidable. In an interview on 1/20/19 at 2:55 PM, EI #6, a CNA was shown the manufacturer's information for the Posey Heel Pillow and asked if anyone in the facility had ever gone over with her the manufacturer's recommendations. EI #6 replied no ma'am. When asked if she had ever been told to monitor and remove the heel pillows every two hours to check for skin integrity, EI #6 said no ma'am. EI #6 was asked if she removed RI #44's heel booties every two hours to check for skin integrity and she answered no. EI #6 explained she was told RI #44 was supposed to have the heel booties on all time whether in the bed or chair. On 1/20/19 at 3:13 PM, EI #8, a CNA was asked what guidance the facility had given her on how to remove RI #44's heel booties and check the resident's skin. EI #8 replied, they haven't. EI #8 was shown the manufacturer's information for the Posey Heel Pillow and asked if anyone in the facility had ever gone over with her the manufacturer's recommendations. EI #8 replied no. When asked if she had ever been told to monitor and remove the heel pillows every two hours to check for skin integrity, EI #8 said no. EI #8 was asked if she removed RI #44's heel booties every two hours to check for skin integrity and she answered no. In an interview on 1/20/19 at 3:35 PM, EI #12, a CNA was asked what guidance the facility had given her on how to remove RI #44's heel booties and check the resident's skin. EI #12 replied, they haven't. EI #12 was shown the manufacturer's information for the Posey Heel Pillow and asked if anyone in the facility had ever gone over with her the manufacturer's recommendations. EI #12 replied no. When asked if she had ever been told to monitor and remove the heel pillows every two hours to check for skin integrity, EI #12 said no. EI #12 was asked if she removed RI #44's heel booties every two hours to check for skin integrity and she answered no. On 1/20/19 at 3:49 PM, EI #14, a LPN was asked what guidance the facility had given her on how to remove RI #44's heel booties and check the resident's skin. EI #14 replied, the Treatment Nurse would put in an order for what to do. When asked how often she checked RI #44's feet for skin integrity, EI #14 stated she didn't, it was very difficult because of the way RI #44's leg was turned. EI #14 was shown the manufacturer's information for the Posey Heel Pillow and asked if anyone in the facility had ever gone over with her the manufacturer's recommendations. EI #14 replied she had never seen it. When asked if she had ever been told to monitor and remove the heel pillows every two hours to check for skin integrity, EI #14 said no. EI #14 was asked what could have been done to prevent the skin breakdown on RI #44's ankle. EI #14 answered, we should have all been checking more thoroughly and removing the heel booties to check the resident's skin. On 1/20/19 at 9:18 AM, EI #9, a CNA was asked what guidance the facility had given her on how to remove RI #44's heel booties and check the resident's skin. EI #9 replied, none. EI #9 was shown the manufacturer's information for the Posey Heel Pillow and asked if anyone in the facility had ever gone over with her the manufacturer's recommendations. EI #9 replied no. When asked if she had ever been told to monitor and remove the heel pillows every two hours to check for skin integrity, EI #9 said no. EI #9 was asked if she removed RI #44's heel booties every two hours to check for skin integrity and she answered no. In an interview on 1/21/19 at 9:30 AM, EI #15, a LPN was asked what guidance the facility had given her on how to remove RI #44's heel booties and check the resident's skin. EI #15 replied, maybe it was listed in the Treatment book. (There were no orders in RI #44's Treatment Administration Record for the use of bilateral heel booties.) When asked what caused RI #44's pressure ulcer to form and be identified as a Stage IV, EI #15 replied no checking the resident's skin. When asked when skin checks were to be done, EI #15 stated there were no guidelines. EI #15 was shown the manufacturer's information for the Posey Heel Pillow and asked if anyone in the facility had ever gone over with her the manufacturer's recommendations. EI #15 replied she had never seen that information. When asked if she had ever been told to monitor and remove the heel pillows every two hours to check for skin integrity, EI #15 said she didn't recall. In an interview on 1/21/19 at 11:23 AM, EI #13, a LPN was asked what guidance the facility had given her on how to remove RI #44's heel booties and check the resident's skin. EI #15 replied, none. When asked what caused the ankle pressure ulcer to form on RI #44's, EI #13 replied no support under the resident's leg to lift it up off the bed. EI #13 was asked how often she checked RI #44's skin integrity on the resident's feet. EI #13 answered that she didn't look under the heel booties. EI #13 was shown the manufacturer's information for the Posey Heel Pillow and asked if anyone in the facility had ever gone over with her the manufacturer's recommendations. EI #13 replied she had never seen that information. When asked if she had ever been told to monitor and remove the heel pillows every two hours to check for skin integrity, EI #13 said no. EI #13 explained that she didn't do it because she had never been told to. EI #13 was asked what could have been done to prevent the pressure ulcer from developing. EI #13 replied with such a bony prominence, being out of bed more and using pillows to float the feet. RI #44's WOUND RECORD revealed a Stage IV pressure ulcer on the resident's right outer (lateral) ankle was first observed on 11/26/18 by EI #2, the DON. The pressure ulcer measured 1.8 centimeter (cm) by 1.4 cm with 0.4 cm of depth. The pressure ulcer was assessed as having minimal drainage, no odor and exposed bone. During an interview on 1/22/19 at 1:09 PM, EI #2, the DON was asked what was done to prevent pressure ulcer development when RI #44 was placed on bed rest on 10/4/18. EI #2 replied, nothing new. RI #44's PHYSICIAN'S ORDER for November 2018 documented . Bed rest 10/4/18 . In a telephone interview on 1/22/19 at 4:01 PM, with EI #1, the facility's Administrator and Medical Director, also RI #44's physician, he was asked what the purpose of the heel pillows for RI #44. EI #1 said it was padding for the resident's feet and ankle to protect the heels and ankles. EI #1 explained RI #44's right leg turns outward laterally and presses on the bed. When asked why he felt RI #44's pressure ulcer was avoidable, EI #1 stated if the aides (CNAs) had been inspecting the resident's ankle at least a couple times a day, they would have recognized the discoloration and a treatment could have been ordered. When asked to explain why he felt it would have been ideal for the staff to follow the manufacturer's recommendations, EI #1 replied obviously if they had been using the guidelines they would have seen a change in color and skin. EI #1 was asked what caused the pressure ulcer and he stated after RI #44 sustained a fracture, the resident became immobile and was unable to move that right leg. The right leg was rotated outward and the lateral portion of the ankle rested on the bed. ************************* On 1/24/19 at 5:20 PM, the facility submitted an acceptable Allegation of Compliance (AOC), which documented: Allegation of Compliance on Pressure Ulcer-01/23/2018 (01/23/2019) Physical Therapist from Tri-Rehab to evaluated resident #44 for pressure relief devices to alleviate pressure from stage IV wound on right ankle. Completed on 01/23/2019 New order received for 6 inch Skil-Care Standard Foot Elevator to right lower leg and Posey Heel Pillow/Foot Positioner to left foot per PT (Physical Therapy) recommendations and implemented. Every two hours checks to remove devices and check skin integrity are to be completed and documented on the TAR (Treatment Administration Record) by the charge nurse completing the skin check. Oversight will be completed by DON. Completed 01/23/2019 Direct care R.N.'s, L.P.N.'s and C.N.A's of resident #44 educated on use of 6 inch Skil-Care Standard Foot Elevator and Posey Heel Pillow/Foot Positioner per manufacturers guidelines and policy and procedure by D.O.N. and A.D.O.N. Completed 01/23/2019 American Medical Technologies re-educated D.O.N., A.D.O.N. and Staff R.N. on Identifying Residents at Risk for Pressure Ulcers and Skin Integrity issue. Completed 01/23/2019 Body audits on all resident are to be completed by licensed nurse to reassure no other residents have any unidentified skin issue/ulcers. In addition, all residents that are potential at risk will be identified and pressure relief devices are to be implemented as needed and used according to manufactures guidelines. Completed 01/23/2019 In-service on Body Audits for R.N.'s and L.P.N.'s to be held 01/24/2019 at 3:00pm to re-educate nursing staff on the importance completing Body Audits on a weekly basis for all residents will be provided by D.O.N. and A.D.O.N. All R.N.'s and L.P.N.'s that fail to come to in-services will not be allowed to return to work until they attend an in-service for re-education provided by D.O.N. or A.D.O.N. To be completed on 01/24/2019 A.D.O.N. to assure all weekly body audits are completed on all resident weekly. Licensed nurses are to document on MAR as the body audit are completed. A.D.O.N. will keep a log with completed Body Audits for continued compliance. The log and Body Audits are to reviewed by DON and complied in a binder and kept in DON office. Oversight by DON. Started 01/23/2019 and ongoing A Mandatory Adaptive Equipment In-Service to re-educate R.N.'s, L.P.N.'s and C.N.A.'s on the appropriate use of 6 inch Skil-Care Standard Foot Elevator and Posey Heel Pillow/Foot Positioner is to be provided by D.O.N. and A.D.O.N. at 3:00pm on 01/24/2019. D.O.N. and A.D.O.N. were re-educated on 01/23/2019 by Physical Therapist from Tri-Rehab. To be completed on 01/24/2019 D.O.N. and A.D.O.N. will provide in-service on Prevention of Pressure Ulcers to R.N.'s, L.P.N.'s and C.N.A.'s at 3:00pm on 01/24/2019 at 3:00pm. All R.N.'s, L.P.N.'s and C.N.A.'s that do not attend will not be allowed to return to work until they attend an in-service for re-education provided by D.O.N. and A.D.O.N. To be completed on 01/24/2019 ************************* After reviewing the facility's information provided in their AOC and verifying the immediate actions had been implemented, the scope/severity level of F656 was lowered to a D level on 1/25/19, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and review of the JOB DESCRIPTION DIRECTOR OF NURSING SERVICES and JOB DESCRIPTION ADMINISTRATOR, the facility's Administrator, responsible for the day-to-day operatios of the facility and the Director of Nursing, responsible for the overall operation of the Nursing Service Department, failed to ensure there was a policy to address the use of adaptive devices used to relieve pressure utilized by the facility. The facility's administrative staff futher failed to ensure they were aware of the manufacturer's recommendations for the Posey Heel Pillow applied to Resident Identifier (RI) #44's bilateral lower extremities. Lastly, the administrative staff failed to ensure the staff were educated on the manufacturer's recommendations to remove every two hours to check for skin integrity, proper circulation and range of motion. RI #44, a resident totally dependent on staff for all Activities of Daily Living (ADLs) and at risk for pressure ulcer development, was placed on bed rest on 10/4/18. When placed on bed rest, there were no changes in RI #44's treatment plan to address the resident's right leg. According to staff interviews, RI #44 wore bilateral heel booties (Posey Heel Pillows) every day. On 11/26/18, RI #44 develop a facility-acquired Stage IV pressure ulcer on the right outer (lateral) ankle on 11/26/18 that measured 1.8 centimeter (cm) by 1.4 cm with 0.4 cm of depth. The pressure ulcer was assessed as having minimal drainage, no odor and exposed bone. These deficient practices affected RI #44, one of five sampled residents reviewed for pressure ulcers and placed RI #44 in immediate jeopardy, as these failures were likely to cause serious injury, harm or death. On 1/22/19 at 8:40 PM, the Assistant Administrator, Director of Nursing (DON), Assistant Director of Nursing, Social Service Designee and Secretary were notified of the findings of immediate jeopardy in the area of Administration, F835. Findings include: Refer to F656 and F686 The unsigned JOB DESCRIPTION DIRECTOR OF NURSING SERVICES documented . PURPOSE OF YOUR JOB POSITION The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Services Department in accordance with current Federal, State and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Administrator and the Medical Director, to ensure that the highest degree of quality care is maintained at all times . In an interview on 1/19/19 at 2:07 PM, EI #2, the DON was asked why RI #44 wore heel booties. EI #2 said for protection; RI #44 had a history of stasis ulcers. When asked how long RI #44 had worn the heel booties, EI #2 said she was not sure. When asked why the heel booties were not care planned, EI #2 said she just overlooked them. EI #2 was asked should the heel booties have been care planned. EI #2 replied, yes they should have been. When asked what information should have been included on RI #44's care plan related to the heel booties, EI #2 said when and how often to apply and check for skin integrity. EI #2 explained RI #44 used to do leg lifts but after September (2018), the resident stopped moving the right leg. When asked what was done after RI #44 stopped moving the right leg to relieve pressure, EI #2 said nothing new. When asked who was responsible to ensure interventions were implemented, EI #2 stated it was all of our responsibility. EI #2 was asked why nothing was implemented and she replied, nobody did anything. When asked if RI #44's care plan related to the resident's fracture addressed any approaches for positioning and/or pressure relief, EI #2 said no. EI #2 was asked why there was no individualized approaches for positioning and/or pressure relief. EI #2 replied it was overlooked. When asked should there have been any individualized approaches to address RI #44's leg positioning and/or pressure relief, EI #2 said yes. EI #2 was asked why the facility was not following the manufacturer's recommendations for the Posey Heel Pillows. EI #2 replied that she had not read it. When asked who was responsible for ensuring nursing products utilized in the facility were used according to the manufacturer's specifications, EI #2 replied she was. When asked why she had not read the manufacturer's recommendations, EI #2 stated because she didn't have it in the facility. During a follow-up interview on 1/22/19 at 1:09 PM, EI #2, the DON was asked what was done to prevent pressure ulcer development when RI #44 was placed on bed rest on 10/4/18. EI #2 replied, nothing new; there was no change in the resident's care plans. EI #2 explained there was a care developed for the fracture but it didn't address any new interventions. When asked who was responsible for updating RI #44's care plans with interventions after 10/4/18, EI #2 stated it would have been her. The unsignedJOB DESCRIPTION ADMINISTRATOR, documented . PURPOSE OF YOUR JOB POSITION The primary purpose of your job position is to direct the day-to-day functions of the facility in accordance with current Federal, State and local standards, guidelines, and regulations that govern the Long-Term Care Facility to assure that the highest degree of quality care can be provided to our residents at all times . During an interview on 1/19/19 at 3:05 PM, EI #1, the facility's Administrator and Medical Director, also RI #44's physician, was asked why the wound was not discovered it was a Stage IV, EI #1 stated there was not a Treatment Nurse and RI #44's leg turned out laterally and the staff were afraid to move it. EI #1 was asked how the facility-acquired Stage IV pressure ulcer could have been prevented. EI #1 answered, if the staff had followed the manufacturer's guidelines and inspected RI #44's ankles frequently. EI #1 explained it would have been ideal for the nursing staff to follow the manufacturer's recommendations. In a follow-up interview on 1/21/19 at 1:40 PM, EI #1, the facility's Administrator and Medical Director, also RI #44's physician, stated RI #44's Stage IV pressure ulcer was avoidable. In a telephone interview on 1/22/19 at 4:01 PM, with EI #1, the facility's Administrator and Medical Director, also RI #44's physician, he was asked what the purpose of the heel pillows for RI #44. EI #1 said it was padding for the resident's feet and ankle to protect the heels and ankles. EI #1 explained RI #44's right leg turns outward laterally and presses on the bed. When asked why he felt RI #44's pressure ulcer was avoidable, EI #1 stated if the aides (CNAs) had been inspecting the resident's ankle at least a couple times a day, they would have recognized the discoloration and a treatment could have been ordered. When asked to explain why he felt it would have been ideal for the staff to follow the manufacturer's recommendations, EI #1 replied obviously if they had been using the guidelines they would have seen a change in color and skin. EI #1 was asked what caused the pressure ulcer and he stated after RI #44 sustained a fracture, the resident became immobile and was unable to move that right leg. The right leg was rotated outward and the lateral portion of the ankle rested on the bed. ************************* On 1/24/19 at 5:20 PM, the facility submitted an acceptable Allegation of Compliance (AOC), which documented: Allegation of Compliance-Administration 01/23/2019 Policy and Procedure for Posey Heel Pillow/Foot Positioners for [NAME] Nursing Home was developed by D.O.N. Policy and Procedure describes the purpose for the Posey Heel Pillows/Foot Positioners to protect heels and ankles form skin irritation, friction and pressure injuries as well as assisting with the healing process of existing wounds. Furthermore, the Policy and Procedure instructs how to use the Posey Heel Pillow/Foot Positioners according to manufactures guidelines. Also included is how to care for the Posey Heel Pillow/Foot Positioners. Completed on 01/23/2019 Policy and Procedure for 6 inch Skil-Care Standard Foot Elevator for [NAME] Nursing Home was developed by D.O.N. Policy and Procedure describes the purpose for the 6 inch Skil-Care Standard Foot Elevator to lift resident's heels off surface (bed/chair) to eliminate pressure as well as allowing air circulation to aid in faster healing process. Furthermore, the Policy and Procedure instructs how to use the 6 inch Skil-Care Foot Elevator according to manufactures guidelines. Also included is how to care for the 6 inch Skil-Care Foot Elevator. Completed on 01/23/2019 R.N.'s, L.P.N.'s and C.N.A.'s will be educated on Posey Heel Pillow/Foot Positioners policy and procedures at Mandatory in-service to be held 01/24/2019 at 3:00pm. R.N.'s, L.P.N.'s and C.N.A's will also be re-educated on Weekly Body Audit policy and procedure at this time. Employee that fail to attend will not be allowed to work until they attend an in-service provided by D.O.N. or A.D.O.N. Completed on 01/24/2019 D.O.N. and A.D.O.N. will review all pressure relief devices within the facility and assure appropriate policy's and procedures are in place. D.O.N. and A.D.O.N. will assure all R.N.'s, L.P.N.'s and C.N.A's are educated on such policies and procedures at 3:00pm on 01/24/2019 by D.O.N and A.D.O.N. D.O.N. will also assure that policies and procedure are appropriate and the purpose, use and care are based on manufactures guidelines. All newly developed policy's and procedure will be reviewed by Medical Director. Completed on 01/24/2019 ************************* After reviewing the facility's information provided in their AOC and verifying the immediate actions had been implemented, the scope/severity level of F835 was lowered to a D level on 1/25/19, to allow the facility time to monitor and/or revise their corrective actions as necessary to achieve substantial compliance.