**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of eight sampled residents (Resident 76 and 179) received care to prevent pressure ulcer (localized areas of injury that occur when skin and underlying tissue are compressed between a bony prominence and an external surface such as a mattress) development, by failing to: 1. Implement Resident 179's care plan which indicated staff were to check the resident's skin for presence of sores, breakdown, impairment, and skin trauma, and use pressure reducing devices. 2. Implement its policy which indicated to initiate a care plan to address Resident 76's newly developed deep tissue injury ([DTI] an injury to a residents underlying tissue below the skin's surface that results from prolonged pressure in an area of the body) to the left heel, obtain treatment orders, and monitor the effectiveness of the treatment. This deficient practice resulted in Resident 179 developing an unstageable pressure ulcer on the sacrococcygeal (base of the spine, tailbone) area and Resident 76 developing a DTI on the left heel. Findings: a. A review of Resident 179's admission Record indicated the resident was admitted to the facility on [DATE], and last readmitted on [DATE]. Resident 179's diagnoses included status post left hip surgery, diabetes mellitus (high levels of sugar in the blood), polyneuropathy (damage to the nerves outside the brain and spinal cord), Alzheimer's disease (a type of brain disorder that causes problems with memory, thinking and behavior), dementia (disorder affecting memory, thinking and social abilities severely enough to interfere with your daily life), anemia (a condition in which you lack enough healthy red blood cells to carry adequate oxygen to your body's tissues) and muscle weakness. A review of Resident 179's Quarterly Minimum Data Set (MDS), a standardized assessment and screening tool, dated January 23, 2022, indicated the resident had severe cognitive (ability to think and reason) impairment. The MDS indicated Resident 179 required limited assistance with transfer, dressing, toilet, personal hygiene and bathing. The MDS indicated Resident 179 was at risk for pressure ulcer development. A review of Resident 179's admission Body assessment dated [DATE], indicated Resident 179 had a surgical wound on her left hip, otherwise the resident's skin integrity was intact. A review of Resident 179's Braden Scale for Predicting Pressure Ulcers dated January 29, 2022, indicated the resident scored a 12, indicating a high risk. A review of Resident 179's Physician's admission Order dated January 29, 2022, indicated that there were no pressure ulcer preventions ordered. A review of the facility's Change of Condition logbook dated from January 29, 2022, to February 6, 2022, indicated that there were no reported records that Resident 179 had skin breakdown. A review of the facility's Treatment Monitoring logbook for the month of February 2022, indicated there was no treatment monitoring documented for Resident 179's sacrum (base of the spine) and coccyx areas. During a concurrent observation and interview on February 9, 2022, at 11:46 a.m., in Resident 179's room, Resident 179 was lying in bed in a supine (face up) position with an abduction pillow (a device used to prevent your hip from moving out of the joint) in between the legs. Licensed Vocational Nurse (LVN) 1 and LVN 4 were observed performing a routine body skin assessment for Resident 179. Resident 179 was observed to have an unstageable wound (full thickness tissue loss) covered with slough (dead, separated tissue) and eschar (collection of dry, dead tissue within a wound) to the sacrococcygeal area measuring approximately three (3) centimeters (cm) by 3 cm. LVN 1 and LVN 4 stated they did not know Resident 179 had developed a pressure ulcer. LVN 4 stated a skin assessment should have been performed properly and thoroughly on a daily basis for Resident 179 who was at risk for developing pressure ulcers. During an interview on February 10, 2022, at 10:23 a.m., LVN 1 stated certified nurse assistants (CNAs) were supposed to inform the licensed nurses of any skin changes on the residents. LVN 1 stated registered nurses (RNs) performed resident skin assessment on admission, and CNAs performed skin assessments on every shower day and were to report any abnormal findings. During an interview on February 10, 2022, at 2:30 p.m., Certified Nurse Assistant (CNA) 8 stated it was Resident 179's shower day but confirmed he did not shower Resident 179 on that day (2/10/22). CNA 8 stated the charge nurse and the supervisor told him not to touch Resident 179 because of the surgical wound on the resident's left hip. CNA 8 stated there were no other wounds on Resident 179 per his knowledge. CNA 8 stated the facility had a resident turning schedule that staff followed, but there was no documentation indicating Resident 179 was turned every two (2) hours. A review of Resident 179's Care Plan dated January 30, 2022, and titled Pressure Ulcer Risk, indicated a goal for Resident 179 was to minimize pressure ulcer risk daily for 3 months. The staff's interventions included to check skin for presence of sores, breakdowns, impairment, and skin trauma, notify physician if reddened areas, change in weight, change in intake or abnormal laboratory, assist with position changes, and use pressure reducing devices. A review of the Nurse Assistant Notes logbook dated February 1, 2022, to February 10, 2022, indicated there was no documentation Resident 179 had been repositioned every 2 hours and had no pressure reducing devices used during that timeframe. A review of the facility's Daily Skin Inspection Tool dated from January 29, 2022, to February 10, 2022, used by CNAs during the residents shower day indicated that Resident 179's skin integrity was not inspected. There was no record Resident 179 received a shower during this period. During an interview on February 10, 2022, at 11:24 a.m., the Director of Nursing (DON) stated for newly admitted and readmitted residents the licensed nurses were expected to perform a resident admission assessment which included a body assessment. The DON stated all licensed nurses were expected to perform a daily skin assessment during the residents' shower days. The DON was not able to explain why Resident 179's unstageable pressure ulcers at the sacrum and coccyx areas was not identified timely during the earlier stage. b. A review of Resident 76's admission Record indicated the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 76's diagnoses included diabetes mellitus, Alzheimer's disease, dementia, and muscle weakness. A review of Resident 76's Quarterly MDS dated [DATE], indicated the resident had severe cognitive impairment. The MDS indicated Resident 76 required extensive assistance with bed mobility, dressing, personal hygiene and total dependence with eating, toilet use, and bathing. The MDS indicated Resident 76 was at risk for pressure ulcer development. A review of Resident 76's readmission Body assessment dated [DATE], indicated the resident's skin integrity was intact. A review of Resident 76's Physician's admission Orders dated January 2, 2022, indicated there was no preventative measures ordered to decrease the resident's risk of pressure ulcer development. A review of the facility's Change of Condition logbook dated from January 7, 2022, to February 6, 2022, indicated Resident 76 was reported to have a DTI with no specific location documented on January 20, 2022. A review of Resident 76's Change of Condition (COC) dated January 20, 2022, indicated a DTI was identified to the resident's left heel. There was no documentation that treatment was ordered. During a concurrent observation and interview with LVN 4 on February 10, 2022, at 9:30 a.m., Resident 76 was observed lying in bed with both knees in a bent position with a pillow underneath his knees and both heels were touching the mattress. Resident 76 was observed with a DTI on the left heel measuring approximately 2 cm by 2 cm. LVN 4 stated there was no care plan initiated for Resident 76's DTI of the left heel. LVN 4 confirmed that a wound specialist had not seen Resident 76 and there was no treatment ordered by the physician. LVN 4 stated the facility had issues with the wound care contractor. LVN 4 stated he followed up with the wound specialist multiple times but did not document. LVN 4 stated the facility did not have a wound care nurse at the time and that the charge nurses were responsible for the current wound care of residents. During an interview on February 10, 2022, at 9:48 a.m., CNA 6 stated she followed Resident 76's turning schedule every 2 hours, but she stated that there was no documentation of the repositioning in the resident's chart. A review of Resident 76's Nursing Notes from January 20, 2022, to January 25, 2022, indicated that LVN 6 noted the resident's DTI was reported by a CNA when a shower was given. Physician was notified and referred to a wound specialist, however, no follow up notes with wound specialist was documented. A review of the facility's undated policy and procedure (P/P) titled, Change in a Resident's Condition or Status, indicated that the facility shall promptly notify the resident, his or her attending Physician, and representative of change in the resident's medical/mental condition and/or status. The Nurse Supervisor/Charge Nurse will notify the resident's Attending Physician or On-call Physician when there has been: 1. An accident or incident involving the resident. 2. A discovery of injuries of an unknown source. 3. A significant change in the resident's physical/ emotional/ mental condition. 4. A need to alter the resident's medical treatment significantly. 5. Refusal of treatment or medications two (2) or more consecutive times. 6. Instructions to notify the physician of changes in the resident's condition. A review of the facility's undated P/P titled, Pressure Ulcers Prevention Guidelines, indicated to implement evidenced-based interventions for all residents who are assessed at [NAME] or who have a pressure ulcer present. Preventive skin care: 1. Inspect skin while providing care, paying close attention to bony prominences. 2. Inspect skin underneath medical devices at least twice daily. Keep skin clean and dry underneath. Adjust devices as needed for proper fit. 3. Avoid positioning the resident on an area of redness whenever possible. 4. Keep the skin clean and dry. Manage incontinence with absorptive products. Check every 2 hours, and provide perineal care as needed after incontinent episodes. Diaper usage in bed is not recommended. Protect skin from exposure to excessive moisture with barrier products. 5. Moisturize dry skin. 6. Use positioning devices or folded linens to keep body surfaces from rubbing against one another. Nutrition/Hydration: Consult for nutritional screen for each resident who is at risk for a pressure ulcer or has a pressure ulcer present. Repositioning: Reposition all residents at risk of, or with existing pressure ulcers, unless contraindicated due to medical condition. Utilize small shifts in repositioning, if otherwise contraindicated. Pressure relieving devices: Support surfaces do not eliminate the need for turning and repositioning. Provide alternative support surfaces as needed. Considerations for utilizing specialized support surfaces. A review of the facility's undated P/P titled Wound Treatment Guidelines, indicated to promote wound healing of various types of wounds, the facility must provide evidence-based treatments in accordance with current standards of practice and physician orders. 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change. 2. In the absence of treatments orders the license nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatments nurse. 3. Treatments will be documented on the Treatment Administration Record. 4. The effectiveness of treatments will be monitored through ongoing assessment of the wound.