**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** c. During a review of Resident 38's Face Sheet, the Face Sheet indicated Resident 38 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, persistent vegetative state (condition of not being aware), respiratory failure (unable to breath on your own), and diabetes (high blood sugar). During a review of Resident 38's admission assessment dated [DATE], the admission Assessment indicated the resident had intact skin. During a review of Resident 38's MDS dated [DATE], the MDS indicated Resident 38 was dependent on staff to reposition from side to side. The MDS indicated Resident 38 was at risk for pressure ulcer development. During a review of Resident 38's care plan for Impaired Skin Integrity (date illegible), the care plan indicated Resident 38 had the potential for impaired skin integrity related to impaired mobility, weight loss, and steroid therapy. The care plan indicated the staff would reposition the resident every two hours and assess skin condition daily. During a review of Resident 38's Braden Scale Highest (a lower score represents a higher risk), dated 10/18/2022, indicated Resident 38 scored 10. During a concurrent interview and record review on 2/8/24 at 12:05 p.m. with TN 1, Resident 38's Wound Management form dated 8/31/23 was reviewed. The Wound Management indicated Resident 38 had a new pressure ulcer to the left gluteal fold (the horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks) acquired on 8/31/23. TN 1 stated Resident 38 acquired a pressure ulcer because the resident was immobile. TN 1 stated Resident 38 had to be repositioned every two hours and there was no medical reason why the resident could not be repositioned. During a review of Resident 38's Physician's Orders Report dated 8/31/2023, the Physician's Orders Report indicated an order for Hydrogel (medication that promotes wound healing) with dry dressing to the left gluteal fold pressure ulcer to be done daily. During a review of Resident 38's Physician's Orders Report dated 2/1/2024, the Physician's Orders Report indicated an order to continue Hydrogel with dry dressing to the left gluteal fold pressure ulcer daily. During an interview on 2/8/24 at 12:28 p.m. CNA 1 stated residents were turned every two hours to prevent a pressure ulcer development. CNA 1 stated bed sores (pressure ulcers) are preventable. During an observation on 2/9/24 from 8:10 a.m. until 2:07 p.m. (six hours) Resident 38 was in bed in a supine (on the back) position. During an observation on 2/9/24 at 8:20 a.m. TN 2 observed performing wound care and measuring the pressure ulcer of the left gluteal fold. The pressure ulcer measured 1.5 cm x 1.5 cm and assessed as a Stage II pressure ulcer. During a concurrent interview and record review on 2/9/24 at 11:25 a.m. with RN 2, a wound evaluation (pressure ulcer) order dated 9/1/2023 was reviewed. RN 2 stated it was the responsibility of the treatment nurse to notify the wound nurse of a new pressure ulcer by entering a wound evaluation order. During a review of the facility's P&P titled, Turning and Repositioning, dated 6/2018, the P&P indicated staff will turn and reposition residents every two hours and as needed. Based on observation, interview, and record review, the facility failed to ensure the residents who were admitted to the facility with intact skin did not develop a pressure ulcer ([PU], injury to skin and underlying tissue resulting from prolonged pressure on the skin or bony prominences) for three of three sampled residents (Residents 163, 40, and 38). The facility failed to: 1. Ensure Resident 163's did not develop a Stage III PU (Full thickness tissue loss) to the right buttocks after the admission to the facility. 2. Ensure the nursing staff monitored Resident 163 skin condition to identify development of a PU to the right buttock at the earlier stage to prevent development of a Stage III PU. 3. Ensure the nursing staff implemented Resident 163's care plan titled Skin Integrity by ensuring the resident will not have a skin breakdown. 4. Ensure nursing staff turned and repositioned Resident 40 every two hours to prevent a deep tissue pressure injury ([DTPI] a serious form of pressure injuries defined as purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear) from reopening. 5. Ensure the nursing staff turned and repositioned Resident 38 every two hours as care planned to prevent the resident from developing a Stage II pressure ulcer to the left gluteal fold (a horizontal skin crease that forms below the buttocks, separating the upper thigh from the buttocks). These deficient practices resulted in Resident 163 acquiring a Stage III PU, the reopening of Resident 40's DTPI, and Resident 38 developing Stage II pressure ulcer to the left gluteal fold. Findings: a. During a review of Resident 163's Face Sheet (admission Record), the Face Sheet indicated, Resident 163 was admitted to the facility on [DATE], with diagnoses including chronic respiratory failure with hypoxia (a condition that occurs when the lungs cannot get enough oxygen into the blood or eliminate enough carbon dioxide from the body), tracheostomy (an opening created at the front of the neck so a tube can be inserted into the windpipe [trachea] to help you breathe), multiple fractures (partial or complete break of a bone), and gunshot wound. During a review of Resident 163's Minimum Data Set ([MDS] a standardized assessment and care screening tool) assessment, dated 1/4/2024, the MDS indicated, Resident 163 had severely impaired cognitive (ability to think and reason) skills for daily decision making. The MDS indicated, Resident 163 was dependent to staff for oral hygiene, toileting, dressing, and personal hygiene. The MDS Section M (Skin Conditions) indicated, Resident 163 was at risk for developing a pressure ulcer and had one unhealed Stage III to a sacral (tailbone) area. The MDS indicated Resident 163 was incontinent of bowel and had a condom catheter (sheath-like device that is placed around the penis and secured with adhesive or a strap) for a sacral ulcer management. During a review of Resident 163's admission Assessment, dated 12/23/2023, the admission Assessment indicated Resident 163 was admitted with a Stage III pressure ulcer to a sacral area. During a review of Resident 163's Occupational Therapy Evaluation form, dated 12/23/2023, the Occupational Therapy Evaluation Form indicated Resident 163 was totally dependent for bed mobility. During a review of Resident 163's Braden Scale (tool commonly used in healthcare to assess and document a resident's risk for developing pressure ulcers) form, dated 12/24/2023, 12/30/2023, 1/7/2024, and 1/14/2024, the Braden Scale form indicated Resident 163 had very limited sensory perception (ability to respond meaningfully to pressure-related discomfort), was constantly moist, bedfast (confined in bed), completely immobile, was receiving nutrition via a gastrostomy tube ([GT] a soft tube surgically inserted into the stomach through the abdomen) and had a problem in friction and shear. The Braden Scale indicated, Resident 163 had a score of nine (total score of 12 or less represent high risk), indicating the resident was high risk for developing a pressure ulcer. During a review of Resident 163's Daily Assessment Inquiry under Certified Nursing Assistant (CNA) Documentation from 12/23/2023 to 2/7/2024, the Daily Assessment Inquiry indicated there were no documentation of Resident 163 having a pressure ulcer on a right buttock. During a review of Resident 163's Progress Notes Inquiry from 12/23/2023 to 2/6/2024, the Progress Notes Inquiry, indicated there were no documentation of Resident 163 having a pressure ulcer to a right buttock. During a review of Resident 163's Sub-Acute Nursing Weekly Summary dated 12/25/2023, 1/1/2024, 1/8/2024, 1/22/2024, 1/29/2024, and 2/5/2024, the Sub-Acute Nursing Weekly Summary, indicated there were no documentation of Resident 163's having a pressure ulcer to a right buttock. During a review of Resident 163's Wound Photographic Documentation-Nursing, dated 2/8/2024, the Wound Photographic Documentation-Nursing indicated Resident 163 had a Stage III pressure ulcer to the right buttock, which was not present on admission. Resident 163's Stage III pressure ulcer to the right buttock was measured 2.5 centimeters ([cm] unit of measurement) in length, 3.0 cm in width, and 0.1 cm in depth, and documented to have a scant (minimal) amount of serosanguineous (fluid containing both blood and blood serum [clear liquid part of the blood after blood cells have been removed]) fluid with no odor. During a concurrent observation and interview on 2/9/2024 at 9:21 a.m. with Treatment Nurse 1 (TN 1) in Resident 163's room, TN 1 was observed conducting a wound care treatment to Resident 163's pressure ulcer on the right buttock. The wound bed was observed to have an adherent yellow slough (dead tissue, usually cream or yellow in color) dark gray skin and pink tissue, with indistinct (not sharply outlined or separable) wound margins (edge). The Peri wound (tissue surrounding the wound) was noted to have deep purple skin discoloration. TN 1 stated Resident 163's Stage III pressure ulcer to the right buttock was acquired at the facility. TN 1 stated she identified Resident 163 having a Stage III pressure ulcer to the right buttock on 2/7/2024. TN 1 stated she did not document about it and did not notify Resident 163's physician (MD 1) until the next day on 2/8/2024. TN 1 stated she was overwhelmed with other tasks on 2/7/2024 and that was the reason why she did not document about newly identified Resident 163's pressure ulcer and did not called MD 1. TN 1 stated she did not follow the standard of practice by not reporting Resident 163's Stage III pressure ulcer to the right buttock to MD 1 in a timely manner. TN 1 stated she had seen Resident 163's on several occasions soiled (dirty) with urine because his condom catheter was dislodged. TN 1 stated Resident 163 had only one Stage III pressure ulcer to the sacral area upon admission. TN 1 stated she did not observe Resident 163's developing redness, blister, or any skin damage to his right buttock until 2/7/2023 when he developed a Stage III pressure ulcer to his right buttock. TN 1 stated Resident 163 had no skin maintenance treatment order to the right buttock prior to identification of a Stage III pressure ulcer. During an interview on 2/9/2024 at 10:23 a.m. a Certified Nursing Assistant 2 (CNA 2) stated she was giving a bed bath (bathing a patient who is confined to bed and cannot have the physical and mental capability of self-bathing) to Resident 163 every time she was assigned to care for Resident 163. CNA 2 stated, she did not observe Resident 163 had a new pressure ulcer. CNA 2 stated she documents in the flowsheet of a resident's electronic health record if a resident noted with skin issues including bed sore, redness, and skin tear. During an interview on 2/9/2024 at 10:33 a.m. the Registered Nurse 2 (RN 2) stated protecting and monitoring the condition of Resident 163's skin was important for preventing development of a pressure ulcer and identifying a pressure ulcer earlier so it can be treated at the early stage and not to let it to get worse. RN 2 stated she was not aware Resident 163 developed a Stage III pressure ulcer to his right buttock. RN 2 stated the licensed nurses need to check resident's skin when completing the Nursing Weekly Summary and report it to the supervisor when areas of concern identified. During a concurrent interview and record review on 2/9/2024 at 2:25 p.m. with Infection Preventionist Nurse (IP 1), Resident 163's Subacute Pressure Injury Weekly Report dated 12/24/2023 and 1/28/2024 were reviewed. IP 1 stated Resident 163 had only one pressure ulcer Stage III to the sacral area. IP 1 stated it was important to identify the presence of a pressure ulcer and its stages early so nurses can implement the necessary interventions. During a concurrent interview and record review on 2/9/2024 at 3:00 p.m. with Director of Nursing 1 (DON 1), Resident 163's care plan titled Skin Integrity, dated 12/27/2023, was reviewed. The care plan problem indicated, Potential for impaired skin integrity related to impaired mobility, incontinence, fragile skin, history, or current pressure ulcer, and on anticoagulant therapy. The care plan goals included the following: 1. To maintain Resident 163's skin integrity as evidenced by intact skin daily for next three months. 2. Resident 163 will be free from skin breakdown daily for next three months. 3. There will be no further sacral pressure ulcer deterioration daily for the next three months. The DON stated the facility failed to prevent Resident 163's pressure ulcer development to the right buttock and failed to identify this pressure ulcer prior its progression to a Stage III. The DON stated a Stage III pressure ulcer can develop fast but not right away. The DON stated with proper care treatment and interventions and early detection of a pressure ulcer Resident 163's new Stage III pressure ulcer to the right buttock could had been avoided. During a review of facility's policy and procedure (P&P) titled, Dignity, Patient/Resident, dated 9/2023, the P&P indicated, the facility will provide, in accordance with Federal law requirement, every resident with the care and quality of life sufficient for them to attain and maintain their highest practicable physical, emotional, and social well-being. During a review of facility's policy and procedure (P&P) titled, 'Change in Residents Condition, dated 11/2023, the P&P indicated, the licensed nurse in charge will notify the physician immediately of any sudden or serious change in residents condition manifested by a marked change in physical or mental behavior. b. During a review of Resident 40's admission Record (Face Sheet), the admission Record indicated Resident 40 was admitted to the facility on [DATE] with diagnoses including respiratory failure (a condition that makes it difficult to breathe on your own), seizures (a sudden, uncontrolled body movements due to abnormal electrical activity in the brain), and diabetes mellitus (a problem in the way the body regulates and uses sugar as a fuel). During a review of Resident 40's Minimum Data set ([MDS] a standardized assessment and care screening tool), dated 11/30/2023, the MDS indicated, Resident 40's cognitive (ability to learn reason, remember, understand, and make decisions) skills for daily decision making were severely impaired. The MDS indicated Resident 40 was dependent on staff for activities of daily living (ADL) including toileting, hygiene, and showering. During a review of Resident 40's admission assessment dated [DATE], the admission Assessment indicated the resident had the following: 1. Left heel undetermined (UTD) skin injury. 2. Sacral pressure ulcer Stage III. 3. Right lateral malleolus UTD skin injury. 4. Right buttock UTD skin injury. During a review of Resident 40 's care plan for Impaired Skin Integrity dated 8/18/2023, the care plan indicated a goal for the resident was to maintain intact skin daily for the next three months (until next care plan evaluation). One of the care plan interventions was to reposition the resident every two hours. During a review of Progress Note Inquiry dated 9/21/2023 completed by a Wound Consultant, the Progress Note Inquiry indicated Resident 40's left heel was assessed as unstageable pressure ulcer and measured 1.0 cm by 0.8 cm. The Wound Consultant documented recommendation for intervention to promote pressure ulcer healing included heel off loading, heel protector, and turning and repositioning the resident. During a review of Resident 40's Physician's Orders, dated 2/1/2024, Physician's Orders indicated the order to cleanse left heel DTPI with Normal Saline solution, pat dry. Apply Betadine and cover with dry dressing daily. During a review of Wound Photographic Documentation/Nursing dated 2/1/2024, the Wound Photographic Documentation indicated Resident 40 had DTPI to left heel measured 1.0 cm in length by 1.5 cm in width. During an observation on 2/6/2024 from 11:09 a.m. until 4:00 p.m. (a total of five hours), Resident 40 was observed in bed on a left side facing the window. During an observation on 2/7/2024 from 9:17 a.m. until 4:15 p.m. (a total of seven hours), Resident 40 was observed in bed on a left side facing the window. During an observation on 2/8/2024 from 8:15 a.m. until 12:15 p.m. (four hours) Resident 40 was observed lying on the left side facing the window. During a concurrent observation and interview on 2/8/2024 at 12:15 p.m. with Restorative Nurse Assistant (RNA 1) in Resident 40's room, Resident 40 was observed in bed lying on a left side facing the window. Resident 40 was observed to have a heel protector (a soft cushion covering the heel) on the left heel. Resident 40's left heel had a sock on inside the heel protector. RNA 1 confirmed Resident 40 was facing the window and lying on the left side of his body. RNA 1 stated Resident 40 should be facing the door at 12:00 p.m. RNA 1 stated Resident 40 should be repositioned from side to side every two hours to prevent a pressure ulcer from developing, to help with blood circulation (the flow of blood through the heart and blood vessels), and to prevent DTPI to have a recurrent pressure ulcer. During a review of Resident 40's Repositioning Schedule, date unknown, the Repositioning Scheduled indicated Resident 40 should be turned (repositioned) every two hours. During a concurrent observation and interview on 2/8/2024 at 12:30 p.m. with Infection Preventionist (IP 1), in Resident 40's room, Resident 40 was lying on the left side facing the window. IP 1 stated Resident 40 had a sock on and a heel protector. IP stated if the resident is not turned every two hours, even though there is a heel protector on the heel, the resident can develop a pressure ulcer to the skin. IP 1 stated it was 30 minutes passed the time for Resident 40 to be repositioned on the right side and facing the door. IP 1 stated we should be following the reposition schedule every two hours. IP 1 stated it was important to reposition Resident 40 as scheduled to prevent a pressure ulcers development. During a concurrent interview and record review on 2/8/2024 at 3:54 p.m. with the Director of Nursing (DON 2) Resident 40's Progress Notes Inquiry, dated 9/21/2023 were reviewed. The Progress Notes Inquiry indicated Resident 40 had to have heels offloading (not bearing weight) as one of the interventions to promote DTPI healing. The DON 2 stated its important to reposition a resident every two hours to prevent pneumonia (a condition that inflames the air sacs in one or both lungs). The DON 2 stated repositioning Resident 40 every two hours and offloading the left heel would help healing proceed of Resident 40's left heel DTPI. During a concurrent interview and record review on 2/9/2024 at 2:02 p.m. with the Registered Nurse (RN1) Resident 40's Progress Notes Inquiry, dated 9/21/2023 were reviewed. The Progress Notes Inquiry indicated Resident 40 interventions to promote healing to a left heel included offloading. RN 1 stated the left heel had DTPI. RN 1 stated the recommendation were to offload the left heel. RN 1 stated it was important to offload the left heel to prevent skin breakdown and to promote DTPI healing. RN 1 stated by not following the Wound Consultant's recommendations to offload Resident 40's left heel the pressure ulcer on a heel can continue to breakdown further and could become infected. During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcer Assessment, Treatment and Prevention, dated 7/2019, the P&P indicated, preventive measures used to prevent further breakdown of the skin and did not disclose to offload heels. The P&P did not disclose to turn the Residents every two hours. During a review of the facility's P&P titled, Pressure Ulcer Assessment, Treatment and Prevention, dated 7/2019, the P&P indicated that upon admission to the facility each resident shall have a total body check by a licensed nurse for the presence of pressure injuries or risk to develop a pressure injury. The resident care plan will include preventive equipment used to help prevent further ulcer breakdown. DTI is a skin injury resulted from intense or prolonged pressure and shear force at the bone muscle interface.