**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries for one (#1) of three residents reviewed for pressure ulcers out of 39 sample residents. Resident #1, who was known to be at risk for pressure injuries, was admitted on [DATE] and readmitted on [DATE]. The resident had diagnoses of multiple sclerosis (disabling disease of brain and spinal cord), neurogenic bladder and metabolic encephalopathy (brain disorder caused by chemical imbalance of the blood). Hospital documentation recommended treatment for the wounds which were present to the Resident #1's sacrum, right lower extremity and left lower extremity upon the resident's readmission to the facility on 3/17/24. The recommendations further indicated the resident was to follow up with outpatient wound care. However, the facility failed to initiate a care plan and interventions to prevent the development of pressure injuries until 5/11/24. On 5/6/24, Resident #1 developed a stage 2 pressure injury to the right heel which worsened to a stage 4 pressure injury on 6/28/24. The resident developed a second stage 2 pressure injury to the right lateral (outside) heel on 5/17/24 which worsened to a stage 4 pressure injury on 7/2/24. Resident #1's pressure injury care plan was not updated until 7/2/24, despite the resident having developed a second stage 2 pressure injury to her right lateral heel. Review of the resident's electronic medical record (EMR) did not reveal documentation to indicate the physician was notified when the resident's two stage 2 pressure injuries worsened to stage 4 pressure injuries. Additionally, the facility failed to assess Resident #1's wounds weekly between 5/6/24 to 5/17/24 and again between 6/19/24 to 6/28/24. Due to the facility's failure to implement timely interventions to prevent the development of pressure injuries and the facility's failure to implement additional interventions following pressure injury development, Resident #1 developed two facility-acquired stage 2 pressure injuries, which worsened to stage 4 pressure injuries. Findings include: I. Professional reference According to the National Pressure Injury Advisory Panel, European Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance Prevention and Treatment of Pressure Injuries: Clinical Practice Guideline, third edition, [NAME] Haesler (Ed.), EPUAP/NPIAP/PPPIA (2019), retrieved on 8/5/24 from https://www.internationalguideline.com/guideline, Pressure ulcer classification is as follows: Category/Stage 1: Nonblanchable Erythema (discoloration of the skin that does not turn white when pressed, early sign of tissue damage) Intact skin with nonblanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category/Stage 1 may be difficult to detect in individuals with dark skin tones. May indicate 'at risk' individuals (a heralding sign of risk). Category/Stage 2: Partial Thickness Skin Loss Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising.This Category/Stage should not be used to describe skin tears, tape burns, perineal dermatitis, maceration or excoriation. Category/Stage 3: Full Thickness Skin Loss Full thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/ Stage 3 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and Category/ Stage 3 ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage 3 pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage 4: Full Thickness Tissue Loss Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage 4 pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Category/ Stage 4 ulcers can extend into muscle and/ or supporting structures ( fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable Unstageable: Depth Unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore Category/ Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed. Suspected Deep Tissue Injury: Depth Unknown 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. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment. II. Facility policy and procedure The Skin Management policy and procedure, dated June 2022, was provided by the nursing home administrator (NHA) on 7/30/24 at 1:43 p.m. It read in the pertinent part, Individuals at risk for skin compromise are identified, assessed, and provided treatment to promote healing, prevent infection, and prevent new pressure injuries from developing. In accordance with CMS guidelines, 'unavoidable' means that 'the resident developed a pressure injury even though the center had evaluated the resident's clinical condition and pressure injury risk factors; defined and implemented interventions that are consistent with resident needs, goals and recognized standards of practice; monitored and evaluated the impact of the interventions; and revised the approaches as appropriate.' All of this must be clearly defined in the resident's medical record. Upon admission or readmission, residents are assessed for skin integrity by completing a head-to-toe physical assessment of skin condition and completing the Braden scale for predicting pressure sore risk under defined assessment (UDA) in conjunction with the new admission nursing data collection set (UDA). Following admission, the braden scale for predicting pressure sore risk will be completed weekly for 3 (three) additional weeks (for a total of 4 (four) weeks, including admission), quarterly, annually, and with a significant change of status to determine the risk for development of pressure injuries. Appropriate preventative surfaces (beds, wheelchairs) will be implemented for residents identified at risk. Interventions are documented on the care plan. Residents admitted with skin impairment will have interventions to promote healing. A care plan is developed upon admission, and reviewed upon readmission, identifying the contributing risks for breakdown, including history of skin impairment or the actual impairment, and the interventions implemented to promote healing and prevent further breakdown. III. Resident #1 A. Resident status Resident #1, age greater than 65, was admitted on [DATE] and readmitted on [DATE]. According to the June 2024 computerized physician orders (CPO), diagnoses included multiple sclerosis and neurogenic bladder. The 7/12/24 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment documented the resident was dependent on staff for dressing, toileting hygiene, personal hygiene, bathing, and putting on/taking off footwear. The assessment documented the resident required maximal assistance with turning side to side in bed. The assessment indicated the resident was at risk for pressure ulcers and had stage 2 and stage 4 pressure ulcers that were not present on admission/readmission. The assessment indicated the resident did not reject care. B. Resident observations On 7/30/24 at 10:38 a.m. Resident #1 was lying in her bed. Resident #1 had a wrapped dressing on her right foot. She did not have compression stockings or shoes on her feet. On 7/30/24 at 2:37 p.m. Resident #1's wound care was observed with the director of nursing (DON), the assistant director of nursing (ADON) and certified nurse aide (CNA) #1. The resident's right heel had an open wound with visible white bone measuring 2.8 cm (centimeters) long, 2.0 cm wide and 1.0 cm deep. The resident had a second wound visible on the bottom of the foot which was not open. The second wound on the bottom of the foot was dark purple in color and was nonblanchable on assessment. The second wound on the bottom of the foot measured 1.2 cm long and 1.0 cm wide. Resident #1 was not observed to exhibit verbal or nonverbal signs of pain or discomfort during the wound dressing change. C. Resident Interview Resident #1 was interviewed on 7/30/24 at 10:41 a.m Resident #1 said she had developed two pressure ulcers at the facility that she felt were avoidable. Resident #1 said she did not always receive weekly skin assessments and the facility did not provide her with the specialty shoes she was promised by nursing staff. Resident #1 said a few months ago she was walking and able to perform several complex self care activities. Resident #1 said she developed the first pressure ulcer on her right heel a few months ago (May 2024) and lost the ability to stand and perform her self-care activities in April 2024. Resident #1 said she felt very angry that she had lost so much of her independence in such a short period of time. Resident #1 was interviewed again on 7/30/24 at 3:58 p.m. Resident #1 said she did not feel pain or discomfort during the wound dressing change earlier today (7/30/24). Resident #1 said she did not normally need pain medication during her foot wound dressing changes because she could not always feel pain in her feet. Resident #1 said she did not reject care. Resident #1 said she did not refuse to exit her wheelchair but had fallen asleep in her wheelchair frequently with her shoes on in the past few months because she could not stand with her heel pressure wounds and staff did not always wake her up to assist her in transferring back into her bed. Resident #1 said she wished staff had tried to wake her up and assisted her with removing her shoes. Resident #1 said this had not been a problem for the last month or so because she did not currently have any shoes to wear for any situation. Resident #1 said she had been bed and wheelchair bound for the last month (July 2024). Resident #1 said she required assistance from staff and a mechanical lift to get in and out of bed. Resident #1 said she had not refused to remove her compression stockings because it was important for her to wear them to help her legs with swelling. Resident #1 said the swelling in her legs is what created leg wounds for her and it had been identified by a doctor in the hospital in March 2024 as a way to prevent pressure sores from occurring. D. Record review Hospital documentation, dated 3/12/24, revealed Resident #1 had wounds on her sacrum, left lower extremity, and right lower extremity. The documentation recommended cleansing sacral wounds daily and as needed for soiling and covering the wound with an optifoam sacral dressing. The documentation recommended wearing tubigrip compression wrappings daily for the left lower extremity wound. The documentation recommended silvasorb covered with a foam dressing over partially open wounds and tubigrip compression wrappings to the right lower leg. The documentation further recommended that Resident #1 elevate her lower extremities with pillows, turn frequently to offload pressure from her sacrum, and follow up with outpatient wound care. -Review of Resident #1's EMR did not reveal documentation to indicate the resident had been scheduled to follow up with outpatient wound care per the physician's recommendations. -Review of the resident's EMR further revealed there was no head to toe skin assessment conducted on 3/17/24 upon the resident's readmission to the facility. A head to toe skin assessment, dated 3/24/24, documented Resident #1 had intact skin. -However, according to hospital documentation prior to the resident's readmission on [DATE], Resident #1 had wounds on her sacrum, right lower extremity and left lower extremity (see hospital documentation above). A head to toe skin assessment, dated 3/31/24, documented the resident had intact skin. It documented the resident had blanchable redness to the coccyx and a treatment was in place to an area on Resident #1's right leg. -The assessment failed to document the skin condition on Resident #1's right leg. -The facility failed to implement a pressure ulcer prevention plan of care after identifying an area of redness on the resident's coccyx (see care plan below). Resident #1's pressure ulcer care plan, initiated on 5/11/24 (after the resident developed the first stage 2 pressure wound on 5/6/24) and updated on 7/18/24, documented the resident had a pressure ulcer related to edema and the resident was refusing to remove her shoes and compression stockings. The identified interventions included adding an air mattress to the resident's bed, compression stockings for edema management, providing the resident with a DARCO boot (specialized footwear designed to promote foot wound healing), educating the resident about proper skin care to prevent skin breakdown, providing education on the importance of elevating extremities, encouraging the resident to elevate legs for edema management, encouraging the resident to avoid lying on her back and rolling side to side as tolerated, evaluating ulcer characteristics, monitoring ulcer characteristics for signs of progression or declination, notifying the provider if no signs of improvement on current wound regimen, offloading shoes as needed, providing wound care per treatment orders, referring the resident to a specialized practitioner for wound management, using enhanced barrier precautions and using a temporary wheelchair with elevating foot pedals. -However, the resident did not receive the DARCO boot (see resident observation and interview above and ADON interview below). A Braden Scale for predicting pressure sore risk assessment was completed on 4/12/24, 6/17/24, and 7/25/24. All three assessments documented the resident was at risk for developing pressure ulcers. All three assessments documented the resident had no sensory deficit which would limit her ability to feel pain or voice discomfort. -However, the resident was diagnosed with multiple sclerosis and metabolic encephalopathy which the facility said could impact the resident's sensation (see interview below) and the resident said she did not normally feel pain in her feet (see resident interview above. Resident #1's progress notes were reviewed for documented rejections of care between 5/6/24 and 7/21/24. The resident was documented to refuse returning to bed on five occasions, refusing to elevate her legs on 14 occasions and refusing to remove her shoes or compression stockings on three occasions. -There was no documentation to indicate the facility had reoffered care to the resident on the occasions she refused care or that education was provided to the resident regarding the potential outcomes to skin integrity related to refusing care. -Additionally, the facility failed to update the resident's pressure ulcer care plan to reflect the reason the resident occasionally refused care or document the reasons the resident refused the care. A skin pressure injury note, dated 5/6/24, documented the resident had a stage 2 pressure ulcer to the right heel measuring 1.5 cm long, 4.0 cm wide and 0.3 cm deep. The note documented interventions included a pressure reducing mattress and a pressure reducing cushion. -However, the facility failed to implement a pressure injury care plan until 5/11/24, five days after the pressure injury was identified. -Additionally, the facility did not implement a pressure-reducing mattress for Resident #1 until 7/9/24 when a performance improvement plan (PIP) for wounds was implemented (see interviews below). -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the new pressure injury. A weekly skin pressure injury note, dated 5/17/24, documented the resident had a stage 2 pressure ulcer to the right heel measuring 1.5 cm long, 3.0 cm wide and 0.3 cm deep. The assessment further documented a second pressure wound on the resident's right lateral foot measuring 0.5 cm long, 0.5 cm wide and 0.2 cm deep. The note documented interventions included a pressure reducing mattress and a pressure reducing cushion. -The facility did not conduct the weekly skin assessment until 11 days after the previous assessment on 5/6/24. -The facility did not implement a pressure-reducing mattress for Resident #1 until 7/9/24 when a PIP for wounds was implemented (see interviews below) -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the new pressure injury. -The assessment failed to identify new interventions to prevent the deterioration of current skin conditions identified by nursing staff. A weekly skin pressure injury note, dated 5/23/24, documented the resident had a stage 2 pressure ulcer to the right heel that had not improved or worsened. The assessment documented the second pressure wound on the right lateral foot had deteriorated and now measured 0.6 cm long, 0.6 cm wide and 0.2 cm deep. -The assessment failed to identify new interventions to prevent the stagnation or deterioration of current skin conditions identified by nursing staff. -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the worsening pressure injury. -The facility did not implement a pressure-reducing mattress for Resident #1 until 7/9/24. A weekly skin pressure injury note, dated 5/30/24, documented the resident had a stage 2 pressure ulcer to the right heel that had deteriorated and now measured 1.6 cm long, 3 cm wide and 0.3 cm deep. The assessment documented the second pressure wound on the right lateral foot had deteriorated and was now an unstageable wound measuring 1.0 cm long, 1.3 cm wide and had an unknown depth. The assessment documented the wound on the right lateral foot had approximately 50% eschar. (dead skin tissue) -The assessment failed to identify new interventions to prevent the stagnation or deterioration of current skin conditions identified by nursing staff. -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the worsening pressure injury. -The facility did not implement a pressure-reducing mattress for Resident #1 until 7/9/24. A weekly skin pressure injury note, dated 6/6/24, documented the resident had a stage 2 pressure ulcer to the right heel that had improved and now measured 1.5 cm long, 2.1 cm wide and 0.3 cm deep. The assessment documented the second pressure wound on the right lateral foot had deteriorated and was now a stage 3 pressure wound measuring 1.5 cm long, 2.8 cm wide and was 0.3 cm deep. The assessment documented Resident #1 would supinate (to face a part of the body upwards) her feet which contributed to the deterioration of the wounds. The assessment documented Resident #1 would sleep in her wheelchair all day and all night, would refuse to elevate her legs, and would refuse to remove her shoes or compression stockings. The assessment documented the resident would often refuse to bathe which resulted in poor skin health. -However, Resident #1 was only documented to refuse to return to bed on five separate occasions between 5/6/24 and 7/21/24 and refusing to remove her shoes on three occasions between 5/6/24 and 7/21/24. -The facility failed to identify new interventions to prevent the stagnation or deterioration of current skin conditions identified by nursing staff. -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the worsening pressure injury. A weekly skin pressure injury note, dated 6/15/24, documented the resident had a stage 2 pressure ulcer to the right heel that had deteriorated and now measured 1.5 cm long, 3 cm wide and 0.3 cm deep. The assessment documented the second pressure wound on the right lateral foot had improved and was a stage 3 pressure wound measuring 1.5 cm long, 1.0 cm wide and was 0.2 cm deep. The assessment documented Resident #1 would sleep in her wheelchair all day and all night, would refuse to elevate her legs, and would refuse to remove her shoes or compression stockings. The assessment documented the resident would often refuse to bathe which resulted in poor skin health. -However, Resident #1 was only documented to refuse to return to bed on five separate occasions between 5/6/24 and 7/21/24 and refusing to remove her shoes on three occasions between 5/6/24 and 7/21/24. -The facility performed the weekly assessment nine days after the previous weekly assessment on 6/6/24. -The facility failed to identify new interventions to prevent the stagnation or deterioration of current skin conditions identified by nursing staff. -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the worsening pressure injury. A weekly skin pressure injury note, dated 6/19/24, documented the resident had a stage 2 pressure ulcer to the right heel that had deteriorated and now measured 2.3 cm long, 3.4 cm wide and 0.5 cm deep. The assessment documented the second pressure wound on the right lateral foot had deteriorated and was a stage 3 pressure wound measuring 1.2 cm long, 1.2 cm wide and was 0.3 cm deep. -The assessment failed to identify new interventions to prevent the stagnation or deterioration of current skin conditions identified by nursing staff. -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the worsening pressure injuries. A weekly skin pressure injury note, dated 6/28/24, documented the resident had a wound on the right heel that had deteriorated and was now a stage 4 pressure ulcer measuring 4.5 cm long, 4.0 cm wide and 0.7 cm deep. The assessment documented the wound bed was eschar and bone. The assessment documented the second pressure wound on the right lateral foot had deteriorated and was a stage 3 pressure wound measuring 0.7 cm long, 1.5 cm wide and was 0.5 cm deep. -The assessment failed to identify new interventions to prevent the stagnation or deterioration of current skin conditions identified by nursing staff. -The facility performed the weekly skin assessment nine days after the previous assessment on 6/19/24. -There was no documentation to indicate the resident's physician or the facility's medical director were notified of the pressure injury deteriorating to a stage 4 pressure injury A weekly skin pressure injury note, dated 7/2/24, documented the resident had a stage 4 pressure ulcer on the right heel that measured 3 cm long, 3.7 cm wide and 1 cm deep. The assessment documented the second pressure wound on the right lateral foot had deteriorated and was a stage 4 pressure wound measuring 1.2 cm long, 1.2 cm wide and was 0.9 cm deep. -The assessment failed to identify new interventions to prevent the stagnation or deterioration of current skin conditions identified by nursing staff. -There was no documentation to indicate the resident's physician or the facility's medical director were notified Resident #1 now had two stage 4 pressure injuries. A telehealth (virtual) physician's visit note, dated 7/2/24, documented Resident #1 had a stage 4 pressure wound on her right heel and had another wound on the lateral middle part of the foot that was a stage 2 pressure injury. The assessment documented the resident had been in her bed since yesterday (7/1/24) and would not get out of bed. The assessment documented the resident was to receive new shoes and an offloading boot. The assessment further documented the resident was receiving daily dressing changes to the heels and compression stockings were being changed every couple of weeks when the resident would allow a shower. The assessment documented the resident had lower extremity edema (swelling) and required compression with tubigrips and compression wraps. The assessment documented the resident was wheelchair bound but could transfer herself. A weekly skin pressure injury documentation, dated 7/9/24, documented the resident had a stage 4 pressure ulcer on the right heel that deteriorated and measured 2.8 cm long, 4.0 cm wide and 0.5 cm deep. The assessment documented the second pressure wound on the right lateral foot had improved and was a stage two pressure wound measuring 1 cm long, 1 cm wide, and was 0.2 cm deep. The assessment identified new interventions to include nutritional supplements, and a plan of care discussion that included Resident #1, the nursing home administrator (NHA), the MDS resource nurse, and the corporate consultant (CC). The discussion included education to Resident #1 that her compression stockings were causing increased pressure to her heels, the importance of turning side to side in bed, and the importance of accepting showers. -The facility failed to document weekly skin pressure injury documentation between 7/10/24 and 7/30/24. A telehealth physician visit note, dated 7/10/24, documented a referral for Resident #1 to see wound care to assist with wound debridement (removal of damaged tissue from the wound). -However, there was no documentation to indicate Resident #1 was seen by a wound care physician for wound debridement between 7/10/24 and 7/30/24. A Performance Improvement Plan (PIP) for wounds, dated 7/10/24, was provided by the DON on 7/31/24 at 8:46 a.m. The PIP documented the facility had an opportunity to improve several areas of wound care management in the facility, including the accuracy and timeliness of pressure ulcer assessment, appropriately identifying pressure ulcer wounds, appropriately changing treatment orders, implementing interventions as needed, and holding care conferences with a resident's decision maker as needed. The PIP documented the facility experienced communication breakdown in shift-to-shift report, nursing management assessments and follow-up was inadequate, and a lack of communication with outside resources such as wound clinic specialists. The PIP documented the facility would intervene with several new interventions on 7/10/24. The PIP documented all residents in the facility would have an accurate and in depth skin assessment completed within 24 hours, and all residents would have a head-to-toe skin assessment that was accurate, on time, and thorough. The PIP documented all nursing staff members would receive education on pressure injury prevention, the Braden scale and reporting requirements of skin conditions. -The facility failed to identify when the PIP would be re-evaluated for effectiveness. E. Staff interviews The DON was interviewed on 7/30/24 at 12:10 p.m. The DON said she was previously the facility's NHA and transitioned into the role of DON on 7/29/24. The NHA was interviewed on 7/30/24 at 1:34 p.m. The NHA said the facility did not have documentation indicating the facility notifying a physician when either of Resident #1's wounds progressed to stage 4 (see documentation above). LPN #1 was interviewed on 7/30/24 at 3:58 p.m. LPN #1 said Resident #1 sometimes did not want to shower. LPN #1 said she did not personally have this issue because she and Resident #1 had a good relationship and Resident #1 did not refuse showers for her. LPN #1 said Resident #1 did not often refuse cares for her as long as she took her time with Resident #1 and made the care enticing by explaining that the resident would feel better afterwards. The DON was interviewed again on 7/30/24 at 4:23 p.m. The DON said Resident #1 had a stage 4 pressure wound on her right heel and an unstageable pressure wound on the resident's right lateral foot. The DON said both wounds were currently improving. The DON said the facility's previous DON no longer worked at the facility. The DON said the facility's previous DON had been solely responsible for wound care in the facility, but she had been on vacation since late June 2024 and had not worked in the building in July 2024 at all before she left the facility. The DON said the facility had identified concerns with resident wound care in July 2024 and implemented a PIP to address these concerns. The DON said the facility did not implement new interventions for Resident #1's plan of care after wound deterioration was documented on 5/30/24, 6/6/24, 6/15/24, 6/19/24, or 6/28/24. The DON said she was not aware that the facility did not implement new interventions because she was in the NHA role at the time. The DON said the facility should have implemented new interventions to prevent deterioration of Resident #1's foot wounds. The DON said the facility should perform weekly wound skin assessments every seven days consistently. The DON said the facility failed to consistently assess Resident #1's wounds weekly. The DON said she did not have documentation of weekly wound assessments being completed between 7/10/24 and 7/30/24. The medical director (MD) was interviewed on 7/30/24 at 4:58 p.m. The MD said Resident #1's wounds were facility-acquired and avoidable. The MD reviewed documentation regarding the resident's wounds and said he could not tell if or when any physician was told about Resident #1's stage 4 pressure wounds. The MD said that his physician's office performed assessments of Resident #1's wounds on 7/2/24 and 7/10/24 and issued recommendations only on those occasions. The MD said the first time he assessed the wounds they were already stage 4 pressure wounds. He said a physician should be alerted that a resident had a wound before the wound reached the status of a stage 4 pressure wound. The MD said if he had been notified earlier he would have reassessed the resident's medications and treatments to further prevent the development of the facility-acquired pressure ulcers. The MD said he was unsure if sufficient education was provided to Resident #1 early enough to help prevent pressure injuries. The MD said the facility had one discussion with Resident #1 in July 2024 regarding care plan adherence and since that time Resident #1 had not had rejections of care. The MD said he had evaluated Resident #1's compression stockings and was unsure if they contributed to any specific pressure development for the resident. The MD said it was important for Resident #1 to wear compression stockings to prevent the development of wounds due to swelling. The MD said the facility[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure one (#11) of two residents reviewed for pressure injuries, out of 26 sample residents, received care consistent with professional standards of practice to prevent and heal pressure injuries. Resident #11 had a facility acquired unstageable pressure injury which was not identified as unavoidable in the medical record. The review of the resident's progress notes and medical record between 11/11/21 and 1/10/22 did not identify the resident was seen by her primary physician or by a wound physician after it was identified the resident had an unstageable pressure injury/DTI (deep tissue injury). The review of the resident's medical record indicated the resident was not identified to have any skin related issues to her left heel until it was identified as unstageable on 11/11/21. The resident was at risk for developing pressure injuries according to the Braden scale risk assessment and the 10/21/21 minimum data set (MDS) assessment. The last risk assessment completed was on 8/3/21. The resident did not have a risk assessment completed after the 10/21/21 quarter review or after the resident had an identified unstageable pressure injury on 11/11/21. The weekly summary assessment documented by the nursing staff did not identify the resident had pressure injuries or other skin related conditions on 11/2/21 a week before the resident was identified to have an unstageable DTI/pressure injury to her left heel. The nursing staff continued to document the resident did not have a pressure injury or skin conditions each week following the identification of the unstageable DTI/pressure injury to her left heel. A pressure reducing air mattress was not provided until 12/7/21, 26 days after the resident was identified to have an unstageable pressure injury. The care plan was last updated on 10/28/21. The care plan did not include interventions to treat the unstageable DTI/pressure injury discovered on 11/11/21. A change of condition assessment was not conducted after the resident was identified to have an unstageable pressure injury. Observation identified a second area discoloration on her left heel on the outer lateral side. An LPN (licensed practical nurse) described it as a possible old blister from her boot. There was no mention in the medical record regarding the discolored site. Findings include: I. Facility policies and procedures The policy for wound care, dated 11/1/17, was provided by the nursing home administrator (NHA) on 1/10/22 at 10:24 a.m. The policy provided guidelines to promote wound healing. According to the policy, staff were to: -Verify physician's orders for wound care; -Review the resident's care plan to assess any special needs of the resident; -Provide wound documentation weekly; -Document physician wound care notes, if resident was followed by a wound care physician; and, -Report other information in accordance with facility policy and professional standards of practice. The Prevention of Pressure Ulcers/Injuries policy, revised July 2017, was provided by the clinical care coordinator (CCC) on 1/11/22 at 11:34 a.m. According to the policy, its purpose was to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. The policy read: Assess the resident on admission for existing pressure ulcer injury risk factors. Repeat the risk assessment weekly and upon any changes in condition Inspect the skin on a daily basis when performing or assisting with personal care or activities of daily living (ADLs). Identify any signs of developing pressure injuries (i.e non-blanchable erythema). For darkly pigmented skin, inspect for changes in skin tone, temperature, and consistency; Inspect pressure points ( sacrum, heels, buttocks, coccyx, elbows, ischium, trochanter, ect .Moisturize the dry skin daily; and Reposition resident as indicated on the care plan . Select appropriate support services based on the resident's mobility, continence, skin moisture and perfusion, body size, weight, and overall risk factors .Evaluate, report and document potential changes in the skin. Review the interventions and strategies for effectiveness on an ongoing basis. II. Resident #71 status Resident #11, age [AGE], was admitted on [DATE], with an initial admission on [DATE]. According to the January 2022 computerized physician orders (CPO), diagnoses included type II diabetes mellitus (DMII) with unspecified complications, chronic obstructive pulmonary disease (COPD), cognitive communication deficit, and vision loss. The 10/21/21 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired, with a brief interview for mental status (BIMS) score of five out of 15. The resident required extensive assistance of one person for bed mobility, transferring, locomotion on and off the unit, dressing, toileting, and personal hygiene. The MDS indicated the resident was at risk for developing a pressure ulcer and was not on a positioning/turning program. The 1/3/22 annual MDS in progress identified Resident #11 had one unstageable pressure injury presenting as deep tissue injury (DTI). According to the MDS, the resident had a pressure reduction device to her bed. III. Observation On 1/6/22 at 12:50 p.m., Resident #11 was observed in the lobby sitting in her wheelchair. She wore a Lanard boot on her left foot. The social service director (SSD) attempted to assist the resident to her room but the resident could not lift her feet so the wheelchair could be moved forward. The SSD requested the CNA to place foot pedals on the wheelchair so the resident could be taken to her room. On 1/11/22 at 10:25 a.m. Resident #11 was observed in her bed. Two pillows and a folded blanket floated her heels. She wore socks over her feet. The staffing development coordinator (SDC), identified she was a licensed practical nurse (LPN). The SDC removed the resident's left sock and proceeded to wash her foot with a wet cloth. Two separated areas of the left foot were observed. On the backside of the left heel a dark purple large scab hung from the heel. The area was sensitive to touch. The resident said No, no, don ' t touch as the SDC washed her heel. She blotted the wound with gauze. She applied betadine to the whole left heel. On the outer lateral side of the heel was a purple discolored mark. The mark was not connected or in the same location as the DTI pressure injury located on the cusp of the resident's heel. The SDC said the discolored mark was considered part of the pressure injury because it was all on the same heel and that was why she applied betadine to the entire left heel. The SDC applied A&D ointment to both feet and placed the socks back on the resident. She offered the Lanard boot over the left foot but the resident refused. On 1/11/22 at 12:03 p.m. LPN #2 was observed to measure the area on Resident #11's lateral left heel. The LPN measured the discolored mark at 2 cm (centimeters) x 1 cm. According to the LPN, it appeared to be a triangle sized, old and dried blister, possibly from her Lanard boot. On 1/11/22 at 1:40 p.m. the director of nursing (DON) observed the possible old blister with the registered nurse (RN) surveyor. The DON described the area on the resident's lateral heel as non-blanchable discolored flakey skin. The RN described the area as an old, non blanchable discolored intact site, purplish read in color, with a dry skin flap that was hard and hanging. IV. Record review A. Skin risk assessment The Braden scale for predicting pressure sore risk, dated 8/3/21, identified Resident #11 was at risk for developing pressure injuries. The 8/3/21 was the most recent skin risk assessment completed. A risk assessment was not completed after the resident acquired an actual pressure injury. According to the 8/3/21 risk assessment, the resident was chairfast, identifying her ability to walk was severely limited or non-existent. The assessment indicated friction and shearing was a potential problem. The assessment read the resident moved freely or required minimal assistance where her skin probably slid to some extent against sheets, chairs, restraints or other devices. B. Care plan The care plan for potential/actual impaired skin integrity, revised on 1/4/21, read the resident had the potential/actual impaired skin integrity was related to her falls, limited mobility, blind, incontinence, and DMII (diabetes). Interventions dated 10/28/21 directed staff to: -Maintain or develop clean and intact skin; -Avoid the resident from scratching herself, keeping her fingernails short and her hands and body parts from excessive moisture; -Encourage good nutrition and hydration in order to promote healthier skin; -Follow facility protocols for treatment of injury; and -Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The care plan identified the resident had a deep tissue injury (DTI). The care plan did not identify new interventions to treat the DTI/pressure injury/ulcer documented on 11/11/21 to current. (See below) C. Computerized physicians orders The CPO identified Resident #11 had orders on 11/11/21 to monitor the resident's left heel deep tissue injury (DTI) on each shift until resolved. Staff were to offload at all times and document any changes noted to the left heel on every shift for left heel DTI. The CPO on 11/11/21 included orders for a lanard boot on at all times to the left lower leg secondary to the left heel DTI. The orders directed staff to document if the boot was in place on every shift. The CPO on 11/20/21 directed staff to conduct a weekly skin assessment every night shift every Wednesday. According to the orders staff need to document with the following key: D=Dry; I=Intact; NI=Not Intact; N=New; O=Old. The CPO on 11/22/21 with a discontinue date of 12/29/21 (see below), read to paint the left heel with betadine to aid in drying out the area and promote healing daily until resolved on every shift for left heel DTI. The CPO on 11/24/21 identified an order for Juven (a nutritional supplement), provided in the morning for wound healing. The CPO on 12/29/21 read to paint the left heel with betadine to aid in drying out the area and promote healing daily on every shift for left heel DTI until resolved. The review of the CPO did not identify the resident had orders for a pressure reduction device/air mattress. D. Treatment administration record The treatment administration record (TAR) was reviewed for November 2021, December 2021, and January 2022. The TAR included the order to conduct a weekly skin assessment every night shift every Wednesday. According to the orders, staff needed to document with the following key: D=Dry; I=Intact; NI=Not Intact; N=New; O=Old. The review on the November 2021, December 2021, and January 2022 TAR, identified staff did not use the ordered key to describe the condition of Resident #11 skin. A check was marked weekly instead of the above code. The key did not indicate what the check meant in relation to the condition of the resident's skin. E. Weekly summary assessment The 11/2/21 weekly summary assessment identified the resident had blanchable redness to her sacrum and upper mid vertebrae. No other skin conditions were identified. The weekly summary assessment between 11/16/21 and 1/9/22 did not identify the resident had a pressure injury/DTI. According to the assessments, the nursing staff marked no for presence of a current pressure injury or other skin conditions. Under the assessment section to identify a site for concern, the section was left blank. According to the weekly assessments, Resident #1's skin was intact and she did not have a current pressure injury or other skin conditions present. F. Wound log The wound log was provided by the DON on 1/10/22. The wound log identified the DTI/pressure injury measurements and treatments. -11/11/21: Acquired in house left heel DTI unstageable measuring 2 cm (centimeters) x 2.5 cm. Interventions were to offload in a Lanard boot and apply betadine. According to the log entry the DTI was intact but identified as a new onset as of 11/11/21. -11/21/21: Left heel (DTI/pressure injury) measuring 2.5 cm x 1.8 cm. Interventions were to paint the heel with betadine, and apply the Lanard boot to offload. According to the log entry, there was a slight improvement and there was no drainage or odor present. -11/24/21: (Left heel DTI/pressure injury) measuring 2.5 cm x 1.8 cm. The heel was painted with betadine and applied boot to offload. There was no drainage and hard, intact and decreased in size (from original onset). -11/29/21: (Left heel DTI/pressure injury) measuring 3 cm x 2 cm (an increase in size from original onset). (Provide) betadine, lanard boot, off load and air mattress. According to the log entry, no drainage was present and the DTI/pressure injury was dry with a hard intact scab. -12/6/21: (Left heel DTI/pressure injury) measuring 2.8 cm x 2.5 cm. The 12/6/21 entry identified it as hard, dry, and an intact scab. No new interventions. -12/12/21: The review on 12/12/21 wound log indicated other residents were seen on 12/12/21 but Resident #11 did not have a log entry. -12/23/21: Unstageable (Left heel DTI/pressure injury) measuring 2.2 cm x 2.6 cm . There were no new interventions. -12/31/21: Left heel (DTI/pressure injury) measuring 1.8 x 2 unstageable. According to the entry log, there was no drainage and the resident had orders for a wound consult. -1/8/22: Left heel (DTI/pressure injury) measuring 2.2 cm x 2 cm without drainage. Interventions included betadine daily and a wound consult. The review of the measurements identified the pressure injury had very little improvement between 11/11/21 and 1/8/22. The review of the log did not include identification or measurement of the discolored area on her lateral left heel. G. Progress notes The 11/1/21 physician note read the resident received an office visit with her primary care physician on 11/1/21 for chronic conditions and medication reconciliation. The 11/1/21 was the most recent encounter Resident #11 had with the physician. No skin concerns were identified by the physician on 11/1/21. The resident was not seen by the physician after it was discovered on 11/11/21 she acquired a pressure injury/DTI. The 11/10/21 interdisciplinary team (IDT) note read Resident #11 had no skin related issues noted. The 11/11/2021 skin/wound note read the nurse on duty reported Resident #11 had an injury to left heel. According to the note, the DON completed the assessment and noted left heel DTI. The area of the DTI was dark purple in color and tender to touch upon palpation of the site. There were no signs of infection or drainage noted. Resident #11 stated her heel was sore. A Lanard boot was applied to the site to ensure pressure was offloaded and heels floated while she was in bed. The resident was noted to have three plus pedal edema to both of her feet and one plus pitting edema to bilateral extremities (BLE). The physician was notified with a pending follow up call regarding edema and pressure injury to the left heel. The nurse on duty would monitor daily and document any changes and report and DON to monitor weekly and PRN (as needed) until resolved. The 11/17/21 IDT note met to review new DTI on Resident #11's left heel. According to the note, a Lanard boot was implemented and the facility would initiate Juven once a day for wound healing. The 11/21/2021 skin/wound note read the DON completed wound rounds on 11/21/21. The note identified the area to the left heel was dry and hard with an intact scab. The resident did not verbalize the complaint of pain with palpation of the site. The Lanard boot remained in place without resident complaints of wearing the boot to aid in offloading at all times. According to the note, the area was cleaned and painted with betadine as ordered by the physician to aid in drying the area out and eventual goal for the scab to fall off. The note indicated staff would continue to monitor weekly and note any changes. The 11/24/21 IDT note read the resident's DTI to the left heel had a hard dry intact scab to site. Interventions identified in the note included a Lanard boot and Juven once a day. The 12/1/21 IDT note read the resident resided on an air mattress however according to the DON interview (see below), an air mattress for pressure reduction had to be ordered for the resident. -According to the purchase order (see below) a mattress was not ordered till 12/1/21 and did not arrive at the facility till 12/7/21. The IDT note did not note the increase of size of the DTI between 11/24/21 at 2.5 cm x 1.8 cm and 11/29/21 at 3 cm x 2 cm. The 12/6/2021 skin/wound note identified the area to the left heel remained intact with dry hard scab and did not have buoyancy when pressure applied to site and no signs of pain note. According to the note, staff would continue to monitor. The 12/7/21 IDT note read the heal appeared to be healing. The 12/15/21 IDT note read the resident's DTI to the left heel was healing and decreasing in size. According to the note, the left heel was offloaded with the Lanard boot and an air mattress to alleviate pressure. The note identified the resident's heels were floated on pillows when in bed. The resident was frequently turned when in bed. The 12/19/2021 skin/wound note was identified as a late entry note on 12/13/21. According to the note, the left heel unstageable 2.2 x 2.4 cm DTI was decreasing in size and dead tissue was noted to be flaking off with new tissue growth present under dead tissue that came off during cleaning. According to the note, the turning schedule continued. The 12/21/21 IDT note read the DTI to the left heel was now considered unstageable. However, according to the wound log, the DTI was considered unstageable on 11/11/21 when it was first identified. No new interventions were identified in the CPO or the care plan. The 12/29/21 IDT note read Resident #11 had an ongoing left heel unstageable pressure injury. According to the note, the physician was contacted to request orders for a wound care consult. A wound care consult was not requested for the unstageable DTI/pressure injury prior to 12/29/21. The 1/2/2022 skin/wound note read wound rounds were completed on 12/31/21. A dark hard intact callous to the left heel was identified. According to the note, no dramatic changes noted to the site since last the assessment. However the note indicated the area to have a slight amount of buoyancy to the center of callous when the area palpated upon assessment which was not present during prior assessments of the left heel. The note read an appointment would be scheduled with the wound care clinic for further evaluation of the site. The left heel was dry and had sloughing skin which was noted to come off during cleaning of the site. The area was painted with betadine as ordered. Both feet remain dry but noted improvement in appearance of feet since both are being moisturized daily with A&D ointment excluding left heel. The left lower leg remained in the Lanard boot to offload pressure to the left heel and both feet are floated on pillows while in bed. Resident #11 continued use of the air mattress with no other skin issues present. The review of the resident's progress notes and medical record between 11/11/21 and 1/10/21 did not identify the resident was seen by her primary physician or by a wound physician after it was identified the resident had an unstageable pressure injury/DTI. The progress notes did not include a second area on her left lateral heel. H. Air mattress A purchase order for an air mattress was provided by the DON on 1/11/21. The purchase for an air mattress was submitted on 12/1/21 and arrived at the facility on 12/7/21. V. Staff interview The SDC was interviewed on 1/11/22 at 11:18 a.m. She said the location of the wound on the heel appeared to be from pressure of her bed. She had no current signs of infection and was starting to dry out. She identified two areas on her heel. The LPN said one was intact, the other was open. She said the left lateral area on the heel was about the size of a quarter. She said the resident prefers to be in bed and would often wiggle her feet potentially causing shearing. LPN #2 was interviewed on 1/11/22 at 11:53 a.m. LPN #2 said the facility was treating a wound to the back of Resident #11's heel, describing it as a quarter sized area with a scab hanging from the site. He said he did not notice any other areas to the resident's heel. She said she would look at her heel again (see above observation). The DON was interviewed on 1/11/22 at 12:10 p.m. with the corporate clinical consultant (CCC). The DON identified preventive measures to prevent pressure injuries. She said the resident would be assessed for risk of pressure injuries. She said if the resident was at a high risk, the resident would be frequently repositioned and toileted. They would be evaluated for nutrition at risk, ensuring adequate fluids and nutritional needs. The resident would have weekly skin assessments. The DON said offloading would be implemented and an air mattress would be put in place if warranted. The DON said Resident #11 had a current unstageable pressure injury that was facility acquired on the cusp of her heel. The DON said she last saw the pressure injury on 1/8/21. She said the injury had a hard center and the skin around the area was sloughing off. The DON said residents should not have a facility acquired pressure ulcer/injury but sometimes they were unavoidable. The DON said if a facility was doing prevention care for pressure injuries, injuries could be potentially avoided. She said they were trying their best to avoid facility acquired pressure injuries. She said prior to the pressure injury, Resident #11 had weekly skin assessments, repositioning, and fluid and nutritional needs were met. The DON said when the deep tissue injury was first reported to her on 11/11/21, the condition of the DTI was determined to be unstageable. The DON said the resident was frequently positioned prior to her facility acquired pressure injury, however, according to the 10/21/21 MDS the resident was not on a repositioning/turning program. The resident's care plan did not direct staff to frequently reposition/turn the resident. The DON said an air mattress to reduce pressure to the heel was implemented in December 2021. She said the air mattress had to be ordered. The DON provided the purchase order for the air mattress, arriving on 12/7/21 (see above). The DON said all resident treatments needed to have a physician's order for it. The DON reviewed the orders and confirmed the resident did not have an order for the air mattress. The DON said she was unsure what caused the pressure injury. She said the resident did not use foot pedals because she was able to slightly propel herself with use of her feet. The DON said a Lanard boot was implemented when the pressure injury was identified. The DON reviewed the resident's care plan and confirmed interventions to treat the unstageable pressure injury were not included in the care plan. She said the care plan should have been person centered and included all the interventions they incorporated to treat the pressure injury. She said the plan should have included the air mattress, the Lanard boot, a turning schedule, offloading, floating the heels, physicians orders, and weekly skin monitoring. The DON said the nurses should review the pressure injury daily and document the treatment. She said a weekly summary should be completed and include a review of the resident's skin. The review should include any potential changes in the skin as well as current identified skin conditions such as a pressure injury/DTI. The DON reviewed the weekly summaries prior to the 11/11/21 unstageable pressure injury and the summaries after the pressure injury was identified. The DON confirmed the weekly summaries indicated there were no skin concerns or pressure injuries. She said she did not know why the nurses did not document the resident's skin issues. The DON said she would create an action plan to include a facility audit of weekly summaries with possible corrective actions as needed. She said she would stress the importance of the accuracy of the summaries. She said the nursing staff were responsible for reviewing and promoting good skin integrity on every resident in the facility. The CCC said the facility would investigate why staff were not documenting skin concerns. The DON said she needed the nurses to continue to check on the resident's skin and notify her of new injuries or changes in condition. The DON said a change of condition MDS assessment was not completed after the resident had an identified unstageable pressure injury. She said a change of condition assessment could have possibly identified the missing orders for the air mattress and the lack of interventions on the care plan. The DON confirmed Resident #11 was last seen by her primary care physician on 11/1/21. The DON said Resident #11 had not had an appointment with her physician after she identified on 11/11/21 a pressure injury to her left foot. The DON said Resident #11's primary care physician was located in another town and it was a challenge to see him for appointments. She said the physician does not visit the facility and the resident has not had a telehealth appointment with him. The DON said the physician has not seen the pressure injury but was aware of it. The DON said the resident had not been seen by a wound physician. The DON said she noticed over the holidays, there was buoyancy to the pressure injury and determined a need for a wound consult. She said she set up an appointment on 1/13/21 at the wound clinic but the resident was currently in isolation for COVID and would not be able to go. The DON said she would contact the clinic and request the wound team to visit her at the facility. The DON was asked about the second skin condition on the resident's heel, identified as a possible old blister on the left lateral heel. She said she was not aware of a second skin condition on the resident's heel or had staff communicate any other skin conditions to the resident's left heel. She said she would look at her heel to review (see observation above). The DON said she would do a whole house sweep audit reviewing resident care/treatment. She would review risk assessments, skin documentation, orders for treatment and make sure all interventions were included in residents ' care plans to help prevent skin breakdown.