**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review policy and interviews for 2 of 6 residents (Resident #9 and Resident #62) reviewed for pressure ulcers, the facility failed to prevent the development of pressure ulcers and failed to provide the necessary treatment and services for residents with a pressure ulcer. For Resident #9, the facility failed to prevent the development of a pressure ulcer in a dependent resident, failed to ensure timely turning and repositioning and off-loading/floating (removal of pressure from a body part), failed to conduct pressure ulcer risk assessments per the facility policy, and failed to conduct weekly skin assessments. For Resident #62, the facility failed to conduct an initial pressure ulcer assessment, failed to obtain initial pressure ulcer measurements, failed to inform the wound nurse of the development of a new pressure ulcer, and failed to ensure off-loading/floating of a pressure area. The findings include: 1. Resident #9 's diagnoses included pneumonia, urinary tract infection, dementia, and bipolar disorder. The quarterly Minimum Data Set assessment dated [DATE] identified that Resident #9 was severely cognitively impaired and required supervision with bed mobility and transfers. Additionally, Resident #9 was not at risk for pressure injury or development, a pressure reducing bed and chair were in use, and Resident #9 did not have a turning or repositioning schedule. The Resident Care Plan dated 10/10/23 identified a risk for skin breakdown related to impaired mobility. Interventions directed to encourage the resident to offload/float heels while in bed and encourage the resident to turn and reposition frequently. Review of the nurse aid flow sheets dated 10/1/23 to 10/4/23 identified that Resident #9 had been independent with bed mobility. Review of APRN orders dated 10/5/23 through 10/10/23 directed to administer antibiotics to treat Resident #9's urinary tract infection and pneumonia. APRN notes dated 10/5/23 through 10/10/23 identified that Resident #9 was seen in follow-up of pneumonia, urinary tract infection, acute kidney injury on chronic kidney disease, anemia, and decreased platelet count. Resident #9 was noted to be fatigued, lacked an appetite, was not taking food or fluids well, had increased confusion, dysuria (pain on urination), increased lethargy, and weakness/tiredness due to his/her infection. A change in condition nurse's note dated 10/8/2023 at 2:48 AM identified Resident #9 had an exacerbation (worsening of an already present) respiratory condition and that antibiotics were being used to treat pneumonia. Resident #9 was noted to be alert/verbal, appeared comfortable, was resting in bed without issue, and was provided with incontinent care and repositioning in bed, however the note failed to indicate encouragement or assistance with heel off-loading. Review of the nurse Situation, Background, Assessment, and Recommendation documentation dated 10/10/23 at 10:50 AM identified that Resident #9 was noted with generalized weakness. Review of the nurse Situation, Background, Assessment, and Recommendation documentation dated 10/11/23 identified Resident #9 was resting in bed without issue, was weak, incontinent care and repositioning in bed was provided, and the resident had a peripheral intravenous catheter inserted at 1:30 AM for antibiotic administration. The documentation failed to indicate encouragement or assistance with heel off-loading. Review of the facility Skin and Wound evaluation dated 10/13/23 identified a new, in house acquired, unstageable pressure ulcer to the left heel that was 100 percent eschar (hardened dead tissue debris) measuring 3.5 centimeters (cm) by 4.6 cm. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #9 was moderately cognitively impaired and required extensive assistance of 2 staff with bed mobility and transfers. Additionally Resident #9 had one unstageable pressure ulcer and was not on a turning or repositioning program. Review of the NA flow sheets from 10/5/23 to 10/13/23 identified that Resident #9 had required substantial/maximal assistance to total dependence on staff for bed mobility. The revised Resident Care Plan dated 10/13/23 identified that Resident #9 was at risk for skin breakdown related to fragile skin. Interventions directed to encourage the resident to offload/float heels while in bed and encourage to turn and reposition frequently. The care plan failed to reflect Resident #9's increased need for assistance as documented on the NA flow sheet. An APRN note dated 10/13/23 identified Resident #9 was seen in follow-up. Nursing staff reported a new blister to Resident #9's left heel noted during care. Resident #9 admitted to discomfort and was noted to have large intact blister to the left heel filled with light blue/red fluid. The plan included applying skin prep twice daily, off load heels at all times, and the wound team was to follow up. Additionally, Resident #9 admitted to discomfort. An APRN order dated 10/13/23 directed to apply skin prep to Resident #9's left heel unstageable pressure ulcer twice daily and keep heels elevated at all times. Review of the transcribed APRN order dated 10/13/23 directed to off load heels every day and evening shift. The transcribed order failed to include the night shift. Review of the wound care provider note dated 10/16/23 identified a left heel, pressure induced, deep tissue pressure injury that measured 6.5 cm x 8 cm (an increase in size from the initial measurement from 3 days prior). The plan included cleansing the wound with normal saline, apply xeroform, apply an abdominal pad followed by kerlix, change twice weekly, and ensure off-loading per facility protocol. Review of the facility wound tracking log and wound care provider note dated 10/30/23 identified that Resident #9 had refused to be seen the previous week. The wound care provider note identified a left heel deep tissue pressure injury that measured 5.8 cm by 7.5 cm and modifying factors included poor off-loading. Review of the weekly wound care provider measurements dated 11/6/23 identified the left heel pressure ulcer measured 6.5 cm x 7.0 cm (an increase in size from 7 days prior.) Every 15 minute observations on 11/6/23 from 10:45 AM to 1:50 PM, identified Resident #9, lying on his/her left side, in bed, with his/her head at the foot of the bed. A pillow was noted on the floor at the foot of the bed. Resident #9 had 1 slipper sock on his/her left foot, and both heels were noted to be in direct contact with the mattress throughout each 15 minute observation time. Although staff was observed to enter the room on 4 separate occasions for 30 seconds to 1 minute, the Resident's position remained unchanged and Resident #9's left heel (the heel with the pressure ulcer) remained in direct contact with the mattress without the benefit of off-loading. Interview with NA #5 on 11/6/23 at 1:45 PM identified that she had looked in on Resident #9 after breakfast. The next time she saw Resident #9 was when she dropped off his/her lunch tray. NA #5 told Resident #9 that lunch was available, Resident #9 was noted to open his/her eyes, lift his/her head, and returned back to sleep. NA #5 denied she had offered Resident #9 assistance to reposition or move prior to leaving the room after breakfast or when dropping off Resident #9's lunch tray. Interview with APRN #1 on 11/6/23 at 1:10 PM identified that Resident #9 had been reasonably independent prior to becoming ill around 10/5/23 but had been bed bound following the development of his/her illness. APRN #1 stated after observing Resident #9's new pressure wound, she directed skin prep and off-loading at all times (off-loading was transcribed to indicate the 7:00 AM to 3:00 PM and 3:00 PM to 11:00 PM shifts only). APRN #1 indicated that once Resident #9 had declined due to his/her illness, potentially, measures for off-loading such as booties or off-loading pillows would have been appropriate. APRN #1 stated that pressure ulcers develop as a result of not off-loading heels, and that potentially, the pressure ulcer could have been avoided if preventative measures had been put in place. Interview with NA #6 on 11/6/23 at 1:50 PM identified that prior to becoming ill Resident #9 was fiercely independent. NA #6 stated that Resident #9 had developed his/her pressure ulcer a few weeks ago when s/he was sick. NA #6 indicated that when Resident #9 became sick, s/he required full care. Although Resident #9 was able to use the grab bar to turn and reposition his/her upper body, s/he required full assistance with his/her lower extremities to reposition. NA #6 indicated that in order to prevent Resident #9 from developing a pressure ulcer, pillows were to be placed for off-loading, however, NA #6 was unable to explain why Resident #9's left heel had been observed resting on the mattress for 3 hours. Interview and review of Resident #9's clinical record on 11/6/23 at 2:20 PM with LPN #2 identified Resident #9 had developed the left heel pressure ulcer when s/he was not feeling well, wasn't moving as much, and was not getting out of bed. LPN #2 indicated that Resident #9 was relatively independent prior to becoming ill but was unable to find supporting documentation that measures to prevent pressure ulcer development were implemented when Resident #9 became more dependent on staff. LPN #2 identified that when preventative measures were put in place, they were typically directed by the physician/APRN and were written on the Medication Administration or Treatment Administration Records for staff to implement and sign as being completed. LPN #2 identified that Resident #9 was known to refuse care at times, but she was unable to find documentation that Resident #9 had been refusing off-loading. Additionally, if Resident #9 had refused off-loading during her shift, she would have expected the NA to notify her immediately so she could intervene. LPN #2 indicated that although she had given Resident #9 medications around 1:00 PM, she had not repositioned or offered off-loading assistance to Resident #9 and staff had not reported that Resident #9 had refused assistance. Interview with NA #4 on 11/6/23 at 2:38 PM identified that she had last seen Resident #9 between 9:00 AM and 9:30 AM when s/he refused care at the time. The next time NA #4 entered the room was approximately 2:10 PM. NA #4 indicated that when any resident has a pressure ulcer, the foot should be propped up but that Resident #9 didn't have sufficient off-loading under his/her feet when she arrived to provide care. Further, NA #4 indicated that initially the unit had 4 staff scheduled for 11/6/23, but that 1 NA had been taken to work on the other unit. NA #4 indicated that everybody was responsible to ensure that resident heels were off-loaded and that it was common sense. NA #4 indicated that Resident #9's heels were not appropriately off-loaded because it was a crazy day due to staffing issues, and she was unable to get to assist Resident #9 with care needs any sooner than she had. Interview and review of Resident #9's clinical record with the Wound Nurse, RN #3, on 11/8/23 at 9:45 AM identified that she became responsible for the wound program on 10/16/23. RN #3 identified that, according to the care plan, Resident #9 had been encouraged to independently perform turning and positioning and off-loading since 2/12/23. RN #3 stated that when Resident #9 became ill, and more dependent on staff, the clinical record failed to reflect new interventions to prevent pressure ulcer development. Although Resident #9's left heel pressure ulcer had become worse and increased in size between 10/13/23 and 10/16/23, and again between 10/30/23 and 11/6/23, no new interventions were implemented to prevent further deterioration. RN #3 identified a nurse's note she had written on 11/7/23 indicating that she had offered Resident #9 an off-loading boot on 10/23/23, which was subsequently refused by Resident #9, but failed to indicate further attempts to provide Resident #9 with other alternatives to prevent deterioration of his/her pressure wound. Further, RN #3 had thought about providing the resident with a different type of mattress but had not followed through. RN #3 was unable to find a pressure ulcer risk assessment prior to or upon development of Resident #9's left heel pressure ulcer, but that upon development Resident #9 should absolutely have had a risk assessment performed. Additionally, although RN #3 indicated that the facility should be documenting weekly skin assessments, the facility had not conducted any weekly skin assessments in some time. Interview and review of Resident #9's clinical record with the DNS on 11/13/23 at 1:34 PM identified that when a resident has a newly developed pressure ulcer, a pressure ulcer risk assessment should be conducted. The DNS identified that Resident #9's last pressure ulcer risk assessment had been completed on 2/14/2019. The DNS indicated that the facility policy was to conduct risk assessments quarterly and with a change in condition. Although the DNS indicated new interventions should have been put in place first when Resident #9 had a decline in bed mobility, after the pressure ulcer developed, and with a deterioration of the pressure injury, the DNS failed to identify any new measures had been documented or implemented. Additionally, the DNS identified that weekly skin checks should have been conducted on Resident #9's scheduled bath/shower days, however, Resident #9 had not had a weekly skin assessment conducted since 8/4/2020. 2. Resident #62's diagnoses included dementia with agitation, muscle weakness and Type II diabetes mellitus. A Braden skin risk assessment completed on 7/30/23 identified a score of 14 indicating that Resident #62 was at high risk for pressure ulcer development. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #62 was severely cognitively impaired and required the assistance of 2 staff with bed mobility and transfers. Additionally, Resident #62 was identified as at risk for pressure ulcer development and had a current pressure injury to the right heel. The Resident Care Plan dated 9/18/23 identified that Resident #62 was at risk for skin breakdown related to a history of a pressure ulcer, advanced age, nephrostomy tube, decreased activity, and impaired cognition, Interventions included to turn and reposition every 1-2 hours, observe skin condition daily with care and report abnormalities, off load/float heels (remove pressure) using heel boots at all times, and conduct a weekly skin check by licensed nurse. A physician's order originally dated 8/23/23 and still in effect as of 11/7/23 directed heel boots at all times, remove every shift for skin checks, daily hygiene, and treatment. Review of the Treatment Administration Record from 10/1/23 through 11/7/23 identified that Resident #62 had been directed to wear heel boots to both lower extremities, at all times, and that facility staff had signed off that the heel boots were in place every day on every shift. Review of the facility weekly skin check dated 10/26/23 indicated that Resident #62 had a previously identified pressure ulcer of the heel but failed to indicate which heel was affected. A new physician's order dated 10/27/23 directed skin prep to be applied to the left heel twice daily. Observation on 10/31/23 at 1:08 PM identified Resident #62 sitting in wheelchair wearing slipper socks without the benefit of heel boots. Review of the facility provided current resident pressure ulcer tracking received on 11/1/23 failed to indicate that Resident #62 had a pressure ulcer. Interview and review of facility documentation with the wound nurse, RN#3, on 11/1/23 at 11:43 AM identified that Resident #62 previously had a pressure ulcer of the right heel which developed on 8/30/23 but had subsequently healed as of 9/18/23. RN #3 indicated that her tracking documentation failed to identify that Resident #62 had a current pressure ulcer to his/her right or left heel. RN #3 indicated that she would have to review the clinical record. Re-interview with RN #3 on 11/1/23 at 12:05 PM identified that after reviewing Resident #62's clinical record, that Resident #62 did have a new facility acquired, stage 2 pressure ulcer of the left heel that had been identified on 10/26/23. RN #3 indicated that facility staff had never informed her of Resident #62's newly developed pressure ulcer. Further, RN #3 was unable to locate documentation in the clinical record, nursing notes, of the new pressure ulcer or that the left heel pressure ulcer had been measured since 10/26/23, when the pressure ulcer had been identified. Subsequent to surveyor inquiry, RN #3 indicated she would obtain left heel pressure ulcer measurements. Interview and review of facility documentation with the DNS on 11/1/23 at 12:41 PM indicated an APRN note dated 10/26/23 identified a new pressure ulcer to Resident #62's left heel. The APRN ordered skin prep to be applied twice daily beginning on 10/27/23, off-loading heels at all times, and the wound team was to follow-up. The DNS indicated that per facility policy her expectation with a new pressure ulcer, would have been that staff conduct a full skin assessment, document wound measurements in the medical record, conduct a change in condition assessment, and notify the wound nurse. Observation on 11/1/23 at 12:49 PM, identified Resident #62 sitting in wheelchair wearing slipper socks without the benefit of heel boots. Review of the revised Resident Care Plan dated 11/1/23 indicated a potential for impaired skin integrity as evidenced by Braden scale (used to predict pressure ulcer risk) and that Resident #62 was at high risk for pressure ulcer development. Interventions included the use of heel boots to bilateral lower extremities while in bed and wound care to the left heel as ordered. Although the Resident Care Plan indicated heel boots to bilateral lower extremities while in bed, the physician order continued to direct heel boots at all times and the new APRN order dated 10/27/23 directed off-loading heels at all times. Review of RN #3's wound note dated 11/1/23 at 2:04 PM identified a new left heel blister (pressure ulcer) measuring 4 (centimeters) cm by 4 cm, lacking depth. A new treatment order included skin prep twice daily and offloading boots while in bed. Although the wound note identified a change to the physician's order, review of the physician's orders failed to indicate that the physician had changed the order from wearing the boot at all times to wearing the boot while in bed. Observation on 11/7/23 at 2:24 PM, identified that Resident #62 was in the television room wearing slipper socks and a green, foam waffle boot to his/her left foot. Although Resident #62 was noted to be wearing the green foam waffle boot, his/her left heel was resting on the wheelchair foot pedal. Observation of the heel area of the green foam boot failed to identify that the boot had off-loading properties such as a cut out which would relieve pressure off the pressure injury. Additionally, Resident #62's right heel lacked a heel boot and failed to be off-loaded from the wheelchair foot pedal. Interview with NA #8 on 11/7/23 at 2:28 PM identified she had not seen Resident #62 wearing shoes or heel boots recently. Review of a late entry nursing change in condition assessment note entered by LPN #1 on 11/1/23 at 2:44 PM indicating that a blister was present on the left heel and that s/he had mistaken the new blister to be the one that was a previously documented wound on the right heel. Interview with LPN #1 on 11/7/23 at 3:42 PM identified she was on duty on 10/26/23 on the 7:00 AM to 3:00 PM shift when the pressure ulcer to the left heel was identified. LPN #1 stated that she floated between units and was not initially aware that the left heel was a new skin impairment when it was brought to her attention. LPN #1 indicated that she believed the pressure ulcer was still the same pressure ulcer of the right heel (that had been noted to have been healed on 9/18/23). LPN #1 identified that the facility policy was to measure new pressure ulcers and notify the wound nurse, but she had not known the left heel was a new pressure ulcer. LPN #1 identified she was directed, by the DNS, on 11/1/23 to write a late entry nursing note. Review of the facility Skin Integrity and Wound Management policy dated 2/1/23 identified, in part, that a comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin/wound impairment, and the ability of a wound to heal would be performed. The plan of care for the patient would be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff would continually observe and monitor patients for changes and implement revisions to the plan of care as needed. Risk evaluations would be conducted quarterly and with a significant change in condition, and a complete wound evaluation with new in-house acquired wounds and with unanticipated decline in the wounds would be conducted. Pressure injury prevention would be implemented for identified, modifiable risk factors. Determination of appropriate support surfaces for the bed and chair would be made as well as the need for heel off-loading and revise the care plan as indicated.