**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary care and services to prevent and treat pressure ulcers (localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) and prevent further skin and pressure injury for two Residents (#26 and #53), of four applicable residents reviewed for pressure ulcers, out of a total sample of 25 residents. Specifically, the facility failed to: 1. For Resident #26: -offload (minimizing or removing any weight or force to help prevent and heal pressure ulcers) pressure on his/her buttocks and provide repositioning and assistance out of bed daily per Resident's plan of care to reduce the risk of developing pressure ulcers per the comprehensive plan of care and Resident preference/request. -assess the Resident's skin when he/she complained of buttocks discomfort. -implement interventions per professional standards of care and practice when a pressure ulcer was identified, including having hoyer pads available to transfer the Resident out of bed daily. -ensure the low loss air mattress was at the appropriate setting per the Resident's weight and comfort. 2. For Resident #53: -complete skin screening and assessment as required for the Resident who was at risk for pressure ulcers. -identify and implement treatment for a pressure ulcer that developed from the use of a nasal cannula (a thin flexible tube that provides supplemental oxygen through the nose via nasal prongs) resulting in a Stage Two pressure ulcer (partial-thickness skin loss with exposed dermis) of the philtrum (the vertical groove between the base of the nose and the border of the upper lip) and the base of the nostrils. Findings include: Review of the facility Policy titled Skin Integrity Management, revised November 15, 2024, indicated the following: -The facility must ensure the resident receives care, consistent with professional standards of practice to prevent pressure ulcer or injury and does not develop pressure ulcer or injury unless the individual's clinical condition demonstrates they were unavoidable. -Any resident with pressure ulcer or injury receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. -Skin assessment can and should be included in the normal workflow such as: >during provision of care, when turning, lifting, or transferring a resident. >each time you apply oxygen, check the resident's ears for any pressure areas. -When a resident has a device [sic], obtain Medical Doctor (MD) order to remove device and monitor skin integrity every shift unless it is medically contraindicated. Secure the device properly and regularly monitor and adjust if needed, the degree of tension to reduce pressure at the skin device interface. -When a skin breakdown is identified, report this timely to the Medical Practitioner. Obtain a wound treatment and document in Physician order and ETAR (electronic treatment administration record). -Use wound care and treatment products consistent with the company's protocol. Document each prescribed wound treatment in the resident's electronic health record 1. Resident #26 was admitted to the facility in April 2013, with diagnoses including Multiple Sclerosis (MS: a chronic autoimmune disorder of the central nervous system marked by numbness, weakness, loss of muscle coordination, and problems with vision, speech, and bladder control), Type 2 Diabetes (DM II - condition in which the body does not produce enough insulin hormone and has trouble controlling blood sugar levels), Cerebral Palsy (a group of conditions that affect movement and posture caused by brain damage to the developing brain before birth), and Morbid Obesity (when the body weight is found to be more than 80 - 100 pounds above the individual's ideal body weight). Review of the High Risk for Skin Breakdown Care Plan, initiated 8/15/17, indicated Resident #26 was at high risk for pressure ulcer development and indicated the following: -Resident should be encouraged to get out of bed daily, initiated 8/15/17 -Encourage activity and mobility, initiated 8/15/17 -Observation of skin condition during care - report pink, red or open areas to Nurse, initiated 8/15/17 -Apply Periguard (barrier cream that helps moisture and protect the skin) with each incontinent episode, initiated 11/24/17 -Gel pressure relieving cushion while in wheelchair, initiated 9/28/23 Review of the Activities of Daily Living Care Plan initiated 8/15/17, with an effective date of 10/11/23 indicated Resident #26 had decreased mobility and should be Out of Bed to wheelchair daily. Review of the Resident's Profile Care Plan effective 8/24/18, indicated the following: -Behaviors exhibited by Resident- none at present, initiated 8/24/18 -Resident prefers to get up later in the morning before lunch and goes to bed before supper, initiated 8/24/18 -Transfers with Hoyer Lift (mechanical device used to transfer individuals with limited mobility) - Large Hoyer pad (GREEN), initiated 7/21/21 -Decubitus Ulcer (bedsores that develop when an individual was unable to change positions for extended periods of time) Prevention- barrier cream to coccyx (tailbone), buttocks each shift, initiated 7/24/21 Review of the Occupational Therapy (OT) Discharge summary, dated [DATE], indicated the following discharge recommendation: -Staff to assist the Resident with Hoyer transfer into the gerichair (specialized wheelchair) daily for at least one meal per day. Review of the Resident#26's MDS Assessment, dated 8/15/24 indicated: -he/she was cognitively intact as evidenced by a BIMS score of 13 out of a total possible 15. -had range of motion impairment affecting bilateral (both) lower extremities. -required total assistance from staff for toileting, showering, dressing, personal hygiene, rolling side to side, and transfers out of bed. -was frequently incontinent of bladder and bowel function. -was at risk for pressure ulcer development with a history of Moisture Associated Skin Damage (MASD - erosion of skin caused by prolonged moisture such as urine, stool or sweat). -utilized a Pressure Reducing Bed -weighed 190 pounds -had no rejections of care, refusals or change in behaviors. Review of Resident #26's October 2024 Physician orders indicated the following: -Alternating pressure mattress overlay. Every shift ensures inflation and correct setting every shift. Setting at 260 [sic] based on weight and manufacturers guidelines. Set at 260 for pain management based on resident assessment and preferences, initiated 6/26/24. -Weekly Skin screening for new areas of concern on Monday day shift, initiated 6/17/22 On 11/3/24 at 9:55 A.M., the surveyor observed Resident #26 lying in bed on his/her back with the head of the bed slightly elevated. The surveyor observed the Resident's legs were elevated on pillows and an air mattress was on the bed and set at 250 pounds. During an interview at the time, Resident #26 said that the air mattress was not always comfortable, and he/she needed to sleep with a pillow under his/her buttocks because if he/she was in the wrong position it hurt because there was a sore on his/her buttocks. Resident #26 said that he/she has not been out of bed in at least a week because the staff had not been able to find a Hoyer pad for the lift that assists with transferring him/her out of the bed and that he/she would like to get out of the bed. On 11/4/24 at 8:11 A.M., 8:43 A.M., 9:58 A.M., and 4:15 P.M., the surveyor observed the Resident lying in bed. At 8:43 A.M., the surveyor observed the Nurse Practitioner (NP) enter Resident #26's room and the Resident reported that he/she had buttocks pain. The NP asked the Resident if he/she was getting out of bed daily, and the Resident said that he/she had not been out of bed because the staff did not have the Hoyer pad and that he/she would like to get out of the bed. On 11/4/24 at 12:55 P.M., the surveyor observed Resident #26 lying on his/her back in bed with the head of the bed elevated. The Resident said that he/she was not getting out of bed today because the CNA said a Hoyer pad was not available. The surveyor observed a sign on the Resident's wall beside the bed, from OT which indicated the following: Resident was to be out of bed three to five (3-5) times per week for two to three (2-3) hours to get stronger and prevent sacral (skin injury near the base of the spine from extended pressure on the area) ulcers. On 11/5/24 at 7:42 A.M., and 2:32 P.M., the surveyor observed the Resident lying in bed. During an interview with CNA #9 at 2:32 P.M., she said the Resident did not get out of bed today because there were not enough Hoyer pads for all the residents and that it was difficult to find the correct size Hoyer pad for Resident #26. CNA #9 said if a Hoyer pad cannot be found, then Resident #26 cannot get out of bed, and she would notify the Nurse or the Unit Manager (UM). CNA #9 further said that if Resident #26 stayed in the bed, this would put him/her at risk for skin breakdown and that the Resident recently had an area that healed on his/her buttocks. CNA #9 said Resident #26 currently had redness and pain on his/her buttocks, and that she applied a cream and repositioned her. CNA #9 said if she noticed a skin issue, she would alert the Nurse. At this time, the surveyor requested to evaluate Resident #26's buttocks redness with CNA #9 and Nurse #9 and observed the following: -the Resident's right and left buttocks were deep red in color. -the left buttocks were painful upon touch and appeared deep red in color and was intact. -the right buttocks had two small round superficial (outer layer of the skin is open and damaged) open areas, each about 1.0 centimeter (cm) in diameter. During an interview at the time, Nurse #9 said the Resident had a Stage Two pressure area on his/her right buttock and a possible Stage Two on his/her left buttock but wanted to have the Wound Nurse evaluate the Resident's skin. Nurse #9 said they would make the NP/MD aware of his/her areas. Review of the medical record failed to indicate interventions were implemented for the two stage 2 pressure injuries observed on 11/5/24 On 11/6/24 at 7:56 A.M., the Resident was observed lying in bed with the air mattress set at 250 pounds. During an interview at the time, the Resident said his/her buttocks was sore this morning. During an interview on 11/6/24 at 8:24 A.M., CNA #9 said Resident #26 had complaints of discomfort in his/her buttocks. CNA #9 said she notified the Resident's Nurse (#5), who gave CNA #9 a cream to apply to the Resident's buttocks area. During an interview on 11/6/24 at 8:30 A.M., Nurse #5 said she had administered the scheduled pain medication to Resident #26 for complaints of buttocks pain and was aware there was an open area on his/her buttocks. During an interview on 11/6/24 at 8:43 A.M., UM #1 said she did not recall being told about missing Hoyer pads for Resident #26, that he/she was supposed to get out of bed every other day but sometimes refused and needed encouragement. UM #1 further said that if the Resident refused care, it would be documented. UM #1 said she was aware that the Resident had not been out of bed for a week and a half and thought it was due to the refusals and did not know it was because there was a lack of Hoyer pads. On 11/6/24 at 12:06 P.M., the surveyor observed Resident #26 dressed and seated in a recliner chair next to his/her bed prior to lunch. During an interview at the time, the Resident said he/she was happy to be up and out of bed but was starting to get a sore on his/her buttocks again. Resident #26 said the facility staff applied a cream to his/her buttocks early that morning and that he/she was scheduled to see the Wound Nurse. During an interview on 11/6/24 at 1:43 P.M., Nurse #5 said she provided CNA #9 Zinc Oxide (medicated cream to treat or prevent skin irritation) ointment, to be applied to Resident #26's painful buttocks. Nurse #5 said she had not assessed the Resident's buttocks yet today. The surveyor and Nurse #5 reviewed the current Physician's orders for Resident #26, and Nurse #5 said there were currently no treatment orders for the Resident's buttock areas. Nurse #5 said the Resident had two open areas on his/her buttocks that were identified on 10/23/24 (14 days prior) and she thought the current areas the Resident had were the same areas that were previously identified. Nurse #5 said when an alteration in a Resident's skin integrity was identified, the Nurse would assess the area, notify UM #1, complete an incident report and notify the Physician by utilizing the Provider Communication Book. The surveyor and Nurse #5 reviewed the Provider Communication Book and were unable to locate where there was notification about the Resident's identified buttocks areas on 11/5/24. Further review of the Provider Communication Book indicated an entry from Nurse #5, dated 10/23/24, notifying the Provider of two open areas to Resident #26's buttocks, that Zinc Oxide ointment had been applied, and a request for a treatment to the areas. An additional notation next to the written communication from Nurse #5 indicated a handwritten ? Triad (cream applied to promote wound healing and protect skin). Nurse #5 said she thought this notation for Triad was a response from the Provider and that she was not aware that this notation was made. Nurse #5 further said that if there was a Provider response in the Provider Communication Book, then the Nurse should have clarified with the Physician about the response and should have transcribed treatment orders if that was what was intended. Nurse #5 said she should not have provided CNA #9 with the Zinc Oxide ointment to apply to Resident #26 because it was not ordered by the Physician for use. Review of the medical record failed to indicate an assessment was completed for the two open areas identified on 10/23/24 or additional interventions were implemented. On 11/6/24 at 2:45 P.M., the surveyor observed Resident #26's buttocks with Nurse #5 and observed the following: -A layer of white cream was covering the Resident's left and right buttocks. -The right buttocks had two small circular superficial (on the surface or shallow) areas about 1.0 cm in diameter, due to the white cream covering the buttocks, the wound beds (open areas) were unable to be thoroughly visualized by the surveyor. -Redness was observed on both the right and left buttocks. During an interview immediately following the observation, Nurse #5 said the Resident's left buttocks was impaired, but it was difficult to assess as the areas were covered in a thick white cream. Nurse #5 further said she thought the Resident's current areas were in the same spots as the areas identified on 10/23/24 but was unable to verify this. The surveyor observed the Resident's air mattress was set at 260 pounds and Nurse #5 also said the Resident's air mattress was set to 260 pounds and that air mattresses were supposed to be set according to the Resident's weight. The surveyor and Nurse #5 reviewed the current weight for Resident #26 which was 174 pounds on 10/15/24. Nurse #5 said that the current setting on the Resident's air mattress did not match what the Resident's current weight was and if the air mattress was set too high (increased pressure/firmness), that would put the Resident at a higher risk for skin breakdown. Nurse #5 said she did not feel comfortable adjusting Resident #26's air mattress because she had never been taught how to do that (adjust the settings). During an interview on 11/6/24 at 3:37 P.M., UM #2, who was identified as the Wound Nurse, said she had not been notified of any new alterations in skin or areas of concerns for Resident #26 over the past month. UM #2 said if an alteration in a Resident's skin is identified, the Nurse completes a notification form which is put in her mailbox. UM #2 said she completes weekly wound rounds on Tuesdays and had not been notified therefore was not following Resident #26. UM #2 said the Nurse who identified the Resident's areas should have followed the facility's wound protocol, completed an assessment of the wound including the measurements and description, and notified the Physician to obtain treatment orders. UM #2 said the Provider should have been contacted immediately to obtain an appropriate treatment order for Resident #26 and the Nurse should not have written the request in the Provider Communication Book. UM #2 said Zinc Oxide ointment was a prescription medication, and only the Licensed Nurses should be applying the medication, and it should only be applied when there was a Physician's order. During an interview on 11/6/24 at 3:58 P.M., UM #1 said Resident #26 had re-occurring moisture associated skin damage on the buttocks and would be followed by the Wound Nurse until resolved. UM #1 said when the Resident's areas were identified, an incident report should have been promptly completed, the Physician called to notify of the areas and obtain treatment orders, and the facility Wound Nurse also notified so that the Resident would be assessed on weekly wound rounds. UM #1 said the Nurses should be checking in the Provider Communication Book to review any new orders. The surveyor and UM #1 reviewed Resident #26's current Physician orders, and UM #1 said there were no current treatments in place for Resident #26's buttocks areas and orders would need to be obtained prior to applying any treatments. UM #1 said that a Licensed Nurse should be assessing the Resident's skin condition when applying Physician ordered treatments, not the CNAs. UM #1 said once a wound was identified, it would be monitored daily on the Resident's treatment record, and the Nurse would complete assessments which include any pain, condition/status of the wound, the skin condition surrounding the wound, the condition of the wound bed, drainage, odor and if the area was worsening to call the Physician. UM #1 said the Resident wounds were to be measured weekly. UM #1 said the Resident's air mattress should be set to the Resident's weight and comfort. UM #1 said the Resident's weight obtained today was about 190 pounds, so the air mattress should be set at about 200 pounds but was set to 260 pounds. UM #1 said if an air mattress was set higher than it should be, it could affect the Resident's skin negatively and cause increased pressure because the air mattress was firmer. UM #1 said the air mattresses were monitored every shift by the Nurses to ensure that they are set appropriately. UM #1 said if a Resident on an air mattress developed a wound or complained of pain, the Nurse should assess the air mattress setting to determine if it was an appropriate setting based on the Resident's weight and comfort. UM #1 said Resident #26 was alert, oriented and able to communicate his/her needs. 2. Resident #53 was admitted to the facility in December 2022 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD- a chronic lung disease that causes obstructed airflow from the lungs that leads to respiratory problems including difficulty breathing, shortness of breath and wheezing), Hypoxemia (low levels of oxygen in the blood), and Non-ST Elevation Myocardial Infarction (NSTEMI: type of heart attack that occurs when an artery is partially blocked, reducing blood flow and oxygen to the heart muscle). Review of the Activities of Daily Living Care Plan, initiated 12/22/22, indicated Resident #53 had an alteration in his/her ability to provide self care and included the following interventions: -Check skin during care and report any abnormalities/issues to nursing/Medical Doctor (MD), initiated 12/22/22 -Assistance of one staff with bathing, dressing, grooming, initiated 1/16/23 Review of the Cardiac Care Plan, initiated 12/22/22, included the following intervention: -Administer oxygen as ordered by the MD . Monitor O2 (oxygen) saturation (SpO2 - measure of oxygen in the blood as a percentage of the maximum oxygen the blood could carry) as ordered and as needed (PRN), initiated 12/22/22 Review of the Minimum Data Set (MDS) Assessment, dated 9/5/24, indicated: -Resident #53 had severe cognitive impairment as evidenced by a Brief Interview of Mental Status (BIMS) score of 3 out of a total possible score of 15. -required moderate assistance from staff with bathing, grooming and dressing. -was at risk for pressure ulcers. -utilized oxygen therapy during the reference period. Review of Resident #53's Nursing Progress Notes indicated the Resident was using 2 LPM (LPM: amount of oxygen administered per minute) oxygen via nasal cannula on the following dates: -9/11/24 at 10:37 P.M. -9/12/24 at 2:45 P.M., and 9:18 P.M. -10/2/24 at 10:50 P.M. -10/6/24 at 9:48 P.M. -10/7/24 at 10:58 P.M. -10/8/24 at 1:49 P.M., and 3:27 P.M. -10/13/24 at 2:02 P.M. -10/23/24 at 12:37 A.M. Review of the Resident's clinical record indicated the following: -he/she was transferred to the hospital on 9/7/24 for increased fevers and generalized malaise and returned to the facility on 9/11/24. -a skin check completed on 9/11/24 (upon return from the hospital) indicated he/she had bruises on both arms and a scratch on the left arm. -weekly skin checks completed for September 2024, October 2024, and November 2024 indicated no new areas of concern. Review of November 2024 Physician's orders indicated: -Oxygen as needed (PRN) to keep pulse oximetry (amount of oxygen in the blood) above 93 percent (%) as needed for shortness of breath, initiated 11/29/23 -Replace oxygen tubing every 7 days, weekly on Wednesdays, initiated 10/23/24 -Weekly Skin Screening for new areas of concern during the day shift on Tuesdays. Complete incident report for any new areas of concern, initiated 2/16/24 On 11/3/24 at 9:40 A.M., the surveyor observed Resident #53 lying in bed with oxygen being administered via nasal cannula from an oxygen concentrator which was set at 2 LPM and included a humidifier bottle. The surveyor observed a reddened open area at the base of the Resident's nose (below the nostrils) underneath the nasal cannula tubing/prongs. During an interview at the time, Resident #53 said that he/she had been having pain to the open area and he/she did not think the staff were aware of the open area. The surveyor observed Resident #53 utilizing 2 LPM humidified oxygen and visible open area at the base of the nostrils on the following: -11/4/24 at 9:56 A.M., and 12:53 P.M. -11/5/24 at 7:47 A.M. During an interview on 11/4/24 at 2:59 P.M., Certified Nurses Aide (CNA) #8 said she had given Resident #53 a shower earlier in the day. CNA #8 said she had removed the Resident's oxygen/ nasal cannula during the shower, and re-applied the oxygen, and had not noticed anything abnormal about the Resident's skin condition. CNA #8 further said if a new skin condition had been noticed, a Stop and Watch Form would be filled out, in addition to alerting the Nurse. On 11/5/24 at 7:47 A.M., the surveyor observed Resident #53 with humidified oxygen being administered via nasal cannula at 2 LPM. The Resident said his/her nasal area was sore and lifted the nasal cannula from under the nose to show the surveyor a round, open wound, approximately 1 centimeter (cm) which was red/yellow in color. The surveyor observed scabbed tissue surrounding the wound and that the nasal cannula tubing/prongs was in direct contact with the Resident's nasal wound. On 11/5/24 at 7:54 A.M., the surveyor and CNA #8 observed the area where Resident #53 said he/she was experiencing pain when the Resident lifted the nasal cannula from under his/her nostrils to show the area. CNA #8 said she did not see the area prior to now. During an interview on 11/5/24 at 7:56 A.M., Unit Manager (UM) #1 said the open area under Resident #53's nose was not identified from staff prior to today. UM #1 said she assessed the Resident's open area and thought it was irritated and caused from the use of his/her oxygen nasal cannula tubing. The surveyor relayed the previous observations of the Resident's nostril area to UM #1. UM #1 said if a Resident was on oxygen therapy, the nursing staff should be assessing the oxygen flow rate, the tubing, and the condition of the Resident's skin including the ears and nostrils daily. During an interview on 11/5/24 at 9:13 A.M., Nurse #8 said she assessed Resident #53's nose that morning after being alerted by CNA #8, and described the Resident's skin underneath the nostrils to be an open area with a wound yellow/red base and scabbed areas below the open area. Nurse #8 said the area was likely a result of the oxygen nasal cannula tubing rubbing against the Resident's skin. Nurse #8 said she did not see a progress note or treatment orders written relative to the Resident's open area, so she was going to alert the Nurse Practitioner (NP)/MD and the facility Wound Nurse for an evaluation. Nurse #8 said if a Resident utilized oxygen, the Nurse should be assessing the Resident every shift to ensure the oxygen nasal cannula tubing was an appropriate fit in order to avoid rubbing, pressure and skin breakdown. Review of the Incident/ Accident Report Form, dated 11/5/24, and completed by UM #1, indicated that Resident #53 was on continuous oxygen and that his/her nostrils were red, chaffed and have opened. During an interview on 11/5/24 at 9:36 A.M., UM #2 (Wound Nurse) said she assessed the Resident's skin and the nasal wound area was a Stage 2 Pressure Ulcer (open wound with partial thickness skin loss) which resulted from the oxygen nasal cannula tubing.