LICENSURE REFERENCE NUMBER 175 NAC 12-006.09(H)(iii)(1 & 2)Based on observations, interviews, and record review, the facility failed to evaluate causal factors and failed to implement interventions to prevent pressure wounds for 1 (Resident 3) of 4 sampled residents. The facility staff identified a census of 44.The findings are:Record review of Resident 3's Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and help nursing home staff identify health problems) dated 7/1/2025 revealed the facility staff identified the following about the resident: -Resident 3 was rarely or never understood and had short and long-term memory problems. -Resident 3 did not exhibit behaviors. -Resident 3 was dependent upon staff for all cares including bed mobility, transfers, hygiene, and toileting. -Resident 3 had a gastrostomy tube (g-tube, a flexible tube passed into the stomach for introducing fluids and liquid food into the stomach) and that Resident 3 received 51% or more of calories through and 501 milliliters (mL) per day or more of fluids through the g-tube. -Resident 3 was identified as at-risk for pressure ulcer development. -Resident 3 had one stage 4 pressure ulcer present on admission.Record review of Resident 3's Braden Risk Evaluation-V2 dated 6/30/2025 identified the resident was at high risk for pressure ulcer development.Record review of Resident 3's Comprehensive Care Plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) identified Resident 3 had an actual impairment of skin integrity dated 3/28/2025, and had the potential for the development of a pressure ulcer dated 5/5/2025. The CCP identified interventions that included: -4/17/2025: Bed mobility dependent, transfers dependent. -5/5/2025 Air mattress to bed -5/5/2025 Off load heels as ordered and as needed -5/5/2025: Reposition frequently or more often as needed or requested. -5/5/2025: Pressure relieving/reducing devices on bed/chair. -7/8/2025 Blisters/wounds to bilateral feet -7/16/2026 Foot board removed from bedRecord review of Resident 3's Skilled Nursing Visit Note dated 7/4/2025 identified Resident 3 had impaired skin integrity with a goal to be free from additional wounds.Record review of Resident 3's Order Summary Report printed 8/19/2025 revealed the following provider orders: -Elevate HOB (head of bed) 30 to 45 degrees at all times during feeding and for at least 30 to 40 minutes after feeding is stopped dated 3/24/2025. -Keep Negative Pressure Wound Therapy (wound vac) @ 120 millimeters of mercury (mmHg), assess pump per shift, ensure pump is charged/plugged in (check middle of cord), change canister when full, document output dated 5/8/2025. -If wound vac comes off, okay to pack wound with gauze lightly soaked with saline until next wound vac change day, cover with Mepilex (an absorbent, soft foam dressing) dated 6/30/2025. -Wound vac to coccyx at 120mmHg with continuous suction. Assess pump Q shift for function and change canister prn if full and document output dated 7/10/2025. -Cleanse with Vashe wound cleanser (a hypochlorous acid-based wound cleanser designed to cleanse, irrigate, moisten, and debride acute and chronic wounds, including ulcers and burns, as well as minor cuts and abrasions), cut and apply double layer of collagen alginate (a composite wound dressing made from a combination of natural collagen fibers and acts as a scaffold for new tissue growth, providing a moist wound environment that supports wound healing) to wound bed, specifically over exposed bone, apply DuoDerm (a hydrocolloid dressing that creates an airtight seal and is used to help manage wound under a vacuum assisted closure device) to peri-wound, apply protective layer of film, apply black sponge from wound bed to hip then apply top layer of film, apply suction appliance. Do not allow resident to lay on her back. Change dressing every Tuesday, Thursday, and Saturday dated 7/13/2025. -Pedal Wounds - cleanse area with soap and water, pat dry, apply betadine paint to wound, allow to completely dry daily by facility or hospice nurse dated 8/18/2025.A. Record review of Resident 3's Progress Notes (PN) dated 7/6/2025 identified a fluid filled blister on the bottom Resident 3's right foot measuring 5.5 centimeters (cm) by (x) 4.5 cm and an open area remained to the right heel.Record review of Resident 3's PN dated 7/8/2025 revealed facility staff contacted Resident 3's hospice provider regarding blisters/pressure wounds on bilateral feet. The hospice provider reported they would be at the facility on 7/9/2025. New orders were received for all pedal wounds: Betadine wet to dry dressing: A betadine-soaked gauze followed by dry gauze and abdominal pad (ABD, a large, multi-layered, and highly absorbent dressing) over them as well for padding and so betadine doesn't leak through to socks/bedding. Secure with kerlix (a sterile gauze bandage made of pre-washed, fluff-dried, 100% woven cotton gauze that provides bulk and cushioning) and a light layer of Coban (self-adherent elastic wrap that functions like a tape but sticks only to itself) (no compression) change three times a week and as needed (PRN). Hospice will bring supplies on 7/9 to assess skin, prevalon boot, and bed length.Record review of an Incident Audit Report dated 7/8/2025 regarding Resident 3's new skin alteration revealed a left heel pressure wound 4 cm x 4.5 cm area is black and blister like. Bottom of right foot 6cm x 4.2cm black blister, fluid filled, area is intact. Right heel 3cm x 3cm area is black and non-fluid filled. Further review of the Incident Audit Report revealed other predisposing physiological factors was marked yes and other information was marked bedbound.Record review of Resident 3's Skilled Nursing Visit Note dated 7/9/2025 by the hospice Registered Nurse showed Notified by LPN yesterday of new pedal wounds. RT (right) plantar black fluid filled sack. Blister like wound not to be popped-6 cm x 4cm x 2cm; RT heel 3x3cm appears to be eschar with pink to epithelializing area with frank blood visualized under the skin around wound. LT heel 4cm x 4.5cm appears to be eschar with pink to epithelializing area. Wound care supplies left. Will plan on calling DME (durable medical equipment) to check what's needed to place a ‘bed extender.' PT is 6 feet 0 inches and with HOB elevated feet are continuously pushing against prafo boots and footboard.Record review of Resident 3's Tissue Analytics (TA) dated 8/14/2025 identified a left heel unstageable pressure ulcer that measured 2.99 cm x 3.88 cm. Further review of the TA identified a right plantar foot unstageable pressure ulcer that measured 3.63 cm x 4.59 cm.Observation on 8/20/2025 at 10:35 AM of Resident 3's right foot revealed an eschar (a thick, dry, dark, and leather layer of dead tissue that forms over a wound or burn) covered fluid-filled blister with an intact covering at the middle of the right foot extending to the edge of the right foot. The skin surrounding the top edge of the blister had a light purple colored appearance, while the remaining three edges of the wound were free from discoloration. There was no swelling or drainage identified. Observation of the left heel revealed an eschar covered dry blister covering the back of the heel of the left foot. The skin surrounding the blister was free from discoloration and there was no swelling or drainage identified.Observation on 8/20/2025 at 10:35 AM of Registered Nurse (RN)-F performing bilateral foot wound treatment revealed RN-F performed the wound treatment as prescribed. After the treatment, RN-F called for staff to help reposition Resident 3 to the head of the bed. Prior to repositioning, Resident 3's bilateral feet were at the edge of the foot of the bed, and no footboard was present.An interview on 8/20/2025 at 10:40 AM with RN-F revealed the left heel and right plantar foot wounds were facility acquired. RN-F stated the footboard was a factor as Resident 3's feet pushed against it, so the footboard was later removed. RN-F confirmed that Resident 3 was very tall and needed a longer bed.An interview on 8/20/2025 at 3:08 PM with the Director of Nursing (DON) revealed when a new wound is developed, causal factors would be discussed in the morning clinical meeting. The DON revealed [gender] was unsure of the causal factors for the right plantar and left heel wounds. The DON confirmed the footboard was removed from Resident 3's bed on 7/16/2025, 11 days after identification of the wounds to bilateral feet. The DON reported the hospice company did send a longer bed for Resident 3 and since facility staff were unaware of the longer bed's delivery, it was sent back.B. Record review of undated Operating Instructions for Drive 14026, a low air loss mattress replacement system (a specialized type of medical mattress designed to prevent and treat pressure ulcers) revealed staff should determine the patient's weight and set the control knob to that weight setting on the control unit.Record review of Resident 3's Weight Summary printed 8/20/2025 identified Resident 3's weight as 176.8 pounds on 6/20/2025. There were no additional recent weights for review.Observation on 8/19/2025 at 3:04 PM revealed a low air loss mattress control unit set at 200.Observation on 8/20/2025 at 10:35 AM revealed a low air loss mattress control unit set at 200.Observation on 8/20/2025 at 3:27 PM revealed a low air loss mattress control unit set at 250.An interview on 8/20/2025 at 10:40 AM with RN-F confirmed the air mattress was set at 200 pounds. RN-F revealed that she was unaware of what setting the air mattress should be at or how the setting is determined.An interview on 8/20/2025 at 1:37 PM with the DON revealed the air mattress control unit was not set by the resident's weight and the setting was determined by touch.An interview on 8/20/2025 at 3:27 PM with the Assistant Director of Nursing (ADON) confirmed the control unit was set at 250 pounds. The ADON revealed that it is difficult to tell where the air mattress should be set because hospice discontinued the weight order.C. Observation on 8/19/2025 at 2:32 PM of Resident 3's coccyx wound identified a circular wound with a tear-drop shaped extension at the bottom of the wound. The wound bed was beefy red, and the surrounding skin was clean, dry, and free from discoloration. There was no drainage. The wound vac canister was absent from drainage.Observation on 8/19/2025 from 2:32 PM through 3:04 PM of Registered Nurse (RN)-F performing wound treatment to Resident 3's coccyx wound with the ADON present revealed after performing hand hygiene and donning (applying) a gown and gloves, RN-F removed the prior wound vac dressing and one piece of black foam and discarded. RN-F doffed (removed) gloves, performed hand hygiene, and donned new gloves. RN-F cleansed the wound using a can of normal saline and 4 x 4 gauze squares using a new piece of gauze with each wipe and cleaning the outside of the wound followed by the inside of the wound. RN-F doffed gloves, performed hand hygiene, and donned new gloves. RN-F cut DuoDerm in half and applied one piece to either side of the coccyx wound. RN-F doffed gloves, performed hand hygiene, and applied a double layer of calcium alginate to the wound bed. RN-F doffed gloves, performed hand hygiene, cut a rectangular shaped piece of black foam in half and placed the black foam on top of the circular wound, and applied draping. RN-F attached the suction device directly to the wound vac site. RN-F changed the suction canister and turned the device on. The foam compressed and the device display showed 120mmHg. Resident 3 was repositioned in bed and heel boots were applied.An interview on 8/19/2025 at 3:42 PM with RN-F confirmed normal saline was used to wash the wound instead of the provider-ordered Vashe wound wash. RN-F revealed the facility was out of Vashe. RN-F further confirmed the suction device was not bridged from the wound to the hip as ordered.During an interview on 8/19/2025 at 3:47 PM, the Director of Nursing (DON) confirmed black foam should be trimmed to the size of the wound and placed in the wound.A telephone interview on 8/20/2025 at 12:45 PM with Advanced Practice Registered Nurse (APRN)-G, confirmed black foam should be trimmed to the size and shape of the wound and placed gently in the wound. APRN-G revealed the wound had the potential to deteriorate if the black foam was not trimmed to the size and shape of the wound.Record review of a facility policy entitled Negative Pressure Wound Therapy dated revised 8/2024 revealed: -To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. This policy addresses the use of negative pressure wound therapy (NPWT) for the treatment and management of wounds. - Negative pressure wound therapy is an active wound care treatment that uses controlled sub-atmospheric (negative) pressure to assist and accelerate wound healing. The therapy may be gauze based, foam based, or peel and stick, and includes an evacuation tube and a computerized pump that applies the negative pressure. -1. Negative pressure wound therapy will be provided in accordance with physician orders, including the desired pressure setting, continuous or intermittent therapy, and frequency of dressing change. Clean technique shall be utilized unless otherwise specified by the physician. -8. General application process: -a. Carefully remove the existing wound dressing and discard. -b. Cleanse the wound according to physician order. -e. Select foam type or gauze appropriate to the size and characteristics of the wound, and place gently into the wound. -i. Fill the entire wound base and sides, tunnels, and undermined areas. -g. Apply the tubing to the dressing. -ii. Using the attached tubing adhesive drape, or additional dressing drape, seal the tubing assembly on top of the dressing and ensure that it will not lie on bony prominences. -12. The physician shall be notified of any complications associated with the use of NPWT.There was no further information available for review at the time of the survey exit.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09(H)(iii)(1) and 12-006.09(H)(iii)(2) Based on observation, interview and record review the facility failed to evaluate, monitor and implement interventions for pressure ulcer prevention and to promote wound healing for 2 (Resident 2 and 3) of 3 residents sampled. The facility census was 43. The findings are: A.Record review of Resident 2' Minimum Data Set (MDS: a federally mandated assessment tool used for care planning) dated 03-27-2025 revealed the facility staff assessed the following about the resident: -an admission date of 03-24-2025 -had a right hip fracture. -Brief Interview of Mental Status (BIMS) was scored as a 15. According to the MDS Manual a score of 13-15 indicates a person is cognitively intact. -Required extensive assistance with toileting, lower body dressing and bathing. -Required partial assistance with bed mobility, transfers, upper body dressing and personal hygiene. -Resident was at risk of developing pressure ulcers. -Required pressure relieving surfaces to the bed and wheelchair. Record review of Resident 2's admission assessment dated [DATE] revealed Resident 2 admitted to the facility with a surgical incision to the right hip that was 8 centimeters (cm), maceration associated skin damage (MASD: skin erosion due to prolonged exposure to moisture) to the sacrum (the bone between the 2 hip bones) without measurements, and an unmeasured area to the left heel that had a small amount of redness. Review of Resident 2's Care Plan, Progress Notes, Practitioner Orders and Skin Evluation Sheets revealed there was no indications the facility staff implemented interventions to prevent futher skin breakdown to Resident 2's left heel. Record review of a skin evaluation dated 03-31-2025 identified a stage 1 pressure area to the right and left buttock and did not identify any skin irregularities to the left heel. Record review of Resident 2's progress notes dated 04-02-2025 revealed an unmeasured skin issue was identified to the left heel. Record review of Resident 2's wound assessment conducted by a Nurse Practitioner (NP) on 04-03-2025 revealed a pressure ulcer stage 3 measuring 1.64 centimeters (cm) in length and 2.99 cm in width to the left heel. The wound bed was red without dead skin tissue present. No treatment orders were identified on the wound assessment. Record review of Resident 2's Comprehensive Care Plan (CCP) revealed the following under Pressure Ulcer Risk -Resident 2 had the potential for the development of a pressure ulcer and on 04-02-2025 had an open area to the left heel. Date initiated 04-08-2025. -The goal was resident's current skin concerns will show signs of healing with a decrease in size through the next review date. Date initiated 04-08-2025 Interventions identified on the CCP that were initiated on 04-08-2025: -prevalon boot (pressure relieving boot) per physician's orders. -reposition frequently or more often as needed or requested. -apply moisture barrier with each incontinent change. -provide nutritional supplements as ordered to maintain skin integrity. -weekly skin checks to monitor for redness, circulatory problems, pressure sores, open areas, and other changes in skin integrity. Report new conditions to the physician. Two other goals were added to the CCP on 04-25-2025 of Stage 3 pressure ulcer to left medial heel will improve/resolve by the review date and a Stage 2 pressure ulcer to the sacral area will improve/resolve by the review date. Additional interventions were initiated on 04-25-2025 of a low air loss mattress. Record review of Resident 2's progress notes dated 04-05-2025 revealed a big blister was noted to the left heel measuring 2 cm by 3 cm that was covered with a band-aid. Record review of Resident 2's wound assessment conducted by a NP on 04-10-2025 revealed the stage 3 pressure ulcer to the left heel measured 2.70 cm length by 2.86 cm in width. The wound bed had a moderate amount of dead skin tissue revealing a decline in the wound condition since 04-03-2025. New orders identified on the assessment were to cleanse the wound with mild soap and water, apply Santyl (a wound debridement) ointment to the wound bed, cover with mepilex (a type of wound dressing) daily and as needed and for a prevalon boot to be worn while in bed. Record review of Resident 2's Treatment Administration Record (TAR) for April 2025 revealed an order for a pressure relieving boot dated 04-11-2025 and a treatment for the stage 3 pressure ulcer to the left medial heel dated 04-12-2025. An observation on 05-05-2025 at 12:00 PM of Registered Nurse (RN) A providing wound care to Resident 2's stage 3 pressure ulcer to the left heel which revealed a dry brown round shaped area. During the observation, RN A measured the wound at a length of 3.5 cm by 1.5 cm in width. An interview was conducted with the Director of Nursing (DON) on 05-05-2025 at 3:30 PM revealed orders for treatment were not obtained on 04-03-2025 and the facility should have followed up with the practitioner for orders. The DON also confirmed that treatment for the stage 3 pressure ulcer to the left heel was not initiated until 04-12-2025 and the wound had worsened. B. Record review of Resident 3's face sheet printed on 05-01-2025 revealed an admission date of 08-17-2022. Record review of Resident 3's MDS dated [DATE] revealed the facility staff assessed the following about the resident: -BIMS was scored as a 9. According to the MDS Manual a score of 8-12 indicates moderate cognitive impairment. -required extensive assistance with eating and bed mobility. -required total assistance with toileting, bathing, dressing and transfers. -was identified at risk of pressure ulcer development and currently did not have one. Record review of Resident 3's CCP dated 08-17-2025 and revised on 12-05-2023 revealed Resident 3 had a potential for pressure ulcer development related to decreased mobility. The goal was Resident 3 would be free from pressure ulcers through the review date. Interventions included the following: -turn and reposition at least every 2 hours and as requested. Date initiated 09-02-2022. -administer treatments as ordered and monitor for effectiveness. Date initiated 08-17-2022. -assess/monitor/record wound healing as needed: Measure length, width, and depth. Assess and document the status of the wound perimeter, wound bed and healing progress. Report improvements and declines to the practitioner. Date initiated 08-17-2022 -follow facility policies/protocols for the prevention/treatment of skin breakdown.Date initiated 08-17-2022. -monitor/document/report as needed any changes in skin status: appearance, color, wound healing, signs of infection, wound size and stage. Date initiated 08-17-2022. -pressure reducing mattress and wheelchair cushion. Date initiated 08-17-2025 -monitor nutrition status.Serve diet as ordered, monitor intake and record. Date initiated 08-17-2022. Record review of Resident 3's progress note dated 04-17-2025 revealed an open area was noted to the left side of the back below the shoulder blade measuring 3 cm in length by 2.5 cm in width. Record review of Resident 3's Weekly Skin Evaluation (WSE) dated 04-17-2025 revealed Resident 3 was evaluated as having an open area to the left shoulder that measureed 3 cm by 2.5 cm. Record review of Resident 3's entire health record including the care plan, progress notes, practitioner's orders, and weekly skin evaluations revealed no indication of the resolution of the left shoulder open area. An observation on 05-05-2025 at 2:35 PM of RN A and the Assistant Director of Nursing (ADON) providing wound care for Resident 3 right foot and ankle revealed an undated foam dressing to the left side of Resident 3's back and an undated foam dressing to the sacrum. Furthermore, the ADON removed both dressings which revealed an open wound to the left side of the back approximately the size of a quarter with yellow slough (dead tissue) in the center, and an open wound to the sacrum that was round approximately 2.5 cm in length by 2.5 cm in width with yellow slough in the center. An interview with ADON on 05-05-2025 at 2:55 PM confirmed the wound to the sacrum was a pressure ulcer and the area on the left side of back could have been caused by friction. An interview with RN A was conducted on 05-05-2025 at 3:00 PM confirmed there were no treatment orders for the wounds to the left back or sacrum. An interview conducted with the DON on 05-05-2025 at 3:30 PM confirmed the wounds had not been measured and a treatment had not been requested. Record review of the facility policy titled Pressure Injury Prevention and Management revealed the following: -Policy- the facility is committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries. -the facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions and modifying the interventions as appropriate.