**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during an abbreviated survey and partial extended survey (NY00349917), the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent new ulcers from developing and promote healing of facility acquired pressure ulcers for 3 out of 5 residents (Resident #1, #7, #8) reviewed. Specifically, (1) Resident #1 was admitted to the facility with intact skin and was identified as a low risk for pressure ulcer development. Interventions/measures ordered by the physician to prevent pressure ulcer development were not consistently provided by direct care staff and Resident #1 developed a facility acquired pressure ulcer to their sacrum and bilateral heels. (2) Resident #7 developed a facility acquired Stage III pressure ulcer (a full thickness tissue loss where subcutaneous fat is visible within the wound, but bone, tendon, or muscle are not exposed) to the right buttocks after not receiving consistent incontinence care. (3) Resident #8 developed a facility acquired Stage III pressure ulcer to their sacrum. Resident #8 had upper/lower extremity impairment was dependent on staff for bed mobility and was not consistently provided skin observations or turning and positioning by direct care staff. Findings include: The facility's Pressure Injury/Pressure Ulcer Assessment, Prevention and Management policy dated 7/2018 documented it is the policy of the facility that residents will not develop pressure injury/ulcers unless clinically unavoidable. The facility shall provide care and service consistent with professional standards of practice to prevent pressure injury development. The purpose of the policy is to provide guidelines for the prevention as well as timely identification and treatment of pressure injury. When a pressure injury is present on an in-house resident, document the assessment of the wound on a weekly basis on the weekly evaluation form, update the pressure injury care plan to reflect the status of the pressure injury and plan of care. 1) Resident #1 was readmitted to the facility on [DATE] with diagnoses including, but not limited to, Chronic Obstructive Pulmonary Disease (lung disease causing restricted airflow and breathing problems), Muscle Wasting and Atrophy (the loss of muscle mass and strength, often occurring due to lack of use, injury, malnutrition, or certain diseases, resulting in a decrease in muscle size and function) and Muscle Weakness (lack of muscle strength). A 5-day Minimum Data Set (an assessment tool) dated 6/11/2024 documented the resident had moderate cognitive impairment. The resident required moderate assistance for eating, maximum assistance for bed mobility/transfers and was dependent for toileting. The resident was at low risk for pressure ulcers. There was no documented staged pressure ulcers or unstageable pressure ulcers. The resident had no dressings applied to their feet but received ointment or medication to areas other than their feet for dryness. Review of the Resident #1's admission/readmission nursing assessment dated [DATE] revealed the resident's skin was intact and they had dryness and skin discoloration to their bilateral heels. The Admission/readmission assessment categorized Resident #1 as a low risk for pressure ulcer. Review of a risk for skin integrity impairment care plan initiated 6/5/2024 identified risks related to decreased mobility and documented Resident #1's skin would be free from pressure related injury through 6/25/2024. Interventions listed included assist with turning and positioning as needed, heel protectors and keep resident clean and dry. Review of an activities of daily living care plan dated 6/6/2024 revealed self-care performance deficit related to activity intolerance. Interventions listed included inspect skin every shift and observe for redness and open areas and report changes to the nurse. Toilet every 2 hours and as needed. The admission Braden Scale (a risk assessment tool that predicts a patient's likelihood of developing pressure ulcers) dated 6/7/2024 documented Resident #1 had a score of 15 and was categorized as low risk for pressure ulcers. Review of an actual skin integrity impairment care plan initiated on 6/21/2024 documented on 6/19/2024 Resident #1 had a skin tear (a wound that occurs when the layers of skin separate due to mechanical forces, such as friction, shear or blunt trauma) to their right buttock measuring 4 cm x 5 cm. Interventions listed included apply treatment to site as ordered and prevent excessive moisture to other body parts. Review of Registered Nurse #2/wound care nurse's progress note dated 6/25/2024 documented Resident #1 was noted to have a skin tear on their right lower buttocks which measured 2 cm x 2 cm x 0.1 cm with scant serosanguinous (contains or relates to both blood and liquid part of blood) drainage. There was no further documented tracking of Resident #1's right buttock skin tear on the care plan after 6/21/2024 and no wound assessment documented in the nursing progress notes after 6/25/2024. Review of a pressure ulcer care plan initiated 6/24/2024 documented on 6/21/2024 Resident #1 had a right heel deep tissue injury (a type of pressure ulcer that occurs when the tissue beneath the skin is damaged by pressure or shearing force) 6.5 cm x 4 cm and redness to the left heel 6 cm x 4 cm. Interventions listed included assess/record/monitor wound healing weekly, turn/reposition at least every 2 hours or more as needed or requested, and wound care consults as ordered. Review of a nurse's progress note dated 6/24/2024 documented discoloration noted to right heel measuring 6 cm x 7 cm x 0 cm. Red and purple discoloration noted on left heel measuring 2 cm x 2 cm x 0 cm. Skin was noted to be intact. There was no documented evidence of a weekly skin assessment of the wound. There was no documented evidence of an updated pressure ulcer care plan related to Resident #1's heels after 6/24/2024. Review of Registered Nurse #2/wound care nurse's progress note dated 6/27/2024 documented they were informed Resident #1 had an opening to their right heel deep tissue injury measuring 6 cm. Treatment will be applied until Resident #1 is seen by wound specialist. Review of Registered Nurse #2/wound care nurse's skin/wound care progress note dated 7/9/2024 documented Resident #1 was noted with redness on their right bunion measuring 2 cm x 2 cm and red to purple discoloration on their right outer ankle measuring 1 cm x 1 cm. There is no documented evidence Resident #1 was evaluated by the wound specialist prior to their transfer to the hospital on 7/12/2024 for evaluation of left facial droop. Resident #1 was discharged to the hospital on 7/12/2024. Hospital records revealed the resident had a stage 3 pressure ulcer to the sacrum and 2 pressure ulcers to the right malleolus (ankle), and the right heel. The right heel pressure ulcer was debrided (a medical procedure that removes dead, damaged, or infected tissue from a wound to promote healing). The infectious diseases evaluation documented proposed diagnosis as sepsis with source being right heel necrosis. Review of Resident #1's certified nurse assistant accountability report for June 2024 revealed the following care was not provided: bilateral heel booties in place when in bed every shift - no documentation on six (6) occasions, skin observation of right buttock and bilateral heels every shift - no documentation on eight (8) occasions and turning and positioning every two (2) to four (4) hours - no documentation on 24 occasions. Review of Resident #1's certified nurse assistant accountability report for July 2024 revealed no documented evidence indicating care, as per the care plan, was implemented: bilateral heel booties in place when in bed on 5 occasions, skin observation of right buttock and bilateral heels on 2 occasions and turning and positioning on 12 occasions. During an interview on 10/17/2024 at 12:04 PM with Registered Nurse #2/wound care nurse, they stated when Resident #1 went to the hospital in July 2024, they had facility acquired wounds on their right buttocks and on bilateral heels. Registered Nurse #2/wound care nurse stated Resident #1 was not able to move around on their own and they were turned and repositioned by the certified nurse assistants. Registered Nurse #2/wound care nurse stated Resident #1 was not turned and positioned frequently enough, and their heel booties were not applied as ordered. Registered Nurse #2/wound care nurse stated interventions such as the turning and positioning and heel booties are entered on the care [NAME] and the certified nurse assistants sign off on them when completed. During a telephone interview on 10/18/2024 at 11:32 AM, Registered Nurse #1 stated when Resident #1 was admitted to the facility, they had redness to their heels, and they developed a deep tissue injury. During an interview on 10/18/2024 at 1:18 PM, Registered Nurse #3 stated they did Resident #1's admission assessment on 6/5/2024 and the resident's skin was intact with some discoloration on their heels. Registered Nurse #3 stated the discolored areas were blanchable (pressing on the area will turn the redness white or pale) and very dry and there were no signs that their heels would turn into pressure ulcers. On admission Resident #1 had no skin breakdown on their sacrum. Registered Nurse #3 stated they were concerned about the dryness to Resident #1's heels, and they activated their admission order set which included: applying antiseptic to the sacrum, using bilateral heel booties, certified nurse assistants were to elevate the resident's bilateral legs with pillows and to report any skin changes or openings to the Registered Nurse or nursing supervisor. During an interview on 10/21/2024 at 2:20 PM, Certified Nurse Assistant #2 stated they remember Resident #1, and they recall repositioning the resident and applying their heel booties. Certified Nurse Assistant #2 stated an empty signature box on the certified nurse assistant accountability report looks like the care was not provided but they do not recall if they signed for Resident #1's care after completion. They usually do their documentation. During an interview on 10/21/2024 at 3:41 PM, Certified Nurse Assistant #3 stated they worked in the facility for about 3 years, and they remember Resident #1. The resident needed assistance with Activities of Daily Living care and turning and positioning in bed. Resident #1 also needed heel booties and pillows for positioning every 2 hours. Certified Nurse Assistant #3 stated if there is no signature in a box on the certified nurse accountability report then the care was not provided. Certified Nurse Assistant #3 stated they provided care to Resident #1 as ordered and cannot recall why they did not sign the accountability record. During an interview on 10/21/2024 at 3:50 PM, the Director of Nursing stated the residents are assessed to identify their risk factors for pressure ulcers and the Braden scale assessment is conducted weekly for 4 weeks for each resident after admission. Pressure relieving devices as well as heel booties and incontinence products are provided for all residents . The Director of Nursing stated all comorbidities are monitored and regulated from admission to lower risks of acquiring pressure ulcers. Upon identification of a pressure ulcer the physician is notified for a treatment order, the resident's plan of care is reviewed, preventative measures are implemented, and the residents are added to the list for wound rounds. 2) Resident #7 admitted on [DATE] with diagnoses including but not limited to Chronic Pulmonary Embolism (a medical condition that occurs when blood clots in the pulmonary arteries do not dissolve or are left untreated), Gastrointestinal Hemorrhage (a medical condition when a bleeding occurs within the gastrointestinal tract) , and Benign Prostatic Hyperplasia (a medical condition that causes the prostate to enlarge) without lower urinary symptoms. A last Quarterly Minimum Data Set (an assessment tool that measures health status) dated 8/2/2024 documented the resident had moderate cognitive impairment. The resident required moderate assistance with eating and bed mobility and was dependent for toileting and transfers. Foley catheter in place and frequently incontinent of bowels and has MASD (moisture associated skin damage). Review of a Registered Nurse #2 wound progress note dated 8/14/2024 documented Resident #7 was seen for a rash to their buttocks and was noted to have moisture associated skin damage measuring at 1.5 cm x 1 cm x 0.1 cm. Review of a wound progress note dated 8/21/2024 documented Resident #7 was seen for a bilateral buttock rash which is now a Stage III pressure ulcer to the right buttocks measuring 1.8 cm x 0.6 cm x 0.1 cm. Review of Resident #7's wound assessment reports revealed the following: - On 8/14/2024 the wound assessment report documented Resident #7 had moisture associated skin damage to their bilateral buttocks measuring 1.5 cm x 1 cm x 0.10 cm. The treatment ordered to cleanse daily with soap and water and apply medical grade honey and cover with a bordered gauze. - On 8/21/2024 the wound assessment report documented a Stage III pressure ulcer to the right buttocks measuring 1.8 cm x 0.6 cm x 0.10 cm. - On 8/28/2024 Stage III pressure ulcer to the right buttocks measuring 1.2 cm x 0.6 cm x 0.10 cm. - On 9/11/2024 Stage III pressure ulcer to the right buttocks measuring 3.0 cm x 4.0 cm x 0.10 cm. - On 9/18/2024 and 9/24/2024 documented a stage III pressure ulcer to the right buttocks measuring 2.2 cm x 2.0 cm x 0.10 cm. Review of Resident #7's treatment administration records for August 2024 and September 2024 revealed the physician ordered treatments were not documented as completed on 8/26/2024, 8/31/2024, 9/1/2024 and 9/3/2024. Review of a potential for pressure ulcer development care plan last updated 10/21/2024 documented Resident #7 would have intact skin by/through 11/21/2024. Interventions listed included to assist with turning and positioning every two (2) hours and as needed. Review of a bladder incontinence care plan initiated on 8/16/2022 documented Resident #7 will remain free of complications related to urinary incontinence such as skin breakdown. Interventions listed included assist with toileting as requested and check the resident every two (2) to four (4) hours and as needed as required for incontinence. There were no documented updates to the interventions on the bladder incontinence care plan. A target date of 11/21/2024 was documented. Review of the foley catheter care plan, last updated 8/19/2024, listed interventions to change catheter every four (4) weeks, monitor intake and output, position catheter bag and tubing below the level of the bladder. Review of Resident #7's certified nurse assistant accountability report for August 2024 revealed the following care was not provided: skin observation of sacrum and bilateral buttocks every shift - not documented on 31 occasions, bladder incontinence care every shift - not documented on 31 occasions. Review of Resident #7's certified nurse assistant accountability report for September 2024 revealed the following care was not provided: skin observation of sacrum and bilateral buttocks every shift - not documented on 36 occasions, bladder incontinence care every shift - not documented on 30 occasions. 3)Resident #8 was admitted with diagnoses including but not limited to Nontraumatic Intracerebral Hemorrhage (a type of stroke that occurs when blood pools in the brain without trauma or surgery), other Encephalopathy (any brain disease that alters brain function or structure) and Muscle Wasting and Atrophy (the loss of muscle mass and strength, often occurring due to lack of use, injury, malnutrition, or certain diseases, resulting in a decrease in muscle size and function). An admission Minimum Data Set (an assessment tool that measures health status) dated 8/7/2024 documented the resident had moderate cognitive impairment. The resident had upper and lower extremities impairment and was dependent for eating, toileting, bed mobility and transfers. The resident was a high risk for pressure ulcers but had no skin conditions noted. Review of Resident #8's Admission/Reassessment nursing assessment dated [DATE] documented the resident's skin was intact and categorized them as a low risk for pressure ulcers. Review of Registered Nurse #1's progress note dated 8/11/2024 documented they were informed by the certified nurse assistant that Resident #8 had a wound to their sacral area. Resident noted to have a superficial skin opening to the sacral area measuring 0.5 cm x 0.5 cm x 0.1 cm. Review of the wound care Nurse Practitioner's progress note dated 8/14/2024 documented Resident #8 had a Stage III pressure ulcer to the sacrum measuring 0.6 cm x 0.2 cm x 0.1 cm. Review of a risk for skin integrity impairment care plan initiated 8/14/2024 documented Resident #8 would be free from pressure related injuries by 12/21/2024. Interventions listed included assist with turning and positioning as needed and turn and position every two (2) hours. Review of Resident #8's certified nurse assistant accountability report for August 2024 revealed the following care was not provided: skin observation every shift - not documented on 41 occasions and turning and positioning every two (2) hours - not documented on 53 occasions. Review of Resident #8's certified nurse assistant accountability report for September 2024 revealed the following care was not provided: skin observation every shift -not documented on 39 occasions and turning and positioning every two (2) hours -not documented on 160 occasions. Review of Treatment Administration Record for August/September 2024 revealed wound treatments for the Stage III pressure ulcer were not documented as completed on the following dates: 8/18/2024, 8/22/2024, 8/31/2024, and 9/1/2024. During an interview on 10/21/2024 at 2:13 PM, Certified Nurse Assistant #1 stated if their signature was not in the box, then it would look as if they did not provide the care, but they make rounds on their residents regularly and sometimes, they forget to sign off on their tasks in the computer, because they get caught up in their work. During an interview on 10/21/2024 at 3:50 PM, the Director of Nursing stated the expectation is the certified nurse assistants complete their documentation for all residents assigned before the end of their shift. It is the responsibility of the unit managers to check the documentation and notify the certified nurse assistants of incomplete documentations. The Director of Nursing stated the certified nurse assistants can go back and document any missed information. The last In-service on documentation was completed 10/20/2024. The Director of Nursing stated they have not received any recent complaints from the residents about not receiving care, and there have been no complaints regarding care from the families in the past. During an interview on 11/25/2024 at 10:13 AM, Registered Nurse #2/wound care nurse stated they were not wound care certified but are in the process of taking online seminars. Registered Nurse #2/wound care nurse stated when they assess a wound and it is superficial, they categorize it as a skin tear, meaning it is affecting only the epidermal layer (the outermost layer) of the skin. These wounds are pressure ulcers, but the Nurse Practitioner must categorize them as such. Registered Nurse #2/wound care nurse stated they are not allowed to stage the wounds if they are not sure of the staging. Registered Nurse #2/wound care nurse stated they initiate the initial treatment plan per the facility protocol until the wound Nurse Practitioner comes in and stages the wound. The wound Nurse Practitioner is the one who does the staging of the wounds. During an interview on 11/25/2024 at 11:21 AM, the Director of Nursing stated Registered Nurse #2/wound care nurse can stage a wound, but they are scared to stage. The Director of Nursing stated they even provided Registered Nurse #2/wound care nurse with different terms to describe the wounds. The nurses are very good at identifying and treating the wounds, but they need to build their confidence to stage the wounds. The Director of Nursing stated Registered Nurse #2/wound care nurse was re-educated to determine the cause of the wound, because that is how they can identify pressure from non-pressure injuries. The Director of Nursing stated Registered Nurse #2/wound care nurse and all staff in the facility were provided education last month by a wound care company. The Director of Nursing also stated Registered Nurse #2/wound care nurse has attended training on wounds for the last 2 consecutive months. During a telephone interview on 11/21/2024 at 11:55 AM, the Medical Director stated they are aware of the facility acquired pressure ulcers in the facility and that there is a wound care specialist team that provides service in the building. The Medical Director stated the wound care specialist team works very closely with nursing and the Director of Nursing. The nurses communicate any concerns and issues about wounds to them. The Medical Director stated they see an incredible service being provided by the wound care specialist team and that there is always room for improvement with the facility acquired pressure ulcers. The Medical Director stated residents need to be checked constantly/around the clock for their incontinence needs, skin condition and wound status. If a resident has fragile skin, the resident needs to be turned and positioned and have their incontinence brief changed frequently to avoid skin breakdown. On admission, residents are assessed by the admitting nurse. If there is the need for wound care, a verbal order is given by them to the nurse. Verbal orders are also given for turning and repositioning. The Director of Nursing is in constant communication with the wound care consultants to follow through with recommendations provided. The Medical Director stated that turning and repositioning is part of their preventative measures/protocol to minimize facility acquired pressure ulcers, which is done with or without orders from them. The Medical Director stated with any wound or skin issue that occurs, the nurses are expected to institute turning and positioning as per protocol. All measures must be written on the physician orders for final signature including orders as per the facility protocol such as turning/repositioning/skin observations/heel booties. 10 NYCRR 415.12