Based on interview, observation and record review during a Recertification Survey conducted from 8/26/2024 through 8/30/2024, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and to prevent the development of pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable. This was evident for 1 of 4 residents reviewed for pressure ulcers (Resident #24). Specifically, Resident #24 was assessed as high risk for pressure ulcers and was identified to have left heel redness on 08/24/2024. The resident's care plan and interventions were not promptly updated and implemented to prevent further deterioration of the left heel skin integrity. Subsequently, on 8/29/2024, the resident's left heel was observed and assessed by the facility nurse practitioner and diagnosed to be an unstageable decubitus (damage to a person's skin caused by constant pressure on an area for a long-time) ulcer. This resulted in actual harm to Resident #24 that is not Immediate Jeopardy. The findings are: The facility's policy titled Pressure Ulcers: Prevention and Care of (dated 5/2001, revised 6/2012) documented it is the policy of the facility to maintain the skin integrity of residents with intact skin and to restore the skin integrity of those residents with pressure ulcers. Actions include: may refer to the Pressure Ulcer Protocol, initiate the resident's care plan with nursing interventions for treatment and prevention of the pressure ulcer, review and update care plan accordingly, may convene a care planning team meeting including the dietician, rehabilitation therapist, physician or nurse/wound care team to develop the interdisciplinary steps required for healing the ulcer, update the interdisciplinary team to reflect the physicians orders and any other interventions decided upon. Supervise care rendered by Certified Nursing Assistant (CNA) to assure optimal positioning (including use of devices) and incontinence care. The undated facility policy for Turning and Positioning a Resident documented turning and positioning of resident in bed is performed as specified in the resident plan of care. The following residents are to be considered for a specified turning and positioning schedule: residents identified as high risk for pressure ulcer development, residents with actual skin ulcer, and residents with limited bed mobility. The Facility Pressure Ulcer Protocol for Care for Stage 1 pressure ulcer guidelines identifies a Stage 1 ulcer definition as intact skin with redness (in darker skin may appear as red/blue or purple hues) of a localized area which is usually over a bony prominence). Please note not all reddened areas are stage 1 pressure ulcers. Some reddened areas are due to moisture associated with skin damage. Guidelines for Interventions include: complete full body assessment on admission, hospital return, during bed bath, shower, incontinent care or anytime when red area is noted, skin assessment to be completed by registered nurse on admission, quarterly and for significant change. May update plan of care with turn and repositioning task. Turn and position for relief of pressure, if applicable. Reduce shear and friction, lubricate skin, inform physician and dietician, provide resident/family/staff education and document on the resident/family care plan, documentation in medical record on staging, location, and treatment, update comprehensive care plan/minimum data set as necessary. Resident #24 had diagnoses including type 2 diabetes, Alzheimer's disease, and a history of pressure injuries. The Quarterly Minimum Data Set (an assessment tool) dated 7/15/2024 documented Resident # 24 had severe cognitive impairment, was dependent on staff for chair/bed-to-chair transfers and required substantial to maximal assistance for bed mobility and sitting on the side of the bed. Resident #24 was frequently incontinent of bowel and bladder, was at risk for pressure ulcers, had no pressure ulcers/other skin problems (ulcers, wounds), had a pressure reducing device for chair/bed, was on a turning/repositioning program, received nutrition or hydration intervention to manage skin problems, and received ointments/medications other than to feet. The 8/19/2024 Skin Integrity Care Plan documented Resident #24 was at risk for skin breakdown or pressure ulcer injury. The goal was to have no skin breakdown for 90 days. Interventions included turn and position every 2 hours / as needed, monitor skin during daily care, assess for changes in skin condition each shift, and provide incontinent care every 2 hours and as needed. On 8/26/2024 a wound consult secondary to redness of left heel was added to the care plan. The 8/24/2024 Braden Scale (an assessment used to predict a resident's risk of developing pressure sores/ulcers) documented a score of 11 which indicated that resident was at high risk. The risk factors documented sensory perception: very limited. Moisture: very moist. Activity: chairfast. Mobility: very limited. Nutrition: probably inadequate. Friction and shear: problem. There was no documented evidence Resident #24's care plans were updated to include interventions for the left heel redness and to prevent the further deterioration of left heel skin integrity. The 8/24/2024 Care Plan Activity Report for care area: pressure ulcer/injury/skin integrity potential for skin breakdown note documented: It was reported to the writer that the resident had left heel redness, seen, and examined by nurse practitioner, order zinc ointment to be applied to affected area after cleansing with normal saline then cover with foam dressing every shift and as needed. Wife made aware personally. All needs being attended and anticipated. Morning care done, assisted from bed to geriatric chair (large padded reclining chair with wheeled base for people with limited mobility). Kept clean and dry. Continue plan of care. Currently monitored. The Certified Nursing Assistant Documentation History Detail report documented skin checks were performed each shift (3 times a day) by staff from 8/24/2024 through 8/28/2024. The 8/24/2024 at 3:18 PM Nurse Practitioner note documented left heel skin changes. Came to resident secondary to family informing the left heel had skin changes. Skin on left heel had redness with some bleeding. Changes in left heel skin integrity, wound consultation. Start zinc oxide. The 8/24/2024 at 3:50 PM Nursing Progress note documented resident in bed, awake, calm not in any distress. Noted with redness on their left heel, seen by Nurse Practitioner with treatment advised, cleansed with normal saline, applied zinc oxide and covered with foam dressing as ordered. Out of bed at lunch time. Plan of care to continue. There was no documented evidence of further interventions, or progress notes until 8/29/2024. The August Treatment Administration Record documented Resident #24 received treatment each shift (7 AM- 3 PM, 3 PM-11 PM, 11 PM-7 AM) of topical zinc oxide 20%, apply by topical route every shift to left heel after cleansing with normal saline, then cover with foam dressing from 8/24/2024 through 8/28/2024. The Certified Nurse Aide Documentation Record dated August 2024 documented the resident was turned and positioned every 2 hours from 8:00 PM to 8:00 AM. There was no documented evidence the resident was turned and positioned between 8:00 AM and 8:00 PM. The 8/26/2024 at 3:06 PM Interim Physician Order signed by the Medical Director on 8/27/2024 at 9:54 AM documented wound consult for left heel redness. During observation on 08/27/2024 at 9:34 AM Resident #24 was sleeping on their back in a geriatric chair with their heels resting directly on the geriatric chair footrest. The heels were not off-loaded or elevated. During observation on 08/27/2024 at 11:42 AM Resident #24 was resting on their back in a geriatric chair with their ankles crossed and their heels resting directly on the geriatric chair footrest. Heels were not off-loaded and Resident #24 had socks and slippers on. During a continuous observation on 08/28/2024 from 8:50 AM to 11:41 AM Resident #24 was resting on their back with their ankles crossed and heels resting on the footrest. Resident #24 had socks and slippers on and was not turned/repositioned during this time. During an interview on 08/28/2024 at 1:20 PM Resident #24's family member stated they noticed left heel redness during a visit last week and requested staff to look at the heel. The family member was not aware of any interventions put in place except a request for wound consult to take place Friday, August 30, 2024. During observation on 08/29/2024 at 8:35 AM Resident #24 was resting in bed on their back and their heels were not off-loaded. During observation and interview with Registered Nurse #26 on 08/29/2024 at 9:55 AM, Resident # 24's heels were resting on an air mattress and not off-loaded. The left heel was observed with a soiled, white gauze dressing which was removed by Registered Nurse #26. During an immediate interview, Registered Nurse #26 stated it was an unstageable wound and they were not aware why the wound was dressed in white gauze, not in foam dressing as ordered or why heels were not off-loaded. Registered Nurse #26 did not have an explanation when asked what interventions were implemented to prevent further decline of the heel after report of heel redness on 8/24/2024. Further review of the August 2024 Treatment Administration Record revealed Registered Nurse #26 signed for the heel dressing treatment for the 7:00 AM to 3:00 PM shift on 8/25/2024, 8/26/2024, 8/27/2024, and 8/28/2024. On 08/29/2024 at 10:00 AM, Registered Nurse Supervisor #1 was asked to observe the left heel wound with Registered Nurse #26. During an immediate interview Registered Nurse Supervisor #1 stated, the wound was not stageable and there were areas of necrosis (dead tissue) present. Registered Nurse Supervisor #1 stated they did not know why Resident #24's heels were not off-loaded and was unaware of interventions put in place when redness of the left heel was identified on 8/24/2024. They did not know why the wound was covered with gauze and did not have a foam dressing present as ordered. During observation and interview on 08/29/2024 at 11:59 AM Nurse Practitioner #27 stated the left heel wound was unstageable and had progressed from heel redness which was reported 8/24/2024. Nurse Practitioner #27 stated nurse judgement should have been applied and heel off-loading, turning and repositioning and heel boots should have been added to the care plan immediately upon report of heel redness. During an interview on 08/29/2024 at 1:21 PM, Certified Nursing Assistant #28 stated they report all changes in resident status to the floor registered nurse or Unit Supervisor. Certified Nursing Assistant #28 stated they had not noticed any changes in Resident #24's skin during care since Sunday, August 25, 2024, and Resident #24 was not discussed during reports over the last week. Certified Nursing Assistant #28 stated the resident's family member asked them to check resident's left heel about 4-5 days ago and they informed family member they would provide information to floor registered nurse to assess. Certified Nursing Assistant #28 stated they informed the floor registered nurse of the family member request to assess the left heel. Certified Nursing Assistant #28 stated they were not aware of any interventions put in place for the residents left heel. During an interview on 08/29/2024 at 1:33 PM Registered Nurse #26, stated skin assessments were only completed if there is a change reported and during wound care. Registered Nurse #26 stated they are familiar with Resident #24 and the resident has a wound on the left heel. Registered Nurse #26 stated offloading and repositioning are techniques used to prevent pressure ulcers and they did not routinely off-load the resident's heels except for once on 8/28/2024 when they returned the resident to bed in the evening. Registered Nurse #26 stated the resident is repositioned at mealtimes when in the day room and was not able to provide an answer why the resident was not repositioned every two hours while in the day room or why their heels were not off-loaded while the resident was in the geriatric chair. Registered Nurse #26 stated they should have delegated the task. The 8/29/2024 Nursing progress noted documented the resident was seen and examined by the nurse practitioner with the family at the bedside for a left heel diabetic unstageable ulcer. The nurse practitioner ordered to start Santyl 250 topic ointment to the affected area once daily for 30 days to left heel wound after cleansing with normal saline then cover with foam dressing. To off load bilateral heels with pillows every shift while on bed, to continue to reposition every 2 hours and as needed. Also ordered chest and heel x-ray and lab work. Needs attended to and kept monitored. During interview and observation on 08/30/2024 at 9:15 AM Wound Consultant Nurse Practitioner stated the left heel wound was unstageable. They stated pressure ulcer preventative measures could have been put in place when redness was reported on 8/24/2024 including skin prep, heel booties, off-loading, elevating feet, turning and repositioning every two hours. The staff could have taken a picture and sent it to them, and they could have made a referral to physical therapy and occupational therapy to address the resident crossing their legs and for assistive devices. During interview on 8/30/2024 at 12:03 PM the Director of Nursing stated when a change in skin integrity is reported, the resident should be assessed by the unit registered nurse and an assessment requested from the facility nurse practitioner. Once registered nurse assessment is completed, registered nurse should enter care plans, document notes, notify family of changes and plan of care. Director of Nursing stated interventions should be started immediately based on nursing judgement and orders. Interventions include off-loading, turning and repositioning, resident taken out of bed for period of time, personal hygiene, nutrition review for supplements, supportive devices including cushions, heel boots, hand rolls and possibly, x-rays. Labs including albumin should be ordered. Director of Nursing stated residents at risk for pressure ulcers should be assessed for devices such as chair cushions, heel booties and hand rolls. During interview on 08/30/2024 at 1:30 PM the Medical Director stated the expectation for residents who were at risk for pressure ulcers, included off-loading to begin immediately, turning and repositioning every two hours, efforts to minimize skin excoriation by changing residents frequently, booties used if applicable, and skin barrier ointment. 10 NYCRR 415.12(c)(1)