**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of three unstageable pressure ulcers for Resident #55. Actual Harm occurred on 12/05/19 when Resident #55, who was bedfast and required extensive assistance to total dependence on staff for activity of daily living care, including bed mobility and transfers developed unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough [yellow, tan, gray, green or brown tissue] and/or eschar [tan brown or black tissue] in the wound bed) pressure ulcers to the right heel, left heel and coccyx. This affected one Resident (#55) of two residents reviewed for pressure ulcers. The facility identified three current residents with pressure ulcers. Findings include: Record review revealed Resident #55 was admitted to the facility on [DATE] with diagnoses including type two diabetes mellitus without complications, dementia, congestive heart failure and chronic obstructive pulmonary disease. Review of the physician's orders revealed the following orders: A diet order on 07/02/19 for a consistent carbohydrate diet, no added salt. On 08/13/19 a physician order for Med Plus no sugar added (NSA) four ounces twice a day as a nutritional supplement. On 10/18/19 fortified foods three times a day were added to the resident meals along with a 2:00 P.M. snack and bedtime (HS) snack. Review of Resident #55's care plan initiated 07/02/19 revealed Resident #55 had a potential for actual impairment to skin integrity due to fragile skin, edema to her lower extremities, a deficit in self care performance related to dementia, incontinent of urine and stool and was at nutritional risk for weight loss and dehydration. The interventions included apply barrier cream to buttocks and peri area after each incontinent episode, encourage good nutrition and hydration in order to promote healthier skin, provide and serve snacks and supplements as ordered, pressure relieving devices to bed and wheelchair, turn and reposition every two hours and elevate legs in bed. Record review revealed Resident #55 was discharged to the hospital on [DATE] with diagnoses of urinary retention and exacerbation of chronic obstructive pulmonary disease. The resident returned to the facility on [DATE]. Review of the 11/04/19 admission Evaluation completed by Licensed Practical Nurse (LPN) #352 upon the resident's return from the hospital revealed Resident #55 could not walk, did not stand or sit in a chair, used a mechanical lift for transfers and was dependent on staff to roll in the bed from back to sides and sides to back. The Braden Observation Tool dated 11/04/19 and authored by LPN #352 revealed Resident #55's skin was very moist, she was confined to bed, had potential problems with friction and shearing of the skin and very limited mobility being unable to independently make significant changes in body position. The tool scored the resident at moderate risk for skin breakdown with interventions listed as encourage turn and reposition, float heels, elevate legs above heart while in bed and place a blanket between resident and mechanical lift. Review of the physician orders, dated 11/04/19 revealed the resident was ordered to be non weight bearing (NWB), pressure reduction mattress to the bed, encourage and assist resident to float heels in bed, encourage and assist her to turn and reposition every two hours and a consistent carbohydrate, no added salt diet. The Med Plus NSA nutritional supplement was not reordered by the physician upon readmission. Review of a progress note dated 11/05/19 and authored by Certified Registered Nurse Practitioner (CRNP) #900 revealed Resident #55 had been recently in the hospital for urinary retention, had a decrease in weight following the hospital stay of 12.4 pounds (weight noted at 160 pounds) and trace edema to the bilateral extremities. Review of the facility document titled MD Progress Note, dated 11/08/19, authored by Primary Care Physician (PCP) #901 revealed Resident #55 had an elevated blood sodium level at 149, her weight was stable at 174 pounds and she may have been dehydrated. The quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #55 had cognitive impairment, did not reject care, was at risk for pressure ulcers requiring pressure reducing devices to her bed and chair, was always incontinent of bowel and bladder and required total assistance by two staff for transfers and extensive assistance of two staff for bed mobility, dressing, toileting and hygiene. A physician order dated 11/12/19 revealed an order for Prafo boots (specialized boots used to relieve pressure to the heels in people who spend most of the time in bed ) while in bed. Review of a progress note dated 11/13/19 and authored by CRNP #900 revealed Resident #55 had not been eating well, would not sit up in bed more than 30 degrees, had trace edema and needed fluids encouraged due to high blood sodium levels being monitored by the CRNP. Review of the Braden Observation Tool dated 11/17/19 indicated Resident #55 was chair fast, had very limited mobility, adequate nutrition and was low risk for skin impairment. Review of the MD Progress Note dated 11/22/19 and authored by PCP #901 revealed Resident #55 had decreased by mouth intake of meals and was at risk for weight loss and dehydration so a diet downgrade would be considered because she refused to sit upright for meals. Review of the documented titled Skid Grid Non Pressure, dated 11/24/19, revealed the resident had developed on 11/17/19 an abrasion to her left front thigh from improper briefing. The abrasion was described as no skin loss, red in color, no exudate and size of 10.0 centimeters (CM) length by 10.0 cm width and 0.0 depth. Review of the Weekly Skin Check document dated 11/26/19 revealed new areas since the last skin check. A progress note dated 11/27/19 authored by Registered Dietitian (RD) #373 revealed the resident's weight was up three percent (%) and nursing staff reported her by mouth intakes were increased. RD #373 added the RN was made aware of the weight gain and current interventions would continue along with monitoring. There was no assessment of actual percentage of meal intakes or implementation of any supplements or meal fortifiers (foods used to provided a concentrated source of calories and protein) for nutritional support during this review by RD #373. Review of the Weekly Skin Check documented dated 12/03/19 indicated there were no new skin areas. Review of the facility documents titled Skin Monitoring Comprehensive CNA Shower Review, from 11/07/19 to 12/05/19 revealed the resident was provided bed baths due to shower refusals during that time frame, there were no skin impairment areas identified to the heels or coccyx and the sheets were signed and dated by the charge nurses. Review of a progress note dated 12/06/19 at 7:54 P.M. revealed while Resident #55 was being moved with the mechanical lift from the bed to the shower chair it was identified the resident had discoloration to her bilateral heels, an area to the right lateral foot, an abrasion to left third toe and discoloration to coccyx. The note continued to describe the right heel had a deep tissue injury measuring four centimeters (cm) in length by five cm, the left heel had deep tissue injury measuring 2.5 cm in length by 5.8 width, the coccyx had an unstageable ulceration measuring 1.2 cm by 1.5 cm and third toe had an abrasion. The physician and daughter were made aware of the ulcers and treatments were ordered at that time. Review of the document titled Skin Grid Pressure, dated 12/06/19 and authored by LPN #370 revealed an in-house acquired right heel pressure ulcer identified on 12/05/19 measuring 4.0 cm length by 5.0 cm width with an undetermined (UTD) depth and suspected deep tissue injury (SDTI). The ulcer was assessed to have indistinct edges, red color with granulation tissue present, no drainage or pain. The treatment order was paint with betadine (an anti-septic solution used to prevent infection) and cover with a foam dressing daily. Review of the document titled Skin Grid Pressure, dated 12/06/19, and authored by LPN #370 revealed an in-house acquired left heel pressure ulcer identified on 12/05/19 measuring 2.5 cm length by 4.8 cm width with an undetermined (UTD) depth and suspected deep tissue injury (SDTI). The ulcer was assessed to have indistinct edges, eschar (tan, brown or black color) with necrotic (dead) tissue present, no drainage or pain. The treatment order was paint with betadine (an anti-septic solution used to prevent infection) and cover with a foam dressing daily. Review of the document titled Skin Grid Pressure, dated 12/06/19 and authored by LPN #370 revealed an in-house acquired coccyx pressure ulcer identified on 12/05/19 measuring 1.2 cm length by 1.5 cm width with an undetermined (UTD) depth and unstageable. The ulcer was assessed to have distinct edges, with yellow slough (dead skin tissue that may have yellow or white appearance) present, bloody drainage and no odor. The treatment order was for medihoney and a foam dressing daily. On 12/16/19 at 1:31 P.M. RN #375 and LPN #335 were observed completing wound care for Resident #55. Proper infection control procedures were followed and the resident denied pain before starting the dressing changes. Upon positioning the resident to expose the coccyx there was no dressing in place and a small area of dry pink and dark color skin was noted on the coccyx. A dressing dated 12/15/19 was removed from the right heel. The right heel was observed to have a large purple and black colored area which was covered with eschar. A dressing dated 12/15/19 was removed from the left heel. The left heel appeared calloused with purple dotted areas of deep injury. The resident retracted her left foot during cleansing and complained of extreme tenderness to the left heel. All ordered treatments were implemented and dated 12/16/19. On 12/17/19 at 11:01 A.M. observation and interview with Resident #55 revealed she appeared pale and tired, as she closed her eyes a few times during the conversation. The resident was able to have reciprocal conversation remaining oriented to the situation. She was laying on her back on a pressure reducing mattress, head elevated to approximately 30 degrees and her heels were wrapped in white bandages and elevated on a bolster. Resident #55 had been watching television while waiting for her lunch. She was alert with some confusion, as she said she did not remember why she had bandages on her feet. She indicated she preferred to stay in bed only occasionally getting up to a chair and did not have a good appetite. On 12/17/19 at 4:54 P.M. during an interview with Certified Dietary Manager (CDM) #372, CDM #372 revealed prior to her going to the hospital on [DATE] the resident had been receiving fortified foods that consisted of fortified cereal, fortified potato and fortified pudding but it was not restarted when she returned from the hospital on [DATE]. CDM #372 said it was up to the registered dietitian to implement the fortified foods. She added the resident did receive snacks twice a day as before she went to the hospital. On 12/18/19 from 9:56 A.M. to 10:27 A.M. interview with RD #373 verified she had not completed a comprehensive nutritional assessment on the resident when she returned to the facility on [DATE] but instead did a progress note on 11/27/19 addressing the three percent weight gain with no new recommendations. RD #373 identified Resident #55 as a nutritional risk prior to her hospitalization on 11/01/19, had put her on fortified foods three times a day and Med Plus NSA supplement four ounces twice a day with snacks twice a day. RD #373 verified the Med Plus NSA and fortified foods were not restarted for the resident upon return to the facility on [DATE]. RD #373 shared she implemented a Promod (protein) supplement on 12/06/19 after the multiple in-house acquired pressure ulcers were reported to her at the weekly meeting but as of 12/18/19 she had still not done a comprehensive nutritional assessment of the resident with the last one being 09/25/19 when her quarterly review was due. On 12/18/19 at 1:11 P.M. interview with LPN #314 who reviewed the Skin Monitoring Comprehensive CNA Shower Review documents from 12/01/19 and 12/05/19 verified the documents indicated there were no skin impairment areas notated on them. LPN #314 added she would assume the resident's skin was intact during that time period based on the documents reviewed. On 12/18/19 at 4:02 P.M. interview with the Director of Nursing (DON) and RN #375 both verified Resident #55 developed pressure related wounds to her bilateral heels and coccyx in the facility. The DON revealed she believed the wounds were caused because Resident #55 had edema in her legs and was wearing Prafo boots in bed which caused the pressure on her heels. She had no comment regarding how the ulcer on the resident's coccyx developed or how it first identified as an unstageable pressure ulcer. On 12/18/19 at 4:41 P.M. during an interview with RN #375, the RN indicated she believed the coccyx pressure ulcer developed from prolonged pressure as a result of the resident having the head of her bed elevated, edema in her heels and keeping her legs elevated put pressure on the coccyx.