**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of clinical records and staff and resident interviews it was determined the facility failed to develop and implement care and services, consistent with professional standards of practice, to prevent pressure ulcer development for one resident (Resident 89) and failed to assess and monitor facility acquired pressure injuries for two residents out of 14 sampled (Residents 18, and 8). Findings included: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of the clinical record revealed that Resident 89 was most recently admitted to the facility on [DATE], with diagnoses that included chronic foot drop (difficulty lifting the front part of the foot, which might cause foot to drag on the ground when walking) of the right lower extremity, cellulitis (a bacterial infection that affects the skin and underlying tissues) of the left lower limb, and after care for a fractured left tibia and fibula (leg). A review of hospital discharge orders dated September 6, 2024, revealed Orthopedic Instructions which instructed, strict elevation, compressive ace wrap, continue antibiotics, and keep upcoming appointment with Orthopedic surgeon. A review of Resident 89's admission physician orders dated September 6, 2024, indicated an appointment was scheduled for September 10, 2024, with the Orthopedic surgeon. There was no evidence that a compression ace wrap and/or strict elevation of the resident's surgically repaired left lower extremity was implemented as instructed in hospital discharge orders. A review of facility Admission/readmission observation dated September 6, 2024, indicated that Resident 89 had 2+ pitting edema (a grade given to swelling caused by fluid buildup in the body, where a slight indentation remains in the skin after pressure is applied and disappears within 15 seconds) of the left lower extremity. The left lower extremity had redness and discoloration (red and inflamed), weight bearing limitations, toe touch weight bearing of the left extremity, the resident complained of pain of the left lower extremity, alterations in skin integrity included surgical incisions of the left lower extremity and a pressure injury to the thoracic spine. Further review of the Admission/readmission Braden scale (a tool used to predict the risk of pressure ulcers) indicated the resident scored a 14 which indicated a moderate risk for development of pressure ulcers. A review of the facility's Wound Management Detail Report dated September 6, 2024, identified the following skin concerns upon Resident 89's return from the hospital: 1. Pressure ulcer to mid-upper back on the spine which measured 1cm x 1cm, and treatment was initiated. 2. Surgical incision to left knee over patellar (kneecap) region, no measurements and/or observation performed, site covered with surgical dressing. 3. Surgical incision to left shin median (inner) side which measured 2.5cm x 1cm, edges well approximated, and bruising noted. A dry sterile dressing was applied after incision was cleansed with normal saline solution. 4. Surgical incision to left shin with blood blisters present which measured 1.5cm x 0.1cm with edges well approximated, and five staples present, surrounding skin was warm. A dry sterile dressing was applied after observation. 5. Surgical incision to the left ankle just above the ankle medial side which measured 2cm x 1cm with four staples present, and surrounding skin was warm. No treatment initiated according to report. 6. Surgical incision to left shin lateral (outer) lower shin above the ankle which measured 1cm x 0.1cm with two staples present, surrounding skin was bruised, and a dry sterile dressing was applied after observation. An MDS Assessment (Minimum Data Set assessment - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated September 10, 2024, revealed the resident was cognitively intact with a BIMS score of 15 (brief interview for mental status, a tool to assess the residents attention, orientation and ability to register and recall new information, a score of 13-15 equates to being cognitively intact), required substantial/maximal assistance from staff for toileting, showers, putting on/taking off footwear, and lower body dressing and was at risk for pressure ulcer development. A review of Resident 89's care plan failed to identify a focus area related to the resident's risk for development of pressure ulcers, therefore, there was no evidence that interventions were implemented to prevent the development of pressure ulcers. A review of nursing documentation dated September 6, 2024, indicated the nurse practitioner ordered to have an ultrasound doppler of the resident's left leg to rule out DVT (deep vein thrombosis formation of a blood clot in a deep vein). A review of nursing documentation dated September 10, 2024, revealed that a doppler study and ultrasound of Resident 89's left lower extremity was completed and was positive for a DVT. Further review of the documentation revealed the attending physician ordered changes to the resident's medication regimen and blood work due to the positive doppler results. A review of nursing documentation completed from September 6, 2024, through September 19, 2024, revealed that Resident 89 continued to be treated with antibiotic therapy for cellulitis of the left lower extremity, and had persistent mild edema. A review of documentation completed by Physical Therapy on September 19, 2024, indicated that Resident 89 had complained of pain in the left heel, nursing identified a DTI (deep tissue injury, is an injury underlying tissue below the skin's surface that results from prolonged pressure in an area of the body. Similar to a pressure sore, a deep tissue injury restricts blood flow in the tissue causing the tissue to die.) on left heel. Resident instructed in positioning in bed and pressure relieving techniques. Documentation dated September 19, 2024, at 11:56 p.m. indicated that Resident 89 had acquired a DTI (deep tissue injury) of the left heel which measured 2cm x 2cm x 0cm. According to the documentation, immediate keep safe intervention was implemented which included a treatment to the area, to offload the weight with pillows under her calf by wearing heel boots. A review of a facility Skin/Skin Integrity event report dated September 19, 2024, revealed that Resident 89 had acquired an unstageable DTI (deep tissue injury) to the left heel which measured 2cm x 2cm, was dark purple in color, and skin was intact. Interventions implemented at time of discovery were heel protectors to be worn at all times except while in therapy, pressure reduction device to bed and/or chair, and therapy consult. Review of a witness statement dated September 19, 2024, completed by the ADON (assistant director of nursing)/Wound care nurse revealed the ADON was informed of the area on Resident 89's heel by the Occupational Therapist and the therapist advised off-loading the heel with pillows under the calf and to use heel bows (heel protectors). Review of witness statement dated September 19, 2024, completed by Employee 5, a Nurse Aide (NA), indicated that Employee 5 was not aware the resident had a pressure sore on her heel due to the presence of a dressing on her heel. A review of the facility's Wound Management Report dated September 19, 2024, indicated that Resident 89 had a pressure injury to the left heel which measured 2cm x 2cm, and treatment orders for Santyl to the wound were initiated as ordered by the podiatrist. A review a wound care consultant documentation dated September 23, 2024, at 1:19 p.m. indicated that Resident 89's left heel DTI had evolved to an unstageable pressure ulcer (pressure ulcers covered with slough or eschar are by definition unstageable) which measured 3cm x 3cm x 0.1cm, 30% slough (moist dead tissue), and 70% eschar (dark, dry, firm dead tissue). Recommendations included to cleanse the ulcer with normal saline, apply betadine on area of eschar, apply Santyl (ointment used to remove damaged tissue from skin) to areas of slough to base of the wound, secure with bordered gauze, change daily and as needed, and float heels while in bed with use of Prevalon boots (device used to help prevent heel pressure ulcers by keeping the heel off of a surface like a bed). Review of clinical record revealed that on September 24, 2024, Resident 89 was transferred to the hospital for evaluation of worsening swelling of the left lower extremity, inability for resident to bend her knee, and increased tenderness of the leg. Resident 89 was admitted to the hospital with diagnosis of a bacterial skin infection. When reviewed at the time of the survey ending October 18, 2024, there was no documented evidence prior to the development of the unstageable left heel pressure ulcer, that nursing staff had implemented interventions to prevent the development of the ulcer despite the resident's numerous risk factors. The facility failed to demonstrate the timely and consistent implementation of specific measures designed to prevent pressure sores on the resident's heels. Interview with the Director of Nursing on October 18, 2024, at approximately 2:10 PM, confirmed that preventative interventions were not timely and consistently implemented to prevent the development of the left heel pressure ulcer for a resident at risk for skin breakdown. A review of the clinical record revealed Resident 18 was admitted to the facility on [DATE], with diagnoses to include symbolic dysfunction (a type of social communication and language disorder), chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), arthritis, and protein-calorie malnutrition (a condition caused by not getting enough calories or the right amount of protein and nutrients needed for health). A review of the quarterly Minimum Data Set Assessment (MDS - a federally mandated standardized assessment completed at specific times to identify resident care needs) dated May 3, 2024, revealed that Resident 18 was at risk for a pressure ulcer development, had pressure reducing devices for her bed and chair, and was not on a turning/repositioning program. Further review revealed the resident was on hospice services (end of life care) and was dependent on staff for all activities of daily living (turning/repositioning, bed mobility, transfers, eating, bathing, toileting). A review of the resident's care plan, initiated May 4, 2024, revealed the facility identified the resident was at risk for skin breakdown related to decreased mobility and weakness. Interventions included to apply barrier cream to bilateral buttocks, keep skin clean and dry, monitor for skin breakdown, elevate heels off mattress, provide skin prep to bilateral heels, provide a pressure reducing mattress, and provide a pressure reducing cushion on the wheelchair. Review of a nurses note dated June 21, 2024, at 10:38 AM revealed the nurse was called to Resident 18's room during morning care by the certified nursing assistant who noticed an open area to her coccyx. The area measured 1.5 cm x 0.2 cm x 0.1 cm. The area was cleansed with normal saline solution and a hydrogel (wound dressing), and a dry dressing was applied. The resident was returned to bed after her meal and repositioned from side to side. The resident did not complain of pain. Call placed to physician, responsible party, and Hospice to make aware. Review of the Wound Consultation documentation dated June 26, 2024, at 11:48 AM indicated that Resident 18 had a Stage 3 pressure wound (a serious wound caused by pressure in which the wound has worn through all skin layers, exposing the fat) to the left inner buttock that measured 2 cm x 0.5 cm x 0.2 cm, exudate was moderate serosanguineous (wound drainage that contains both blood and a clear yellow liquid known as blood serum). Recommendations included: cleanse the wound with normal saline, apply Hydrogel to wound base and apply barrier cream to surrounding skin, the resident is to be out of bed for meals only, continue with pressure redistributing cushion to wheelchair, turning/repositioning precautions per protocol, ensure setting on low air-loss mattress (a mattress designed to distribute the resident's body weight over a broad surface area and help prevent skin breakdown) was maintained at appropriate levels, and continue ongoing interventions for incontinence management as resident is incontinent of urine and stool. A review of facility documentation Point of Care History (POC- general care nursing tasks completed for the resident) from May 1, 2024, through June 20, 2024, failed to identify that preventative measures were developed and implemented in order to prevent the development of a pressure ulcer. At the time of the survey ending October 18, 2024, the facility was unable to provide documented evidence that staff provided a turn and repositioning schedule and proper and timely incontinence care to prevent a pressure ulcer. Interview with the Director of Nursing on October 17, 2024, at 2:00 PM confirmed that there was no evidence the facility had implemented adequate interventions to prevent the development of Resident 18's pressure ulcer. A review of Resident 8's clinical record revealed the resident was admitted to the facility on [DATE], with diagnoses that included dementia (is a term used to describe a group of symptoms affecting memory, thinking and social abilities) with behavior disturbances, diabetes, congestive heart failure (CHF is a long-term condition that happens when the heart can't pump blood well enough to give the body a normal supply resulting in blood and fluids to collect in the lungs and legs over time and require medication), and anxiety (characterized by excessive, persistent and uncontrollable worry and fear about everyday situations). A clinical record review of Resident 8's admission/readmission observation assessment that was completed by Employee 1, a licensed practical nurse (LPN), dated May 27, 2024, at 1:27 PM, revealed the resident had no skin alterations, no abrasions, no bruises, no burns, no dermatitis, no skin grafts, no surgical incisions, or pressure injuries. Employee 1 commented that Resident 8 had a fluid filled blister (a small bubble on the skin filled with fluid caused by rubbing surfaces together) to the right heel. Additionally, the resident's Braden Scale Score (is a standardized, evidence-based assessment tool commonly used in health care to assess and document a client's risk for developing pressure injuries) was a thirteen 13 which indicated moderate risk of developing pressure injuries due to the risk factors related to very moist skin, bedfast (confined to bed), very limited mobility, friction and shearing (frequently slides down in bed or chair, requiring frequent repositioning with maximum assist). Interventions for skin ulcer/injury treatments such as a turning and repositioning program, pressure reducing device for chair, ointments/medications other than to feet, and applications of dressings to feet (with or without topical medication) was coded by Employee 1 as none of the above were provided. A review of the resident's pressure ulcer healing report completed by Employee 2, a Registered Nurse (RN), dated May 28, 2024, at 7:24 AM, indicated that Resident 8 had a serous (clear to yellow fluid) filled blister to the right heel (no measurements or description noted). Further review of Resident 8's clinical record revealed a functional abilities assessment completed by Employee 3, a RN, and dated May 28, 2024, at 7:38 PM, revealed the resident required substantial/maximal assistance (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) for bed mobility and was dependent (helper does all of the effort. Resident does none of the effort to complete the activity or requires the assistance of 2 or more helpers is required for the resident to complete the activity) for all activities of daily living such as toileting, hygiene/care needs, transfers, sit to standing, and all other ADLs (activities of daily living). On May 28, 2024, at 12:25 PM, the Assistant Director of Nursing (ADON) noted an observation of the blister measurements as 7.0 centimeters (cm) in length and 5.5 cm in width and commented the resident's podiatrist would follow up with the blister and does not want the facility wound care team to treat the resident. However, on May 29, 2024, at 9:02 AM, the Director of Nursing (DON) modified the documentation of the wound on the resident's wound history report and noted the right heel was a stage 2 pressure ulcer (is a shallow open wound, abrasions, or blisters due to partial thickness loss of the dermis) instead of a blister. Resident 8's clinical recorded revealed that the consulted podiatrist was at the facility on May 30, 2024, at 11:21 AM, and evaluated the right heel blister. A review of the podiatrist's consult dated May 30, 2024, and faxed to the facility on May 31, 2024, at 11:04 AM, revealed that Resident 8 had a diagnosis of peripheral vascular disease (PVD - is the buildup of plaque inside the artery wall. Plaque reduces the amount of blood flow to the limbs) and noted to continue skin prep and dry dressing to the right heel and air pillow heel protectors (cushion to elevate heels to prevent pressure) for bedtime. A review of a wound observation completed by Employee 4, an RN, on May 31, 2024, at 10:09 PM, revealed that Resident 8's intact blister to the right heel ruptured with a small amount serous drainage, no odor noted, and a red beefy moist base with blister shell cleared to one side of wound but still intact. No signs or symptoms of infection. Attending MD, responsible party (RP) and podiatry aware of changes. A review of a wound observation completed by the ADON on June 3, 2024, at 11:19 AM, revealed that Resident 8's right heel measurements were 7.0 cm in length by 8.0 cm in width and 0.2 cm in depth with a heavy amount of serous (clear) exudate and moderate odor from the discharge and noted that the area was at a stage 3 pressure ulcer (have gone through the second layer of skin into the fat tissue with symptoms that include a crater appearance, may have a foul odor, and may show signs of infection such as red edges, pus, odor, heat, and/or drainage with the tissue in or around the sore appearing black indicating dead tissue) with slough present and commented that a sterile border foam dressing was applied after cleaning with betadine. The facility could not provide documented evidence the attending physician, consulted podiatrist, or RP were notified of Resident 8's right heel deterioration from a stage 2 to stage 3 pressure ulcer. Additionally, there was no documented evidence that the area was evaluated to determine if alternate treatments or interventions were indicated to promote healing and prevent infection. Further review of a wound observation completed by the ADON on June 7, 2024, at 3:33 PM, revealed the resident's right heel wound exhibited further deterioration as evidence by changes in the appearance of the exudate from serous (clear) to serosanguineous (pale red to pink, thin and watery) with faint odor and covered with twenty percent necrotic (dead) tissue and irregular wound edges/margins. The area was measured at 7.0 cm in length by 8.0 cm in width with 0.2 cm depth. A review of Resident 8's clinical record revealed that on June 7, 2024, at 3:28 PM, the ADON completed a progress note that a message was left at the podiatrist's office to follow up with the wound as the area has black eschar in the wound bed. A review of the resident Medication Administration Summary report dated May 27, 2024, through June 10, 2024, revealed no documented evidence the facility timely developed and implemented pressure ulcer prevention measures that deterred Resident 8's right heel blister from deteriorating. Further review of the resident's record revealed that Employee 2 completed a progress note dated June 10, 2023, at 2:52 PM (four days later), revealed that the podiatrist was in to examine resident's right heel with new orders noted to change order to thin Duoderm (a flexible waterproof dressing used to cover burns and reduce infection) to the area and change every other day. Resident 8's clinical record failed to reveal documented evidence the resident's right heel blister was timely and thoroughly assessed by a registered nurse to develop and implement effective preventative measures to deter the area from evolving (worsening) from a blister to a stage 3 pressure ulcer. Additionally, Resident 8's clinical record failed to reveal the facility timely notified the resident's attending physician, consulted physician (podiatrist), of deterioration to the resident's right heel and failed to document applied treatments/interventions. An interview with the DON on October 18, 2024, at 2:00 PM, confirmed that upon admission to the facility Resident 8 failed to be timely and thoroughly assessed by an RN to ensure that effective preventative pressure relieving measures were timely implemented to deter the right heel blister from deteriorating to a Stage 3 pressure ulcer. Additionally, the DON confirmed the facility failed to timely notify the resident's attending physician or consultant physician (podiatrist), of Resident 8's deterioration to the resident's right heel and ensure that proper treatments/interventions were applied and documented timely and accurately in the resident's clinical record. 28 Pa. Code 211.5(f) Medical records 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of clinical records and select reports and staff interviews it was determined that the facility failed to consistently monitor a resident's skin integrity during use of a therapeutic device to prevent the development of multiple unstageable pressure sores and a Stage II pressure sore, for one resident (Resident 1) and failed to provide timely and necessary care to prevent the development of bilateral heel pressure sores, deep tissue injuries, for one resident (Resident 2) at risk for pressure sores out of three residents sampled. Findings include: According to the US Department of Health and Human Services, Agency for Healthcare Research & Quality, the pressure ulcer best practice bundle incorporates three critical components in preventing pressure ulcers: Comprehensive skin assessment, Standardized pressure ulcer risk assessment and care planning and implementation to address the areas of risk. The American College of Physicians (ACP) is a national organization of internists, who specialize in the diagnosis, treatment, and care of adults. The largest medical-specialty organization and second-largest physician group in the United States) Clinical Practice Guidelines indicate that the treatment of pressure ulcers should involve multiple tactics aimed at alleviating the conditions contributing to ulcer development (i.e. support surfaces, repositioning and nutritional support); protecting the wound from contamination and creating and maintaining a clean wound environment; promoting tissue healing via local wound applications, debridement and wound cleansing; using adjunctive therapies; and considering possible surgical repair. A review of the clinical record revealed that Resident 1 was most recently admitted to the facility on [DATE], with diagnoses that included dementia, diabetes and after care for a fractured left tibia. admission physician orders dated October 26, 2023, included an immobilizer brace to the resident's left lower extremity at all times, which staff may remove for hygeine and skin checks every shift. An MDS Assessment (Minimum Data Set assessment - a federally mandated standardized assessment process conducted at specific intervals to plan resident care) dated October 30, 2023, revealed that the resident was severely cognitively impaired, dependent on staff assistance for bed mobility, transfers, dressing, personal hygiene, and toilet use and was at risk for pressure sore development. Resident 1's care plan initiated October 27, 2023, revealed that the resident was at risk for skin breakdown related to decreased mobility, weakness, diagnosis of diabetes and an immobilizer in place to the resident's left lower extremity. The planned interventions were for nursing staff to assess the resident for increased edema when giving care, provide diet as ordered, incontinence products per routine and as needed, a pressure reducing surface to the resident's bed and chair, provide/assist/encourage resident to turn in bed frequently and prn (as needed), and to float heels intermittently as the resident allows. A nursing note dated October 27, 2023 at 9:31 PM revealed that the resident sustained an abrasion to the right inner ankle caused by bumping the immobilizer on left lower extremity. The RN assessed the abrasion on the resident's right inner ankle and treatment as provided. The immobilizer was padded to prevent further incident. The physician was updated and a referral made to Physical Therapy for evaluation of the immobilizer brace. When reviewed at the time of the survey ending January 17, 2024, there was no documented evidence that physical therapy had evaluated the resident's use of the immobilizer brace as noted following the abrasion to the resident's right ankle on October 27, 2023. Nursing noted on November 14, 2023, at 10:40 P.M. that three new pressure injuries were found on the resident's left lower leg under the immobilizer. Nursing noted that the resident was anxious with frequent moaning and calling out. Evidence of pain was noted to the resident's right foot, left lower legion, with verbal signs of pain noted. The resident's daughter was present when the new pressure injuries to left lower leg were found under the immobilizer. Wound care was provided and the physician was notified and a treatment was ordered. There was no nursing assessment of the three new pressure sores documented at the time of identification to include size and appearance. A review a skin and wound note dated November 15, 2023, at 11:50 AM revealed three pressure areas were found under Resident 1's left leg immobilizer/brace: -area #1, an unstageable pressure area on the left medial leg measuring 3 cm x 1.5 cm x 0.1 cm, covered in 100% slough ( dead skin, yellow/white in color) with scant amount of serous (Serous drainage is a clear to yellow fluid that leaks out of a wound with tissue damage) and a faint odor; -area #2, an unstageable pressure area on the left posterior lower leg, measuring 3.5 cm x 2 cm , covered in 100% eschar (Eschar, dead tissue that sheds or falls off from the skin. It ' s commonly seen with pressure ulcer wounds. Eschar is typically tan, brown, or black, and may be crusty); and -area #3, a stage 2 pressure area on the left posterior ankle measuring 2.5 cm x 2.5 cm x 0.1 cm with scant serous drainage. A review of a treatment administration record for October 2023 and November 2023 revealed nursing staff documented, once a shift, that the resident wore the Immobilizer Brace to Left Lower Extremity for the closed fracture of the left tibia at all times and that it may be removed for hygiene and skin checks, every shift, since October 26, 2023. However, there was no documented evidence at the time of the survey ending January 17, 2024, that prior to the development of the multiple pressure areas that nursing staff had consistently removed the left lower leg brace to inspect the resident's skin to timely identify skin impairments and prevent the development of the unstageable and stage 2 pressure sores under the brace. A review of facility provided information indicated that the root cause for the development of the pressure area was an ill fitting immobilizer had been provided to the resident prior to admission to the facility for her fractured left leg. There was no evidence at the time of the survey that the facility's therapy staff had assessed the resident's use of the immobilizer after the initial right ankle abrasion on October 27, 2023. During an interview on January 17, 2024 at approximately 2 PM the Nursing Home Administrator confirmed that the facility did not have evidence that nursing staff had removed Resident 1's immobilizer to conduct skin checks prior to the discovery of the three pressure areas on November 15, 2023. The NHA also confirmed that therapy had not conducted the evaluation of the resident's use of the brace as noted on October 27, 2023. Clinical record review revealed that Resident 2 was admitted to the facility on [DATE], with diagnoses of dementia and hypertension. A physician order was noted upon admission, dated January 2, 2024, to elevate the resident's heels off the bed, as tolerated, every shift for preventative measures to prevent skin breakdown. The resident's care plan noted that the resident was at risk for skin breakdown related to decreased mobility and weakness dated January 3, 2024, with interventions to keep the resident's skin clean and dry, monitor for skin breakdown and pressure reducing surface to bed and chair. The care plan did not specifically identify the physician order to elevate the resident's heels off the bed as tolerated, dated January 2, 2024. An MDS assessment dated [DATE], revealed that Resident 2 was cognitively impaired, required staff assistance for activities of daily living including transfers and bed mobility and was at risk for the development of pressure areas. A review of the resident's January 2024 TAR (treatment administration record) revealed that nursing staff documented completion of the task of elevating the resident's feet daily during each shift of nursing duty. A change in condition note dated January 10, 2024 at 02:59 AM revealed that The Change In Condition/s reported on this CIC Evaluation are/were: Change in skin color or condition, Noted drainage of right heel, blister of bottom of heel opened,with clear drainage noted. Area cleansed and a dressing applied. There was no documented evidence at the time of the survey ending January 17, 2024, of any additional nursing assessment, including the size of the pressure area documented in the resident's clinical record at the time of change in condition on January 10, 2024. A wound and skin note dated January 12, 2024, at 04:15 AM revealed that the resident had developed an additional pressure sore on the left heel. Pressure, a blister located on the left planter area of the foot (incorrect area noted in this entry, the pressure sore was actually located on the resident's left heel) measuring 0.3 cm x 0.4 cm, in house acquired. Wound bed appearance is pink, area is noted as a blood blister. The physician was contacted and a treatment as well as apply heel bows while in bed ordered. Skin impairment was not present on admission. During an interview January 17, 2024 at 11 AM the Director of Nursing confirmed that the wound and skin note was incorrect, as it noted that the Wound Location was the left plantar area of left foot and verified at the time of the interview that the pressure sore was a left heel blood blister. A review of a wound note dated January 12, 2024, at 07:51 AM revealed that on assessment, DTIs (deep tissue injuries) were noted to the resident's bilateral heels. Location: -LEFT HEEL Pressure, DTI, 2.5 cm x 2 cm x 0 cm. Calculated area is 5 sq cm. Wound Base: Localized area of maroon intact skin Wound Edges: Attached Periwound: Intact - RIGHT LATERAL HEEL Pressure Stage/Severity: DTI Wound Status: New Size: 3 cm x 4 cm x 0.1 cm. Wound Base: 1-24% epithelial , Localized area maroon skin - small opening with epithelial tissue exposed Wound Edges: Attached Periwound: Intact Exudate: Scant amount of Serous A review of a facility investigation report dated January 12, 2024, at 9:40 A.M. revealed that on January 10, 2024, a change in condition was completed for the identified blood blister to the resident's right heel that had opened and was draining serous fluid. The immediate action taken by the facility was that the nurse completed the change in condition form on January 10, 2024, notified the physician of the identified area and received an order for a treatment. An interdisciplinary meeting note dated January 12, 2024, revealed that the entry was status post identification of the area to resident's right heel on January 10, 2024, and the left heel on January 12, 2024. On January 10, 2024 a change in condition was completed for a blood blister to the right heel that opened and was draining serous fluid. On January 12, 2024, a report was completed for a blister on the left heel. Nursing noted an intact blister to the left plantar area measuring 0.3 cm x 0.4 cm. The wound care nurse practioner was in the facility and assessed both heels and documented that both were deep tissue injuries. The facility failed to demonstrate the timely and consistent implementation of specific measures designed to prevent pressure sores on the resident's heels. Interview with the Director of Nursing on January 17, 2024, at approximately 2:10 PM, confirmed that preventative interventions were not timely and consistently implemented to prevent the development of the bilateral heel pressure areas for a resident at risk for skin breakdown. 28 Pa. Code 211.12 (d)(3)(5) Nursing services. 28 Pa. Code 211.5 (f) Medical records