**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, resident record review and review of the facility's policy, the facility failed to develop a pressure ulcer care plan in accordance with professional standard of quality for one (1) of 19 sampled residents. Resident #190 was assessed to be at risk for developing a pressure ulcer. On 7/16/21 the resident developed an unstageable right outer heel pressure ulcer. The facility failed to develop a care plan with interventions to prevent the development of a pressure ulcer. This standard is cited at harm level. The findings include: 1. Review of the facility's policy titled Comprehensive Care Plan date reviewed/revised 10/19/20 and implemented date 1/1/21 revealed, in part, the following documentation: the care plan is individualized, and resident centered. The compliance guidelines 1. The care plan development process will include a complete assessment of the resident's care needs. 2. The care plan will be developed in seven (7) days after the completion of comprehensive Minimum Data Set (MDS) assessment. All Care Assessment Areas (CAA) triggers are considered in developing the plan of care. 4. The comprehensive care plan will be reviewed and revised by the Interdisciplinary Team (IDT) after each comprehensive and quarterly MDS assessment. Resident #190 was admitted to the facility on [DATE] with diagnoses to include a chronic obstructive pulmonary disease (COPD), muscle weakness, bilateral asymptomatic varicose veins, and atherosclerotic heart disease (ASDH). The resident was admitted having a left lower leg venous ulcer. Review of Resident #190's Annual MDS dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) was assessed as six (6) indicating severely impaired cognition. The resident was assessed as having no demonstrated behaviors and requiring limited assistance of one (1) person with bed mobility and walking. Resident #190 required extensive assistance of one (1) with transfer, movement on the unit, dressing, and personal hygiene. The resident had no upper or lower extremity impairment with range of motion. The admission assessment revealed that the resident was at risk for pressure ulcers, the intervention treatments were implemented; pressure reducing device for chair and bed. Review of Resident #190's Pressure Care Area Assessment (CAA) dated 4/29/21 revealed the triggers indicating the resident was at risk for developing pressure ulcers. The resident required assistance with activities of daily living, limited assistance with bed mobility, frequent urinary incontinence. The CAA indicated the resident would be care plan for pressure ulcers. Review of Resident #190's most recent Quarterly MDS assessment was in progress dated for 7/26/21. Review of Resident #190's initial care dated 4/23/21 revealed the resident was at risk for developing a pressure ulcer. However, on 4/23/21 the pressure care plan was cancelled. Instead a left leg venous area care plan was initiated dated 4/23/21. The interventions were 1. Monitor for sign and symptoms of infection, failure to heal and maceration. 2. Measure and document measurement of each skin breakdown, type of exudate and notable changes. Review of the admission Braden Scale for Predicting Pressure Score Risk dated 4/23/, 4/30, 5/7, 7/13, 7/16/21 revealed Resident 190's Braden scale score was (15-17) on 4/23/21 indicating at risk for pressure ulcer. Review of Resident #190's facility's Skin Assessment dated 6/19, 6/26, 7/3, 7/10/21 revealed the resident's admitted with a left lower leg (rear) open area, which was vascular in nature and was treated according to the physician orders. Review on 7/16/21 of Resident #190's Pertinent Charting revealed a right outer heel pressure had developed and measured 1.7x1.2x2 centimeter (cm). The charting noted, tissue around the resident's heel pressure was intact. However, no documentation noted regarding drainage or the description of the pressure ulcer. The facility's implemented interventions were to apply heel boots to float heels. The charting indicated, physician and Responsible Party (RP) were notified. The physician ordered the right heel pressure, to be clean with wound cleanser, apply skin prep to wound edges, apply honey gauze, cover with ABD pad, and wrap with Kerlix. Review of Resident #190 Certified Nursing Assistant's (CNA) plan of care dated from 7/10/21 through 7/16/21 revealed the resident's skin was observed, with no identified open area until 7/16/21. On 7/16/21 the care plan identified; the resident's right outer heel had an open area. Further review of the CNA's care plan revealed no heel preventive intervention were noted. Review of the Event Recommendation Form dated 7/16/21 at 11:30 AM revealed a staff noted an area to Resident #190's right outer heel. The wound measurements (1.7x1.2.02) were obtained. The wound was described to be 100% necrotic. The surrounding wound tissue was without peeling, no odor noted. The resident denies pain. The facility obtained witness statements to include CNA #4 and LPN #4. During initial tour on 07/20/21 10:28 AM, Resident #190 was upright in recliner eyes closed, not easily aroused, oxygen at two (2) liters per nasal cannula. The resident was wearing appropriate clothing and bilateral heel boots. The mattress has a pressure reducing device to the bed and chair. On 7/21/21 at 9:45 AM revealed Resident #190 sitting upright in recliner, alert able to answer general questions appropriately. She/he was wearing appropriate clothing and bilateral heel boots. Further observation at 11:45 AM resident showed resident remained in the same position. Interview on 7/21/21 at 10:15 AM with CNA #3 revealed the resident is normally dressed, up in the recliner when s/he starts her/his day. Last cared for Resident #190 on 7/15/21; s/he revealed to her/his knowledge the resident had no skin concerns. S/he revealed CNAs are trained to report any skin concerns to the license nurse immediately. S/he confirmed the resident did not utilize heel boot prior to 7/16/21. Further stated the nurse will inform the CNA when new interventions are developed. Interview on 7/21/21 at 11:10 AM with CNA #4 revealed being knowledgeable of Resident #190's care needs. The CNA described the resident to have limited mobility and sat in recliner most of the day. The CNA recalled caring for Resident #190 on 7/16/21, when the resident requested a shower. The shower was completed, while drying off the resident complained of discomfort at the right outer heel. The CNA observed the right heel closer, to her/his surprise, the resident's right foot had a dark wound with seeping drainage. The CNA immediately notified the nurse. CNA #4 revealed the resident did not have heel protectors until after the wound was identified. Phone interview on 7/21/21 at 11:40 AM was conducted with License Practical Nurse (LPN) #4 revealed the facility trains the CNAs to report any skin concerns to a licensed nurse immediately. LPN #4 revealed the licensed staff assess and monitors residents' skin weekly for sign and symptoms of breakdown. The LPN further revealed when a skin breakdown is identified, the resident's care plan should be developed/updated with interventions. LPN #4 revealed the CNAs are responsible for monitoring skin during showers and anytime care is provided. The LPN revealed CNA#4 notified him/her of Resident #190's right outer heel pressure. S/he indicated the MDS Coordinator was responsible for developing the care plan. Phone interview was conducted with CNA #6 on 7/21/21 at 9:40-9:47 PM revealed the facility trained her/him to observe a resident skin during showers, and when ever care is being provided. The CNA was knowledgeable of Resident #190's care needs. S/he revealed the resident is usually up in the recliner, wearing a hard-sole shoe with the back heel open. Further stated the resident would sit up in the recliner with her/his right foot straight out. The CNA revealed the resident normally goes to bed around 6:30 PM. CNA#6 stated the resident had no specific skin care interventions to follow. Phone interview was conducted with RN #1 on 7/21/21at 9:48-9:55 PM revealed being responsible for Resident #190's weekly skin assessments. S/he revealed on 7/10/21 the resident's weekly skin assessment was intact. The nurse indicated the resident would sit in the recliner with heels dug into the floor. S/he revealed floating the heels even though it was not a care plan intervention. The RN revealed working night shift on 7/12 and 7/13 and was unaware of any skin concerns. Interview with the Wound Nurse on 7/22/21 at 11:20 AM revealed on 7/21/21 Resident #190's wound was assessed as right heel as un-stageable pressure (with sloughing and/or eschar). S/he indicated Resident #190's un-stageable heel pressure was a result from intense and/or prolonged pressure on the heel. The Wound Nurse revealed pressure interventions should have been developed. Phone interview was conducted on 7/22/21 at 2:42 PM with Resident #190's physician, he/she revealed the resident has vascular impairment. The physician revealed the resident was a heavy smoker and oxygen dependent. The physician indicated the right heel wound was a pressure ulcer. He/she indicated the pressure ulcer should heal with consistent treatment. An interview with the MDS Coordinator on 7/22/21 at 3:10 PM revealed the MDS Coordinators expectations are to develop, update, revise the care plan, participate in IDT meetings, capture and care plan resident care needs. The Coordinator revealed the initial pressure ulcer care plan was developed but cancelled when the vascular wound care plan was developed. S/he indicated along with the vascular care plan a pressure prevention care plan should have been implemented. In an interview with the Director of Nursing (DON) on 7/22/21 at 3:30 PM revealed being made aware of Resident #190's acquired pressure. S/he indicated immediate pressure prevention and skin assessment retraining were implemented. The DON indicated a pressure preventive care plan should have been developed. A phone interview was conducted with the family of Resident #190 on 7/22/21 at 6:25 PM revealing they visited the resident at least twice a week. He/she revealed the resident did not wear protected heel boots until after the pressure developed. The family voiced being very pleased with Resident #190's the care. Resident #190's family member was notified of the pressure and that it developed from the resident's shoe.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, resident record review and review of the facility's policy, the facility failed to ensure the resident received care to prevent development of a pressure ulcer for one (1) of 19 sampled residents. Resident #190 was discovered to have a skin breakdown on the right outer heel on 7/16/21. The facility failed to, monitor the resident's skin to prevent the development of an unstageable pressure ulcer. This standard is cited at harm level. The findings include: 1. Review of the facility's policy titled Pressure Injury Prevention and Management date reviewed/revised 1/30/20 revealed, in part, the following documentation: 'To prevent avoidable pressure injuries and the promotion of healing of existing pressure injuries.' The policy defines: Avoidable means that the resident developed a pressure ulcer/injury that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors; define and implement interventions that are consistent with the resident's needs; goals, and professional standards of practice, monitor and evaluate the impact of the interventions; or revise the interventions as appropriate. 2. The policy compliance guidelines: 2. The facility will establish and utilize a systematic approach for pressure injury prevention and management. a. Licensed nurses will conduct a pressure injury risk assessment, using [NAME] or Braden tool on all residents upon admission/re-admission, weekly x4 weeks, then quarterly or whenever the resident's condition changes significantly. b. Licensed nurses will conduct a full body skin assessment on all residents upon admission/ re-admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. c. Assessments of pressure injuries will be performed by licensed nurse and documented in the medical record. d. Nursing assistants will inspect skin during bath and will report any concerns to the resident's nurse immediately after the task. 3. 4. Intervention for Prevention and to Promote Healing a. After completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for revention and management of pressure injuries with appropriate interventions. b. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g. moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). c. Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk for pressure injury. Basic or routine care interventions could include, but are not limited to: (i) Redistribution of pressure (such as repositioning, protecting and/or offloading heels, etc) (ii) Minimize exposure to moisture and keep skin clean, especially of fecal contamination. (f.) Interventions will be documented in the care plan and communicated to all relevant staff. The National Pressure Ulcer Advisory Panel (NPUAP) defines an unstageable ulcer as, full thickness and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Sloughing and/or eschar may be visible. If eschar or sloughing occur the extent of the tissue loss is an unstageable pressure injury. If the slough or eschar is removed a Stage III or Stage IV Pressure Ulcer will be revealed. Resident #190 was admitted to the facility on [DATE] with diagnoses to include a chronic obstructive pulmonary disease (COPD), muscle weakness, bilateral asymptomatic varicose veins, and atherosclerotic heart disease (ASDH). The resident admitted having a left lower leg venous ulcer. Review of Resident #190's Annual Minimum Data Set (MDS) dated [DATE], revealed the resident's Brief Interview for Mental Status (BIMS) was assessed as six (6) indicating severely impaired cognition. The resident was assessed as having no demonstrated behaviors and requiring limited assistance of one (1) person with bed mobility and walking. Resident #190 required extensive assistance of one (1) with transfer, movement on the unit, dressing, and personal hygiene. The resident had no upper or lower extremity impairment with range of motion. The admission assessment revealed that the resident was at risk for pressure, the intervention treatments were implemented; pressure reducing device for chair and bed. Review of Resident #190's Pressure Care Area Assessment (CAA) dated 4/29/21 revealed the triggers indicating the resident was at risk for developing pressure ulcers. The resident required assistance with activities of daily living, limited assistance with bed mobility, frequent urinary incontinence. The CAA indicated the resident would be care plan for pressure ulcers. Review of Resident #190's most recent Quarterly MDS assessment was in progress dated for 7/26/21. Review of the admission Braden Scale for Predicting Pressure Score Risk dated 4/23, 4/30, 5/7, 7/13, 7/16/21 revealed Resident #190's Braden scale score was (15-17) indicating at risk for pressure. Review of Resident #190's facility's Skin Assessment dated 6/19, 6/26, 7/3, 7/10/21 revealed the resident's admitted with a left lower leg (rear) open area, which was vascular in nature and was treated according to the physician orders. Review on 7/16/21of Resident #190's Pertinent Charting revealed a right outer heel pressure ulcer had developed and measured 1.7x1.2x2 centimeter (cm). The charting noted, tissue around the resident's heel pressure ulcer was intact. However, no documentation noted regarding drainage or the description of the pressure ulcer. The facility's implemented interventions were applied heel boots to float heels. The charting indicated, physician and Responsible Party (RP) were notified. The physician ordered the right heel pressure ulcer, to be clean with wound cleanser, apply skin prep to wound edges, apply honey gauze, cover with ABD pad, and wrap with Kerlix. Review of Resident #190 Certified Nursing Assistant's (CNA) plan of care dated from 7/10/21 through 7/16/21 revealed the resident's skin was observed, with no identified open area until 7/16/21. On 7/16/21, the care plan identified; the resident's right outer heel had an open area. Review of the Event Recommendation Form dated 7/16/21 at 11:30 AM revealed a staff noted an area to Resident #190's right outer heel. The wound measurements (1.7x1.2.02) were obtained. The wound was described to be 100% necrotic. The surrounding wound tissue was without peeling, no odor noted. The resident denies pain. The facility obtained witness statements to include CNA #4 and LPN #4. Review of the physician orders revealed, in part, the following: 7/16/21 clean wound with wound cleanser, pat dry. Apply Honey gauze, skin barrier wipe to peri wound. Cover with ABD and wrap with Kerlix. 7/18/21 clean wound with wound cleanser, pat dry. Apply Honey Alginate, skin barrier wipe to peri wound. Cover with ABD and wrap with Kerlix. 7/18/21-7/25/21 Cephalexin Capsule (cap) 500mg one (1) cap by mouth four (4) times a day for infection/wound to back of left lower leg related to asymptomatic varicose veins of bilateral lower extremities x seven (7) days. Review of Physician Progress Note dated 7/18/21 revealed on 7/16/21 by license nursing staff messaged him that Resident #190 had developed a pressure sore on her/his heel and needed to be evaluated but did not appear to need debridement. During initial tour on 07/20/21 10:28 AM, Resident #190 was upright in recliner eyes closed, not easily aroused, oxygen at two (2) liters per nasal cannula. The resident was wearing appropriate clothing and bilateral heel boots. The mattress had a pressure reducing device to the bed and chair. On 7/21/21 at 9:45 AM revealed Resident #190 sitting upright in recliner, alert able to answer general questions appropriately. S/he was wearing appropriate clothing and bilateral heel boots. Further observation at 11:45 AM resident showed resident remained in the same position. On 7/21/21 at 1:15 PM observation was made of the Infection Preventionist (IP) and Director of Nursing (DON) assessing Resident #190's right outer heel pressure. DON removed the Kerlix wrap, small amount of serous drainage noted. The IP described right outer heel as being round and size of nickel, no odor, wound edges with eschar and wound bed has sloughing. Interview on 7/21/21 at 10:15 AM with Certified Nursing Assistant (CNA) #3 revealed the resident is normally dressed, up in the recliner when s/he starts her/his day. CNA #3 last cared for Resident #190 on 7/15/21 and revealed to her/his knowledge the resident had no skin concerns. S/he revealed CNAs are trained to report any skin concerns to the licensed nurse immediately. S/he confirmed the resident did not utilize heel boot prior to 7/16/21. Interview on 7/21/21 at 11:10 AM with CNA #4 described the resident to have limited mobility and sat in recliner most of the day. The CNA recalled caring for Resident #190 on 7/16/21, when the resident requested a shower. The shower was completed, while drying off, the resident s/he complained of discomfort at the right outer heel. The CNA observed the right heel closer, to her/his surprise, the resident's right foot had a dark wound with seeping drainage. The CNA immediately notified the nurse. CNA #4 revealed the resident did not have heel protector until after the wound was identify. Phone interview on 7/21/21 at 11:40 AM was conducted with License Practical Nurse (LPN) #4 revealed the facility trains the CNAs to report any skin concerns to the licensed nurse immediately. LPN #4 revealed the licensed staff assess and monitors residents' skin weekly for sign and symptoms of breakdown. The LPN further revealed when a skin breakdown is identified, the resident's care plan should be developed/updated with interventions. LPN #4 revealed the CNAs are responsible for monitoring skin during showers and anytime care is provided. The LPN indicated observing the unit, making frequent rounds, and communicating with CNAs is how s/he ensures resident's care needs are met. The LPN revealed CNA#4 notified her/him of Resident #190's right outer heel pressure. LPN #4 immediately assessed the resident, notified the physician, DON and responsible party. S/he described the right outer heel tissue as being dark in color, but the surrounding tissue was intact. The LPN revealed investigating as to why the foot ulcer occurred, and s/he concluded it was the resident's shoe. Phone interview was conducted with CNA #6 on 7/21/21 at 9:40-9:47 PM revealed the facility trained her/him to observe a resident skin during showers, and whenever care is being provided. The CNA was knowledgeable of Resident #190's care needs. S/he revealed the resident is usually up in the recliner, wearing a hard-sole shoe with the back heel open. Further stated the resident would sit up in the recliner with her/his right foot straight out. The CNA revealed the resident normally goes to bed around 6:30 PM. CNA#6 stated she/he had not cared for the resident for several days prior to the discovery of the foot ulcer. Phone interview was conducted with RN #1 on 7/21/21 at 9:48-9:55 PM revealed being responsible for Resident #190's weekly skin assessments. S/he revealed on 7/10/21 the resident's weekly skin assessment was intact. The nurse indicated the resident sits in recliner with heels dug into the floor. S/he revealed floating the heels even though it was not a care plan intervention. The RN revealed working night shift on 7/12 and 7/13 and was unaware of any skin concerns. Interview on 7/22/21 with Wound Nurse on 7/22/21 at 11:20 AM revealed on 7/21/21 Resident #190's wound was assessed as right heel as un-stageable pressure (with sloughing and/or eschar). S/he indicated Resident #190's un-stageable heel pressure was a result from intense and/or prolonged pressure on the heel. The Wound Nurse revealed pressure interventions should have been developed. Phone interview was conducted on 7/22/21 at 2:42 PM with Resident #190's physician, revealed the resident has vascular impairment. The physician revealed the resident was a heavy smoker and oxygen dependent. The physician indicated the right heel wound was a pressure ulcer. He/she indicated the pressure ulcer should heal with consistent treatment. In an interview with the MDS Coordinator on 7/22/21 at 3:10 PM revealed the MDS Coordinators expectations are to develop, update, revise the care plan, participate in IDT meetings, capture and care plan resident care needs. The Coordinator revealed the initial pressure care plan was developed but cancelled when the vascular wound care plan was developed. She/he indicated along with the vascular care plan a pressure prevention care plan should have been implemented. Interview with the DON on 7/22/21 at 3:30 PM revealed being made aware of Resident #190's acquired pressure. S/he indicated immediate pressure prevention and skin assessment retraining were implemented. The DON indicated a pressure preventive care plan should have been developed. Phone interview was conducted with the family of Resident #190 on 7/22/21 at 6:25 PM revealed visiting the resident at least twice a week. He/she revealed the resident did not wear protected heel boots until after the pressure developed. Resident #190's family member was notified of the pressure ulcer and that it developed from the resident's shoe.