**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, policy review, medical record review, observation, and interview, the facility failed to ensure a resident received preventative care, received treatment and services to promote healing and prevent further pressure ulcers and tissue injuries for 1 of 4 sampled residents (Resident #16) reviewed with in-house acquired pressure ulcers. The facility's failure to provide preventative treatment, identification, assessment, reporting, and appropriate treatment resulted in actual Harm for Resident #16. The findings include: Review of the National Pressure Injury Advisory Panel (NPIAP) Prevention and Treatment of Pressure Ulcers: Quick Reference Guide, dated 2019, revealed .Conduct a comprehensive skin and tissue assessment for all individuals at risk of pressure injuries: As soon as possible after admission/transfer to the healthcare service .As a part of every risk assessment .Periodically as indicated by the individual's degree of pressure injury risk Unstageable: Depth unknown Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and therefore Category/Stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as 'the body's natural (biological) cover' and should not be removed .Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid exposing additional layers of tissue even without optimal treatment . Review of the facility's undated policy titled, .Skin Assessment, dated 2/24/2021, revealed .It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management .A full body .skin assessment will be conducted .The assessment may also be performed after a change of condition or after any newly identified pressure injury .Thoroughly inspect each surface of a skin fold . Review of the facility's undated policy titled, .Wound Treatment Management, revealed .To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders .Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change .the facility will follow specific physician orders for providing wound care .Treatments will be documented on the Treatment Administration Record .treatments will be monitored through ongoing assessment of the wound . Review of the medical record, revealed Resident #16 was admitted to the facility on [DATE] with a diagnoses of Dementia, Hypertension, Dysphagia, and Gastroesophageal Reflux Disease. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 had severely impaired cognition, was totally dependent on staff for Activities of Daily Living (ADLs), was always incontinent of bladder and bowel, was at risk for pressure ulcers, had 3 unstageable pressure ulcers, and 1 deep tissue injury pressure ulcer. Review of a quarterly Braden Scale dated 4/12/2022, revealed Resident #16 was at risk for developing pressure ulcers. Review of the undated Care Plan revealed .I have a pressure ulcer .Addition pressure ulcers form brace that was ordered .Right medial knee. 5/19/22-foul odor noted from R medial knee wound .Right lateral knee .Right posterior leg with 3 wounds .DTI-right heel . Review of a Physicians' Order dated 4/6/2022, revealed .Okay to remove brace from Right Knee for bathing. Apply brace on the outside clothing to the right upper leg . Review of the Physicians' Order dated 4/22/2022, revealed .DC [discontinue] brace Resident to stay in bed at all times . Review of the Physicians' Orders dated 5/13/2022, revealed .Wound Care Mon [Monday] & [and] Fri [Friday] R [right] post [posterior] thigh .R Heel .R medial Knee .R lateral Knee . Review of the Physicians' Orders dated 5/19/2022, revealed Augmentin 875 mg[milligrams]/125 PO [by mouth] BID [twice day] x [times] 10 d [day] .wound infec [infection] .Flagyl 50 mg PO TID [three times day] x 10 d . Review of the Interdisciplinary Notes dated 4/4/2022, .Returned to facility .from [Named Hospital] .Brace to Rt [right] leg in place . Review of the Interdisciplinary Notes dated 4/6/2022, .Possible DTI [deep tissue injury] noted to right heel . Review of the Interdisciplinary Notes dated 4/22/2022, .resident has 5 new wounds noted under leg brace. Addressed by wound care MD [medical doctor] .MD wish for brace to remain off at this time . Review of the Wound Flow Sheet. Dated 4/22/2022, revealed .DTI [deep tissue injury] .R [right] heel 3.4 x [times] 2.5 x 0.1 .DTI .R distal Lg [leg] 1.4 x1 x0 x 0 .R distal Lg 6 x 4 x 0 .R distal Lg 1.8 x 0.5 x 0 .R Knee Lateral 2.8x2 x 9 x 0 .R medial Knee 4.5x2.8x0.1 . Review of the Interdisciplinary Notes dated 4/29/2022, revealed .Resident seen by [Named Wound Care MD] .Wound to right lateral knee was a fluid filled blister measuring 3x2.5x2.1 .Wound cleansed .calcium alginate applied and covered .Wound to right knee medial measured 4x2x0.1 .Calcium alginate .applied and covered with bordered gauze .Wound to right posterior foot measured as cluster of 3 as 5x3x0.1 .Wound to right heel measured 4x3x0 .wound bed is becoming eschar .apply iodosorb paste [topical treatment of chronic exuding wounds] and cover with overly that provides protection . Review of the Interdisciplinary Notes dated 5/27/2022, revealed .Resident seen by [Named Wound Care Doctor] During his assessment he noted that wound to R [right] pos [posterior] leg had tendon exposed .right heel has stable eschar .right thigh excoriations .Lateral Right knee remains dry with eschar .Right medial knee was denrided [debrided] and packed .right medial knee is looking better. Odor is gone. Resident remains on oral abx [antibiotic] for infection to right medial knee wound . Review of the Medication Administration Record (MAR) for 4/2022, revealed treatments were not documented for the wounds identified on 4/22/2022 and treatment were not documented to remove brace from right knee for bathing. Review of the [Named Wound Care MD] History and Physical Note dated 4/8/2022, revealed .right leg immobilizers in place .Right ft [foot] is floating .small medial heel deep tissue injury [DTI] .Applied hydrocolloid bandage with application of wound boots . Review of the [Named Wound Care MD] Progress Note, dated 4/15/2022, revealed .right heel wound .Deep tissue injury over heel continues to evolve, with formation of surface eschar .measure approximately 1.5 x 1.5x 0 cm [centimeters] .hydrocolloid dressing for protection, with recommendation to change twice a week . Review of the [Named Wound Care MD] Progress Note, dated 4/22/2022, revealed .On exam today, her right heel DTI has transition to eschar, measuring 3.4 x 2.5 x 0.1 .has 5 new sites of pressure injury, 3 on the posterior leg measuring .1.4 x 1 x 0 cm; 6 x 4 x 0 cm; 1.8 x 0.5 x 0 cm. All have formation of eschar .has 2 proximal lesions that have blistered near her knee measuring .Right knee lateral, 2.8 x 2.9 x 0 cm .right knee medial 4.5 x 2.8 x 0.1 cm .with recommendations to maintain hydrocolloid protection .remove her knee immobilizer give contribution of this to her pathology .remain bedbound . Review of the Product Insert for DeRoayal Knee Immobilizer [Knee Immobilizer (deroyal.com)] revealed .The knee immobilizer should fit, generally. 2 [symbol for inches] above ankle bones and 2 below groin. Any longer could result in abnormal wear and skin pressure . The facility was unable to provide orders for treatment for the DTI to right heel. The facility failed to remove and assess the right leg with the knee immobilizer. The facility provided shower/skin observation sheet for 4/6/2022, 4/8/2022, 4/13/2022, 4/14/2022 and 4/25/2022. Review of the shower/skin observation sheets revealed no documentation of the knee immobilizer or the identified wounds or dressings. Observation in the resident's room on 9/21/2022 at 9:29 AM, with the Wound Care Physician revealed the right heel with thick dark eschar cap measuring 4.5 x 5.0 x 0.6 cm, the right outer ankle a newly identified unstageable DTI measuring 1.1 x 0.8 x 0 cm, and the back of the lower leg measuring 3.0 x 1.0 x 0.3 cm. Observation and interview in the resident's room on 9/22/2022 at 10:16 AM, revealed the Director of Therapy removed the knee immobilizer from Resident #16's closet and demonstrated the placement of the knee immobilizer. The Director of Therapy confirmed the knee immobilizer should be placed from the upper thigh to the mid-calf of the resident's leg for proper placement. During a telephone interview on 9/21/2022 at 2:31 PM, Licensed Practical Nurse (LPN) #1 confirmed she never removed the resident knee immobilizer she was not on her shift for the weekly skin assessment. LPN #1 confirmed the only time the immobilizer was taken off was with wound care. During an interview on 9/21/2022 at 4:36 PM, the Wound Care Nurse confirmed the nursing staff should have removed the knee immobilizer and assessed the resident's skin daily. Observation and interview on 9/22/2022 at 7:44 AM, the Administrator confirmed the staff members should monitor, treat, and assess a resident skin with a knee immobilizer. The Administrator confirmed the facility completed a PIP (Performance Improvement Program) on the pressure ulcers but was unable to provide documentation of the weekly audits, education with all staff members, and follow-ups. The Administrator confirmed the PIP was not effective and was not completed. Observation of the Quality Assurance and Performance Improvement (QAPI) minutes from April 2022, June 2022 and July 2022 there was no documentation of the PIP on wound management. The Administrator confirmed she is ultimately responsible for the staff to assure they are doing their jobs. Observation and interview on 9/22/2022 at 6:57 PM, the Director of Nursing (DON) confirmed there should be doctor orders to address each wound identified and should be reflected on the Medication Administration Records (MAR) for treatments. Observation of the April 2022 show sheets showed no documentation the knee immobilize. The DON confirmed she would expect the staff to remove the knee immobilizer to assess the skin for skin breakdown once a shift, that is the standard of practice for monitoring a resident with a knee immobilizer. During an interview on 9/22/2022 at 7:33 PM, the Quality Assurance Nurse confirmed there were no treatments on the MAR for the pressure ulcers identified on 4/22/202. The facility's failure to identify, assess, report, and provide treatment before newly identified skin changes and pressure ulcers deteriorated and progressed to Unstageable pressure ulcers resulted in actual Harm for Resident #16.