**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 1 of 2 residents reviewed for pressure injuries (R30). R30 was at risk for developing pressure injuries related to immobility and multiple fractures. The facility failed to implement aggressive pressure injury interventions; failed to complete weekly assessments per standard of practice; failed to provide risk and benefits despite knowledge of R30 refusing repositioning. Facility did not assess or measure R30's left gluteal pressure injury. R30 developed two stage three, and one unstageable facility acquired pressure injuries. Facility failure to ensure R30 received care consistent with professional standards of practice to prevent pressure injuries from developing or deteriorating, created a finding of immediate jeopardy that began on 2/18/25. Surveyor notified NHA A (Nursing Home Administrator) and DON B (Director of Nursing) of the immediate jeopardy on 3/7/25 at 10:15AM. The immediate jeopardy was removed on 3/7/25. However, the deficient practice continues at a scope/severity of D (potential for more than minimal harm/isolated) as the facility continues to implement its action plan Findings include: The facility's policy, titled Pressure Injury/Skin Breakdown-Clinical Guidelines states: Assessment and Recognition: *The nursing staff will, upon admission complete an evaluation of the residents skin and resulting risk factors for developing pressure injuries; for example, immobility, recent weight loss, and a history of pressure injuries. * The staff will examine the skin of a new admission and/or re-admission for ulcerations or indications of a stage 1 pressure area that has not yet ulcerated at the surface. *A standardized tool example (ex. Braden or [NAME]) will be utilized weekly for four weeks after admission and/or readmission and at least quarterly to determine risk for clinical breakdown. * The nursing staff will complete an evaluation of the skin weekly. Treatment/Management: *Based upon need and the results of the evaluations the staff will implement interventions for the prevention and care of skin issues. The IDT will review measures upon admission, quarterly and with significant change. Note: *Although poor nutritional status is associated with increased risk of pressure injury development, no specific nutritional interventions have been proven conclusively to prevent or heal pressure injuries. There are no pressure injury dash specific nutritional measures that should be provided routinely to those with or at risk for developing a pressure injury. Nutritional supplementation should be based on realistic appraisal of need and identification of medical conditions and factors that affect appetite, weight, and overall nutritional balance. *As needed, the physician will help identify medical and ethical issues influencing wound healing; for example, because of end stage heart disease or because cause-specific treatment is not advisable, not feasible, or not desired by the resident or family. Per the NPIAP (National Pressure Injury Advisory Panel) a pressure injury is defined as .localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. NPIAP definitions include: Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. An Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. R30 was admitted to the facility on [DATE] and has diagnoses that include wedge compression fracture of fourth lumbar vertebra (L4 is near the tailbone and wedge indicates the vertebra collapsed inward resulting in a wedge shape), Type 2 Diabetes, and muscle weakness. His most recent MDS (Minimum Data Set), dated 12/20/24, includes a BIMS (Brief Interview for Mental Status) score of 15, indicating R30 is cognitively intact. According to section GG of R30's admission MDS, dated [DATE], R30 needed substantial/maximal assistance with rolling left and right, sitting to lying, lying to sitting, sitting to standing, chair/bed-to-chair transfer, and tub/shower transfers. On 10/16/24, the facility conducted a Braden assessment (a tool used to assess a patient's risk of developing pressure ulcers) with a resulting score of 17, indicating R30 was at risk for developing pressure ulcers. R30's care plan states, Focus: .is at risk for skin breakdown and pressure ulcer development related to limited mobility, diabetes. Resident was admitted with multiple abrasions and open area to gluteal cleft. Refuses or removes pressure relief devices at times such as heel lifts .Goal: .will be free from new open skin concerns through the review date .Interventions: assist to turn/reposition as needed or requested (initiated 10/17/24), follow protocols for the prevention of skin breakdown (initiated 10/17/24), Roho wheelchair cushion (initiated 10/17/24), diabetic: float heels when in bed/recliner (initiated 10/17/24), inform family/caregivers of any new areas of skin breakdown (initiated 10/17/24), lotion skin PRN (initiated 10/17/24), monitor nutritional status. Serve diet as ordered and monitor and record intake (initiated 10/17/24), obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated (initiated 10/17/24). Additionally, R30's care plan states, Focus: .has an ADL self care deficit related to limited mobility, impaired balance, and weakness secondary to motor vehicle accident with fractures to multiple right ribs and L4 spine .Goal: will maintain or improve current ADL function .Interventions: Bed mobility: Requires 1 staff participation to reposition and turn in bed. On 10/15/24, as part of R30's admission assessment, it was noted that there was a 0.5cm in diameter open area to R30's intergluteal cleft (the groove or crease located between the two buttocks). No further assessment, measuring, or documentation was made of this area, nor did the facility provide any documentation that this was reported to R30's physician. On 10/24/24, the facility discovered an area on R30's coccyx/sacrum, described as MASD (Moisture Associated Skin Damage) IAD (incontinence associated dermatitis). The facility assessed the wound at this time, measuring 4.19 cm x 2.42 cm (Length x Width) with 90% slough (dead tissue within a wound) and 10% epithelial tissue (new layer of skin). treatment .soap & water Primary dressing, no dressing applied. The 10/24/24 skin assessment states, Sent message to NP on 10/24/24 requesting zinc oxide to buttocks BID (twice daily) and PRN. There is no order, documentation on facility administration records or progress notes indicating that this order was fulfilled and it was being deployed nor is there documentation that any specific order was being used to address R30's coccyx/sacrum wound until 11/6/24. Of note: Facility failed to complete a weekly assessment around 10/31/24 and the next assessment and measurement was not completed until 11/4/24. 11/4/24: coccyx/sacrum 3.95 x 5.12 (MASD, 100% granulation) Treatment: cleansing solution, soap & water.other, specify zinc oxide . no secondary dressing. Progress deteriorating .practitioner notified. 11/5/24: coccyx/sacrum6.58 x 5.11 (MASD, 100% granulation) additional care: cushion, foam mattress, nutrition/dietary supplementation. Physician order on 11/6/24 indicates Cleanse sacral ulcer with cleanser, pat dry, skin prep edges, allow to dry, cover with foam dressing every 8 hours as needed. Physician orders from 11/7/24 to 11/20/24 indicate Cleanse sacral ulcer with cleanser, pat dry, skin prep to edges, allow to dry, cover with foam dressing, one time per day every other day. 11/11/24: coccyx/sacrum 5.49 x 5.72 (MASD, progress deteriorating, education explained importance of turning way over on his side off his bottom.) On 11/11/24, the facility ordered a pressure-relieving mattress for R30, with correspondence via fax to the NP (Nurse Practitioner) stating, Area on bottom looking worse. Skin prep to edges and foam dressing is what we are doing. We are ordering an air mattress for him. Non-compliant with turning off/staying off bottom. Of note: there is no evidence that the facility completed risk vs benefits with R30 despite knowing that R30 was non-compliant with turning and/or staying off his bottom. The facility did not proactively implement an air mattress until R30's wound deteriorated to an unstageable Pressure injury despite R30 having multiple fractures and needing substantial assistance with cares. On 11/12/24, the facility documented this coccyx/sacrum wound as unstageable, noting the wound was 5.64 cm x 5.81 cm, Type pressure. Stage unstageable due to slough and/or eschar. Acquired present on admission. Wound bed with 70% slough. Treatment soap & water, primary dressing foam, no secondary dressing. Additional care: cushion; incontinence management; mattress with pump; moisture control; repositioning device(s); turning/repositioning program. Progress: deteriorating. 11/13/24: 3.9 x 4.69 (Coccyx, Unstageable, 70% slough) 11/19/24: 2.27 x 3.33 x 0.1 (Sacrum, Unstageable, 100% slough, in house acquired) It should be noted that the facility documented that R30's wound was on his coccyx until 11/19/24 at which time this same area was referred to as the sacrum. The coccyx wound is labeled as upon admission, however, once the wound is assessed as a sacrum wound, it is documented as in-house acquired. Physician orders from 11/20/24 to 1/9/25 indicate 1. Cleanse with cleanser, pat dry 2. Skin prep to edges and allow to dry 3. Cut to fit wound base Hydrofera Blue Transfer 4. Cover with foam dressing, one time per day every other day. 11/26/24: 2.94 x 6.18 x 0.1 (Sacrum Unstageable, 60% slough, 40% epithelial) Of note R30's wound has almost doubled in width. 12/9/24: 1.02 x 1.13 (Sacrum Unstageable, 70% slough, 30% epithelial) education: resident educated on continuing to offload pressure to the sacral area and to alert staff with urge to void or BM. Of note, there are 12 days between 11/26/24 and 12/9/24 measurement/assessment. 12/19/24: 1.79 x 1.05 (sacrum, Stage 2, 100% epithelial) (Of note, the standard of practice, does not allow for the down staging of pressure injuries. There is 10 days between this measurement and R30's last measurement on 12/9/24.) 12/30/24: sacrum 0.87 x 0.73 (Unstageable, 100% epithelial) Of note: there are 11 days between this measurement and R30's last measurement on 12/30/24. 1/6/25: sacrum 1.75 x 1.1 (Healed) Of note: the facility measured this area as 1.75x1.1, but the facility is calling it healed. The facility was unable to provide any documentation that R30's coccyx/sacrum wound was assessed between 11/26/24 and 12/9/24 and between 12/19/24 and 12/30/24. Additionally, on 11/22/24 R30 developed what the facility called MASD, IAD (Incontinence Associated Dermatitis) on his right gluteal fold (Right ischial tuberosity). The initial assessment of the wound was 4.24 x 3.86 with light sanguineous/bloody exudate. Additional documentation shows (L x W in centimeters with facility-documented type of wound): 11/27/24: 5.14 x 4.13 (MASD-IAD, 10% granulation, 90% slough) Location ischial tuberosity. 12/9/24: Right ischial tuberosity 3.73 x 2.2 (MASD-IAD, 100% slough) Of note: there are 11 days since R30's last measurement on 11/27/24. Additionally, R30 required transfer to the hospital on [DATE] due to a UTI (Urinary Tract Infection) and returned to the facility on [DATE]. Upon return from the hospital, R30 was put on Juven powder twice daily and house supplement three times daily between meals. The coccyx/sacrum and gluteal wound were not reassessed upon returning to the facility on [DATE] until 12/19/24. 12/19/24: Right ischial tuberosity 2.75 x 2.7 (MASD-IAD, 100% slough) 1/6/25: Right ischial tuberosity 3.4 x 2.49 (MASD-IAD, 20% granulation, 80% slough). Of note, there are 18 days between R30s last assessment on 12/19/24. R30's physician orders 1/9/25 to 2/1/25: Bilateral buttocks wound care: 1. Cleanse with cleanser, pat dry 2. Skin prep edges and allow to dry 3. Cut to fit wound base Puracol Ag 4. Cover with foam dressing, one time per day every other day and as needed. (It is important to note, that the physician orders indicate bilateral buttock wound care meaning there are wounds to both of R30's buttocks.) 1/13/25: Right ischial tuberosity 2.15 x 2.22 with 0.1 depth (MASD-IAD, 90% slough, 10% epithelial) 1/20/25: Right ischial tuberosity 1.96 x 1.92 (MASD-IAD, 20% granulation, 80% slough) 1/31/25: Right ischial tuberosity 3.09 x 2.61 (MASD-IAD, 100% slough) This is 11 days after the last assessment. R30's Physician orders: 2/1/25 to 2/7/25: Bilateral buttocks wound care: 1. Cleanse with cleanser, pat dry 2. Skin prep edges and allow to dry 3. Apply Medi-honey 4. Cover with foam dressing, one time a day every other day for wound care and as needed. 2/6/25: Right ischial tuberosity 1.94 x 2.13 (MASD-IAD, 50% granulation, 50% slough) R30's Physician order: 2/8/25 to 2/20/25: Bilateral buttocks wound care: 1. Cleanse with cleanser, pat dry 2. Skin prep edges and allow to dry 3. Apply zinc barrier cream to bases 4. Cover with foam dressing, one time per day every other day and as needed. 2/12/25: Right ischial tuberosity 2.38 x 2 with 0.1 depth (MASD-IAD, 100% slough) 2/18/25: Right ischial tuberosity 2.92 x 2.25 with 0.1 depth (Stage 3, 100% slough) education: educated resident to alert staff when having urge to void or defecate and also on the importance of offloading pressure to area. R30's Physician orders: 2/20/25 to present: Bilateral buttocks wound care: 1. Cleanse with cleanser, pat dry 2. Skin prep edges and allow to dry 3. Pack lateral wound bases with collagen powder when available 4. Cover with foam dressing, one time per day every other day and as needed. 2/25/25: Right ischial tuberosity 2.17 x 9.03 (Stage 3, tissue type unknown/not assessed) The facility did not have any documentation that R30's right gluteal/ischial tuberosity pressure injury was assessed between 11/27/24 and 12/9/24 or 1/20/25 and 1/31/25. Of note, it was identified by the facility that R30 had developed a pressure injury on his left gluteal. This was evident in pictures that accompany facility wound assessments and confirmed on 3/3/25 at 10:40 AM in an interview with RN D (Registered Nurse), who conducts most of the wound care at the facility and is also a nurse manager. At this time, RN D stated that although the facility was aware of the left gluteal pressure injury, they did not assess or measure this wound until today (3/3/25) and assessed it to be a stage 3 pressure injury. Of note, this is the third facility acquired pressure injury for R30. On 2/25/25, R30 would not allow surveyors to observe his pressure injuries when approached. On 2/26/25 at 2:01 PM, Surveyor interviewed RN D who stated that it was her interpretation that when a wound has slough, it is now a stage 3. When asked about the inconsistencies with the assessments for R30's coccyx/sacrum wound (unstageable to stage 2) and left heel (diabetic to unstageable pressure), RN D indicated that the facility did not have a wound certified nurse and those that were at the facility did the best that they could with their judgement. RN D also indicated that R30's gluteal fold wound went from MASD-IAD to a stage 3 pressure injury due to noticing the way he sat in his chair and seeing where the injuries on his bottom were in line with boney prominences. Additionally, RN D stated that she believed the 10/15/24 skin assessment referring to the 0.5 cm open area on the intergluteal cleft was most likely the start of the coccyx/sacrum wound but there was not any follow up with the physician or NP and there was no further assessment. RN D indicated the NP should have been updated on 10/15/24 regarding this open area. RN D also indicated that the facility generally implements air mattresses as a reactive measure rather than a proactive measure, even though R30 was immobile in his bed and relied on staff for mobility and transfers. On 2/26/25, Surveyor gathered additional interviews: *At 2:31 PM, CNA U (Certified Nursing Assistant) stated that R30 is completely dependent on staff and needs help to reposition when in bed. CNA U stated that R30 should be repositioned every 2-3 hours but is not sure if this is documented anywhere. CNA U indicated that she would tell the nurse if R30 refused repositioning. *At 2:38 PM, CNA T stated that R30 requires 2 people to get in and out of bed. CNA T stated that R30 can roll himself in bed, but sometimes needs help and definitely needs 1 person on the night shift. CNA T stated that they try to reposition R30 4 times per shift (on an 8-hour shift). CNA T indicated that she would tell the nurse if R30 refused to be repositioned but wasn't sure if repositioning gets documented anywhere. *At 2:51 PM, CNA I stated that R30 needs 2 people to get in and out of bed and needs staff assistance to reposition in bed. CNA I stated that when R30 is out of bed, they will lay him down after meals. Additionally, CNA I indicated that R30 should be repositioned every 2 hours and she would tell the nurse if he refused but was unaware if this gets documented or if the repositioning is being done consistently. On 2/26/25 at 1:31 PM, Surveyor interviewed DON B (Director of Nursing) and NHA A (Nursing Home Administrator). Both DON B and NHA A indicated that air mattresses are put into place as a reactive measure, rather than a proactive measure. DON B indicated that there were other measures in place before the air mattress such as repositioning. Additionally, DON B stated that it was her expectation that staff be repositioning R30 every 2 hours. When asked if repositioning was being documented and tracked to ensure that it was being completed, DON B indicated that they would not have documentation on that as it was an as needed intervention. Also, DON B indicated that it is her expectation that any open area on a resident be assessed at least once every 7 days. On 3/7/25 at 10:42 AM, Surveyor interviewed NP V (Nurse Practitioner) via phone regarding R30's wounds. NP V indicated that R30 is a complicated case and is high risk for skin conditions due to being diabetic, with neuropathy, spinal stenosis and polyneuropathy. NP V indicated R30 is significantly impaired due to limited mobility and being a very high risk for skin breakdown. NP V indicated she sees R30 weekly. NP V indicated she saw R30 today (3/7/25). NP V indicated R30 has a pressure injury on both ischial tuberosities, and that R30 has two total wounds. NP V indicated she visited R30 on 10/18/24 related to his significant injuries after his accident and was having a difficult time with pain management. NP V indicated on 11/1/24, R30 was seen again for pain management due to being in pain in certain positions and he was leaning due to the pain. NP V indicated she saw R30 on 11/12 and noted that staff made multiple attempts with interventions, and he frequently refused and would remove his boot. NP V indicated that R30 understood that his wound was getting worse. NP V indicate R30's wound was worsening due to noncompliance and he was educated on following interventions. NP V indicated on 11/19/24, R30 had a sacral ulcer and R30 was difficult with repositioning and refused. NP V indicated she discussed the importance of repositioning with R30. NP V indicated on 11/26/24, R30's pain was improving and continued to have the sacral area. NP V indicated R30's groin was mentioned, but gluteal fold would be a better location. Surveyor asked NP V if she observed this area, NP V indicated she viewed the area through nursing photos with wound rounds. NP V indicated is unable to describe what the areas looked like due to not seeing the wound. Surveyor asked NP V about when R30's wounds changed from MASD to a pressure injury. NP V indicated the left groin was actually the left ischial tuberosity and the right gluteal was the ischial tuberosity as well. NP V indicated it is difficult to say when it changed to pressure due to R30 being so high risk for pressure injuries. NP V indicated once they started R30 on prednisone his wounds started changing weekly and his risk was extremely high this whole time. Surveyor asked NP V what her expectations are for how often to reposition R30. NP V indicated repositioning and pressure have been an issue this whole time due to R30 being so neuropathic and having no sensation but pain. NP V indicated R30 was not worried about wounds he couldn't feel. Surveyor asked if an air mattress should have been in place since admission given his high risk for PIs. NP V indicated No, as R30 is up and out of bed and would encourage him to lay down, he wants to be up in his chair. Surveyor asked NP V if she had access to the facility wound assessments, NP V replied yes. Surveyor asked NP V to review the 12/19/24 wound assessment photo. NP V reviewed the photo. Surveyor asked NP V if she could tell Surveyor what she sees in the photo. NP V indicated slough tissue with granular tissue. Unable to say percentage due to photo. Surveyor asked NP V if she could see two wounds in the photo. NP V replied, yes. Surveyor asked the location, NP V replied ischial tuberosities. Surveyor asked what type of wounds they were. NP V indicated it was hard to say pressure due to him having incontinence. Surveyor asked if the wounds are circular in shape. NP V indicated yes, circular in shape is a characteristic of pressure. NP V indicated in previous photos, R30 has scar tissue present on the left ischial area and that R30 is at high risk for pressure. Surveyor asked about having slough with MASD, NP V replied yes, as it's dead tissue sloughing off. Surveyor asked how often R30 should be repositioned, NP V replied the facility expectation is every 2 hours. Surveyor asked what R30's left ischial wound looked like today. NP V indicated today (3/7/25), R30's left ischial wound was initially largely slough covered, so it was an unstageable and now it's 90% granulation and 10 % slough with 3cm of scar tissue around it in a week. NP V wanted Surveyor to note that R30 was incontinent of stool three times during wound care today. Surveyor asked NP V about the area measuring 0.5cm on admission. NP V indicated she would expect the hospitalist to address the open area on admit. NP V indicated expected wounds to be measured at least weekly. R30 was at risk for developing pressure injuries related to immobility and multiple fractures. The facility failed to implement aggressive pressure injury interventions; failed to complete weekly assessments per standard of practice; failed to provide risk and benefits despite knowledge of R30 refusing repositioning. Facility did not assess or measure R30's left gluteal pressure injury. R30 developed two stage three, and one unstageable facility acquired pressure injury. The failure to ensure R30 received care consistent with professional standards of practice to prevent pressure injuries from developing or deteriorating led to serious harm for R30, which created a finding of Immediate Jeopardy. The facility removed the jeopardy on 3/7/25 when it completed the following: *The facility failed to implement robust interventions to prevent PI development for R1, The facility failed to provide risk vs benefits for R1 when he declined. Other residnets potentially affected would be resdents with a Braden of less than 15. * Skin Assessment completed for each resident 3.7.25 * Braden Assessment completed for each resident 3.7.25 * Medical Director on site 3.7.25 completed wound rounds assessment with DON, determined etiology, and validated appropriate treatment in place for R1 and all resident with wounds. * Residents who scored <15 on Braden assessments have had care plans reviewed and updated with appropriate interventions based on areas of concern identified on Braden Assessment 3.7.25 * Educated Nursing Staff (Licensed and CNA) on pressure injuries - including risks, treatment guidelines, interventions & care strategies, wound care guidelines, and nutritional choices and support, educated on documentation of risk/benefit conversations in Refusal of Care progress note on March 7, 2025, or before staff next shift worked, starting March 7, 2025. * F686 - Review of F686 Pressure Injury Treatment Guidelines completed by Medical Director 3.7.25 Review of Policy Pressure injury/skin breakdown - clinical guidelines reviewed by Medical Director 3.7.25 * Review of F686 Pressure Injury Risk Assessment Guidelines by Medical Director 3.7.25 * Initiation and education of Progress note specific to Refusals of Care and Risk/Benefits discussion to be used as documentation template for residents who refuse skin interventions 3.7.25 or by next shift worked by DON or RN designee. * F686 - Medical Director and/or Wound NP to review wound assessments weekly with facility nursing team either bedside at the facility or remotely to ensure thorough and accurate assessments, treatments remain appropriate, and standards of practice are maintained. Weekly reviews to continue x 4 weeks unless concerns are noted during reviews. After the Provider oversight DON/Designee will audit 4 wound assessments & care plans weekly x 4 weeks then 2 wound assessments weekly x 2 weeks. Audit result will be reviewed with the Medical Director during QAPI. Audits will be discontinued based on QAPI committee recommendations. Ad hoc QAPI held with Medical Director, Acting Administrator, DON, and Governing Body. Action plans reviewed, discussed and agreed upon at 1:55pm on 3.7.25.