**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility did not ensure that 1 of 4 residents (R16) reviewed for pressure injuries (PI) received care consistent with professional standards of practice to prevent potential skin breakdown and promote healing of existing PIs. R16 was at risk for PI on admission having no PIs, weekly PI assessments were not completed consistently, physician was not notified with changes in the PI, alternate support surfaces were not provided when skin issues were noted. The PI care plan was not developed until 2 months after the identification of the stage 3 PI. Offloading of the PI was not observed by Surveyor. This is cited at actual harm. Findings include: The facility policy, titled Prevention of skin breakdown, revised [DATE], states: .D. Repositioning: a. Reposition bed-bound persons at least every two hours and chair bound persons every hour to hour and half consistent with overall goals of care . The facility policy titled Weekly skin rounds/Quality Assurance Review, revised [DATE], states: .Weekly wound rounds are completed weekly to determine the progress of healing, presences of possible complications, presence of pain and the status of the area and the area surrounding the pressure injury . R16 was admitted to the facility on [DATE]. R16's diagnoses included cauda equina syndrome (when a bundle of nerves at the bottom of spinal cord is compressed or damaged), sepsis, unspecified, malignant neoplasm of prostate, muscle weakness, unsteadiness on feet, diabetes mellitus type 2, and pulmonary hypertension. R16's Minimum Data Set (MDS), dated [DATE], confirmed R16 scored 10 during Brief Interview for Mental Status (BIMS), indicating moderate impaired cognition. R16 was admitted with at risk for skin breakdown, and no current PIs. Surveyor reviewed R16's skin integrity alteration care plan initiated on [DATE], which states in part: - Daily skin observation with cares. Report new or worsening concerns to nurse immediately initiated [DATE]. - House lotion to dry skin with cares as needed initiated [DATE]. - Treatment as ordered. Observe for changes and report concerns to MD/NP as warranted initiated [DATE]. - Inform resident/family/caregivers of any new area of skin breakdown initiated on [DATE]. - Notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises or Discoloration noted during bath or daily care initiated on [DATE]. - Pressure reducing/relieving mattress initiated [DATE]. - ROHO to seated positions initiated on [DATE]. - Turn and reposition q (every) 1-1.5 initiated on [DATE]. - Encourage side to side positioning when in bed initiated on [DATE]. - Enhanced Barrier Precautions in place due to chronic wound initiated on [DATE]. - Float heels initiated on [DATE]. Surveyor reviewed R16's pressure ulcer stage 3 to coccyx area care plan initiated on [DATE], which states in part: -Administer treatments as ordered and monitor for effectiveness. -Assess/record/monitor wound healing (weekly). Measure length, width and depth where possible. --Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. -Monitor dressing (daily) to ensure it is intact and adhering. -Monitor nutritional status. Serve diet as ordered, monitor intake and record. -ROHO to seated positions. Surveyor reviewed R16's physician orders, which state in part: -On [DATE], Reposition every 2 hours to off load buttocks every shift. -On [DATE], Protein gel cup one time a day. -On [DATE], Monitor open area to coccyx daily, until resolved every evening shift. -On [DATE], Cleanse wound, and peri wound tissue with wound cleaner. Apply 2x2 (2 by 2) collagen on the wound base (use all of it on the wound only). Place bordered super absorbent 5x5 dressing diagonally. change daily. Date and time dressing. Surveyor reviewed R16's nurse progress notes, which state in part: R1's skin/wound note dated [DATE] states in part . Location: R gluteal fold, Stage if pressure injury: MASD Measurements (in cm's (in centimeters)) length/width/depth: 5x4x0.1, Description of alteration: partial thickness skin/tissue loss with wound bed granular with maceration throughout wound bed. wound edges ill defined. mod (moderate) amt (amount) of serosanguious drainage noted. peri wound per resident's usual. no odor or s/sx (signs or symptoms) of infection. no complain of pain or discomfort. Additional Comments (if needed): ROHO added to seated positions, change pad Q 2h (every 2 hours). Will request catheter placement until wound healed. R16's skin/wound note dated [DATE] states in part . Location: Right post thigh, L (left) butt, coccyx, Stage if pressure injury: MASD, Measurements (in cm's) length/width/depth: R (right) post (posterior) thigh: 2x1.8x0.1, L butt: 1.5x0.7x0.1, Coccyx: 2.8x1x0.1, Description of alteration: wound bed covered in red granular tissue. Wound edges macerated. Peri wound per resident's usual. No odor or s/sx of infection. No c/o (complaints of) pain or discomfort. Of note: Surveyor found no documentation that R16's provider was notified of skin changes. Of note: Surveyor found no weekly wound measurements or description of wound bed for [DATE]. R16's skin/wound note dated [DATE] states in part . Location: coccyx. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 2.8x1x0.1. Description of alteration: Partial thickness skin/tissue loss with wound bed covered in pink granular tissue. Wound edges oval and intact. Peri wound per resident's usual. Small amt of serosanguinous drainage noted. No odor or s/sx of infection. No c/o pain or discomfort. Location: Left buttock. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 1.5x0.7x0.1. Description of alteration: Partial thickness skin/wound tissue loss with wound bed covered in light red granular tissue. Wound edges irregular and intact. Small amt of serosanguinous drainage noted. No odor or s/sx of infection. No c/o pain or discomfort. Peri wound per resident's usual. Location: Right gluteal fold. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 3x4x0.1. Description of alteration: partial thickness skin/tissue loss with wound bed covered in light red granular tissue. sm (small) amt of serosanguinous drainage noted. Peri wound per resident usual. No odor or s/sx of infection. No c/o pain or discomfort. Autolytic debridement performed. R16's skin/wound note dated [DATE] states in part . Location: Coccyx. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 1.5x2x0.1. Description of alteration: Partial thickness skin/tissue loss with wound bed covered in 75-100% granular tissue. wound edges oval and intact. No drainage noted. Peri wound per resident's usual. No odor or s/sx of infection. No c/o pain or discomfort. Autolytic debridement performed. Location: Left buttock. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 4x3.5x0.1. Description of alteration: Partial thickness skin/tissue loss with wound bed covered in 75-100% granular tissue and 0-25% slough. Wound edges irregular and intact. Peri wound per resident's usual. Scant amt of serosanguinous drainage noted. No odor or s/sx of infection. No c/o pain or discomfort. Autolytic debridement performed. Location: R gluteal fold. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 1.5x2x0.1. Description of alteration: Partial thickness skin/tissue loss with wound bed covered in 75-100% granular tissue. No drainage noted. Peri wound per resident's usual. No odor or s/sx of infection. Autolytic debridement performed. Of note: Surveyor reviewed left buttock wound deteriorating and facility did not implement any new pressure relieving interventions. Facility missed [DATE] weekly skin assessment, no measurements noted. Facility missed [DATE] weekly skin assessment related to gluteal and buttock wounds; no measurement noted. R16's skin/wound note dated [DATE] states in part . Location: Coccyx. Stage if pressure injury: stage 3. Measurements (in cm's) length/width/depth: 4.2 x 2 x 0.2. Description of alteration: Wound bed has 50-75% pink granulated tissue with 1-25% slough present. No tunneling or undermining. Moderate serosanguineous drainage noted. Periwound moist but intact. Concern for deep tissue at 6 o'clock w/in wound bed. Of note: Facility assessed R16's wound to be a PI stage 3 on [DATE]. Provider was not notified of PI deterioration, and no new interventions were put into place. R16's skin/wound note dated [DATE] states in part . Location: Coccyx. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 2.8x2x0.1. Description of alteration: Wound bed covered in pink, granular tissue. Peri wound per resident's usual. No drainage noted. No odor or s/sx of infection. No c/o pain or discomfort. Autolytic debridement performed. Of note: Facility incorrectly labeled R16's PI back to MASD versus assessment of PI stage 3 from [DATE]. Surveyor reviewed Skin/wound notes from [DATE], [DATE], and [DATE] and coccyx wound decreases in size to on [DATE]- measures 0.5x0.5x0.1cm. R16's skin/wound note dated [DATE] states in part . Location: Coccyx. Measurements: 3x3x0.1cm. Of note: R16's PI has increased in size; facility did not implement any new interventions. R16's skin/wound note dated [DATE] states in part . Location: Coccyx. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 4.5 x 5. Description of alteration: Partial tissue loss. Minimal serous drainage. Surrounding tissue per normal skin tone. No pain. Autolytic debridement. No signs or symptoms of infection. Of note: Facility is calling this MASD instead of a PI. Facility did not implement a PI care plan for R16 until [DATE]. R16's skin/wound note dated [DATE] states in part . Location: Coccyx. Stage if pressure injury: MASD. Measurements (in cm's) length/width/depth: 3.5 x 1.5 x <.01. Description of alteration: Epithelial cell noted in wound bed. Minimal serous drainage. Surrounding tissue per normal skin tone. Autolytic debridement. Denies pain or discomfort. Observations and interviews: On [DATE] at 9:59 AM, Surveyor interviewed R16 and asked how R16's care is at the facility. R16 indicated no concerns noted at this time. Surveyor observed wheelchair insert in recliner and asked R16 about the cushion in recliner. R16 indicated that R16 has a pressure injury from sitting too long on buttocks but the facility dresses it every evening on night shift. R16 indicated that R16 had a sore at home for a while, but it healed. Then when R16 was admitted about 1.5 months ago sitting around too long caused R16's buttocks to break open. On [DATE] at 12:19 PM, Surveyor observed R16 in recliner sitting at a 45-degree angle watching TV. Surveyor observed pressure relief pad insert in recliner. On [DATE] at 2:05 PM, Surveyor observed staff in room and laying R16 down. Surveyor walked in and did not see pillows underneath R16 to off load the bottom while lying in bed. Surveyor observed R16 lying flat on back in bed at a 90-degree angle. Surveyor asked R16 if R16 should have pillows underneath to off load the PI on coccyx. R16 stated, Yes I should, but I will have to call for assistance as I cannot do it myself. R16 rang call light. Of note: Surveyor observed no repositioning for 2 hours. On [DATE] at 2:17 PM, Surveyor observed Certified Nurse Assistant (CNA) I enter R16's room and assist R16 with placing pillow underneath R16. Surveyor interviewed CNA I and asked what are R16's repositioning needs. CNA I indicated that R16 should be repositioned every 1.5 hours and to off load bottom. CNA I indicated that R16 is pretty good with it so CNA I just does what R16 asks CNA I to do when R16 is ready. On [DATE] at 6:55 AM, Surveyor observed CNA K enter R16's room. Surveyor observed R16 lying supine on back in bed. Surveyor did not see any pressure relief on coccyx. On [DATE] at 7:11 AM, Surveyor observed R16 sitting in recliner leaned slightly right at a 90-degree angle. Surveyor observed roho cushion insert in recliner. On [DATE] at 8:25 AM, Surveyor observed Registered Nurse (RN) E deliver breakfast tray to R16. Surveyor observed R16 sitting in recliner leaned to right side slightly at a 90-degree angle. Surveyor observed roho cushion insert in recliner. On [DATE] at 8:54 AM, Surveyor observed R16 sitting in recliner leaned to right side slightly at a 90-degree angle. Surveyor observed roho cushion insert in recliner. On [DATE] at 9:13 AM, Surveyor observed RN E go into R16's room and grab breakfast tray. Surveyor observed R16 still in recliner but reclined slightly less than 90-degree angle backwards in recliner. On [DATE] at 9:40 AM, Surveyor observed R16 place call light on. Surveyor observed R16 ask CNA H if R16 could get into bed. On [DATE] at 9:45 AM, Surveyor observed CNA H assist R16 out of recliner with gait belt, and dycem mats on floor. Surveyor observed two pillows on bed located on each side of bed. R16 sat on top of the pillows and swung legs over to lay down. R16 directed CNA H to place pillow under heels. Surveyor observed left heel still touching mattress, right heel elevated. Surveyor observed R16 lying on back. Surveyor observed R16 place head of bed up to a 90-degree angle and CNA H stated, That is high, is that how you do your bed? R16 responded and stated, Yes. Surveyor observed CNA H exit R16's room. Of note: Surveyor did not observe CNA H encourage or offer to lay R16 on side to off load coccyx area. On [DATE] at 11:50 PM, Surveyor observed R16 lying in bed on back. Surveyor observed R16 at a 90-degree angle, lying directly on coccyx area watching tv. On [DATE] at 1:35 PM, Surveyor observed R16 lying in bed on back with head of bed about 90-degree angle with left side pillow down near feet and heel pillow not under feet. On [DATE] at 1:37 PM, Surveyor interviewed R16 and asked who moved pillows. R16 indicated that R16 removed the left side pillow due to R16 being uncomfortable. Surveyor asked R16 and Family Member L if R16 can reposition self. R16 indicated not in this bed. R16 indicated that at home R16 could move around in bed but not in R16's bed at the facility. R16 indicated that R16 must ring call light if R16 wants to be repositioned. R16 stated, I don't want to bother them, so I wait for them. Surveyor asked Family Member L if staff come in every 1 or 2 hours to reposition. Family Member L indicated that sometimes I will come in, in the morning around 9 AM to visit R16 and nothing has been done until lunch time. Family Member L is concerned with PI getting worse. Surveyor asked R16 and Family Member L if facility offered an air mattress for R16 or did R16 refuse the air mattress. R16 indicated that no one has offered an air mattress. R16 asked Surveyor if air mattress would help with R16's wound. Family Member L indicated that Family Member L did not know air mattress was an option. Of note: Surveyor did not observe air mattress in place as care planned. On [DATE] at 2:20 PM, Surveyor interviewed CNA H and asked CNA H what CNA H's process is for R16's repositioning care plan. CNA H indicated that R16 can reposition self in bed and sometimes is on R16's side. Surveyor indicated to CNA H that Surveyor has not seen R16 off back and coccyx [DATE] or today. CNA H indicated that R16 was up in recliner this morning for breakfast. Surveyor indicated to CNA H that R16 has been sitting in recliner for over 3 hours this morning on [DATE]. CNA H indicated that CNA H thought that was fine since R16 has pressure relieving cushion in recliner. Surveyor asked CNA H if CNA H repositioned R16 while lying in bed after breakfast, before lunch, or after lunch since R16 has been in bed since 9:45 AM. CNA H indicated that when I placed R16 in bed I propped R16 with two pillows on each side. Surveyor indicated that when Surveyor was observing the offloading the pillows placed under R16's hips on each side was adequate for pressure relief of coccyx off the bed. Surveyor asked CNA H if CNA H could place hand underneath R16's coccyx and feel the space between mattress and R16's coccyx. CNA H indicated that CNA H did not test if there was space. Surveyor indicates that care plan is to encourage R16 to be off back and reposition unto sides often. Surveyor indicated to CNA H that Surveyor did not observe CNA H offer to reposition R16 on side. CNA H indicated that CNA H did not offer or encourage to reposition R16 on side because R16 will usually ask if R16 wants to be on sides. On [DATE] at 2:41 PM, Surveyor interviewed Director of Nursing (DON) B and asked what is DON B's expectation of R16's repositioning care plan in place. DON B indicated that R16 should be encouraged to get off R16's coccyx and reposition side to side every 1-1.5 hours. Surveyor indicated that Surveyor has not observed R16 repositioned every 1-1.5 hours and at one-point R16 sat in recliner on coccyx for over 3 hours and in bed over 3 hours without being repositioned. DON B indicated that staff should be repositioning every 1-1.5 hours as care planned. Surveyor asked DON B if R16's wound on coccyx was a pressure injury and why R16 did not have a PI care plan in place until [DATE]. DON B indicated there were two wound nurses who thought Moisture Associated Skin Damage (MASD) and the other thought stage 3 PI. DON B reached out to a wound care specialist who confirmed that R16's wound on coccyx is a stage 3 PI. DON B confirmed to Surveyor that R16 should have had a PI care plan implemented back in September when the PI was discovered but was not put into place until [DATE]. Surveyor asked DON B where is R16's air mattress. DON B indicated that DON B was unaware that R16 did not have an air mattress in place. Surveyor confirmed with DON B that R16's mattress was observed to be a basic Direct Supply Panacea foam mattress. On [DATE] at 8:01 AM, Surveyor interviewed DON B and asked expectation of how long R16 should be up for meals. DON B indicated it is R16's right to sit up for however long R16 would like but that DON B's expectation would be that staff still reposition R16 every 1-1.5 hours while sitting as well. Surveyor asked DON B if R16 had any nutritional interventions to assist healing with R16's PI deterioration. DON B indicated that on [DATE], Pro gel was implemented to help with PI healing, but there were no other interventions for nutrition before [DATE]. Surveyor asked DON B when was the first official date R16's PI was found. DON B indicated that [DATE] was the first alteration in skin integrity and identified as a PI on [DATE]. Surveyor asked DON B if R16's development of a stage 3 PI in the facility was avoidable or unavoidable. DON B stated, Well with the observations of lack of repositioning of [R16] off of [R16's] buttocks and no air mattress in place, I feel it could have been avoided if those measures were in place. On [DATE] at 10:40 AM, Surveyor interviewed previous wound care RN J and asked about education in wound care. RN J indicated that RN J took skin and wound management 9 years ago but did not pass the exam to become certified. Surveyor asked how RN J assessed that R16's wound was related to MASD versus PI. RN J indicated that now that RN J looks back on R16's case, R16's wound should had been labeled PI as R16 had a lot of issues like immobility and incontinence but there was a lot going on on R16's back side from back surgery. On [DATE] at 10:45 AM, Surveyor interviewed Nursing Home Administrator (NHA) A and asked for RN F's (current wound nurse) training. NHA A indicated that RN F let RN F's wound certification lapse, but facility is trying to figure out how she can retest. NHA A provided Surveyor with Wound Care Certified certification which expired on [DATE].