**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #61 was admitted to the facility on [DATE] with diagnoses that included Chronic Obstructive Pulmonary Disease, depressive episodes, and a history of traumatic brain injury. Review of a Skin Integrity Report with only the admission date of July 9, 2021 on it, revealed the resident had a stage II pressure ulcer (PU) which was present on admission, that measured 1.0 cm x 2.4 cm x 0 cm., had no undermining, tunneling, drainage, or odor, and that the wound edges and surrounding tissue was healthy. The report also included yes to the presence of pain. Review of the care plan initiated on July 10, 2021 revealed the resident was at for risk of skin breakdown related to poor mobility and or has actual skin breakdown; shearing to the left buttock crease and healing stage II pressure ulcer to the right buttock. The interventions included preventative skin care i.e. lotions, barrier creams as ordered and weekly skin checks by a licensed nurse. The admission MDS assessment dated [DATE] included a BIMS score of 13 indicating the resident was cognitively intact. The assessment also included the resident had one stage II pressure ulcer that was present upon admission to the facility. Continued review of the clinical record did not reveal an order for treatment until July 21, 2021. A physician order dated July 21, 2021 included to apply barrier cream to buttocks every shift and as needed. Review of the skin check assessment dated [DATE] revealed the resident had a stage II PU to the right buttock. The progress note dated July 21, 2021 revealed the stage II pressure ulcer to the right buttock measured 1.0 cm x 1.0 cm x 0.2 cm, the surrounding skin was pink, blanchable and intact. The note included barrier cream was applied to the buttock and that the resident denied pain. Review of the TAR for July 2021, revealed no documentation that the barrier cream to the buttocks was applied on July 23 during the night shift, and July 24 and 26, 2021 during the day shift. A skin check assessment dated [DATE] included a stage II PU to the right buttock, however measurements and description of the PU was not included. A physician order dated July 27, 2021 included to apply Venelex followed by Calmoseptine ointment to the bilateral buttocks two times a day and as needed for wound care. Review of the TAR for July 2021 revealed documentation that Venelex and Calmoseptine ointment was applied as ordered. Skin check assessments dated July 28, 2021 and August 4, 2021 included documentation that there was no skin injury/wound found. A review of the TAR for August 2021 revealed documentation the barrier cream and the Venelex and Calmoseptine ointment was applied as ordered. On August 6, 2021 at 10:25 a.m., a wound observation was conducted with the wound nurse (staff #64). The wound on the right buttock was measured at 0.8 cm x 2.1 cm x 0.1 cm and the left buttock wound was measured at 0.1 cm x 2.4 cm x 1.0 cm. Following this observation staff #64 stated the staff nurse should be completing skin sheets weekly. Review of a nursing note dated August 6, 2021 revealed the left buttock crease wound measured 1.0 cm x 2.4 cm x 0.0 cm and that the skin was ruddy red surrounding the wound and blanchable to touch. The note included the left buttock wound measured 0.8 cm x 2.1 cm x 0.0 cm and that the skin around this wound was intact, red and blanchable. The note also included the wound appeared to be stage II shearing and that Venelex gel was applied and covered with Calmoseptine lotion. The note stated the resident's pain level at times was a 9 out of a scale of 0-10 and that the resident stated the wound burns with dressing change. A Skin Integrity Report dated August 6, 2021 revealed the left buttock stage II PU measured 0.8 cm x 2.1 cm x 0 cm; no undermining, tunneling, or odor; the surrounding tissue and the wound edges were healthy, and that pain was present. Continued review of the clinical record did not reveal weekly wound assessments and weekly skin checks were consistently done. On August 6, 2021 at 11:29 a.m., an interview was conducted with the DON (staff #9). She stated the resident was admitted to the facility with a stage II PU. The DON stated the period of time it took to obtain orders for treatment was not in accordance with standard practice for wound care. She stated that they could have contacted the physician for orders. The DON stated that it is the process of the facility to complete skin checks weekly for all residents to keep abreast of all skin issues and provide appropriate care. She stated the floor nurse is responsible for completing the weekly skin checks which should be documented in a progress note or in an assessment. The DON stated the ADON is responsible for reviewing skin/wound care checks along with the Nurse Manager to ensure it gets done. The facility's policy, Skin Integrity Management, revised June 1, 2021 stated the implementation of the individual patient's skin integrity management occurs within the care delivery process. Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. The purpose of skin integrity management is to provide safe and effective care to prevent the occurrence of pressure ulcers, manage treatment, and promote healing of all wounds. Practice standards include: -Review pre-admission information to plan for patient's needs prior to admission -Complete risk evaluation/re-admission, weekly for the first month, quarterly, and with significant change in condition -Perform skin inspection on admission/re-admission and weekly. Document on the Treatment Assessment Record or in Point Click Care -Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly, and with anticipated decline of the wound -Develop comprehensive, interdisciplinary plan of care including prevention and wound treatments, as indicated -Perform daily monitoring of wound or dressings for presence of complications or declines and document -Implement special wound care treatments/techniques as indicated and ordered -Review care plan weekly and revise as needed. Based on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure two out of two residents (#24 and #61) sampled received necessary treatment and services to promote healing and prevent new ulcers from developing. The deficient practice could result in pressure ulcer complications and new pressure ulcer formation. Findings include: -Resident #24 was admitted to the facility on [DATE] with diagnoses that included fractures of the right fibula and right tibia, dysphagia, and altered mental status. A nurse progress note dated March 13, 2020 revealed a skin check was completed and the heels, area between toes, and bony prominences appeared free from redness, maceration or breakdown. A nursing assessment dated [DATE] revealed the resident was admitted for therapy and wound care, and that the resident had an external fixation device to the lower right extremity with six pins into the skin wrapped with ace wrap from the knee to the ankle. The assessment included a Braden Scale for predicting pressure ulcer risk score of 14 which indicated the resident was at moderate risk for developing pressure ulcers. The assessment also included the resident had intellectual/development disability. Review of the clinical record did not reveal a baseline care plan had been initiated regarding the skin. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3 which indicated the resident had severely impaired cognition. The assessment included the resident did not have any pressure ulcers but was at risk for developing pressure ulcers. The assessment also included pressure reducing devices to the bed and chair. Review of the Braden Scale dated March 20, 2020 revealed a score of 14, which indicated that the resident was at moderate risk for pressure sores. Review of the Braden Scale dated March 27, 2020 revealed a score of 16, which indicated the resident was at mild risk for pressure sores. Regarding the left heel wound #1: Review of a skin integrity report dated April 21, 2020 revealed the resident had a left heel blister that measured 6.0 centimeters (cm/length) x 11.0 cm (width) x 0 cm (depth), had moderate amount of serous drainage, healthy surrounding tissue and wound edges, and no pain present. The place on the form to document the initial wound date was blank, the wound type was not documented, and the name of the staff conducting the assessment was not included. A physician's order dated April 22, 2020 included to clean the left heel with wound cleanser, apply Medihoney alginate to the wound bed, cover with an abdominal pad and wrap with Kerlix daily. A nurse wound care note dated April 22, 2020 revealed the left heel was noted to have a blister that was cleaned, assessed, measured and dressed per order. A skin integrity report dated April 30, 2020 included the left heel wound was an open blister that measured 5.5 cm x 6.5 cm x 0, had small amount of serous drainage, healthy surrounding tissue and wound edges, and no pain was present. The wound type was not documented. A care plan initiated on April 30, 2020 revealed the resident had actual skin breakdown and pressure ulcers to the left heel. The goal was that the wound would heal as evidenced by decrease in size, absence of erythema and drainage and/or presence of granulation. Interventions included lower extremity protectors, weekly wound assessments to include measurements and description of the wound, provide wound treatment as ordered, and weekly skin assessments. Review of a nurse wound care note dated April 30, 2020 revealed the left heel blister was cleaned, assessed, redressed per order, foam foot and heel protectors are on bilateral feet, and no pain. Review of the Treatment Administration Record (TAR) for April revealed the treatment was provided as ordered. The skin integrity report dated May 7, 2020 included the left heel wound was an open blister that measured 5.0 cm x 6.0 cm x 0, had small amount of drainage, healthy surrounding tissue and wound edges, and no pain was present. The report did not include the type of drainage or the wound type. Review of the May 2020 TAR revealed no documentation that the heel wound treatment was completed on May 9, 2020. A nursing progress note dated May 12, 2020 included heel protectors were in place. Review of a progress note from the Wound Care Center dated May 14, 2020 revealed the center had received a referral from the PCP (primary care physician) for wound care, evaluation, and treatment. The note stated the left heel unstageable pressure ulcer (wound #1) had obscured full-thickness skin and tissue loss, measured 5.5 cm x 6.5 cm width with no measurable depth and had an area of 35.75 square cm. The note included there was no drainage noted, the wound bed had 76-100% eschar, the temperature of the peri wound was within normal limits, and the resident reported a pain level of 2 on a scale of 0-10. However, the skin integrity report dated May 14, 2020 revealed the left heel wound was a hard, closed, blister that measured 5.0 x 6.0 cm x 0, had no drainage, the surrounding tissue and wound edges were healthy, and no pain was present. The report did not include eschar. A wound care progress note dated May 14, 2020 revealed the left heel blister was dry, closed, and appeared to be improving. No pain expressed by the resident. Review of the TAR for May 2020 revealed no documentation that the left heel wound treatment was completed on May 15. A physician's order dated May 19, 2020 revealed an order to apply betadine to the left heel and wrap with curled gauze every day for wound care. Review of a skin integrity report dated May 20, 2020 revealed the left heel wound was a healed closed blister with measurements of 3.0 cm x 1.5 cm x 0, no drainage, healthy surrounding tissue and wound edges, and no pain was present. A wound care note dated May 21, 2020 revealed the left heel wound was doing better with new intact skin noted on an area of the heel. The note included the left heel wound was cleaned, assessed, measured and redressed as per order, and no pain was present. Review of a skin integrity report dated May 28, 2020 revealed the left heel wound was a healed closed blister with measurements of 3.0 cm x 1.5 cm x 0, no drainage, healthy surrounding tissue and wound edges, and no pain was present. Review of a wound care note dated May 28, 2020 revealed the left heel wound was doing much better. The note included the blister was removed and a small amount of eschar remained. The note also included the left heel wound was cleansed, assessed, measured and redressed as per orders. The skin integrity report dated June 4, 2020 revealed the left heel wound was a healed closed blister with measurements of 3.0 cm x 1.5 cm x 0, no drainage, healthy surrounding tissue and wound edges, and no pain was present. The note did not include whether the eschar had resolved or not. A wound care note dated June 10, 2020 revealed the left heel wound was closed with 100% epithelial tissue. The note included lotion was applied to the foot and heel, the foot would be kept in a Prevalon boot to offload pressure. A nurse progress note dated June 13, 2020 revealed a friction reducing device was used to position the resident in bed. Review of the quarterly MDS assessment dated [DATE] revealed the resident had no pressure ulcers but was determined to be at risk for developing pressure ulcers. The assessment there were pressure reducing devices to the bed and chair. A skin integrity report dated July 8, 2020 revealed the resident had an in house acquired pressure wound to the left heel with an initial wound date of July 7, 2020. The report included the left heel pressure wound had epithelial tissue, measured 2.5 cm x width 1.5 cm x 0, had no drainage, the surrounding tissue and wound edges were healthy, and there was no pain present. The report did not include the stage of the pressure wound. Continued review of the clinical record did not reveal a treatment had been ordered for the reoccurrence wound to the left heel. The skin integrity report dated July 15, 2020 revealed the left heel unstageable pressure ulcer measured 2.0 cm x 1.5 cm x 0, epithelial tissue appearance, no drainage, the surrounding tissue and wound edges were healthy, and there was no pain present. The signature and/or initials of the assessor was not documented. Review of the skin integrity report dated July 21, 2020 revealed the left heel unstageable pressure ulcer measured 1.2 cm x 1.0 cm x 0, necrotic tissue was present, no drainage, the surrounding tissue and wound edges were healthy, and there was pain present. The skin integrity report dated July 28, 2020 revealed the left heel unstageable pressure ulcer measured 1.2 cm x 1.1 cm x 0, necrotic tissue was present, no drainage, the surrounding tissue and wound edges were healthy, and there was no pain present. Again, the signature and/or initials of the assessor was not documented. The skin integrity report dated August 5, 2020 revealed the left heel unstageable pressure ulcer measured 1.1 cm x 1.1 cm x 0, necrotic tissue was present, no drainage, the surrounding tissue and wound edges were healthy, and there was no pain present. The signature and/or initials of the assessor was not documented. A skin integrity report dated August 12, 2020 stated the left heel was healed, intact, with healthy surrounding tissue and wound edges. A skin integrity report dated August 19, 2020 stated the left heel unstageable pressure ulcer was intact and measured 1.1 cm x 1.1 cm x 0 and was intact with healthy surrounding tissue and would edges. The skin integrity report dated August 26, 2020 revealed the left heel wound was healed. Review of the skin integrity report dated September 2, 2020 revealed there was now an unstageable pressure ulcer to the left heel. The report stated the left heel unstageable pressure ulcer measured 1.1 cm x 1.1 cm, was intact with deep purple color, the surrounding tissue and wound edges were healthy, and pain was present. The signature and/or initials of the assessor was not documented. Review of the skin integrity report dated September 9, 2020 revealed the left heel unstageable pressure ulcer measured 1.1 cm x 1.1 cm, was intact with deep purple color, the surrounding tissue and wound edges were healthy, and pain was present. The signature and/or initials of the assessor was not documented. Review of the skin integrity report dated September 16, 2020 revealed the left heel wound was healed, the surrounding tissue and wound edges were healthy, and pain was present. The signature and/or initials of the assessor was not documented. Review of the clinical record did not reveal any ordered wound treatments to the left heel since the last order was discontinued on June 10, 2020. A wound observation was conducted on August 3, 2021 at 12:13 p.m. with the assistant Director of Nursing/wound nurse (ADON/staff #64). The ADON removed the dressing from the left heel. No pressure ulcer was observed. The ADON stated scar tissue was the site of the previous wound. The ADON cleansed the left heel and applied a square adhesive edge dressing to the left heel. Regarding left heel wound #2: Review of a skin integrity report dated September 16, 2020 revealed the resident had an unstageable pressure ulcer to the left heel that measured 4.0 cm x 19.0 cm x 0 that was deep purple and intact. The note included the surrounding tissue and wound edges were healthy and that there was pain present. Continued review of the clinical record did not reveal a treatment order for this pressure ulcer. The quarterly MDS assessment dated [DATE] revealed the resident had no pressure ulcers and was determined to be at risk for developing pressure ulcers. The assessment included there were pressure reducing devices to the bed and chair. Review of the skin integrity report dated September 26, 2020 revealed an unstageable pressure ulcer to the left heel that measured 4.0 cm x 19.0 cm x 0 cm. The note included the ulcer was deep purple and intact, and that the surrounding tissue and wound edges were healthy. The note also included pain was present. The skin integrity report dated September 30, 2020 revealed the pressure ulcer to the left heel had healed, the surrounding tissue and wound edges were healthy, and that pain was present. A physician order dated October 5, 2020 included an outside wound care group would follow. A wound care center progress note dated October 6, 2020 stated the left heel deep tissue pressure injury (wound #2) had persistent non-blanchable deep red, maroon, or purple discoloration. The note included the wound measured 4.0 cm x 19 cm x 0 cm with an area of 76 square cm, scant amount of serosanguineous drainage was noted, no odor, the wound bed had no slough, no eschar present, and the temperature of the peri-wound was within normal limits. The note also included the resident reported a pain level of 5 out of 0-10. A skin integrity report dated October 7, 2020 revealed the left heel deep tissue pressure ulcer was deep purple and intact, and could not be staged. The report included the ulcer measured 4.0 cm x 19.0 cm x 0 cm, the surrounding tissue and wound edges were healthy, and that pain was present. Review of a practitioner note dated October 7, 2020 revealed the resident did not like to get out of bed and fights staff with re-positioning. A physician order dated October 7, 2020 included to clean the left heel with betadine, apply an abdominal pad to wound site, and wrap in rolled gauze every day shift Monday, Wednesday, and Friday for wound care. Review of the care plan revealed a revision date of October 7, 2020 that the resident had actual skin breakdown to the left heel blister. Interventions dated October 10, 2020 included offloading heels while in bed, turning and repositioning, pressure redistribution surfaces to bed and chair, utilize positioning devices, and to observe for verbal and nonverbal signs of pain related to wound or wound treatment and medicate as ordered. The Medication Administration Record (MAR) for October 2020 revealed no documentation the left heel treatment was completed on October 14. Review of the skin integrity report dated October 14, 2020 revealed the left heel unstageable pressure ulcer was necrotic, measured 4.0 cm x 6.0 cm x 0 cm, the surrounding tissue and wound edges were healthy, and that pain was present. The note did not include the signature and/or initials of the staff completing the assessment. The wound care center note dated October 15, 2020 revealed the left heel unstageable pressure ulcer (wound #2) had obscured full-thickness skin and tissue loss, measured 4.0 cm x 6.0 cm x 0 cm with an area of 24 square cm, the wound bed had 76-100% eschar, no drainage noted, and the resident reported no pain. Review of the October 2020 MAR revealed no documentation the left heel treatment was completed on October 19. A practitioner note dated October 21, 2020 revealed the wound team would be in that day to evaluate the left heel wound with eschar. The note included the resident was non-compliant with turning and fights staff with re-positioning, did not want to get out of bed, and did not want heels elevated. The note also included the resident became agitated and would fight with staff and the practitioner when being touched and when staff were trying to treat the heels. Review of an electronic record wound evaluation dated October 21, 2020 included the stage two pressure ulcer (wound #2) to the left heel was three months old and in house acquired. The evaluation also included the ulcer measurements were 4.65 cm x 4.98 cm x 0 cm, and the area was 19.76 cm. Review of the clinical record revealed the treatment to the left heel wound was discontinued on October 21, 2020 and no new treatment was ordered at that time. The skin integrity report dated October 22, 2020 revealed the left heel unstageable pressure ulcer was necrotic, measured 4.0 cm x 6.0 cm x 0 cm, the surrounding tissue and wound edges were healthy, and pain was present. The note did not include the signature and/or initials of the staff completing the assessment. A skin integrity report dated October 29, 2020 stated the left heel unstageable pressure ulcer was necrotic, measured 4.0 cm x 6.0 cm x 0 cm, the surrounding tissue and wound edges were healthy, and that pain was present. The note did not include the signature and/or initials of the staff completing the assessment. Review of the Certified Nursing Assistant (CNA) documentation for October 2020 revealed the following: -69 out of 93 shifts did not contain documentation of the bed mobility task being completed, including 14 out of 31 days that did not contain documentation of the bed mobility task being completed on any shift. -72 out of 93 shifts did not contain documentation that preventative skin care (heel/elbow protectors) was applied, including 14 out of 31 days that did not contain documentation that preventative skin care (heel/elbow protectors) was applied on any shift. A nursing progress note dated November 9, 2020 revealed the resident was not allowing staff to reposition her. Review of an electronic record wound evaluation dated November 10, 2020 (12 days after the last assessment) included the left heel unstageable pressure ulcer (wound #2) was four months old and in house acquired. The evaluation included that the dressing was intact and saturated. The evaluation also included the ulcer measured 2.82 cm x 3.55 cm x 0.25 cm with an area 8.25 cm, the wound bed was 50% granulation and 50% eschar, light amount of serosanguineous drainage with a faint odor was noted after cleansing, the peri-wound edges were non-attached and the surrounding tissue was macerated and blanching. The evaluation stated the resident pain was assessed. Review of a physician order dated November 10, 2020 now revealed an order to cleanse the left heel with wound cleanser, apply Medihoney to the wound bed, cover with non-adherent dressing, and wrap with gauze every day shift. The order included to notify the PCP/nurse supervisor if decline noted. A skin integrity report dated November 12, 2020 revealed the left heel wound was healed. However, review of an electronic record wound evaluation dated November 16, 2020 revealed the left heel unstageable pressure ulcer (wound #2) measured 3.55 cm x 3.53 cm x 0.25 cm with an area of 10.39 cm, and the wound bed was 40% granulation and 60% eschar. The evaluation did not include an assessment of the wound edges or surrounding tissue, or the presence or absence of exudate and pain. A nursing progress note dated November 16, 2020 revealed the resident was repositioned with pillows and shifted back to the previous position. The note included the nurse attempted to explain to the resident the importance of off-loading heels, attempt was unsuccessful. Review of a nursing progress notes dated November 19 and 20, 2020 revealed the presence of a low air loss mattress and that the resident refused to be repositioned or off load heels. A physician order dated November 20, 2020 included to cleanse the left heel with wound cleanser, apply Silvasorb to the wound bed, cover with a non-adherent dressing, and wrap with gauze every day shift. Notify PCP/nurse supervisor if decline noted. Review of the November 2020 TAR revealed no documentation that the treatments to the left heel was completed on November 24. Review of the clinical record did not reveal that a weekly skin assessment was completed between November 19 and December 1, 2020. An electronic record wound evaluation dated November 25, 2020 included the unstageable pressure ulcer to the left heel (wound #2) measured 2.07 cm x 3.57 cm x 0 cm with an area of 5.77 cm. The evaluation did not include an assessment of the wound bed, the presence or absence of exudate or pain, or an assessment of the wound edges and surrounding tissue. Review of the November 2020 TAR revealed no documentation that the treatment to the left heel was completed on November 30. An electronic record wound evaluation dated November 30, 2020 stated the left heel unstageable pressure ulcer (wound #2) measured 1.38 cm x 0.91 cm x 0 cm with an area of 0.94 cm. The evaluation did not include an assessment of the wound bed, the presence or absence of exudate or pain, an assessment of the wound edges and surrounding tissue, or the signature and/or initials of the assessor. Review of the CNA documentation for November 2020 revealed the following: -50 out of 90 shifts did not contain documentation of the bed mobility task being completed, including 6 out of 30 days that did not contain documentation of the bed mobility task being completed on any shift. -53 out of 90 shifts did not contain documentation that preventative skin care (heel/elbow protectors) was applied, including 6 out of 30 days that did not contain documentation that preventative skin care (heel/elbow protectors) were applied on any shift. Review of the December 2020 TAR revealed no documentation that the treatment to the left heel were completed on December 9. An electronic record wound evaluation dated December 10, 2020 (10 days after the last assessment) included the unstageable pressure ulcer to the left heel (wound #2) measurements were 1.61 cm x 1.66 cm x 0 cm, with area 2.17 cm. The evaluation did not include an assessment of the wound bed, the presence or absence of exudate or pain, an assessment of the wound edges and surrounding tissue, or the signature and/or initials of the assessor. A Skin and Wound evaluation dated December 15, 2020 revealed the left heel unstageable pressure ulcer had obscured full-thickness skin and tissue loss due to slough and/or eschar. The wound measurements were 2.0 cm x 2.1 cm x 0 cm with area 2.9 cm. The evaluation included the in-house acquired pressure ulcer had been present for 1-3 months, no exact date was documented. Another Wound Evaluation for the same date, December 15, 2020, included the unstageable pressure ulcer to the left heel (wound #2) was five months old and in house acquired. This evaluation included the measurements were 1.98 cm x 2.07 cm x 0 cm with an area of 2.94, and that the closure percent was between 80 and 90%. The assessments dated December 15, 2020 differed regarding how long the wound had been present; did not include documentation of the wound bed or the presence or absence of exudate; did not include documentation of the wound edges, surrounding tissue, or presence or absence of pain. The assessments also did not include the signature and/or initials of the assessor. A quarterly MDS assessment dated [DATE] revealed the resident had two unstageable pressure ulcers/suspected deep tissue injury, was receiving pressure ulcer care, and pressure reducing devices were to the bed and chair. Review of the December 2020 TAR revealed no documentation that the treatments to the left heel were completed on December 26, 28, or 30. A Nutritional assessment dated [DATE] included the resident was receiving multivitamin, zinc, and vitamin C for wound diagnosis. The assessment included the resident had pressure ulcers to the bilateral heels which were improving. The assessment also included to keep interventions in place as oral intake was fair and the wound was not completely healed. Review of the CNA documentation for December 2020 revealed the following: -52 out of 93 shifts did not contain documentation of the bed mobility task being completed, including 5 out of 31 days that did not contain documentation of the bed mobility task being completed on any shift. -56 out of 93 shifts did not contain documentation that preventative skin care (heel/elbow protectors) was applied, including 8 out of 31 days that did not contain documentation that preventative skin care (heel/elbow protectors) were applied on any shift. The wound care center progress note dated January 7, 2021 revealed the left heel pressure ulcer (wound #2) was now a stage 3 pressure ulcer. The note included the ulcer measured 3.0 cm x 3.2 cm x 0.2 cm depth, with an area of 9.6 square cm and a volume of 1.92 cubic cm. The note also included the wound bed had 76-100% pink granulation, a moderate amount of sero-sanguineous drainage was noted with no odor, the peri-wound skin did not exhibit edema or erythema and the temperature was within normal limits, and the resident's pain was 1 on a scale of 0-10. This assessment was 23 days after the last assessment. A physician order dated January 7, 2021 included to cleanse the left heel wound with wound cleanser, apply Silvasorb to the wound bed, cover with a non-adherent dressing, wrap with gauze every day shift, and notify the PCP/nurse supervisor if decline noted. A physician order dated January 14, 2021 included for the Wound Care Group to evaluate and treat. A NP progress note dated January 18, 2021 included staff would attempt to get the resident out of bed for all meals, although the resident does fight with staff when cares are being given. Review of a wound care center progress note dated January 21, 2021 revealed the stage 3 left posterior heel pressure ulcer (wound #2) measured 1.0 cm x 0.8 cm x 0.2 cm with an area of 0.8 square cm and a volume of 0.16 cubic cm. The note included the wound bed had 76-100% pink granulation, a scant amount of sero-sanguineous drainage was present with no odor, the peri-wound skin exhibited scarring and the temperature was w[TRUNCATED]