**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. On April 18, 2023, at 9:57 a.m., a concurrent observation and interview was conducted with Resident 18. Resident 18 was observed laying in bed using his computer. Resident 18 stated he had a wound on his bottom. On April 21, 2023, Resident 18's record was reviewed. Resident 18 was admitted on [DATE], with diagnoses of paraplegia (paralysis of legs and lower body) and sepsis (infection in the blood stream). A review of Resident 18's Medical History/Physical Examination, dated March 7, 2023, indicated Resident 18 was alert and oriented. A review of Resident 18's care plan titled, At risk for alteration in skin integrity, pressure ulcers, infection and slow healing related to: impaired mobility, contractures, history of pressure ulcers, weakness and paraplegia, dated March 6, 2023, indicated, .Goal .Skin will remain free of breakdown within limits of disease process .Interventions .Administer treatment per physician orders .observe skin condition with ADL (activities of daily living) care daily; report abnormalities .pressure redistributing device on bed .provide preventative skin care routinely and as needed . A review of Resident 18's Progress Notes, documented by LVN 8, dated March 20, 2023, at 2:33 p.m., indicated, .Charge nurse reported that cna reported open areas to right buttock upper, right lower buttock, and right lower fold of buttock. #1 wound right upper buttock 1.8x3.0x0.1, #2 Right lower buttock 2.0x1.0x0.1, and right lower fold of buttock 1.0x0.4x0.2 . There was no documented evidence a comprehensive evaluation of Resident 18's wounds on the right upper buttock, right lower buttock, and right lower fold of buttock were in place to indicate the status of the wounds (description of the wound bed, presence of drainage, odor, signs, and symptoms of infection). A review of Resident 18's physician's orders, dated March 20, 2023, indicated the following: - .Right buttock upper buttock stg (stage) 2 - cleanse with wound cleanser, pat dry, Apply Medihoney on wound bed and cover with optifoam dressing (a waterproof adhesive foam dressing which absorbs wound drainage) in AM shift .; - .Right lower buttock stg 2 - cleanse with wound cleanser, pat dry, Apply Medihoney on wound bed and cover with optifoam dressing in AM shift .; and - .Right buttock fold stg 2 - Apply Medihoney on wound bed and cover with optifoam dressing in AM shift .; A review of Resident 18's Progress Notes, documented by the RD, dated March 21, 2023, at 1:51 p.m., indicated, .treatment continues to wounds to buttock for aid in healing, labs reviewed, appetite good, meet/exceed established needs, recommend Multivitamin with minerals for aid in healing open wounds . A review of Resident 18's Progress Notes, documented by LVN 8, dated March 23, 2023, at 2:48 p.m., indicated, .#1 wound right upper buttock, 1.8X3.0X0.1, #2 wound right lower buttock, 2.0X1.0X0.1, and right lower fold of buttock, 1.0X0.4X0.1. Patient will be added to wound treatment list, no change to wounds, continue with current plan of care . There was no documented evidence a comprehensive evaluation of Resident 18's wounds on the right upper buttock, right lower buttock, and right lower fold of buttock were in place to indicate the status of the wounds (description of the wound bed, presence of drainage, odor, signs, and symptoms of infection). A review of Resident 18's Progress Notes, documented by LVN 8, dated March 30, 2023, at 2:51 p.m., indicated, .#1woundright upper buttock, 1.8X0.2X0.1 with 70% slough 30% red tissue, #2 right lower buttock 1.0X1.0X0.1, and right lower fold of buttocks resolved. Wounds showing improvement with current treatment, continue with current plan of care . A review of Resident 18's Progress Notes, documented by LVN 8, dated April 6, 2023, at 2:50 p.m., indicated, .#1 wound right upper buttock 2.0X0.2X3.1 with 100% slough tissue, #2 right lower buttock resolved, and right lower fold of buttock resolved. Wounds showing improvement with current treatment, continue with current plan of care, MD (medical doctor) aware of progress of wounds . The wound on Resident 18's right upper buttock increased in size from March 20 to April 6, 2023. The wound on the resident's right upper buttock worsened from stage 2 wound (March 20, 2023) to unstageable due to presence of slough on the wound bed (March 30, 2023). There was no documented evidence the treatment interventions were evaluated for the right upper buttock when the size increased and had presence of slough on the wound bed. A review of Resident 18's Progress Notes, documented LVN 8, dated April 13, 2023, at 3:48 p.m., indicated, .#1 wound right upper buttock 2.0X0.2X0.1 with 70% slough 30% Beefy red tissue . A review of Resident 18's Progress Notes, documented by LVN 8, dated April 19, 2023, at 2:20 p.m., indicated, .MD was made aware of 70% slough and 30% red tissue, that if we can change tx (treatment) to Santyl oint (ointment), d/c (discontinue) medi honey. Md gave phone order to d/c mediHoney and change to Santyl oint . On April 21, 2023, at 2:40 p.m., a group interview was conducted with the ADM, DON, Registered Nurse (RN) 1, LVN 1, the RD, RN 3, LVN 9, and LVN 6. The interviews were as follows: - LVN 1 stated the licensed nurse would take the measurements of the PI, evaluate/assess the wound bed, drainage, edges, and periwound appearance when a PI was identified. She stated the physician was to be notified for treatment orders, document in the resident's record and add the resident on the wound list. - LVN 1 stated wound evaluation were to be done weekly and documented in the resident's record. She stated the physician was involved when the wound started and when the wound worsens. - LVN 1 stated they should fill out a spreadsheet indicating residents with PI with the description of the wound and location. She stated the spreadsheet was not accurately filled out to describe the status of the resident's wounds. - LVN 1 stated she did not involve the RD with wound management of the residents with PI because she was more focused on the skin-physical interventions and not the nutrition component. - The DON stated the RD should be involved with the wound status to be able to give appropriate nutritional recommendations. - The RD stated she would recommend the following to residents with PI: MVI with minerals, check on the resident's laboratory values, liquid protein or nutritional supplement, ensure the resident was eating well, and update the diet order as needed. She further stated nutritional interventions should have been started earlier. The ADM stated they have not conducted IDT meetings to address wound management for more than three months as they had multiple interim DONs and confirmed wound management had fallen through the cracks. - The ADM, DON, RN 1, LVN 1, the RD, RN 3, LVN 9, and LVN 6 all agreed Resident 18's P/I should have been addressed and evaluated appropriately if IDT meetings were done weekly. On April 24, 2023, at 3:20 p.m., LVN 7 was observed to provide wound care to Resident 18. LVN 7 removed the soiled dressing on Resident 18's right upper buttock. In a concurrent interview with LVN 7, he stated the wound on the right upper buttock had mild serosanguinous drainage, measured at 2.7 cm X 1.7 cm X 1.2 cm, with undermining of 0.4 cm from 1 to 2 o'clock, wound bed 70% granulation, 20% necrosis, 10% slough, with macerated edges. 4. On April 17, 2023, at 11:45 a.m., an observation and interview were conducted with Resident 357. Resident 357 was observe lying in bed, with contracture (shortening/hardening of joints) on the right hand. In a concurrent interview with Resident 357, she stated the staff did not provide incontinent care often enough. On April 20, 2023, Resident 357's medical record was reviewed. Resident 357 was admitted to the facility on [DATE], with diagnoses of contractures of muscle, throat cancer, protein calorie malnutrition, and pressure ulcer of the sacrum (a triangular bone located at the base of the spine). A review of Resident 357's history and physical examination, dated April 19, 2023, indicated Resident 357 had limited ability to make decisions. A review of Resident 357's Progress Notes, documented by LVN 14, dated April 12, 2023, at 11:45 p.m., indicated, .Initial skin assessment completed .Non blanchable redness to coccyx and sacral area .Reddened around site . A review of Resident 357's Progress Notes, documented by LVN 8, dated April 13, 2023, at 3:33 p.m., indicated, .Skin assessment by wound team .Coccyx with UTD (unable to be determined - unstageable) 2.0x5.0 black eschar intact stable with surrounding tissue with discoloration . A review of Resident 357's physician's order, dated April 13, 2023, indicated, .Coccyx pressure injury UTD - cleanse with wound cleanser, pat dry. Apply Barrier cream and cover with foam dressing in AM (morning) shift and PRN if soiled or dislodge (sic) . A review of Resident 357's care plan titled, At risk for alteration in skin integrity related to: impaired mobility; incontinence, malnutrition, dated April1 13, 2023, indicated, .Goal .decrease/minimize skin breakdown risks .Interventions .Barrier cream to peri area/buttocks as needed .encourage to reposition as needed; use assistive devices as needed .observe skin condition with ADL (activity of daily living) care daily; report abnormalities . A review of Resident 357's Progress Notes, documented by the RD, dated April 18, 2023, at 10:23 a.m., indicated, .no pressure related skin issues . non blanchable redness to coccyx and sacral area .Recommend .Multivitamin with minerals due to inadequate intake and RD to f/u prn . The nutritional evaluation conducted by the RD on April 18, 2023, indicated Resident 357 had a non-blanchable redness (stage 1) on the coccyx which contradicted the progress note documented by LVN 8 which indicated an unstageable PI on Resident 357's coccyx. There was no documented evidence a weekly wound evaluation/assessment was conducted by the licensed nurse on April 20, 2023, in accordance with the facility's policy and procedure. On April 21, 2023, at 2:40 p.m., a group interview was conducted with the ADM, DON, Registered Nurse (RN) 1, LVN 1, the RD, RN 3, LVN 9, and LVN 6. The interviews were as follow: - LVN 1 stated the licensed nurse would take the measurements of the PI, evaluate/assess the wound bed, drainage, edges, and peri wound appearance when a PI was identified. She stated the physician was to be notified for treatment orders, document in the resident's record and add the resident on the wound list. - LVN 1 stated wound evaluation were to be done weekly and documented in the resident's record. She stated the physician was involved when the wound started and when the wound worsens. - LVN 1 stated they should fill out a spreadsheet indicating residents with PI with the description of the wound and location. She stated the spreadsheet was not accurately filled out to describe the status of the resident's wounds. - LVN 1 stated she did not involve the RD with wound management of the residents with PI because she was more focused on the skin-physical interventions and not the nutrition component. - The DON stated the RD should be involved with the wound status to be able to give appropriate nutritional recommendations. - The RD stated she would recommend the following to residents with PI: MVI with minerals, check on the resident's laboratory values, liquid protein or nutritional supplement, ensure the resident was eating well, and update the diet order as needed. She further stated nutritional interventions should have been started earlier. - The ADM stated they have not conducted IDT meetings to address wound management for more than three months as they had multiple interim DONs and confirmed wound management had fallen through the cracks. The ADM, DON, RN 1, LVN 1, the RD, RN 3, LVN 9, and LVN 6 all agreed the resident's P/I should have been addressed and evaluated appropriately if IDT meetings were done weekly. On April 24, 2023, at 3:23 p.m., a concurrent observation and interview were conducted with LVN 7. LVN 7 was observed to perform wound care on Resident 357. LVN 7 was observed to remove the dressing to the coccyx wound. In a concurrent interview with LVN 7, he stated Resident 357's coccyx wound had mild exudate of serous fluid, measured 5.3 cm x 5.7cm x 0.1cm (size increased from April 13, 2023, evaluation), with macerated edges, wound bed with approximately 30% granulation, 60% maceration, and 10% excoriation. LVN 7 stated the dressing with calazime zinc paste was not the best treatment plan for Resident 357's wound because the eschar tissue is gone and there is mild exudate from the wound. 5. On April 18, 2023, at 10:12 a.m., an observation and interview were conducted with Resident 49. Resident 49 was observed laying in bed. A trapeze device was observed placed above the resident's bed and a pressure relieving cushion in his wheelchair. Resident 49 stated he had a bed sore on his backside. Resident 49 stated he could sit on the side of the bed and needed assistance to stand up and transfer. On April 19, 2023, Resident 49's medical record was reviewed. Resident 49 was admitted to the facility on [DATE], with diagnoses which included diabetes mellitus (DM), peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and sacral pressure ulcer (lower back/pelvis area, injury to skin and underlying tissue from prolonged pressure on skin). A review of Resident 49's history and physical, dated October 17, 2022, indicated Resident 49 had the capacity to understand and make decisions and the resident required maximum assistance with care and was unable to sit for prolonged periods. A review of Resident 49's Progress Notes, documented by LVN 8, dated March 8, 2023, at 3:07 p.m., indicated, .Pressure stage 2 1.0X0.8X0.5 .Exudate: scant, serous drainage Tissue: red granulation tissue, Edges attached to wound bed, Odor: no, S/Sx (Signs and Symptoms): no . Pressure injury reported by cna (Certified Nursing Assistant), that pt was complaining of discomfort. t (sic) was assessed by wound team and noted pressure injury to right upper gluteal (buttock) . A review of Resident 49's physician's order, dated March 8, 2023, indicated, .Right gluteal stg (stage) 2 - cleanse with wound cleanser, pat dry. apply Medihoney to wound and cover with Optifoam foam dressing in Am, and PRN if soiled or dislodge every day shift . A review of the NPIAP PI staging guidelines, indicated a wound with granulation tissue is stage 3. The wound assessment conducted on March 8, 2023, indicated presence of granulation tissue but was evaluated by LVN 8 as stage 2. A review of Resident 49's Progress Notes, documented by the RD, dated March 8, 2023, did not include presence of PI on Resident 49's right upper buttocks. There was no documented evidence a weekly wound assessment was conducted on Resident 49's wound on the right upper buttock on March 16 and 23, 2023, in accordance with the facility's policy and procedure. A review of Resident 49's Progress Notes, documented by LVN 8, dated March 30, 2023, at 2:22 p.m. indicated, .Pressure stage 2- 1.0X0.5x0.5 .Exudate: scant, serous drainage Tissue: red granulation, Edges attached to wound bed, Odor: no, S/Sx: no . Pressure injury improving and treatment effective, wound round in shape, wound bed with 100% red beefy red tissue without slough. Surrounding tissue pink/normal . A review of Resident 49's Progress Notes, documented by LVN 8, dated April 6, 2023, at 12:41p.m., indicated, .Pressure: stg 2- 1.3X1.5x0.5 .Exudate: scant, serous drainage .Tissue: red granulation tissue, without slough, Edges attached to wound bed, Odor: no, S/Sx: no .Pressure injury increase in size d/t (due to) patient staying up in wheelchair for long periods of time. Patient was instructed to minimize hours in wheelchair, plus MD (physician) has talked to patient as well to decrease time in wheelchair to improve healing of right buttock pressure injury. Wound round in shape, wound bed with 100% red beefy red tissue without slough. Surrounding tissue pink/normal. MD aware of progress of wounds, continue with current tx in place . A review of Resident 49's Progress Notes, documented by LVN 8, dated April 13,2023, at 3:51 p.m., indicated, .Pressure: stg 2- 1.3X1.5x0.5 .Exudate: scant, serous drainage, Tissue: red granulation tissue, without slough, Edges attached to wound bed, Odor: no, S/Sx: no . Pressure injury increase in size d/t patient staying up in wheelchair for long periods of time. Pt was instructed to minimize hours in wheelchair, plus MD has talked to patient as well to decrease time in wheelchair to improve healing of right buttock pressure injury. Wound round in shape wound bed with 100% red beefy red tissue without slough. Surrounding tissue pink/normal. MD aware of progress of wounds, continue with current tx in place . A further review of Resident 49's record indicated a follow up nutritional evaluation was conducted by the RD when the resident's wound on the right upper buttocks increased in size. On April 21, 2023, at 2:40 p.m., a group interview was conducted with the ADM, DON, Registered Nurse (RN) 1, LVN 1, the RD, RN 3, LVN 9, and LVN 6. The interviews were as follow: - LVN 1 stated the licensed nurse would take the measurements of the PI, evaluate/assess the wound bed, drainage, edges, and peri wound appearance when a PI was identified. She stated the physician was to be notified for treatment orders, document in the resident's record and add the resident on the wound list. - LVN 1 stated wound evaluation were to be done weekly and documented in the resident's record. She stated the physician was involved when the wound started and when the wound worsens. - LVN 1 stated they should fill out a spreadsheet indicating residents with PI with the description of the wound and location. She stated the spreadsheet was not accurately filled out to describe the status of the resident's wounds. - LVN 1 stated she did not involve the RD with wound management of the residents with PI because she was more focused on the skin-physical interventions and not the nutrition component. - The DON stated the RD should be involved with the wound status to be able to give appropriate nutritional recommendations. - The RD stated she would recommend the following to residents with PI: MVI with minerals, check on the resident's laboratory values, liquid protein or nutritional supplement, ensure the resident was eating well, and update the diet order as needed. She further stated nutritional interventions should have been started earlier. - The ADM stated they have not conducted IDT meetings to address wound management for more than three months as they had multiple interim DONs and confirmed wound management had fallen through the cracks. - The ADM, DON, RN 1, LVN 1, the RD, RN 3, LVN 9, and LVN 6 all agreed the resident's P/I should have been addressed and evaluated appropriately if IDT meetings were done weekly. The facility's policy and procedure titled, Skin Management Guidelines, dated March 2022, was reviewed. The policy indicated, .Purpose .to describe the process steps required for identification of patients at risk for the development of skin alterations, identify prevention techniques and interventions to assist with the management of pressure injuries .Pressure injury can present as intact skin or an open ulcer and may be painful .injury occurs because of intense and, or prolonged pressure .intrinsic factors that follow the patient regardless of care setting may increase the risk of skin alterations and pressure injuries include .immobility .incontinence .Diabetes Mellitus .previous history of pressure ulcer .Body audits are completed: By the licensed nurse daily for pressure injuries and documented on the eTAR; new findings are documented in a progress note .weekly for patients without pressure injuries .wound rounds are completed weekly .The wound team consists of the unit manager, licensed nurse, and nursing assistant. The director of nursing medical practitioners, rehabilitation team members and the registered dietitian may participate in wound rounds if available .Wound rounds should be held on a consistent day of the week and time of day to assure wounds are evaluated no less often than weekly. The role of the wound team is to provide assistance with ongoing management and monitoring of pressure injuries .selecting the most optimal treatment strategies and evaluation and revision of the patient specific plan of care .Documentation should include wound location .presence of exudate/odor, tissue type, measurements, presence of undermining and tunneling, description of periwound .indications of pain or infection, notifications to medical practitioner and patient/responsible party . Based on observation, interview, and record review, the facility failed to ensure care and treatment for pressure injuries (P/Is - localized damage to the skin and underlying soft tissue over a bony prominence or from a medical device) were provided, for five of five residents reviewed for pressure injuries (Residents 98, 92, 18, 357, and 49), when: 1. The facility staff did not assess or evaluate the staging of pressure injuries in accordance with standards of practice. In addition, there was a delay in providing further interventions/treatment of the P/Is; and 2. The facility did not have a process in the timely notification of the Interdisciplinary Team (IDT - a group of healthcare professionals), which included the Registered Dietitian (RD). The RD did not have a process to ensure accurate information of the P/Is were provided to apropriately assess and provide nutritional treatment and/or services to promote healing of the P/Is. On April 21, 2023, at 6:42 p.m., the Administrator (ADM) and the Director of Nursing (DON) were verbally notified of the Immediate Jeopardy (IJ- situation in which the provider's noncompliance with one or more requirements of participation has caused or likely to cause serious injury, harm, impairment, or death to a resident), due to the facility's failure to accurately and timely assess/evaluate and provide the appropriate interventions to address the P/Is for five residents (Residents 98, 92, 18, 357, and 49). These failures resulted in the delay and provision of additional care and treatment which led to the worsening condition of the P/Is for Residents 98, 92, 18, 357, and 49. On April 22, 2023, at 3:51 p.m., the ADM presented an acceptable plan of actions which included the following: - Identified residents (Residents 98, 92, 18, 357, and 49) and other residents identified with pressure ulcers were reassessed and evaluated by the Wound Certified Registered Nurse; - Comprehensive assessment and an updated interdisciplinary care plan were completed for the identified residents and other residents with P/I; - Pain evaluations were completed for the identified residents and other residents with PI; - The RD reviewed the record of the residents with P/I and provided an updated nutritional assessment; - The treatment plan for the residents with PI were reviewed to ensure proper treatment were provided; - Braden assessment (an assessment tool to identify resident at risk for developing pressure injury) was completed for residents with P/I; - The residents with P/I's family and the physician were notified; - A house-wide skin sweep was initiated by the licensed nurses on April 21, 2023, to observe and validate skin status of current residents; - The care plan for residents with P/Is were reviewed and updated as needed by the IDT; - The RD initiated an assessment of the nutritional needs of the residents P/I; - Newly admitted residents would have an accurate comprehensive assessment performed by a Registered Nurse (RN) or evaluated by a Licensed Nurse (LN), followed by a second skin check performed by the member of nursing management (DON, RN Unit Manager) within 24 hours; - Newly admitted residents would have a Braden scale completed upon admission and weekly for 3 weeks and current residents Braden Scale were initiated by the LN to identify risk. Residents identified with moderate to high risk on the Braden Scale assessment would be reviewed to ensure appropriate preventative measures, intervention, and treatment orders were implemented; - LN and the Center's Wound Team were to be reeducated beginning April 21, 2023, by the DON/Designee on the facility's Skin Management Guidelines and the Skin Quick Reference Guide which includes monitoring the effectiveness of the wound treatment; - Wound rounds would be completed at least weekly by the wound team. The RN would ensure accurate assessment was conducted and the appropriate treatment and interventions were in place. Communication to the IDT would be done through the IDT report. The IDT would review the care plan weekly; and - The facility conducted a QA (Quality Assurance) meeting on April 21, 2023, and the Medical Director was notified. On April 24, 2023, at 6:58 p.m., the immediate jeopardy was removed in the presence of the ADM during the onsite survey, upon verification of the implementation of the plan of actions. The facility was notified an extended survey would be conducted due to substandard quality of care issues. Findings: A review of an article published by the National Pressure Injury Advisory Panel (NPIAP) titled, NPIAP Pressure Injury Stages, - .Stage 1 Pressure Injury .intact skin with a localized area of non-blanchable erythema (discoloration of the skin which does not turn white when pressed) .; - Stage 2 Pressure Injury .Partial-thickness loss of skin with exposed dermis (middle layer of the skin containing blood vessels and nerve endings) .The wound bed is viable (living tissue), pink, or red, moist .; - Stage 3 Pressure Injury .Full-thickness loss of skin in which the adipose (fat) is visible in the ulcer and granulation tissue (type of tissue that fill in the wound that is healing) .Slough (dead tissue usually light yellow/cream colored) and/or eschar (dead tissue appearing black or brown dry, thick, and leathery) may be visible .; - Stage 4 Pressure Injury .Full thickness skin and tissue loss with exposed or palpable fascia (connective tissue), muscle .bone in the ulcer. Slough and /or eschar may be visible .; - Unstageable Pressure Injury .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 .; - Deep Tissue Pressure Injury .Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration . 1. On April 17, 2023, at 3:58 p.m., Resident 98 was observed awake and lying on her left side in bed. Resident 98 was observed to have facial grimacing and moaning when she moved while lying in bed. In a concurrent interview with Resident 98, she stated she preferred to lay on the left side because she had a bed sore (pressure injury) on her buttocks. She stated it would hurt when she lay on her back. On April 20, 2023, Resident 98's record was reviewed. Resident 98 was admitted on [DATE], with diagnoses which included chronic obstructive pulmonary disease (COPD - type of lung disease). A review of Resident 98's Progress Note, dated March 2, 2023, at 10:30 p.m., indicated, .Patient's skin is warm, intact, no rashes noted. Plan of care is to prevent skin breakdown . A review of Resident 98's Medical History/Physical Examination, documented by the attending physician, dated March 7, 2023, indicated intact skin condition. A review of Resident 98's progress notes indicated the resident was sent out to acute hospital on March 10, 2023 and readmitted back to the facility on March 14, 2023. A review of Resident 98's Progress Notes, dated March 14, 2023, at 10:15 p.m., documented by the Licensed Vocational Nurse (LVN), indicated, .Head-to-toe skin assessment completed, dry skin noted to BLE (bilateral extremities) and open are (sic) noted to coccyx (tail bone). Open area is dry with pink wound bed . A review of Resident 98's physician's order, dated March 14, 2023, indicated, .Apply to Coccyx topically one time a day for Open wound clean with NS (normal saline - a solution used to clean wounds), apply calazime paste (a skin protectant to treat skin irritation), and cover with foam dressing . A review of Resident 98's ETAR (Electronic Treatment Administration Record), for the month of March to April 2023, indicated the calazime paste was administered to Resident 98 from March 15 to April 6, 2023. A review of Resident 98's Progress Notes, dated March 15, 2023, at 6:02 p.m., documented by the LVN, indicated, .Pt (patient) has a small open area on left buttock measuring 1 cm (centimeter - unit of measurement) x (by) 0.5 cm x (by) 0.1 epithelial (thin tissues covering all the exposed surfaces of the body) wound bed, no exudate (drainage) no odor, no infection . A review of Resident 98's physician's order, dated March 15, 2023, indicated, .Cleanse open area on left buttocks with NS (normal saline) and past (sic) dry, apply medihoney (medication to aid with healing for P/Is) and cover with a foam dressing every day shift . A review of Resident 98's Progress Notes, documented by the Registered Dietitian (RD), dated March 15, 2023, at 6:17 a.m., indicated, .Nutrition/Weight .Patient admitted with open area to coccyx. Recommend MVI (multivitamins) with minerals for aid in healing and RD assessment to follow . A review of Resident 98's care plan, dated March 15, 2023, indicated, .Resident has open wound to coccyx .Goal .Show s/s (signs and symptoms) of healing within normal limits of disease .Administer treatment per physician orders .Dietary consult . A review of Resident 98's Minimum Data Set (MDS - an assessment tool), dated March 21, 2023, indicated the following: - BIMS (Brief Mental Status) score of 15 (cognitively intact - with sufficient judgment and able to manage normal demands of the environment); - Required extensive assistance with bed mobility, transfers, and toilet use; and - Incontinent with bowels. A review of Resident 98's Progress Notes, documented by the RD, dated March 22, 2023, at 2:02 p.m., indicated, .RD readmission/wound note .Patient readmitted with COPD exacerbation .Treatment continues to open are (sic) noted to coccyx and small open area on left buttock .Albumin (protein level in the body) 2.6 low .Recommend .Ensure daily for increased protein d/t (due to) low albumin and RD to f/u (follow up) prn (as needed) . A review of Resident 98's Progress Notes, documented by the LVN 1, dated March 23, 2023, at 2:40 p.m., indicated, .weekly wound measurement, pt (patient) has an open area that now presents with slough and clinically appears as a stage 3. Measures 3.5cm x 3cm x 0.2c[TRUNCATED]