**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure resident care consistent with professional standards of practice, to prevent avoidable pressure ulcers (injuries) for two (#63 and #85) of four residents reviewed out of 39 sample residents. Resident #63 was admitted with dementia and muscle weakness and required extensive two-person assistance for mobility and transfers. This made the resident at risk for skin breakdown. The facility was aware of the resident's condition and failed to implement offloading, pressure relieving interventions until after the resident developed pressure ulcers. The resident had developed five facility-aquired pressure ulcers, two of which were stage 4, and two were unstageable. Furthermore, some interventions that were implemented were not person-centered or effective to assist the ulcers in healing (see observations and physical therapist interview). Additionally, the facility failed to monitor an implemented intervention of a Roho cushion (pressure relief cushion, made of soft flexible aire cells) for Resident #85 to ensure it was inflated and provided the appropriate amount of offloading required to promote healing of a pressure ulcer to the right buttocks. Findings include: I. Facility policies and procedures The Pressure Injury Prevention policy, revised October 2019, was provided by the clinical assistant (CA) on 2/10/2020 at 3:22 p.m. The policy required staff to: -Upon Admission, complete an initial skin risk assessment by utilizing the admission nursing data collection evaluation in the electronic medical record to identify a resident risk factor for development of pressure injuries. -The facility will then complete a Braden scale for predicting pressure sore risk tool upon admission. -The facility will implement a care plan to identify potential risk for development of pressure injuries to include the identified risk (quoted in original) factors. -The facility nursing assistants will complete a skin observation (quoted in original) and document finding by completing the every shift skin observation question in electronic medical record. The skin observation documentation is reviewed by a supervisor or designee daily. An abnormal finding will be reported to the director of nursing (DON) who will initiate additional follow-up. -When a pressure injury is identified, the nurse will obtain a physician order and initiate a prescribed treatment. -The facility will consult with PT/OT about appropriate wheelchair cushion/ positioning as needed. The Pressure Injury Management policy, revised October 2019, was provided by the clinical assistant (CA) on 2/10/2020 at 3:22 p.m. The policy documented in pertinent part: -The charge nurse or designee will be responsible to complete an initial narrative note in the resident's medical record to describe the residents' identified risk factors and a description of how the pressure injury most probably occurred if known. -Risk factors may include but not limited to impaired/ decreased functional mobility, comorbid conditions, such as diabetes mellitus, drugs such as steroids that may affect healing, impaired diffuse or localized blood flow, undernutrition, malnutrition and hydration deficits etc -A care plan will be initiated to identify actual skin breakdown to include identified related to risk factors (quoted in original) and individualized (quoted in original) interventions to aid in wound healing -The resident's pressure reducing surfaces (wheelchair and mattress) will be re-evaluated. An upgrade will be made if indicated. -Resident will be offered position changes at least every two hours unless otherwise specified per their care plan. -Any resident who has a pressure injury, nursing will be responsible to complete daily documentation on the monitoring of the wound in the progress note section of the medical record. -Weekly, the wound nurse or designee will conduct wound rounds and document the evaluation in the medical record. -The facility will have an interdisciplinary team (IDT) meeting to review current treatment plans and initiate any revisions/ changes to the plan of care as indicated. II. Failure to prevent unstageable pressure injuries for a resident with known risk A. Resident #63 status Resident #63, age [AGE], was admitted on [DATE], and readmitted on [DATE]. According to the February 2020 computerized physician's orders (CPO), diagnoses included Alzheimer's dementia, anemia, congestive heart failure, and muscle weakness. The 1/15/2020 minimum data set (MDS) assessment documented the resident was severely cognitively impaired with a brief interview for mental status (BIMS) score of four out of 15. She required extensive two person assistance with bed mobility, dressing, toileting, personal hygiene and bathing. She was totally dependent on staff for transfers. She required supervision to eat. She had six unstageable, deep tissue injuries (DTIs) due to pressure. Two of the wounds were present on admission. Four of the wounds were acquired at the facility. One of the wounds was covered in eschar (necrotic dead tissue). B. Record review 1. Five facility acquired wounds On 2/13/2020 at 10:15 a.m., the clinical advocate (CA) provided a timeline for five (one more than identified on the MDS on 1/15/2020) facility acquired wounds which documented: -Right posterior medial heel, onset date 10/1/19. Initial measurements 4.0 cm (centimeters) long x 5.0 cm wide x 0 cm deep. Current measurements on 2/10/2020 were 0.8 cm long x 1.6 cm wide x 0.2 cm deep. The current treatment was to cleanse with normal saline, apply skin prep to the periwound, Collagen Alginate, cut to fit wound, cover with Allevyn, wrap with kerlix, change three times per week and as needed. -Left plantar lateral heel, onset date 10/1/19. Initial measurements 3.4 cm long x 3.0 cm wide x (unable to determine depth). Current measurements on 2/10/2020 were 0.5cm long x 0.3 cm wide x 0 deep. Current treatment was skin prep to periwound, cover with hydrocolloid dressing, change three times per week and as needed. -Left medial first (not marked on any diagram) foot, onset date 12/9/19, initial measurements 0.6 cm long x 0.3 cm wide x (unable to determine depth). The wound resolved 1/27/2020. -Left plantar heel, onset 12/23/19, initial measurements 0.9 cm long x 0.6 cm wide by 0 cm deep, measurements on 2/10/2020 were 0.6 cm long x 0.2 cm wide x 0 cm deep. Current treatment was skin prep to periwound, cover with hydrocolloid dressing, change three times per week and as needed. -Right distal first toe, onset date 1/6/2020, initial measurements, 0.4 cm long x 0.7 cm wide x 0 cm deep. The wound resolved on 2/10/2020. 2. Delayed treatment after wounds developed The timeline further documented an air mattress was implemented on 10/18/19, 17 days after the heel wounds were identified. Blue lift boots were ordered 10/17/19, 16 days after the heel wounds developed. A nutritional supplement, four ounces three times a day, was added 10/18/19. This was 17 days after the heel wounds developed. Prevalon boots were not ordered until 10/28/19. 3. Facility knowledge of pressure injury risk and failure to implement timely prevention/healing measures The Braden skin risk assessment dated [DATE], prior to the development of the wounds, documented the resident's mobility was very limited and friction and shearing were a problem. The resident scored a 13, moderate risk. The Braden scale documented scores, at risk score were 15-18, moderate risk 13-14, high risk 10-12, very high risk 9 or below. However, the facility failed to implement any repositioning, turning or offloading interventions at that time. The MDS assessment dated [DATE], prior to the onset of the wounds, documented Resident #63 was at risk for developing pressure injuries. She was not on a turning or positioning program. She was on a pressure reduction mattress. She required extensive one person assistance with bed mobility and extensive two person assistance with transfers. However, the facility failed to implement any turning, offloading or repositioning interventions at that time. The CPO dated February 2020 was reviewed. There was an order initiated 10/17/19 to offload heels at all times. Heel lift boots and pillow while in bed. This was 16 days after the wounds developed. There was an order dated 10/18/19 for blue lift heel boots on at all times to both feet. This was 17 days after the heel wounds were acquired in the facility on 10/1/19. There was no order for any kind of air mattress. The care plan initiated 7/21/19, prior to the development of the wounds, was reviewed. The care plan did not document any type of repositioning or offloading of the feet/heels despite the known risk identified in the MDS and Braden risk assessment. The care plan documented potential impairment to skin integrity related to fragile skin and increased use of wheelchair, and reduced walking. Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Encourage good nutrition and hydration in order to promote healthier skin. Keep skin clean and dry. Use lotion on dry skin. The current care plan, initiated 12/10/19, documented Resident #63 had pressure injuries to her bilateral lower extremities. Interventions included: encourage good nutrition, keep skin clean and dry, monitor pain level, obtain lab and diagnostic work as ordered, pressure relieving mattress, weekly skin check by nurse, and wound team. The care plan did not include interventions to offload the heels or use protective offloading boots despite the current orders and known wounds to the heels and feet. The care plan did not include the use of an air mattress. The nurse's note, dated 9/30/19 at 11:02 p.m. (one day before the heel wounds were documented), was reviewed. The nurse's note documented the heels are intact, blanching well, pink and firm. 4. Deep tissue injuries identified to bilateral heels The nurse's note dated 10/1/19 at 3:00 p.m. was reviewed. Deep tissue injury pressure areas noted to bilateral lateral aspect of heels during shower. Left lateral heel 4 x 3 cm, right 4 x 2 cm, both 100 percent deep tissue injuries. -Left heel skin open so dressing applied for protection. Tight fitting shoes removed. Will offload with heel boots during the day and offload with boots and pillows at bed time. These interventions were not included in the care plan. The physician wound notes on 10/7/19, one week after the development of the wounds to the right medial heel and left lateral heel, were reviewed. -The wound notes documented, the resident had an unstageable, DTI of the right, posterior, medial heel for at least six days duration. There was no exudate (drainage). The resident appeared to have associated pain evidenced by restlessness. Measurements were 4.0 cm x 5.0 cm x depth was not measurable. -The left lateral heel was unstageable due to necrosis (dead tissue), there was moderate serosanguinous drainage (clear fluid mixed with blood) and the wound measured 3.4 cm length x 3.0 cm wide x depth was not measurable. -Discussed etiology of her wounds and advised of the importance of offloading her heels. The physician wound notes dated 1/27/2020 were reviewed. The physician documented both heels were stage four wounds. The physician documented off load wounds, prevalon boots instead of bunny boots, pillow between her legs when she is on her sides especially on left which she favors and also under her legs when she is on her sides. However, the care plan and the February 2020 CPO did not document orders for Prevalon boots or offloading the resident with pillows when she was positioned on her side. 5. Additional, unstageable pressure ulcer identified to left plantar heel; bilateral heel wounds assessed as stage IV The physician notes, dated 1/6/2020, for the wound to the left plantar heel, developed 12/23/19 were reviewed. The physician documented the left plantar wound was 0.8 cm long x 0.3 cm wide x not able to measure depth. It was a pressure injury, an unstageable wound, deep tissue injury with intact skin. The wound had no exudate (drainage). Off-load wound. The note summary by the physician on 1/6/2020 documented the right posterior heel was a stage 4 pressure wound, the left lateral heel was a stage four pressure wound, the left plantar foot was an unstageable DTI. 6. Most current wound assessment/condition - two unstageable pressure injuries The nursing pressure injury reports for 2/3/2020 were reviewed. On 2/3/2020, the right medial heel was documented as unstageable, 0.8 cm long x 1.7 cm wide x 0.25 cm depth. The wound had a moderate amount of drainage, serosanguinous.The resident had granulation tissue (pink, red shiny) and slough (yellow white tissue). The resident was to be premedicated before the wound care for pain. On 2/3/2020, the left lateral heel was documented as unstageable, 0.5 cm long x 0.4 cm wide x 0 depth. The wound bed was necrotic tissue with eschar, black brown or tan in color. There was no drainage. The resident was to be premedicated before wound care for pain. On 2/3/2020, the left plantar heel was documented as a stage one, 0.7 cm long x 0.3 cm wide x 0 cm deep. The wound bed had new epithelial tissue growing, light pink and shiney. C. Observations and interview On 2/10/2020 at 10:30 a.m., the resident was up in a wheelchair with her legs lifted and extended, with soft light blue boots on each foot. Her heels were not off loaded. On 2/11/2020 at 1:09 p.m, the resident was in bed, blue soft boots were noted on both feet. Her heels were floated. On 2/13/2020 at 11:10 a.m., the resident was observed with the physical therapist (PT) in the dining room. Both feet were in soft blue boots which had an opening at the heel. The PT confirmed the boots were lift boots. Her feet were covered with kerlix wrap except the toes which were edematous. Her heels were not off loaded D. Interviews and record review Registered nurse (RN) #1 was interviewed on 2/13/2020 at 10:37 a.m. She said the resident was basically bed bound at the time the wounds were found, the night nurse found them. She said, They were from pressure on the bed and probably in the wheelchair. She could not move herself. Certified nurse aide (CNA) #6 was interviewed on 2/12/2020 at 10:45 a.m. She said she knew the resident well and had worked on the residents hallway over the last year. She said Resident #63 had never been able to move in the bed. She said she had to be transferred with a lift. CNA #6 said the nursing staff did not put boots on the resident or offload her heels on a pillow until after the wounds occurred despite her immobility in bed. The director of nursing (DON) was interviewed on 2/12/2020 at 10:46 a.m. She said the wounds could not be observed because the treatment had already been done and was not due again until Saturday. The DON was interviewed again 2/12/2020 at 12:47 p.m. She said the wound could not be observed by looking under the dressing because the resident was in too much pain with dressing changes. She said, She is on Roxanol because she has so much pain with dressing changes so I do not want to lift the dressing for you to see it. The pain assessments were reviewed on the medication administration record (MAR). The resident received morphine before a dressing change on 2/3/2020 for a documented pain level of zero and 2/10/2020 for a documented pain level of two. The morphine ordered on the February CPO, dated 1/29/2020, documented to give morphine sulfate 20mg (milligram)/ml (milliliter), 5mg by mouth before dressing changes weekly. However, the dressing changes were three times a week and as needed. There was no documentation to show the facility requested order clarifications or changes. The CA was interviewed on 2/12/2020 at 1:11 p.m. She said the resident only had pain when the wounds were debrided. She said she would have the morphine order clarified. The CA said she had been at the facility for four years and had been doing the weekly wound assessments for this resident. She said she did not know how the wounds occured. She said she did rounds with the wound care physician weekly. The DON was interviewed again on 2/12/2020 at 2:34 p.m. She said the nurses told her the resident had pain with the wound care treatments. She said that may not be totally accurate after reviewing the records for morphine and pain. She said the wound could still not be observed because there would be too much risk of infection to look under the dressings. Although the facility was aware of Resident #63's risk for skin breakdown, they failed to prevent unstageable pressure injuries from developing. III. Resident #85 A. Resident status Resident #85, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPO), diagnoses included paraplegia, unspecified, other vascular myelopathies, hereditary and idiopathic neuropathy, phlebitis and thrombophlebitis of unspecified deep vessels of unspecified lower extremity, personal history of nicotine dependence, hyperlipidemia, unspecified, personal history of other venous thrombosis and embolism, polyneuropathy, unspecified, osteoarthritis of hip, long term (current) use of insulin, neuromuscular dysfunction of bladder, unspecified, other chronic pain, opioid dependence, uncomplicated, periapical abscess without sinus, type 2 diabetes mellitus with other diabetic neurological complication, type 2 diabetes mellitus with other circulatory complications, encounter for change or removal of nonsurgical wound dressing, pressure ulcer of other site, stage III was added to the list of diseases on 11/26/19. The 1/20/2020 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. The resident required two persons physical assistance with bed mobility, transfers, dressing and toilet use. She also required one person physical assistance with personal hygiene.The assessment identified that the resident was at risk of developing pressure injury. It was further documented that the resident had developed a stage III pressure ulcer. The resident was not on a repositioning program. The resident did not not reject care. B. Resident wheelchair chair observations and record review A physician's order (PO), dated 4/17/19 revealed to monitor roho cushion for proper inflation per (Q) shift. Resident #85's wheelchair was observed on 2/10/2020 at 11:17 a.m. while it was positioned by the resident's bedside. The wheelchair was electric powered and had a roho cushion on it. The roho cushion was deflated and relatively flat to provide any type of cushioning off loading effect See observation below with the therapy program manager. Resident #85's wheelchair was observed on 2/11/2020 at 2:38 p.m. while it was positioned by the resident's bedside. The wheelchair had a roho cushion on it. The roho cushion was deflated and relatively flat to provide any type of cushioning effect. Resident #85's wheelchair was observed on 2/12/2020 at 12:46 p.m. while the resident sat in it. The therapy program manager (TPM) observed the level of inflation of the roho cushion and reported that the cushion was almost completely out of air. Specifically, the therapy manager stated yes the cushion is definitely not cushioning with this level of inflation, there is almost no air in this. The TPM demonstrated the procedure of checking the appropriateness on the inflation of the roho cushion by first seeking and obtaining consent from the resident, he then placed his right hand between the roho cushion and the wheelchair seat, he performed this procedure while the resident sat in the cushion. Therapy program manager was interviewed on 2/12/20 at 12:49 p.m., The TPM verified that the roho cushion was underinflated per his observation as discussed above. He did not recall providing any education to nursing staff on how to check for the proper inflation of the roho cushion. He stated pumping the roho cushion was a primary responsibility of the restorative staff. He verified that nursing staff do not have access to the pump utilized in pumping the roho cushion. He reviewed the resident's PT/OT record and verified that the last time the resident was on their caseload was 10/6/19 through 10/15/19 and that the sessions were primarily for passive range of motion for the residents legs relative to their position while the resident sat in her wheelchair. Certified nurse aide (CNA #8) who transferred the resident to her wheelchair was interviewed on 2/12/20 at 1:03 p.m. about her knowledge of how and when to check the inflation level of the roho cushion. CNA #8 stated she does not know how much air to pump it in, she stated she once tried to pump air in a cushion for another resident, but did the procedure wrong and she pumped too much air which was not beneficial to the resident. She concluded the interview stating she did not recall when last she checked the air in cushions. CNA #9 who assisted CNA #8 with transferring Resident #85 was interviewed on 2/12/2020 at 1:07 p.m. The CNA stated she lacked knowledge of the need to check the roho cushion prior to transferring the resident on it. She said she does not know when to check the inflation level of the roho cushion. She said she does not know where the cushion pump is kept. C. Mattress observation and record review A physician order, dated 6/20/16 revealed to place Resident #85 on low air loss mattress and check air inflation and functioning every shift. The resident's mattress was observed on 2/12/2020 at 9:53 a.m. The mattress had [company name] alternating pressure with 10 low pressure mattress (LPM) compressor. The director of nursing (DON) was interviewed on 2/13/2020 at 10:47 a.m., she stated the mattress currently being utilized by Resident #85 was rented by the facility to accommodate the residents' need. She provided information about the suitability of the mattress to be utilized for a stage 1-4 pressure ulcer. Specifically, the DON provided documentation which reads {company name] CG9900 alternating pressure mattress replaced with probasic satinair alternating pressure low air loss mattress. The document further revealed that the mattress currently in use by Resident #85 had been discontinued. (See follow-up below) D. Record review A review of the Braden scale assessment dated [DATE] (last assessment on the resident's medical record prior to development of the stage III pressure ulcer) revealed a score of 12. The resident had a score of 12 or high risk for the following reasons. Her sensory perception was slightly limited. She responds to verbal commands, but cannot always communicate discomfort or the need to be turned. OR has some sensory impairment which limits ability to feel pain or discomfort in 1 or 2 extremities. The resident is constantly moist. Her skin is kept moist almost constantly by perspiration, urine, etc. Dampness is detected every time the patient is moved or turned. The resident was bedfast (Confined to bed). She has very limited ability to change her body position. She makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. The resident also has potential for skin friction as she moves feebly or requires minimum assistance. During a move skin probably slides to some extent against sheets, chair or other devices. which was interpreted as high risk for developing pressure ulcer. -There were no changes made to the resident care plan to address the identified risk of diminished sensory perception, inability to adequately communicate discomfort or need to be turned, her limited ability to independently change her position and also her potential for skin friction. Another Braden Scale for predicting pressure sore risk was completed on 1/17/2020 at 1:57 p.m. The scale documented resident risk score as 11, which is interpreted as high risk. Per the facility's pressure injury prevention and management policy, a skin observation was to be conducted daily Q (every) shift and observation documented of any skin issues for at risk residents. However a review of Resident #85's pressure injury initial and weekly monitoring report (The first one done after discovery of the pressure ulcer) revealed that though the pressure ulcer was first identified on 11/26/19, a skin evaluation which revealed the pressure ulcer measurement of 1.5cmx0.8cmx0.1cm was not completed until 12/2/19. There was no prior documentation of any suspected skin issues around the area. The evaluation further identified the pressure ulcer as facility (In-House) acquired. There was no interdisciplinary team (IDT) note which documented investigation to find the root cause and analysis of the now identified in-house acquired pressure ulcer. The site of the ulcer was identified as the right buttocks. Exudate type was characterized as serous, and the amount of exudate was rated as small. There was no odor reported for the assessment. The wound bed was described as granulation tissue - pink or red with shiny, moist granular appearance and slough - yellow or white tissue that adheres to the ulcer bed in strings or thick clumps, or is mucinous. The surrounding skin color and surrounding tissue/wound edges were described as normal. The wound summary described the pressure ulcer as 30% slough, 20% granulation, 20% dermis and 30% subcutaneous. A review of the wound doctor's note dated 12/2/19 revealed,a documentation under the history of present illness portion of the assessment which reads ,At the request of the referring provider (Doctors name), a thorough wound care assessment and evaluation was performed today. Resident has a stage III pressure wound of the right buttocks for at least five days duration. There is light serous exudate. There is no indication of pain associated with the condition. Summarized wound care assessment and individualized treatment plan portion of the wound doctor's note reads Plan of care reviewed and addressed, my goal for this wound is healing as evidence by decrease in surface area of the wound and/ or a decrease in the percentage of necrotic tissue within the wound bed. The best medical estimate of the time required for this wound to heal with continued physician evaluation and intervention is 42 days. This estimate is made with an 80 percent (%) degree of certainty. The assessment also recommended to off-load wound and reposition per facility protocol. The Resident's primary care physician note dated 1/25/2020 at 12:19 p.m. documented that Resident #85 was quadriplegic with a recent overall decline following pneumonia. The note further documented that the resident was now on hospice. In addition, the note reported that Resident #85 had no feeling on her back side. Furthermore, the note documented that the resident was on a high end air mattress and that her oral intake has been poor and also that resident is provided protein supplement. It was also reported that the resident was up in her electric scooter several times a day but not more than an hour at a time. The report concluded that all appropriate steps were taken by staff but the decubitus pressure ulcer was unavoidable. The pressure ulcer care plan initiated on 2/3/2020 and revised on 2/3/2020 documented that the resident has hx(history) of pressure ulcers, DM and fragile skin, paraplegia and history of pressure sores in the same area, with surgical flap previously done. In addition, the care plan further documented that Resident #85 is on aspirin (ASA) causing frail skin increasing the risk of bruising and skin tears. Furthermore, it was documented that the resident at times prefers to sit up in her wheelchair for extended amounts of time. The care plan also identified that Resident #85 had a Stage IV pressure ulcer to her right buttocks and traumatic wounds to her right toes The interventions of the care plan documented to: -Administer medications as ordered. Monitor/document for side effects and effectiveness. -Administer treatments as ordered and monitor for effectiveness. -Encourage resident to change position and overload pressure by not sitting up in wheelchair for extended amounts of time. -Resident lays in bed without a brief or underwear per her preference. -Resident requires pressure relieving/reducing device on bed and chair -Low air loss mattress, check air inflation and functioning every shift -Monitor/document/report PRN any changes in skin status: appearance, color, wound healing, s/sx of infection, wound size (length X width X depth), stage. -Pressure relieving cushion(roho) to wheelchair -Skilled nursing documentation including skin assessments every shift while on skilled care. Weekly skin assessments for integrity and wound documentation while not on skilled care requirement. -Weekly skin check by licensed nurse. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate -Wound team to follow-up E. Wound observation The resident's right buttocks wound was observed on 2/12/20 at 12:13 p.m. with the director of nursing. The wound was approximately 1 cm in diameter, crater-maybe 0.2 cm deep. Wound bed red and moist no drainage, edges pink, no odor. Treatment done-wound cleaned with normal saline (NS), cut to fit calcium alginate, covered with hydrocolloid. Hand hygiene and clean field maintained. F. Interviews Resident #85 was interviewed on 2/10/2020 at 12:53 p.m., she stated she used to reposition herself in bed several months back but for a severe shoulder pain she has not been able to help herself. She added that she is not currently getting a specialized treatment to address her shoulder pain other than the generalized pain medication she was taken. She also said she does not get assistance with repositioning. Specifically, the resident stated They only come to get me out of bed into my wheelchair with the lift, and also to change out my brief when it was soaked, other than that, I am not offered repositioning. CNA #10 was interviewed on 2/13/2020 at 6:12 p.m. She stated she worked well with Resident #85. She listed the care she performed with Resident #85 which included transfers from wheelchair to bed and vice versa, bathing, toileting, grooming, dressing. She said she considered the moments when the resident's briefs are changed or when she was transferred to wheelchair as repositioning. She stated the resident could reposition herself. The CNA stated she typically applied barrier cream to the resident's groin and abdominal folds. She did not recall having had any directive instructing her to apply barrier cream to the resident's coccyx since the onset of her current stage III pressure ulcer. CNA #11 was interviewed on 2/13/2020 at 6:10 p.m. She stated Resident #85 was cooperative with care. The CNA said she would apply barrier cream to the resident's groin and abdominal folds. She did not recall having had any directive instructing her to apply barrier cream to the resident's coccyx since the onset of her current stage III pressure ulcer. The wound nurse (WN) was interviewed on 2/12/2020 at 1:28 p.m., She said the pressure ulcer to the resident's right buttocks was a facility acquired ulcer that started late November of 2019. She said she took the measurements of the resident's right buttocks wound and placed this information in the PCC. She said the resident's physician and the IDT could review the information in PCC. She said the wound doctor did visit the facility to look at the resident's right buttocks wound. She said the start date for this right heel wound was on 11/26/19.[TRUNCATED]