**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Based on observation, interview, and record review, the facility failed to document wound assessments for a resident (R1), failed to notify a physician of a resident's worsening pressure wound (R1), failed to obtain new treatment orders for a resident's pressure wound (R1), failed to identify signs of infection for a resident's pressure wound (R1), failed to provide wound care in a manner to prevent infection for a resident (R1), failed to identify three pressure wounds for a resident caused by a medical device (R4). These failures contributed to R1's pressure wound advancing from a Stage 2 to an unstageable wound that became infected and required hospitalization, surgical debridement, and placement of a wound vac (negative pressure wound therapy). These failures also resulted in R4 obtaining two stage 3 pressure wounds and one unstageable pressure wound. These failures apply to 2 of 7 residents reviewed for pressure ulcer prevention and treatment in the sample of 19. The findings include: The Immediate Jeopardy began on 10/21/22 when R4 obtained two Stage 3 pressure ulcers and one unstageable pressure ulcer as the result of a medical device. V1 (Administrator) was notified of the Immediate Jeopardy on 1/12/23 at 1:27PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 1/16/23, but noncompliance remains at a Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training. 1) R4's electronic face sheet printed on 1/12/23 showed R4 has diagnosis including but not limited to displaced fracture of right lower leg, fall, malignant neoplasm of prostate, weakness, and history of pulmonary embolism. R4's facility assessment dated [DATE] showed R4 has no cognitive impairment, 2 unstageable pressure ulcers, and 1 unstageable deep tissue injury. R4's nursing care plan dated 9/20/22 showed, Risk for impaired skin integrity due to decreased mobility and incontinence. R4's care plan update on 10/21/22 showed, (R4) has 3 pressure injuries caused by CAM (Controlled Ankle Motion) boot. Daily skin inspection; report any changes in skin or signs of possible skin breakdown or redness. R4's Orthopedic visit note dated 10/4/22 showed, CAM boot-skin checks. R4's daily skilled nursing notes showed, 10/8/22 staples removed, right ankle healing, dressing dry and intact. 10/10/22 excoriation to right foot related to CAM boot. 10/18/22 no new skin issues. (At this time, no wound assessments had been completed for R4.) R4's physician's orders for October 2022 showed, 10/10/22 apply gauze to right medial ankle, apply foam dressing to top of right foot, change daily. R4's nursing progress note dated 10/8/22 showed, Skin warm & dry with bruising to right lateral ankle, covered with (support bandage) under CAM boot, did not tolerate assessment of area well . R4's weekly skin checks for October 2022 showed, 10/13/22 treatment ordered for right foot. R4's weekly skin checks for the month of October were completed with no identification of 3 pressure wounds until 10/21/22. R4's wound assessment report for 10/21/22 showed, Pressure wound to right heel identified 10/21/22. Unstageable due to suspected deep tissue injury. 4.0x2.5cm. Injury caused by CAM boot. Area of injury is very firm. Cover with absorbent pad and gauze. Pressure wound to right medial malleolus identified 10/21/22. Unstageable due to slough and eschar. 2.0x1cm. 10/21/22 Pressure wound to right top of foot identified 10/21/22. Unstageable due to slough and eschar. 1.0x3.0cm. (All wounds received the same treatment as the right heel). R4's wound assessment notes from the local wound center showed, 11/7/22 Right proximal dorsal foot Stage 3 pressure ulcer acquired 10/18/22 and measures 0.9x2.2x0.1cm with scant serosanguineous (pale red or pink) drainage. Right ankle stage 3 pressure injury acquired 10/18/22 and measures 1x1.1x0.1cm after surgical debridement. Right heel unstageable pressure injury obscured full-thickness skin and tissue loss acquired 10/18/22 and measures 2.1x2.5x0.1cm. R4 continues to receive treatment at the local wound center for his pressure injuries. On 1/12/23 at 2:16PM, V12 (R4's Nurse Practitioner) stated, (R4's) CAM boot caused his pressure ulcers. When a resident is wearing a CAM boot, skin should be assessed at least daily, ideally twice a day with application and removal of the CAM boot. All new skin concerns should be identified immediately and reported to the physician immediately. I know therapy will sometimes help do application and removal of the device, but they don't do skin checks. That is the nurse's responsibility to make sure the skin checks are completed. A Deep tissue injury is a discoloration (purple, dark purple coloring) and should be easy to identify. If the nurses were doing daily dressing changes, then they should have identified these 3 areas well before they started. I'm guessing they did not do skin assessments with application and removal of the CAM boot. On 1/12/23 at 3:44PM, V13 (Wound Care Nurse) stated, (R4) obtained 3 pressure ulcers from his CAM boot. Those things are notorious for causing pressure sores, so you have to be careful and diligent with them and monitor skin closely. I went through his skin checks and saw they were doing them weekly for him. If I was working as a floor nurse, I would be checking his skin daily at a minimum. I don't see any orders or documentation of his skin being checked more than weekly. I agree they should have caught it earlier but there are a lot of agency nurse's working the floor right now. The facility's policy titled, Prevention of Pressure Injuries Protocol revised on 01/2018 showed, C. Pressure can also come from splints, casts, bandages, and wrinkles in the bed linens. If pressure injuries are not treated when discovered, they quickly get larger, become very painful for the resident, and often times becomes infected. 2) R1's electronic face sheet printed on 1/12/23 showed R1 has diagnoses including but not limited to pressure ulcer of sacral region, unstageable, Alzheimer's disease, Dementia without behaviors, and type 2 diabetes. R1's facility assessment dated [DATE] showed R1 has mild cognitive impairment and has no current pressure ulcers. R1's nursing care plan dated 9/20/21 showed, Risk for impaired skin integrity due to decreased mobility, urinary incontinence, and moisture under body folds. I also lean in my wheelchair, and this could cause skin breakdown. (R1) has a pressure injury. Daily skin inspection, pressure reducing pad in my recliner if needed. 12/29/22 air mattress applied. A review of R1's pressure ulcer wound assessments showed: 11/30/22 coccyx wound resolved. Left medial buttock resolved with skin intact. 2.4x2cm (centimeter) dark red/light purple area where wound used to be. Discontinue collagen dressing and use foam dressing daily for protection. 12/7/22 left medial buttock no changes. Apply allevyn dressing for protection and change daily. 12/14/22 left medial buttock resolved. 12/16/22 sacral pressure ulcer 5.5x4.0cm unstageable pressure injury obscured full-thickness skin and tissue loss. Moderate amount of purulent (white, yellow) drainage, 51-75% slough. On 1/11/23 at 2:33PM, V2 (Director of Nursing) and V10 (Clinical Specialist) stated, Skin assessments should be documented on the resident's shower sheet and entered into the skin inspection report in the resident's electronic medical record. We typically do these weekly and as needed. V13 (Wound Care Nurse) assessed (R1's) wounds on 12/16/22 but we cannot find any other assessments after that one. We have been trying to create our own timeline to determine what happened with (R1's) wound but haven't been able to determine anything yet. After 12/16/22 the only other documentation about (R1's) wound is for her to be a direct admission to the local hospital for an infected decubitus ulcer. We would expect (V13) or floor staff to complete weekly assessments on all wounds. If (V13) is not here, then the floor nurses should be doing it. When staff are performing wound care, they should never put their hand inside the wound and should be cleaning from the center of the wound and wipe to the outer edges to prevent infection. You wouldn't want the bacteria being pushed back to the center of the wound. That is standard practice in wound care and our nurses know that. R1's wound assessment documentation entered on 1/12/23 showed, Late entry for 12/16/22 new wound to left buttock, 3.0x1.5cm, purple discoloration, possible deep tissue injury and coccyx, 1.25x0.75cm Stage 2 with epithelial tissue in the bed. (Wound care) representative contacted, and treatment orders received. Resident educated on the importance of relieving pressure to the buttocks and encouraged to lay in bed between meals. However, she does choose to participate in activities in the afternoon. (This wound assessment contradicts prior wound assessment documented on 12/16/22). Late entry for 12/20/22 Wound has deteriorated. Left buttocks is 5.5x2.5cm and is unstageable due to slough. Coccyx is 2.5x1.5cm, Stage 3, slough and granulation. Resident continues to be encouraged to lay down in between meals. Late entry for 12/27/22 Two wounds have now merged into one, measuring 5.5x5.5cm and unstageable to slough. Surrounding tissue has a purple discoloration and appears somewhat blistered. No documentation was present in R1's electronic medical record showing notification to a physician of R1's worsening pressure wound. R1's local hospital records showed, 12/29/22 showed, Yesterday I was contacted about the ulcer and today I saw a picture of the ulcer. It is necrotic and has a gangrenous smell. Unstageable at this time but obviously there is dead tissue on top that needs to be debrided .sacral area has a 7cm ulcer with satellite smaller ulcers of less than a cm . Wound culture shows gram negative bacteria .will continue ceftriaxone and doxycycline as well just in case the MRSA (Methicillin-resistant Staphylococcus aureus) from her nares is present in her wound and did not appear in her wound culture. 12/30/22 Ulcer consists of necrotic tissue with possible involvement of sacral bone. Polymicrobial cultures growing Escherichia coli and proteus mirabilis. 1/3/23 Post-operative day 4- ulcer measures 7x11x3.5cm. 1/5/23 infected decubitus ulcer with necrosis secondary to debridement and application of wound vac. On 1/11/23 at 11:06AM, V5 (Licensed Practical Nurse) was providing wound care for R1. V5 removed R1's wound vac dressing, changed her gloves, and then stuck her gloved finger around the inner side of R1's sacral wound wiping drainage from one area to another along the inside of the wound. V5 then measured R1's wound and obtained a measurement of 10.5x11.75cm. V5 stated she was unable to determine the depth of the wound as she did not have the appropriate supplies with her. V5 then poured saline into R1's wound and wiped from the outer edges of the wound towards the center of the wound. V5 made repetitive statements throughout the wound care that she has not changed a wound vac dressing in at least 3-4 years. V5 stated the staff had not been trained on the care of R1's wound vac and that the wound care nurse has been off on leave. V5 stated, I just watched a video on my phone before we came in to try and refresh my memory. On 1/11/23 at 1:52PM, V5 stated, When cleansing wounds, you should always clean from the center of the wound and continue to the outside of the wound to prevent infection. I guess I didn't do it that way because her wound is so big, and I felt like I was just throwing saline in there and wiping it up with gauze. I definitely should have done a better job. On 1/12/23 at 2:16PM, V12 (R1's Nurse Practitioner) stated, The wound care nurse should be assessing weekly and if she's not there I would think the floor nurses would do it. New orders should be obtained at the time that they see the wound is worsening. There's not an exact timeline but I would say if a wound isn't improving after a week then new orders should be obtained. (R1's) wound initially started in September with a small open area, we followed her closely through October. Her wound was improving, and we talked to the family about her going to the wound center and they did not want to do that due to it being too hard on her because she would have to go out weekly and be lifted. We talked to (R1) about a catheter, and she wasn't completely on board and then the wound improved so we didn't talk about it again. The wound continued to improve, and I was told at the end of November that it had improved and that it had healed in December. I looked at her wound on 12/19/22 with (V13-Wound Care Nurse) and the wound care consultant. The wound at that time was a dry, yellow slough with dark areas. It was an unstageable wound. When you touched it on top it felt like a scab. I typically call and have a conversation with the family but on that day, I did ask the nurse to contact the daughter to notify her. That is the last time I saw the wound before she went to the hospital. (R1's Physician) went to the facility twice the week I was off, and he did not have a chance to look at the wound and then called (V5-LPN) and based on what she said he had (R1) sent to the emergency room. It would not be my expectation that there would be 10 days between a change in wound care orders if the wound was worsening. I don't know what the staffing was like during that time or if it was consistent or not that they would notice a difference in her wound. Someone should have seen that it was different with the daily dressing changes and notified me or (R1's Physician). Her wound got very bad, very fast so it should have been closely monitored. On 1/12/23 at 3:44PM, V13 (Wound Care Nurse) stated, (R1's) pressure ulcer prevention measures were repositioning, dietary consult, liquid protein, encouraging her to lay down in bed to offload pressure as much as possible. At one time she was a safety concern, so she didn't have an air mattress applied. She had a wide bed, and we couldn't give her an air mattress. The staff were concerned when they rolled her for repositioning and incontinence care she would roll out of bed. She finally got her air mattress on 12/29/22. She is now in a regular bed with the air mattress and is doing fine with it. (R1) had a few wounds and she actually healed out on 12/12/22 but I kept her in wound assessment manager just to track her. On 11/30/22 her wounds measured 0x0, but I wanted to keep tracking her due to her high risk for pressure ulcers. Then on 12/16/22 it looked like she had a 3x1.5cm purple area that I thought possibly could be a deep tissue injury on the left buttock and what looked like a stage 2 on her coccyx. I called the wound care rep and told her what was going on and she gave me recommendations. (V12-Nurse Practitioner) signed off on 12/16/22 for the orders. On 12/19/22, (V12) and the wound care representative came in to look at the wound with me. I did not document that assessment. I did go into (R1's) chart and put in late entries today for the wound assessments I did in December. I was lax in doing my documentation in a timely manner. I usually wait 2 weeks at least before I change the treatment orders. (V5-LPN) contacted (R1's physician) on the 29th or 30th I'm not sure which date. I didn't talk to (V12) or (R1's physician) from 12/19-12/29. I don't feel like anything could have been done differently with (R1). On 1/13/22 at 8:39AM, V13 (Wound Care Nurse) stated, On 12/29/22 we noticed purulent drainage coming from (R1's) wound. Up until then it wasn't anything unusual. I don't know why the documentation was different on the wound assessment for 12/16/22. As far as I know the physician was not contacted from the 19th to the 29th. When I do my assessments and the wound is worsening, I would notify the provider. It was getting bigger, but we were using the silver and covering with the antimicrobial. I wanted to give the new treatment a chance to work before I contacted the provider and obviously it didn't work. When you go from a stage 2 to a stage 3 there is a presence of granulation tissue and slough. It doesn't necessarily mean the wound is getting deeper. I haven't seen a wound go from a stage 3 to an unstageable because usually when the wound is a stage 3 the resident will go for a debridement and then there's slough and eschar. I did document that (R1's) wound had deteriorated because it did. I really wanted the treatment to work for her but in this case it did not. I know I should have documented (R1's) wound assessments when I did them and there's no excuse for why I didn't, I was just lax about it. I was keeping an eye on her wounds, so I knew when it was worsening, the floor staff didn't really need to see that documentation because I was there. The facility's policy titled, Wound care/dressing change revised on 12/2017 showed, The purpose of this procedure is to provide guidelines for dressing changes of wounds in a sterile and non-sterile technique to promote healing .M. Cleanse wound with damped gauze using the one swipe method. One circular motion with each gauze 4x4 starting at the center and working to outer edge of wound .The following information should be recorded in the resident's medical record: .E. Any change in the resident's condition. F. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. Complications related to the wound. The facility's policy titled, Prevention of Pressure Injuries Protocol revised on 01/2018 showed, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors .General Guidelines .E. Once a pressure injury develops, it can be extremely difficult to heal. Pressure injuries are a serious condition for the resident. F. The community should have system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family .J. Routinely assess and document the condition of the resident's skin per community wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure injury to the supervisor .Interventions and Preventive Measures: SKIN. A. Surface selection .1. Select surface based on resident/clinical assessment .b. Preventable surface/foam mattress for all residents, including Stage 1 and Stage 2 wounds. The Immediate Jeopardy that began on 10/21/22 was removed on 1/16/23 when the facility took the following actions to remove the immediacy. Immediate Jeopardy Removal Plan: 1.R1 and R4 were assessed by the wound nurse for new pressure areas on 1/13/23. 2. Current residents with pressure injuries and/or medical devices will be assessed by wound care nurse, licensed nursing staff and Quality director (LPN). This will be completed on or before 1/16/23. 3. Current licensed and direct care nursing staff were re-educated by the Director of Nursing or designee on identification of wounds, notification to physician for worsening wounds, pressure injury prevention, medical device application and removal, skin evaluations for residents with medical devices, signs/symptoms of worsening wounds and process for reporting new or worsened wounds. Completed on or before 1/16/23 or prior to working their next scheduled shift. 4. The Wound Care Nurse was re-educated by the Director of Clinical Operations on skin/wound champion training including, wound champion role/responsibilities, skin care & pressure injury prevention, wound assessments, wound treatments, and skin/wound documentation. Completed 1/16/23. 5.Interdisciplinary Team (IDT) reviewed the (facility) Skin Identification, Evaluation and Monitoring policy and procedure and it is in compliance with the CMS (Centers for Medicare & Medicaid) regulation F686. Completed 1/16/23. 6. Residents with new or changed pressure injuries or medical devices will be reviewed by the IDT during the daily clinical meeting for completion of skin evaluation, physician notification, and wound treatment orders. 7. During weekly Resident-at-Risk meetings, IDT will review the clinical record of residents with new or changed pressure injuries or medical devices. The review will be documented in the Resident's clinical record. 8.The Director of Nursing or designee will review weekly wound assessments for completion and complete random weekly observations of medical device application and removal, skin evaluations for residents with medical devices and pressure injury treatments. Results will be part of the plan of correction audit binder and will be reviewed weekly or as needed during IDT clinical meetings. 9. Quality Assurance plans to monitor facility compliance to make sure that correction is achieved and permanent. Monthly review of completed observation and skin/wound evaluation results and trends will be completed by the Director of Nursing or designee and reported to the facility's QAPI (Quality Assurance Performance Improvement) committee for the next three months and then re-evaluated to determine if further monitoring is indicated. Completion Date: 1/16/23 On 1/17/23, a review of the facility's in-service documentation showed 72% of the facility's core staff and 21 agency staff members had been educated regarding the new wound identification, reporting, and monitoring process. The remainder of staff and any new agency staff will be educated prior to the start of their next shift. Interviews with staff working on 1/17/23 showed staff have received the education and were able to verbalize the education they had received that aligned with the facility's abatement plan. II. Based on observation, interview, and record review, the facility failed to notify a physician of a resident's worsening pressure wound (R16), failed to obtain new treatment orders for a resident's pressure wound (R16), failed to identify pressure wounds for 3 residents (R17,R18,R19) prior to a stage 2, failed to obtain treatment orders for a residents pressure wound (R14,R16) and failed to identify a resident's pressure wound prior to a stage 3 (R16). This applies to 5 of 7 residents (R14, R16, R17, R18 and R19) reviewed for pressure ulcer prevention and treatment in the sample of 19. The findings include: 1) R16's electronic face sheet printed on 1/17/23 showed R16 has diagnoses including but not limited to dementia, peripheral vascular disease, major depressive disorder, and anxiety disorder. R16's facility assessment dated [DATE] showed R16 has two unstageable pressure ulcers. R16's nursing care plan initiated 7/15/13 showed, (R16) is at risk for pressure injury onset and delayed wound healing due to impaired mobility related to left above the knee amputation, and history of pressure ulcers. R16's undated nursing care plan showed, Unstageable pressure ulcer to right buttock/ischium, stage 3 pressure ulcer to left buttock/ischium. R16's wound assessment reports showed, 12/2/22 Right buttock/ischium Stage 3 pressure ulcer identified on 11/25/22 and measures 5.0x4.0x0.3cm with scant serous drainage. Padded foam dressing applied. 12/9/22 Right buttock/ischium deteriorated and is now an unstageable pressure ulcer measuring 5.0x4.0x0.3cm with scant serous drainage. R16's treatment administration record for December 2022 showed, 12/9/22 Right ischial wound: cleanse, cover with 2x2 hydrogel gauze and then silicone cover dressing, change daily. (14 days after R16's pressure ulcer was identified). No previous orders were identified on R16's treatment administration records for November 2022 for her right buttock/ischial pressure wound. R16's wound assessment reports for her right buttock/ischium pressure ulcer showed, 12/16/22 wound unchanged measuring 5.0x4.0x0.3cm with scant, serous drainage. Continue current treatment. 12/23/22 wound deteriorated measuring 5.0x5.0cm with wound bed 100% covered with slough and larger. 12/30/22 wound deteriorated measuring 5.0x6.0cm. 1/3/23 wound deteriorated measuring 5.0x6.0cm with 20% eschar. Wound drainage has become purulent. New order for wound treatment received. R16's wound assessment reports for her coccyx wound showed, 12/8/22 irritation/excoriation to coccyx identified 4/18/22 now measuring 4.0x5.0x2.0cm with small serosanguinous drainage. New treatment orders received. 12/15/22 wound unchanged measuring 4.0x5.0x2.0cm. No new orders. 12/22/22 wound unchanged measuring 4.0x5.0x2.0cm. No new orders. 12/29/22 wound deteriorated and measures 4.5x7.5x3.0cm with moderate serosanguineous drainage, wound is larger and deeper and undermining continues all the way around edges. R16's physician's orders and treatment administration records for December 2022 and January 2023 showed R16's wound care orders had not been adjusted despite R16's wounds deteriorating from 12/9/22 to 1/3/23 (24 days). No documentation was present in R16's electronic medical record showing that R16's physician had been notified of R16's wounds deteriorating. R16's wound assessment report for 1/16/23 showed, Stage 3 pressure ulcer to left buttock/ischium identified on 1/16/23 measuring 2.0x2.0x0.3cm with scant, serous drainage. R16's wound assessment reports for January 2023 showed no documentation of any previous wound to R16's left buttock/ischium. On 1/17/23 at 2:32PM, V13 (Wound Care Nurse) stated, (R16's) right buttock/ischium pressure wound started on 11/25/22. I'm sure I initiated a treatment for her but if it's not documented on the treatment administration record, it would be considered not done and that's a problem because her wound did get worse. Her coccyx wound is a pressure ulcer, but I didn't change it to a pressure ulcer in the wound management system. I am able to change the staging of a wound, but I didn't change it because it will be too confusing. If a wound is not documented correctly then someone looking at it may not see that she has a pressure ulcer, just excoriation. (R16) now has a stage 3 pressure ulcer to her left buttock/ischium that was found yesterday. It's a good question if it should have been found before a stage 3, probably should have but in her case, she is falling apart rapidly. She still eats a little bit; we just really don't know how she is getting so many wounds. It's hard to keep up with her skin. I would think the staff would be really paying attention to her skin at least daily, if not every shift because her condition is declining. I did not change wound care orders for (R16's) right buttock/ischial wound between 12/9/22-1/3/23 nor do I recall notifying the physician that her wound was deteriorating. I would have documented that on the wound assessment or in progress notes. The ideal time frame to see if a treatment is working is 2 weeks. I see now that is a problem because I waited too long. The wounds did not show any signs of improvement and actually deteriorated a little bit. 2.) R14's electronic face sheet printed on 1/17/23 showed R14 has diagnoses including but not limited to urinary tract infection, acute kidney failure, end stage renal disease, and morbid obesity. R14's facility assessment dated [DATE] showed R14 has no cognitive impairment and has two stage 2 pressure injuries. R14's nursing care plan dated 12/16/22 showed, Risk for impaired skin integrity due to decreased mobility. (R14) has a pressure injury that was present upon admission. R14's nursing care plan dated 1/16/23 showed, Pressure Ulcer: Sacrum stage 2 on admission. Administer treatment per physician's orders. R14's wound assessment report showed, 12/16/22 Stage 2 pressure ulcer to sacrum measuring 3.0x0.5cm. Stage 2 pressure ulcer to right buttock measuring 1.0x1.0cm. Wounds assessed, measured and allevyn dressing applied. R14's treatment administration record for December 2022 showed, 12/24/22 Apply allevyn to coccyx/buttock area-change daily and as needed. (8 days after R14's two Stage 2 pressure ulcers were identified.) On 1/17/23 at 2:32PM, V13 (Wound Care Nurse) stated, It looks like (R14's) wounds were identified upon her admission to the facility on [DATE]. I know I called the physician for treatment orders on 12/16/22 but I guess the order never made it to the treatment administration record for the floor nurses to complete the treatment on a daily basis. I think we initiated standing wound care orders for her wound care. I can see how it would look like they weren't done but I'm sure they were, the nurses just didn't have anywhere to document it being done. 3.) R17's electronic face sheet printed on 1/17/23 showed R17 has diagnoses including but not limited to Alzheimer's Disease, Dementia, chronic obstructive pulmonary disease, and major depressive disorder. R17's facility assessment dated [DATE] showed R17 has mild cognitive impairment and has no pressure ulcers. R17's nursing care plan dated 1/6/22 showed, Risk for impaired skin integrity due to incontinence and limited mobility. Daily skin inspection; report any changes in skin or signs of possible skin breakdown or redness. The facility was unable to provide evidence of daily skin inspections being performed. R17's weekly skin assessments showed R17's skin was intact from 12/3/22-1/7/22. R17's wound assessment report dated 1/12/23 showed, Stage 2 pressure ulcer right buttock/right of the intragluteal cleft measuring 1.5x3.0x0.01cm identified on 1/12/23. On 1/17/23 at 2:32PM, V13 stated, (R17) has a stage 2 pressure ulcer to her right buttock that was identified on 1/12/23. She should have had her wound identified prior to stage 2. There's no excuse as to why it wasn't identified prior to the skin breaking open. She was not getting daily skin assessments that I am aware of, or we would have caught this earlier. 4.) R18's electronic face sheet printed on 1/17/23 showed R18 has diagnoses including but not limited to systolic congestive heart failure, chronic obstructive pulmonary disease, hypertension and chronic kidney disease. R18's facility assessment dated [DATE] showed R18 has no current pressure ulcers. R18's nursing care plan dated 8/15/18 showed, Risk for impaired skin integrity due to decreased mobility, incontinence, peripheral vascular disease, and colitis with diarrhea. On 1/17/23 at 12:18PM, R18 stated, Someone that works here checked my skin the other day and they found a sore on my bottom. I don't know how bad it is, but it hurts. R18's wound assessment report dated 1/12/23 showed, Stage 2 pressure ulcer left buttock/left gluteal cleft measuring 1.30x1.30x0.01cm identified on 1/12/23. On 1/17/23 at 2:32PM, V13 stated, (R18) has a stage 2 pressure ulcer to her left buttock that was identified on 1/12/23. Her wound should have been found prior to this, especially since she is hospice and gets more visits and opportunities for additional staff to see her skin. 5.) R19's electronic face sheet printed on 1/17/23 showed R19 has diagnoses including but not limited to heart failure, prostate cancer, atherosclerotic heart disease, and anemia. R19's facility assessment dated [DATE] showed R19 has moderate cognitive impairment and has no current pressure injuries. R19's nursing care plan dated 12/21/21 showed, Risk for impaired skin integrity due to limited mobility and incontinence. On 1/17/23 at 2:06PM, R19 stated, I got a sore on my butt from sitting too much. They do[TRUNCATED]