**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Deficiencies at this level require more than one Deficient Practice Statements A. Based on interview and record review, the facility failed to prevent the development of unstageable ulcers, identify and assess newly developed ulcers, consistently implement interventions to promote healing of the ulcers, and implement physician orders to treat ulcers for 1 (R149) of 7 residents reviewed for ulcers in the sample of 52. This failure resulted in R149 developing unstageable ulcers to bilateral heels and subsequently being admitted to the hospital with diagnoses of sepsis, gangrene, and necrosis of the bone, tendon, and surrounding tissue. R149 underwent surgery to debride the ulcers on bilateral heels. Post surgery, R149 was placed on hospice and died on 6/9/25. The Immediate Jeopardy was identified to have begun on 4/17/25, when V27 (Wound Specialist) identified a monthly care goal to decrease odor in the right heel ulcer and indicated infected tissue was removed through debridement, without obtaining a culture of the wound and/or treating the underlying infection. This failure resulted in R149 being admitted to the local hospital with sepsis, gangrene, and required surgery to debride bilateral heels. R149 was placed on hospice after the surgery due to the extent of the injury to his bilateral heels and the severity of the infection. R149 expired at the hospital on 6/9/25, with cause of death listed as cardiorespiratory failure due to septic shock. V1 (Administrator), V2 (Regional Director of Clinical Services/Acting Director of Nurses), and V52 (Operations Consultant) were notified of the Immediate Jeopardy on 6/10/25 at 2:38 PM. The surveyors confirmed by observations, interview, and record review, the Immediate Jeopardy was removed on 6/11/2025, but noncompliance remains at Level Two due to additional time needed to evaluate the implementation and effectiveness of in-service training. Findings Include: R149's admission Record, with a print date of 6/5/25, documents R149 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease, adult failure to thrive, diabetes, hypertension, peripheral vascular disease, and osteoarthritis. R149's Minimum Data Set (MDS), dated [DATE], documents a Brief Interview for Mental Status score of 09, which indicates a moderate cognitive deficit. This same MDS documented R149 was at risk for skin breakdown, no unhealed pressure ulcers, and two venous/arterial wounds. Under Skin and Ulcer/Injury Treatments, this MDS documents the following interventions, pressure reducing device for chair and bed, nutrition or hydration intervention, non-surgical dressings, ointments/medications, and dressings to feet. Turning and repositioning and pressure ulcer/injury care are not marked as interventions to implement. R149's current Care Plan documents, (R149) has potential for pressure ulcer development r/t (related to) Hx (history) of ulcers, impaired mobility, impaired circulation 03/06/2025 Site #22 arterial wound of R (right) heel 03/20/2025 Site #24 Arterial wound to L (left) heel. 03/20/2025 Site #25 End stage skin failure to R (right) buttocks (resolved 04/24/2025). 04/03/2025 Site #26 End Stage skin failure L (left) buttocks (resolved 04/24/2025) Date Initiated: 02/27/2024. This Focus area includes the following interventions, .03/06/2025 Tx (treatment) as ordered Site #22 arterial wound of R heel. EBP (enhanced barrier precautions) per facility policy. Date Initiated: 3/17/2025. 03/20/2025 Tx as ordered to Site #24 arterial wound to L heel. EBP per facility policy Administer medications as ordered. Monitor/document for side effects and effectiveness. Date Initiated: 02/27/2024. Administer treatments as ordered and monitor for effectiveness. Date Initiated: 02/27/2024. Assess/record/monitor wound healing weekly. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Report improvements and declines to MD (physician). Date Initiated: 02/27/2024. Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 02/27/2024. Inform the resident/family/caregivers of any new area of skin breakdown. Date Initiated: 02/27/2024. Low air loss mattress as ordered. Date Initiated: 03/14/2024. Monitor/document/report to MD PRN (as needed) changes in skin status: appearance, color, wound healing, s/sx (signs/symptoms) of infection, wound size (length x width x depth), stage. Date Initiated: 02/27/2024. Nutritional supplements as per MD orders. Date Initiated: 02/27/2024. Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. Date Initiated: 02/27/2024. Skin checks as scheduled. Date Initiated: 02/27/2024. (name of wound specialty) wound specialist to evaluate and treat as indicated. Date Initiated: 02/27/2024. This care plan does not document interventions to float heels and/or wear heal protection. R149's Braden Scale, dated 1/8/25, documents a score of 15, indicating R149 has a low risk of skin breakdown. R149's facility Progress Notes document the following: 5/14/25 1:50 PM, .Resident seems lethargic, able to wake up to voice but falls back asleep quickly. Temp. (temperature) 100.9, HR (heart rate) 116, BP (blood pressure) 96/60, O2 sat (saturation) 97% RA (room air). Blood sugar 355. V35 (Physician) office notified, waiting on call back from (V35) nurse for any new orders. 5/14/25 2:15 PM, .(V35) office called back and gave verbal order per (V35) to send resident to ER (emergency room). EMS (emergency medical services) transported resident to (name of local hospital). POA (Power of Attorney) notified. 5/15/25 5:08 AM, .admitted to (name of local hospital) ICU (intensive care unit) r/t (related to) sepsis. PT (patient) is currently receiving IV (intravenous) ABX (antibiotics) and fluids. R149's local hospital record documents on 5/14/25 under Chief Complaint: Patient presents with Altered Mental Status, Wound Check. 88 yo (year old) wm (white male) is brought to ER (emergency room) for eval (evaluation) of ams (altered mental status). As per nh (nursing home) staff, patient is confused, patient has fever, patient has low bp (blood pressure). Nh staff is concerning of sepsis. Patient has bil (bilateral) heel necrotic ulcers. Patient has no chest pain. No abd (abdominal) pain Pt (patient) arrives for AMS (altered mental status) EMS (Emergency Medical Services) reports we were called for AMS (altered mental status) that was worsening throughout the day. He has sores on both feet that are becoming necrotic. They are concerned he is becoming septic. His BP (blood pressure) was 95/40 .Pungent scent noted. Under Physical Exam, R149's hospital records document temperature of 100.2 degrees Fahrenheit, R149 is ill appearing, bed bound, with bilateral heel ulcers with necrosis. The CT (Computerized tomography) results dated 5/14/25 of the left foot documents under impression, Cellulitis. Deep soft tissue ulceration along the posterior plantar aspect at the calcaneal tuberosity with gas extending to the bone at that level. Erosive change/osteomyelitis involving the posterolateral portion of the calcaneal tuberosity at that level through the attachment the Achilles tendon with appearance concerning for underlying tendinosis/partial-thickness tear of the tendon and possible tendon infection The CT results dated 5/14/25 of the right lower extremity/foot documents the following under Impression, Cellulitis. Progressive, deep soft tissue ulceration overlying the calcaneal tuberosity with exposure the bone and underlying acute osteomyelitis. There is gas and ill-defined fluid throughout the underlying soft tissues at that level as well as gas within abscess cavity extending along the distal plantar fascia with possible infection with gas-forming organisms. Full thickness tear and osseous avulsion fracture involving the Achilles tendon with partial thickness tearing and abscess cavity extending more proximally along the tendon. Under Clinical Impression, R149's hospital record documents, Sepsis, due to unspecified organism .altered mental status .osteomyelitis of foot, unspecified laterality, unspecified . The hospital history and physical dated 5/14/25 documents, heel wounds. In ED (emergency department), patient met criteria for sepsis as patient was noted to have fever, tachycardia, tachypnea, elevated lactic acid, leukocytosis. Patient was started on broad spectrum IV (intravenous) antibiotics after imaging studies showing questionable osteomyelitis. ER provided consulted on-call podiatrist . R149's hospital record documents a physical exam, dated 5/14/25, under skin, the assessment documents, .Multiple healing abrasion/skin tears over extremities. Examination of right heel- on plantar aspect of right heel, large necrotic ulcer with foul-smelling ulcer base/eschar, 5.4 cm (centimeters), ankle swelling with erythema. Examination of left heel - on plantar out of left heel, large necrotic ulcer 3 x 2 cm with purulent base. V33 (Podiatrist/Surgeon) hospital consult note for R149, dated 5/14/25, documents under Assessment, (R149) is an 88 yo male with gangrene of heels, bilateral .Dakins wet to dry gauze applied bilateral. Plan for OR (operating room) debridement tomorrow and wound vac (vacuum) application. R149's Operation Note signed by V33 documents, Preoperative diagnoses: 1. Gangrene of bilateral heel with necrosis of bone. 2. Decubital ulceration, Stage IV, bilateral heel. Postoperative Diagnoses: 1. Gangrene of bilateral heel with necrosis of bone. 2. Decubital ulceration, Stage IV, bilateral heel. Under Description of Procedure the note documents, .Attention was first directed towards the posterior right heel. There was significant foul odor and necrosis of skin, soft tissue, and exposed necrotic bone within the wound cavity of the right heel. There was exposed necrotic bone within the wound cavity of the right heel. There was exposed necrotic Achilles tendon with purulent fluctuance at the Achilles tendon course .The bone at the plantar posterior margin of the calcaneus as necrotic in appearance .Attention was then directed towards the posterior left heel at full-thickness necrotic ulceration .Nonviable bone at the posterior dorsal lateral margin of the calcaneus was excised . The patient was then transported back to the ICU (Intensive Care Unit) on a ventilator with vital signs stable. Heel offloading boots were applied after repositioning the patient in the supine position. R149's hospital Progress Note, dated 5/18/25, documents under Plan for Today, Per discussion with intensivist and ICU RN (Registered Nurse): Plan to extubate later today. Continue management in ICU, as already discussed earlier today with intensivist (name) Prognosis is dismal and this has apparently been relayed to the family; patient remains full coder per his previously stated wishes at this point, per discussion with intensivist R149's hospital Progress Note, dated 6/1/25, documents, patient was made comfort care yesterday after family decided. Pending hospice evaluation tomorrow as per case management R149's three separate Initial skin Alteration Records, dated 1/8/25, document three separate shear wounds to buttocks, with treatments documented as provide relief on chair and bed, turning and repositioning, and dressing care with treatments documented as apply silver sulfadiazine (SSD), collagen, calcium alginate, and apply dry dressing. There is no documentation of any wounds/ulcers to R149's heels documented on this assessment indicating R149 returned to the facility on 1/8/25, with no ulcers/wounds identified on his bilateral heels. R149's skin Monitoring: Comprehensive CNA (Certified Nursing Assistant) Shower Review, dated 3/3/25, documents, Perform a visual assessment of the resident's skin when giving a shower. Report any abnormal looking skin (as described below) to the charge nurse immediately Use this form to show the exact location and description of the abnormality. Using the body chart below, describe and graph all abnormalities by number. This form documents a circle around the feet on body chart with no documentation of what was observed. This surveyor attempted to contact the CNA (Certified Nursing Assistant) who did this assessment, but she no longer works at the facility and didn't answer the phone and/or return this surveyors call. There is no documentation in R149's assessments and/or progress notes related to the abnormal areas indicated by a circle on the body chart on this assessment. R149's facility progress notes document on 3/6/25 at 12:18 AM, .this nurse was in the hallway standing at med (medication) cart during evening med pass when res (resident) daughter approached her stating that she saw blood coming through res white socks. At assessment, nurse observed a 6 cm (centimeter) x 5.8 cm wound to right heel. See skin assessment for details. Wound treated per wound doctor (V27/Wound Specialist) standing order. V27 and V3 ADON (Assistant Director of Nurses) notified to assess on wound rounds. R149's Weekly Skin Record, dated 3/6/25, documents, 3/6/25 - Right heel .full thickness tissue loss wound; 6 cm length x 5.8 cm width x 0.3 cm deep; no slough present. The assessment documents no tunneling, no undermining of the wound, no odor, irregular wound edges, and no pain verbalized. Under comments the assessment documents, Wound cleansed c (with) ns (normal saline); applied ssd/cp (collagen powder) mix et (and) covered c ca (calcium alginate) et dry dressing per standing order. (V27/Wound Specialist) and V3 (Assistant Director of Nurses/ADON) notified of the need to assess during wound rounds. R149's Wound Evaluation and Management Summary (V27/Wound Specialist) note document the following: 3/6/25- .Chief Complaint: Patient has wounds on his upper scalp; right heel, anterior penis, right scalp .Examination of right lower extremities. Foot warm, moderate edema, wound present .Focused Wound Exam (Site 22) Arterial Wound of the Right Heel Full Thickness. Etiology .Arterial, Duration: > (greater than) 5 days, Objective .Healing/Maintain healing, Wound size (L (length) x W (width) x D (depth): 6.4 x 7.2 x 0.1 cm, Surface Area .46.08 cm² (squared), exudate Moderate Serous, Slough 30%, Granulation tissue 70% . Dressing Treatment Plan Primary Dressings: Alginate Calcium apply once daily for 30 days; Betadine apply once daily for 30 days. Secondary Dressing: ABD (abdominal pad) apply once daily for 30 days; Gauze roll (kerlix) 4.5 apply once daily for 30 days. Under Site 22: Surgical Excisional Debridement Procedure, the assessment documents, Indication for Procedure: Remove necrotic tissue and establish the margins of viable tissue Procedure Note: the wound was cleansed with normal saline, and anesthesia was achieved using topical benzocaine. Then with clean surgical technique, curette was used to excise 13.82 cm² of devitalized tissue including slough, biofilm and non-viable subcutaneous level tissues were removed at a depth of 0.3 cm and healthy bleeding tissue was observed . 3/13/25- .Chief Complaint: Patient has wounds on his upper scalp; anterior penis; right heel; right scalp . Under Arterial wound of the Right Heel Full Thickness the assessment documents, Objective Healing/Maintain Healing, Wound Size . 6.4 x 7 x 0.1 cm, Surface Area 44.80 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) 70%, Slough 30%, Wound Progress Improved evidenced by decreased surface area Dressing Treatment Plan Primary Dressing: Alginate calcium apply once daily for 23 days; Betadine apply once daily for 23 days Under Site 22: Sharp Selective Debridement Procedure: Procedure Note: The wound was cleansed with normal saline and anesthesia, though not required, was achieved using topical benzocaine. Then with clean surgical technique, curette was used to selectively remove biofilm, remove devitalized epidermis and/or dermis, remove devitalized tissue at margins of a wound over the wound surface area of 44.8 cm². 3/20/25 - Chief Complaint: Patient has wounds on his upper scalp; anterior penis; right heel; right buttock; left heel; right scalp. Under Focused Wound Exam (Site 22) the assessment documents, Arterial Wound of the Right Heel Full Thickness .Objective .Healing/Maintain Healing, Wound size .6.2 x 7 x 0.1 cm, Surface Area 43.40 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) 70%, Slough 30%, Wound Progress Improved evidenced by decreased surface area Dressing Treatment Plan Primary Dressing: Alginate calcium apply once daily for 16 days; Betadine apply once daily for 16 days . Under Site 22: Sharp Selective Debridement Procedure the assessment documents, .Procedure Note curette was used to selectively remove biofilm, remove dried exudates or debris over the wound surface area of 43.4 cm² Goal primary to control infection risk in a chronic wound. Treating only the margins of an otherwise stable heel eschar. Under Focused Wound Exam (Site 24) the assessment documents, Arterial Wound of the Left Heel Full Thickness. Etiology: Arterial, Duration: > 3 days, Objective: Healing/Maintain Healing, Wound Size . 3.2 x 3 x 0.3 cm, Surface Area 9.60 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) 100%. Dressing Treatment Plan: Primary Dressing: Alginate Calcium apply once daily for 30 days; Betadine apply once daily for 30 days. Secondary Dressings: Gauze roll (kerlix) 4.5 apply once daily for 30 days. Reason For No Sharp Debridement: Non-infected heel necrosis. There is no documentation in R149's facility medical record when the ulcer to R149's left heel was first identified, an assessment of the left heel, or treatment of the area, prior to V27's assessment on 3/20/25. R149's Order Summary Report Active Orders as of 04/01/2025 includes the following orders, Left heel-cleanse with n/s (normal saline) or wound cleanser/pat dry/apply betadine/ca (calcium alginate) and wrap with kerlix daily and PRN (as needed) and Right heel- cleanse with n/s or wound cleanser and apply Betadine/ca and wrap with kerlix every day shift for wound, both orders have a start date of 3/20/25. R149's Order Summary Report does not document an order to treat the ulcer on the right heel from when it was identified on 3/6/25 until 3/20/25. R149's TAR (Treatment Administration Record), dated 3/1/25 to 3/31/25, includes the following orders, Left heel cleanse with n/s or wound cleanser/pat dry; apply betadine/ca and wrap with kerlix daily and PRN every day shift for wound and Right heel- cleanse with n/s or wound cleanser and apply Betadine/CA and wrap with kerlix every day shift for wound. Both physician orders have a start date of 3/21/25. This TAR does not document a physician order to treat the right heel ulcer from 3/6/25 until 3/20/25. On 6/7/25 at 10:55 AM, V2 (Regional Director of Clinical Services/Acting Director of Nurse) stated they were unable to find treatment orders from 3/6 to 3/21/25 for the ulcer located on R149's right heel, but he looked at the wound specialist notes, and the area was improving. V2 stated V3 (Assistant Director of Nurses/ADON) did rounds with V27 (Wound Specialist), and they saw R149 weekly. V2 stated V3 (ADON) remembered there being dressings on R149's right heel when she did rounds with V27 each week, but there was no order in the system for a treatment to the right heel. R149's Wound Evaluation and Management Summary (V27/Wound Specialist) notes document the following: 3/27/25 - .Chief Complaint: Patient has wounds on his upper scalp; right heel; right buttock; left heel; right scalp; anterior penis. Under Focused Wound Exam (Site 22) the assessment documents, Arterial Wound of the Right Heel Full Thickness .Objective: Healing/Maintain Healing, Wound Size .: 6.2 x 6.4 x 0.1 cm, Surface Area .39.68 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) 70%, Slough 30%, Wound Progress Improved evidenced by decreased surface area . Dressing Treatment Plan: Primary Dressing: Alginate Calcium apply once daily for 9 days; Betadine apply once daily for 9 days . Under Site 22: Surgical Excision Debridement Procedure the assessment documents .curette was used to surgically excise 3.97 cm² of devitalized tissue and necrotic subcutaneous level tissue along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. This same assessment documents under Focused Wound Exam (Site24), Arterial Wound of the Left Heel Full Thickness Objective . Healing/Maintain Healing, Wound Size .: 3 x 3 x 0.3 cm, Surface Area .9.00 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue 100%, Wound Progress Improved evidenced by decreased surface area Dressing Treatment Plan, Primary Dressing: Alginate Calcium apply once daily for 23 days; Betadine apply once daily for 23 days . Reason for No Sharp Debridement: Non-infected heel necrosis. 4/3/25 - .Chief Complaint: Patient has wounds on his upper scalp; right heel; left heel; left buttock; anterior penis. Under Focused Wound Exam (Site 22) the assessment documents, Arterial Wound of the Right Heel Full Thickness .Objective Healing/Maintain Healing, Wound Size .: 6 x 6.4 x 0.1 cm, Surface Area 38.40 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) 70%, Slough 30%, Wound Progress Improved evidenced by decreased surface area Dressing Treatment Plan, Primary Dressing: Alginate Calcium apply once daily for 30 days; Betadine apply once daily for 30 days . Under Site 22: Surgical Excision Debridement Procedure, the assessment documents, Procedure curette was used to surgically excise 2.30 cm² of devitalized tissue and necrotic subcutaneous level tissues along with slough and biofilm were removed at a depth of 0.2 cm and healthy bleeding tissue was observed. Under Focused Wound Exam (Site 24) this same assessment documents, Arterial Wound of the Left Heel Full Thickness .Objective Healing/Maintain Healing, Wound Size .: 3 x 3 x 0.3 cm, Surface Area 9.00 cm², Exudate None, Thick adherent black necrotic tissue (eschar) 100%, Wound Progress At Goal Dressing Treatment Plan Primary Dressing: Alginate Calcium apply once daily for 16 days; Betadine apply once daily for 16 days Reason for No Sharp Debridement: Non-infected heel necrosis. Under Site 24: Sharp Selective Debridement Procedure the assessment documents, .Procedure .curette was used to selectively remove devitalized tissue at margins of a wound, remove dried exudates or debris over the wound surface area of 9 cm² . 4/10/25 - .Chief Complaint: Patient has wounds on his right heel, upper scalp, right scalp, left heel, anterior penis, right buttock. Under Exam, this assessment documents Foot Warm, Moderate Edema, Wound present for bilateral lower extremities. Under Focused Wound Exam (Site 22) the assessment documents, Arterial Wound of the Right Heel Full Thickness, Etiology .Arterial, Duration: > 40 days, Objective Healing/Maintain Healing, Wound Size .: 5.6 x 5.3 x 0.8 cm, Surface Area 29.68 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) 70%, Slough 30%, Wound Progress Improved evidenced by decreased surface area Dressing Treatment Plan, Primary Dressing: Alginate calcium apply once daily for 23 days; Betadine apply once daily for 23 days . Under Site 22: Surgical Excisional Debridement Procedure, the assessment documents under Procedure Note, .curette was used to surgically excise 1.19 cm², of devitalized tissue and necrotic periosteum and bone along with slough and biofilm were removed at a depth of 0.9 cm and healthy bleeding tissue was observed This same assessment documents under Focused Wound Exam (Site 24), Arterial Wound of the Left Heel Full Thickness Objective Healing/Maintain Healing, Wound Size 2.8 x 3 x 0.3 cm, Surface area 8.40 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) 100%, Wound Progress .Improved evidenced by decreased surface area .Dressing Treatment Plan, Primary Dressing: Alginate Calcium apply once daily for 9 days; Betadine apply once daily for 9 days Reason No Sharp Debridement: Non-infected heel necrosis. 4/17/25 - Chief Complaint: Patient has wound on his right heel; upper scalp; left heel; right scalp; left buttock; anterior penis. Under Focused Wound Exam (Site 22) the assessment documents, Arterial Wound of the Right Heel Full Thickness Objective .Healing/Maintain Healing, Healing Potential Good, Estimated Time to Heal 2-4 months, Care goal(s) this month . Decrease Ulcer Area, Maintain Skin Integrity, Decrease Odor Wound Size .5 x 5.3 x 0.8 cm, Surface Area 26.50 cm², Exudate Moderate Serous, Thick adherent black necrosis tissue (eschar) 70%, Slough 30%, Wound Progress Improved evidenced by decreased surface area .Infection Assessment .No sign (s) of infection Dressing Treatment Plan, Primary Dressing: Alginate calcium apply once daily for 14 days; Sodium hypochlorite solution (dakins) apply once daily and as needed: if saturated, soiled, or dislodged. For 30 days . Under Site 22: Surgical Excisional Debridement Procedure, the assessment documents under Indication for Procedure, Remove Infected Tissue, Remove thick Adherent Eschar and Devitalized Tissue. Under Procedure Note this assessment documents, .curette was used to surgically excise 5.30 cm² of devitalized tissue and necrotic periosteum and bone along with slough and biofilm and removed at a depth of 1 cm and healthy bleeding tissue was observed . This same assessment documents under Focused Wound Exam (Site 24), Arterial Wound of the Left Heel Full Thickness . Objective: Healing/Maintain Healing, Healing Potential . Good, Estimated Time to Heal 2-4 months, Care goal(s) this month Decrease Ulcer Area .Wound size .2.2 x 3 x 0.3 cm, Surface Area 6.60 cm², Exudate Moderate Serous, Thick adherent black necrotic tissue (eschar) .100%, Wound Progress . Improved evidenced by decreased surface area Infection Assessment No sign (s) of infection) Dressing Treatment Plan, Primary Dressing: Alginate calcium apply once daily for 30 days; Sodium hypochlorite solution (dakins) apply once daily and as needed: If saturated, soiled, or dislodged. For 30 days . Under Site 24: Surgical Excisional Debridement Procedure the assessment documents under Indication for Procedure, Remove Necrotic Tissue and Establish the Margins of Viable Tissue. Under Procedure Note the assessment documents, curette was used to surgically excise 3.30 cm² of devitalized tissue and necrotic subcutaneous level tissues were removed at a depth of 0.4 cm and healthy bleeding tissue was observed There is no documentation in R149's facility records of V27 (Wound Specialist) ordering a wound culture of the right heel ulcer to determine the cause of the odor documented under the care goals of the month, and no documentation of V27 ordering an antibiotic to treat the infected tissue referenced under the surgical debridement section of V27's progress note. There are no facility skin assessments or progress notes documented with assessments of the ulcers to R149's heels and/or assessments of his condition until 4/22/25, when R149's Weekly Skin Record documents, Right heel- measured 6 cm x 5.8 cm x 0.3 cm. Under Additional Narrative Description of Wound the assessment documents Full thickness tissue loss wound .no slough present. The assessment describes the wound bed as greenish/yellow, red/beefy with no odor, and purulent (brownish/yellow) drainage. The healing process is documented as no change. R149's facility Progress Notes document the following: 4/24/2025 12:26 PM, .res (resident) noted more lethargic than usual today, not responding verbally as he normally does but will make eye contact. When fed res is letting food fall out of and not swallowing. Vitals 98.9 t (temperature), 18 r (respirations) 96 p (pulse), 99% O2 (oxygen) on RA (room air), 62/46 b/p (blood pressure), lung sounds clear, bowel sounds present. Res presenting with non-productive cough. MD (physician) notified. MD gave orders for CBC (complete blood count) w/diff (with differential), CMP (comprehensive metabolic panel), TSH (thyroid stimulating hormone), Free T4, Ammonia, Lactic Acid and 2 view chest (sic) xray. Orders put into pcc (point click care), biotech and lab. 4/25/25 5:25 PM, .Sent chest x-ray and labs to (V35/Physician) New ant (antibiotic) Clindamycin 300 mg (milligrams) po (by mouth) TID (three times daily) for 10 days ordered. R149's Order Summary Report active orders as of 05/01/2025 includes the following orders, 4/29/25 Daily skin check every night, 4/12/25 heel protectors on while in bed. Every day and night shift. 4/25/25 Clindamycin 300 mg three times daily for ten days. There are no antibiotic orders documented for treatment to the ulcers on bilateral heels on R149's Order Summary Report from 4/25/25 until his hospitalization on 5/14/25. R149's Weekly Skin Records do not document assessments of the ulcers to bilateral heels on 4/28, 5/5, 5/9, and 5/13/25. The assessments document no new areas noted and/or no changes to current wounds. R149's Wound Evaluation and Management Summary (V27/Wound Specialist) notes document the following: 4/24/25- .Chief Complaint: Patient has wounds on his right heel, left heel; right scalp; anterior penis; right buttocks; left buttocks. Under Focused Wound Exam (Site 22) the assessment documents, Arterial Wound of the Right Heel Full Thickness Objective .Healing/Maintain healing Healing Potential .Good. Care goal(s) this month. Decrease Ulcer Area, Maintain Skin Integrity, Decrease Odor .Wound Size 5 x 5.3 x 0.8 cm .Surface Area .26.50 cm² .Exudate Moderate Serous .Thick adherent black necrotic tissue (eschar) .70%. Slough 30% .Wound Progress .At Goal Infection Assessment .No signs of infection .Dressing Treatment Plan .Alginate Calcium apply once daily for 9 days; Sodium hypochlorite solution (dakins) apply once daily and as needed Under Site 22 Surgical Excisional Debridement Procedure the evaluation documents the indication for the procedure as Remove Infected Tissue, Remove Thick Adherent Eschar and Devitalized Tissue, Remove Necrotic Tissue and Establish the Margins of Viable Tissue. Under Procedure Note the Evaluation documents, curette used to surgically excise 15.90 cm² of devitalized tissue and necrotic periosteum and bone along with slough and biofilm were removed at a depth of 1 cm and healthy bleeding tissue was observed This same assessment documents under Focused Wound Exam (Site 24) Arterial Wound of the Left Heel Full Thickness .Objective .Healing/Maintain Healing Healing Potential .Good Care goal(s) this month .Decrease Ulcer Area Wound Size 2 x 3 x 0.3 cm Surface Area .6.00 cm² Exudate .Moderate Serous .Thick adherent black necrotic ti[TRUNCATED]