**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to follow through with a wound referral for a worsening pressure ulcer, failed to timely reassess and identify worsening pressure ulcer, and timely treat new wounds for 1 of 2 residents reviewed for pressure ulcers in the sample of 16. This failure resulted in the worsening and infection of R12's pressure ulcer to the right ankle. Findings: R12's medical record, New admission Information documents an admission date of 1/03/2023 with diagnoses including Hypertension, Edema (multifactorial component of Congested Heart Failure/Venous Stasis). R12's Minimum Data Set (MDS) dated [DATE], documents in Section C, Brief Interview for Mental Status (BIMS) score is 9, moderately impaired cognition, Section G, Functional Status, Extensive Assistance with one-person physical assistance with bed mobility, dressing, and personal hygiene, Extensive assistance with two-person physical assistance with transfers and toileting. R12's Nursing admission Assessment dated 1/03/2023 documents no skin issues noted. R12's Care Plan documents Moderate Risk for Pressure Ulcer per Braden Risk Assessment. Risk factors include impaired mobility and incontinence. Strengths include can turn self in bed, with a start date of 1/30/2023; Will have no new open areas caused by pressure or friction for the next 90 days, with a goal date of 4/30/2023; Interventions: Skin risk assessment: Braden Scale weekly x 4 weeks upon admission or readmission and then quarterly; Dietary consult to consider nutrition/hydration factors for treating related risk factors; Initiate extra calories, protein, vitamins as recommended; Initiate supplements as needed/recommended; See Physician's Order Sheet for orders; Apply house stock incontinent barrier cream to peri-area after every incontinent episode and as needed; Toilet/change brief when wet and upon rising, at bedtime, and after meals; Maintain clean, dry, wrinkle free linens with a start date of 1/30/2023. R12's Braden Assessments dated 2/12/23, 2/22/23, 3/1/23, and 3/8/23 all documents R12 is considered a high risk for pressure ulcers. R12's Progress Notes dated 2/15/2023, documents R12 has a stage II area to right outer ankle measuring 0.9 centimeters (cm) x 1.1cm, area scabbed over with no drainage or signs and symptoms of infection noted. R12's Physician's Orders dated 2/15/2023, documents 1. Cleanse Stage II area to right outer ankle with normal saline. Apply skin barrier to wound and surrounding area, let dry. Cover area with clean, dry dressing daily and as needed until healed, 2. Heel protectors to be used at all times while in bed. R12's Wound Tracking dated 2/28/2023 documents right ankle measurements of 1.6 cm x 1.7 cm. A fax report from V5 (Nurse Practitioner) dated 2/28/23 documents, Refer to wound care. At the bottom is a handwritten note from V5 that states, cleanse Stage II area to right outer heal bone with normal saline and pat dry. Apply Aquacel to wound and cover with padded dressing. Change every 4 days and as needed. R12's Physician's Orders dated 2/28/2023, documents 1. Add nutritional juice drink twice a day and multivitamin with mineral daily for wound healing, 2. Cleanse Stage II area to right outer ankle with normal saline and pat dry, apply Aquacel to wound bed and cover with padded dressing, change every 4 days and as needed. R12's Wound Tracking dated 3/12/2023 documents right ankle wound measurements of 2cm x 2cm. R12's Progress Notes dated 3/12/2023 documents right great toe, hard, black, scab-like measures 1.75cm x 1.75cm rounded, right third toe measures (1cm x 1cm), wound bed appears yellow colored with red edges. R12's Physician's Orders dated 3/13/2023, documents double protein at breakfast. There we no new orders documented in R12's record to treat the wounds found on the right great or the right third toe for the month of March and no records to indicated R12's physician was notifed of the new wounds. R12's Wound Tracking dated 4/6/2023 documents measurements right ankle of 2.1cm x 1.8cm, right outer great toe 1cm x 0.8cm, and right middle toe 1cm x 1cm. There was no documentation noted in R12's record that R12's physician was notified of the wounds found on the toes on 4/6/23 until 4/16/23. R12's Physician Notification dated 4/16/2023 documents updated wound measurements of right outer ankle 2cm x 2cm, right outer great toe 1cm x 0.75cm, and right middle toe 1cm x 1cm and current treatment orders sent to V8 (Nurse Practitioner) with orders to continue current treatment to right ankle and there were no orders given to treat the wounds on the toes. R12's Physician's Orders dated 4/19/2023 documents skin barrier to right great toe and second toe twice a day as a preventive measure and to monitor twice a day until healed. R12's Physician Notification dated 4/30/2023 documents pressure wounds to right ankle and middle toe are open and have yellow drainage with an odor noted, right ankle measures 2.25cm x 2.25cm and right middle toe measures 1cm x 1.25cm. R12's Physician's Orders dated 5/1/2023 documents obtain culture of all wounds, complete blood count, basic metabolic panel, and start doxycycline 100 milligrams (mg) every 12 hours x 10 days. R12's Lab Results dated 5/3/2023 documents culture wound (ankle), heavy growth of Morganella morganii (Abnormal) with new orders from V8 (Nurse Practitioner) to discontinue doxycycline and start Cipro 500mg every 12 hours x 10 days; if not on probiotic, start daily while on antibiotic. R12's Treatment Record for 2/1/23-2/28/23 documents treatment, start date 2/15/23, apply skin prep to Stage II area and surround tissue. Let dry and cover with clean, dry, dressing twice a day. On the 6AM-6-PM shift the dates 2/22/23, 2/23/23 and 2/24/24 did not contain initials that the treatment was done. On the 6PM-6AM shift the dates 2/21/23, 2/24/23 and 2/27/23 did not contain initials that the treatments were done. On 5/3/2023, at 2:00 p.m., observed R12's right ankle wound to have a yellow-colored wound bed with moderate amount of yellow colored drainage noted, right great toe and right middle toe were scabbed over. R12 stated no complaints of pain noted, the nurse changes his ankle dressing every few days and he wears his heel protectors when he goes to bed. R12 stated that if he has any pain, he tells the staff and the nurse brings him his pain medication and it helps with his pain. R12 stated he does not know how he got the wound on his ankle. On 5/3/2023, at 2:15 p.m., V2 (Licensed Practical Nurse), stated that she has called the wound clinic today to get R12 a referral for his right ankle wound. V2 stated the referral got missed. V2 stated she notified V5 (Nurse Practitioner) on 4/18/2023 that R12's right ankle wound had increased in size from 2.1cm x 1.8cm to 2cm x 2cm and right great toe & middle toe were scabbed over. V2 stated that there was no drainage to any of the areas at that time. V2 stated that when a weekly assessment or treatment has been documented, the assessment and treatment has been completed. On 5/4/2023, at 11:30 a.m., V5 (Nurse Practitioner) stated that R12 had an order for a referral for wound care on 2/28/2023 and it is not an appropriate amount of time to wait and get a referral for wound care until 5/3/2023. On 5/4/2023, at 12:25 p.m., V8 (Wound Clinic Scheduler) stated that yesterday, 5/3/2023, was the first time the facility called the wound clinic to get a referral for R12. V8 stated she received R12's referral for wound care yesterday and R12 has an appointment scheduled for 5/17/2023. The facility's policy Decubitus/Pressure Areas revised 1/18 documents in part, It is the policy of this facility to ensure a proper treatment program has been instituted and is being closely monitored to promote the healing of any pressure ulcer .4) Notify the physician for treatment orders. The physician's orders should include: i) type of treatment, ii) frequency treatment is to be performed, iii) how to cleanse, if needed, iv)site of application