**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observations, interviews and record review, the facility failed to ensure non-pressure wounds on a resident's toes were treated in a timely manner and failed to follow up on an arterial doppler causing a delay in treatment of the wounds which resulted in osteomyelitis, gangrene, and cellulitis for 1 of 3 reviewed for quality of care (Resident 45). B. Based on observation, interview, and record review, the facility failed to ensure residents had appropriate skin assessments and interventions in place to address non-pressure wounds for 2 of 3 residents reviewed for skin management (Residents 31 and 21). The immediate jeopardy began on 4/25/23 when Resident 45 was noted to have developed new wounds on his left and right toes. No treatments were ordered until 4/27/23. The wound doctor observed the wounds on 4/28/23 and diagnosed the resident with osteomyelitis. A bilateral doppler ultrasound was ordered on 4/28/23 and completed on 5/1/23. However, the facility failed to follow up in a timely manner to receive the results which were not on the resident's file until 5/24/23. The resident went to the podiatrist on 5/22/23 where she was able to probe to the bone on both first and fifth digits. The podiatrist sent the resident to the hospital. The hospital admitted the resident with osteomyelitis of the left hallux and left fifth digit, cellulitis of the left foot, exposed bone on left hallux, and gangrene of left fifth digit. The resident would need amputations of the toes. The Executive Director (ED), the Director of Nursing (DON), the Regional Support for Social Services (RSS), and Regional Director of Operations (RDO) were notified of the immediate jeopardy on 5/24/23 at 2:28 p.m. The immediate jeopardy was removed on 5/26/23, but noncompliance remained at the lower scope and severity level of isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy. Findings include: A. On 5/23/23 at 10:00 a.m., Resident 45's medical record was reviewed. Resident 45 was transferred from another skilled nursing facility and admitted to [NAME] Healthcare on 3/3/23. He admitted with diagnoses which included, but were not limited to, a history of non-ST elevation myocardial infarction (heart attack), cerebral infarction (stroke), congestive heart failure, type II diabetes mellitus (a blood sugar disorder), and need for assistance with personal care. A Transition of Care (TOC) document, dated 3/3/23, from the previous nursing facility indicated he had admitted to their facility with a diagnosis of osteomyelitis (inflammation or swelling that occurs in the bone. It can result from an infection somewhere else in the body that has spread to the bone, or it can start in the bone). A nursing admission assessment, dated 3/3/23 at 3:21 p.m., indicated Resident 45 admitted with two areas of compromised skin integrity. One ulcer was noted on his left great toe which measured 1.5 centimeters (cm) long by (x) 1 cm wide. A second ulcer was noted on his left 5th toe which measured 1 cm long by 1 cm wide. An option to proceed with wound care observation, was marked, no. A nursing admission progress note, dated 3/3/23 at 3:39 p.m., indicated Resident 45 was noted to have a 1.5 cm x 1 cm dark scab to his left great toe and a 1 cm x 1 cm area to the lateral side of his 5th toe which was red in color. A baseline care plan, initiated 3/5/23, indicated Resident 45 was at risk for further skin break down due to, .osteomyelitis to L [left] foot and arterial ulcers to L toes A second baseline care plan, initiated, 3/5/23, indicated Resident 45 was at risk for pain, also related to arterial ulcers on his left foot. The record lacked documentation of interdisciplinary team (IDT) follow up related to the areas noted on admission. The record lacked documentation the physician was notified of osteomyelitis in his left foot and/or the areas on his toes noted upon admission. On 3/15/23 Resident 45 was initially seen by the Medical Director (MD). The evaluation indicated no issues with the resident's skin and lacked a review of his history of osteomyelitis and the two areas noted on his toes upon admission. A follow up was conducted by the MD on 3/27/23. The evaluation lacked a review of his history of osteomyelitis and the two areas noted on his toes upon admission. Resident 45's shower sheet/bathing records were reviewed and revealed he had only received bed baths, and no skin issues were noted until 4/25/23 when the aide noted, right foot and left foot had open areas. A nursing progress note, dated 4/25/23 at 2:26 p.m., indicated Resident 45 was noted to have redness and drainage to his left 5th toe and great toe. The MD was onsite and made aware. The Nurse and MD observed Resident 45's left foot. The MD gave no new orders at that time. A new Skin Event was opened on 4/25/23 at 2:47 p.m. which indicated, yellowish drainage on the left great and 5th toes and bright red. Measurements were not recorded. The MD was made aware and gave no new orders. The skin event indicated, Resident noted to have redness and drainage to the left 5th and great toe .MD on site and was made aware. MD and writer observed resident left foot. No new orders given at this time. During an interview on 5/24/23 at 10:21 a.m., LPN 52 indicated she was working on 4/25/23 when a CNA notified her, Resident 45 had open areas on his right and left foot which she found during a bed bath. LPN 52 immediately went to assess the areas and upon her observation she was very concerned. His toes were black and had a lot of drainage. The MD was in the facility at that time, and she asked him to come look. LPN 52 and the MD observed Resident 45's feet. When LPN 52 and the MD left his room, the MD told her it looked like he had osteomyelitis. He showed her a picture example on his phone and indicated the resident would probably lose his foot. The MD did not give LPN 52 any orders at that time. During an interview on 5/25/23 at 6:40 p.m., CNA 53 indicated she worked weekend option and had only worked with the resident once before but not on a shower day. So 4/25/23 was the first time giving him a bath. He was really pleasant and cooperative. While giving him a bed bath she did the top area first and kept his socks on to keep him warm. When she got to the bottom, it was horrible. It was not a situation where she felt comfortable finishing the bath, dressing the resident and changing the bed. She needed to get help right way! It startled me to the point, I thought his toes are falling off, this is scary! She could not identify which toe was the problem as it was his whole foot. It scared me to death. His whole foot was pale. The doctor was there that day, and he came down to look at it. He pressed on the resident's foot, the resident said he could not feel the pressure. The foot was white and did not turn pink with pressure. CNA 53 was surprised he was not sent to the hospital. She indicated she had been a CNA long enough to know that his foot did not get that way in just a couple of days. She indicated there was no way his toes and foot could have been missed if the socks were being taken off during bed bath and it was important to inspect residents' feet. During an interview on 5/24/23 at 10:11 a.m., Licensed Practical Nurse (LPN) 51 indicated she did not recall any issues with Resident 45's feet until the new areas were found in April. She had returned to work after a weekend and saw a new skin event had been initiated by another nurse. She went to Resident 45 to inspect the area and was alarmed at the condition of his left foot. She asked LPN 52, (the nurse who opened the event on 4/25/23) about the areas. LPN 52 told her, a CNA found the areas and let her know. When she assessed the area, she was also concerned and even observed the foot with the MD, but he did not give any orders at that time. LPN 51 indicated, since she was told the MD was already aware, she notified the DON who instructed her to open additional events, get measurements, call the MD, and ask orders. LPN 51 described his toes as, very icky. The 5th digit was macerated with eschar and had yellow slough and drainage. There was a new area to the top of his great toe that was flattened and black. The top of his right great toe had redness and warmth and appeared possibly infected. LPN 51 indicated, the condition of his feet was advanced, and the areas could not have developed overnight. Resident 45 always wore the non-skid socks and did not complain about pain. He was in a regular bed, and it was not until the area were found that the footboard of the bed was removed. LPN 51 indicated Resident 45 usually only got bed baths, and the CNAs should have been removing his socks to observe his feet. A nursing progress note dated 4/27/23 at 3:25 p.m., indicated, Resident 45 was in bed and received a full assessment. New orders were noted for areas to top of his 5th toe, bottom of 5th toe, top of great left toe, inside 1st big toe, and right great toe. The corresponding Skin Events were reviewed: On 4/27/23 at 2:54 p.m., a new area located on the left 5th to which measured 1.3 cm long by 3.4 cm wide. Yellow slough was present as well as redness/warmth (a sign of infection). On 4/27/23 at 3:01 p.m., a new area located on the left bottom of the 5th toe which measured 1.5 cm long by 1 cm long with redness and warmth present. Also noted to be back/brown/dark. On 4/27/23 at 3:08 p.m., the top of the left great toe measured 2.8 cm wide by 2.7 cm long. It was an open area with yellow drainage, redness, and warmth were present. Also noted to be black/brown/dark, (two days prior had been right red). On 4/27/23 at 3:15 p.m., a new area located on the left inner 5th toe which measured 5 cm long by 2.1 cm wide. Yellow slough, redness, and warmth were present. On 4/27/23 at 3:05 p.m., a new area located on the right great toe which measured 1.5 cm long by 1.5 cm wide. It was noted to be bright red with warmth present. Physician's orders, initiated on 4/27/23 (2 days after wounds were found) indicated to cleanse the areas with wound cleanser, apply Xeroform (a type of wound dressing/treatment) and cover, daily. A physician's order was initiated on 4/28/23 to obtain a bilateral doppler ultrasound, (a noninvasive test that can be used to estimate the blood flow through your blood vessels). A nursing IDT progress note, dated 4/28/23 at 2:14 p.m., indicated, the DON, the Minimum Data Set Coordinator (MDSC), Unit Manager (UM) and Wound MD were present. Wounds were described as arterial ulcer on the left great toe with 25% epithelial 35% slough 40% eschar, mild serosanguineous exudate, edges intact, necrotic tissue removed. The Left 5th toe had no drainage, edges intact, 70% eschar and 30% epithelial. Treatments were in put in place, antibiotics, podiatry referral, and arterial doppler. A nursing progress note, dated 4/28/23 at 2:44 p.m., indicated the Wound MD was in to evaluate Resident 45's left foot. A new order was received to start a Peripherally Inserted Central Catheter (PICC) and antibiotic for 6 weeks. A nursing progress note, dated 5/1/23 at 1:21 p.m., indicated a contracted mobile diagnostic and imaging company was noted at the facility to obtain an arterial doppler for Resident 45's left foot. Results were pending. A physician's order for intravenous (IV) meropenem (an antibiotic medication) was obtained on 4/29/23 with the indication for osteomyelitis in the left great toe. A referral was made for Resident 45 to be evaluated and treated by a podiatrist and a nursing progress note, dated 5/22/23 at 10:00 a.m., indicated the doctor from the podiatrist office phoned to inform the facility that Resident 45 was being transferred to the emergency room (ER) for further evaluation and treatment and possible admission for amputation. On 5/24/23 at 8:30 a.m., a copy of a SOAP (subjective/objective/assessment/plan) evaluation conducted by the Doctor of Podiatric Medicine (DPM) was provided. The evaluation indicated, .patient states that for the past 6 months he has had ulcers on his left foot . Ulcer #1: located on the left great toe is [NAME] Grade 3 [deep ulcer with abscess or osteomyelitis) arterial. Wound is full thickness and measured 1.5 cm long by 1.2 cm wide and 0.3 cm deep with moderate serous drainage, undermining noted and was able to be probed to the bone. Ulcer #2: located on the left 5th toe is [NAME] Grade 3 arterial, full thickness and measured 2 cm long by 1.5 cm wide but depth could not be measured. Ulcer #2 had heavy purulent drainage, tan in color with 25% eschar and tunneling noted. Ulcer #2 was also noted with Erythema and fluctuant tracking along the planter aspect of the arch in line with the 5th flexor tendon. When lanced, purulent material expressed from the fluctuant area in the arch Plan: discussed bone infection and the implications it has on healing and limb loss . I stressed the need to treat the problem aggressively. Recommended excision of the infected [NAME] with culture and biopsy of the area . I am very concern with the appearance of the left foot. As there is purulent drainage and he is already on IV antibiotics with a PICC line. He also had exposed bone to 1st and 5th toes of the left foot necessitating amputation of both. He has non-palpable pulses which will need vascular work up before any surgery can be completed. He will also need an MRI. Advised he be sent to the hospital A hospital ER evaluation, dated 5/22/23, indicated Resident 45 came to the Emergency Department (ED) from the podiatrist for a possible arterial occlusion and osteomyelitis of left foot. The podiatrist could not find a pulse in his left foot there was evidence of first and fifth digit dry gangrene. There was drainage out of the planter aspect of the left foot. A CTA (Computed Tomography Angiography- a type of medical test that combines a CT scan with an injection of a special dye to produce pictures of blood vessels and tissues in a part of your body) indicated, .left superficial femoral artery multiple tandem high-grade stenoses, occlusions and minimal reconstruction of the popliteal artery and runoff vessels, the posterior tibial artery is opacified across the ankle on delayed phase imaging A hospital podiatrist consult indicated the DPM was able to get quite a bit of pus out of the foot at bedside from the digit and extending into the medial arch concerning for abscess. She was also able to probe to the bone on both right and fifth digits. The DPM was concerned about blood flow as pulses were not palpated to the left foot, fifth digit had dry gangrene to the planter lateral aspect of the digit. There was a small area in plantar medial arch of necrotic ulcer. The report indicated, .patient has exposed bone on left hallux and gangrene of left fifth digit so will need amputation of these digits but would prefer to optimize perfusion first to help with healing of surgery, per DPM there was concern of infection tracking down flexor tendon, so I did order an MRI to assess for extent of infection During an interview on 5/23/23 at 12:54 p.m., Resident 45's Power of Attorney (POA) indicated, she was unaware Resident 45 had been sent to the hospital or that he had new wounds on his feet. She was concerned about how it would affect his ability to recover, since he was a diabetic and had a history of wounds. He had been doing so well and was recovering from the stroke, she had even planned to make arrangements to have her POA revoked so that he could be independent again. During an interview on 5/23/23 at 2:00 p.m., the MD indicated he rounded at the facility on a weekly basis and was usually in the facility every Tuesday from 10:00 a.m.- 6:00 p.m. He would visit residents upon their admission and conduct comprehensive assessment and evaluation. This assessment would include a comprehensive skin assessment, but only of exposed skin. He indicated, I only look at skin I can see, just the exposed parts. I do not typically check unexposed skin unless the resident and/or staff indicated there was a need, if there is a treatment or bandage in place, I don't remove it. During an interview on 5/23/23 at 2:06 p.m., Certified Nursing Assistant (CNA) 50 indicated, Resident 45 was complaint with his care and treatments. He was pleasant and agreeable. He was interactive and enjoyed conversations. CNA 50 only worked with Resident 45 in the previous couple of weeks, so she was unable to visualize his foot before he left, but she remembered that there was quite a bit of redness to his whole left foot and the start of redness to his right foot. His feet were tender, so she tried to be careful. During an interview on 5/23/23 at 2:51 p.m., the DON indicated Resident 45 never had a doppler ultrasound as a resident at the facility. The above stated physician order and progress notes were reviewed with DON at this time, and she indicated she would double check. During a follow up interview on 5/23/23 at 2:51 p.m., the DON indicated when Resident 45 admitted to the facility, he did not have any open areas that she could recall. Several weeks later, his toes didn't look right and they had begun to change color, so the wound doctor was called in for an evaluation. The DON indicated it was her expectation that upon admission and identification of any skin integrity issues, the areas should be reported to the IDT team, so that the IDT team could review, evaluate and determine if the areas needed to be followed up with or not. During an interview on 5/24/23 at 9:16 a.m., the DON provided a copy of the doppler results and indicated she logged onto the website and found that the results were uploaded so she was able to obtain a copy. Until that time, the results had not been obtained by the facility. It was the DON's expectation for nursing staff to follow up on tests results in a timely manner. The results of the doppler, dated 5/2/23, were reviewed and revealed, .1. Left dorsal pedis artery not visualized may not exclude occlusion. 2. Segmental stenosis in the rest of bilateral lower extremity arteries especially in bilateral superficial femoral and the visualized infrapopliteal arteries. Further examination suggested which may include CT angiography among other workup During an interview on 5/24/23 at 10:03 a.m., the Minimum Data Set Coordinator (MDSC) indicated she had conducted the nursing admission assessment on Resident 45. When the MDSC inspected his feet, she noted the two areas on his toe. She indicated as a nurse she could not diagnosis because that was out of her scope of practice. She did not know what to classify the areas as and that was why she put a follow up progress note in with more details about the areas. Additionally, it was important to note skin integrity issues on the admission assessment so that IDT could follow up as needed. The MDSC indicated, the areas were not open or draining at that time, and she indicated they looked more like scabs. When skin areas were noted on the admission assessment, it should trigger the IDT team to review and determine if further follow up was warranted or not. She did not know why the IDT team did not review his feet after admission. On 5/24/23 at 2:50 p.m., a visit was attempted with Resident 45 at the hospital. He was out of the room at that time. His nurse, a Registered Nurse (RN) for the hospital indicated, he was undergoing a stress test as a part of pre-surgery preparations. She indicated his left foot was in very bad condition and amputation was a certainty. The doctors were concerned about the extent and spread of the infection, as it may have traveled up his leg through the tendon in his foot. If they were unable to restore good enough blood flow to the leg, he may require an amputation below the knee. On 5/25/23 at 11:16 a.m., Resident 45 was observed while in-patient at the hospital. He was reclined in bed. His left foot was wrapped. When asked what happened to his foot, Resident 45 indicated, it's F----- up! When asked what happened, he indicated, I don't know I guess I just have wounds, I think they are going to take my foot off. When asked if the nurses and aids were checking his feet while he was at the facility, he indicated, he thought they were, but when he got bed baths he could not remember if they took his socks off or not. During an interview on 5/25/23 at 11:20 a.m., Resident 45's hospital nurse indicated he was receiving IV heparin due to the occlusions as a blood thinner to try and prevent another stroke. He was also on IV meropenem for the osteomyelitis. She checked his most recent physician notes and indicated, he was going to be transferred to another hospital for more extensive testing and procedures. An MRI performed the day before was positive for osteomyelitis to his whole left foot. On 5/25/23 at 11:30 a.m., Resident 45's left foot was observed. His 5th digit was observed to be fully black from the base of the toe to the tip of his toe, dry and looked like a stone. The tip of his great toe was observed. It was swollen and bulged outward with an oval shaped wound. The wound bed was noted with scant yellow slough, the edges were rolled over and macerated. The top/right side of his great toe had a scabbed, irregular shaped area with reddish-brown dried crust. There was a small puncture wound on the bottom of his foot, in the middle of his arch. Purulent drainage was noted. During an interview on 5/25/23 at 12:40 p.m., the Wound Doctor (WMD) indicated he was asked to see Resident 45 for new areas on his foot. He saw Resident 45 on 4/28/23. By the time, the WMD saw his foot, there was already exposed bone, and he was certain it was infected with osteomyelitis. He was not the doctor who ordered the arterial doppler therefore did not follow up for the results. If he had ordered the test, he would except results and follow up within a couple of days. On a follow up visit on 5/19/23 the WMD indicated it appeared to have worsened and if there had not already been a podiatrist referral scheduled, he would have sent him out. At this time, the WMD provided copies of his wound notes for review. An initial wound evaluation, dated 4/28/23, indicated wounds present on the left 5th toe and great toe. They were classified as arterial ulcers with osteomyelitis of the left great toe and the resident had a history of osteomyelitis of the left great toe and had a history of stroke and heart attack. The peripheral pulse was palpable but weak, his feet were pale, and the left great toe was erythematous and warm. Wound #1 was classified as full thickness with exposed bone and etiology of arterial insufficiency, located on the left 5th toe. The wound measured 1.5 cm long by 3.2 cm wide and 0.1 cm deep with subcutaneous tissue exposed and a small amount of serosanguineous drainage. There was a large (67%-100%) amount of necrotic tissue within the wound bed including eschar. Wound #2 was also classified as a full thickness arterial wound with exposed bone. The wound measured 4.2 cm long by 3.7 cm wide and 0.6 cm deep. There was bone, muscle and subcutaneous tissue exposed. There was a small amount of serosanguineous drainage noted and there was a large amount of necrotic tissue within the wound bed including eschar and adherent slough. At that time, the WMD gave new orders to start IV antibiotic of meropenem for osteomyelitis of the right great toe and also gave a general note, .refer to outside podiatrist regarding possible need for amputation of left toe/s. A WMD note, dated 5/5/23, indicated healing was unlikely and to anticipate then need for surgical intervention per podiatry. A WMD note, dated 5/19/23, indicated the left great toe area was stable but slightly enlarged. Plan was to continue IV meropenem for osteomyelitis but there was a concern that the antibiotic may not reach target tissue in a sufficient concentration to be effective given arterial insufficiency. Await input from podiatry consultant on 5/22. I am concerned the distal left foot remains at risk and amputation may yet be indicated . During a follow up interview on 5/25/23 at 3:10 p.m., the MD indicated he only visited with the resident on 3/14 upon his admission. At that time, he indicated there were no issues with his feet or legs. The MD indicated he did not recall anything significant about the resident's foot or toes. When the nursing progress note from 4/25/23 was read to MD, he indicated he did not recall seeing the resident's foot. On 5/24/23 at 2:15 p.m., the Executive Director (ED) provided a copy of current facility policy titled, Nursing Admission/Return admission Policy and Procedure, revised 2/2019. The policy indicated, It is the policy of American Senior Communities to provide baseline and accurate documentation of the mental and physical condition of each resident admitted . Initial Nursing Assessment: admission Observation . a thorough head to toe assessment (including skin) must be done at admission. Any altercations in skin integrity must be identified on nursing assessment. They physician must be notified for specific treatment orders . After completion of the admission nursing assessment a Baseline care plan will be initiated for all new admissions On 5/24/23 at 2:15 p.m., the Executive Director (ED) provided a copy of current facility policy titled, Skin Management Program, revised 5/2022. The policy indicated, .Procedure for altercations in skin integrity- Pressure and non-pressure . altercations in skin integrity will be reported to the MD/NP . Treatment will be obtained from MD/NP. All altercations in skin integrity will be documented on the admission observation in the medical record on the admission observations . The wound nurse/designee will be notified of altercations in skin integrity . the wound nurse/designee will complete further evaluation of the wounds identified and complete the appropriate skin evaluation on the next business day On 5/24/23 at 2:15 p.m., the Executive Director (ED) provided a copy of current facility policy titled, Labs and Diagnostics, dated 11/2017. The policy indicated, It is the policy of American Senior Communities to provide or obtain laboratory and diagnostic services to meet the needs of its residents. The facility is responsible for the quality and timeliness of the services On 6/1/23 at 2:39 p.m., Resident 45's family member indicated he had his leg surgically amputated above the knee and was recovering. The immediate jeopardy that began on 4/25/23, was removed on 5/26/23, when the facility provided education to all nursing staff for admission process, skin management, and follow up for labs and diagnostics. Further, a facility wide skin-sweep was conducted for all residents as well as an audit of ordered labs/diagnostics to ensure timely follow up. The noncompliance remained at the lower scope and severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need for continued monitoring. B1. On 5/26/23 at 11:18 a.m., Resident 31 was randomly selected for review during the IJ removal. At that time, he was observed seated in his wheelchair beside his bed in his room. He was agreeable and allowed Licensed Practical Nurse (LPN) 23 to remove his socks and shoes, so that an observation of his feet could be conducted. Upon removal of his socks, his bilateral (both right and left) feet, were observed to be discolored. They were ashy and dusky dark purple. The discoloration continued up both of his legs to just below his knees. His legs were very dry, flakey, and scaley with shedding skin. His legs were also deep purple in color. When asked about the discoloration, LPN 23 indicated his legs were not discolored, he only had dry skin. On 5/26/23 at 12:40 a.m., Resident 31's medical record was reviewed. He was a long-term care resident with diagnoses which included, but were not limited to, cellulitis (bacterial skin infection) and peripheral vascular disease (PVD- A circulatory condition in which narrowed blood vessels reduce blood flow to the limbs and can cause the color of the legs and feet to change which can be a sign that not enough nutrients or oxygen are able to be supplied to the legs and feet by the blood). He had a comprehensive care plan, initiated 1/30/21 and revised 5/23/23, which indicated he was at risk for ineffective tissue perfusion related to PVD. The care plan lacked person-centered revision and/or interventions that identified the discoloration of his bilateral lower extremities (BLE). He had a comprehensive care plan, initiated 8/12/202 and revised 5/23/23, which indicated he was at risk for further skin breakdown due to concerns which included, but were not limited to, cellulitis, history of venous ulcers and limited sensory perception. The care plan lacked person-centered revision and/or interventions to identify the discoloration of his BLE. He had a comprehensive care plan, initiated 8/12/20 and revised 5/23/23, which indicated he was at risk for pain related to a left hip fracture, decreased ambulation, PVD and refusal to bear weight on his left lower extremity. The care plan lacked person-centered revision and/or interventions to identify the discoloration of his BLE. Resident 31's weekly skin assessments were reviewed. The assessments completed between 1/27/23 - 5/19/23 all lacked documentation, indication, and/or intervention to identify and/or address the discoloration of his legs. A weekly skin assessment dated [DATE], indicated, a podiatry referral was needed. The record lacked documentation of follow up to schedule the podiatrist visit. The record lacked documentation of identification of his chronic discoloration, therefore no additional monitoring or interventions were in place. On 5/26/23 at 12:11 p.m., the DON provided a copy of a skin-sweep tool for Resident 31. She indicated, as a part of the IJ removal process, a facility-wide skin-sweep had been conducted to ensure residents had not developed new skin integrity issues which had not already been identified, and to ensure previously identified areas had appropriate treatments in place. The DON indicated she had conducted the skin assessment on Resident 31, and there were no areas of concern that she recalled. On 5/26/23 at 12:18 p.m., Resident 31's BLE were observed with the DON and Regional Clinical Consultant (RCC) 24. Upon visualization, the DON indicated, the discoloration of Resident 31's BLE were chronic and had always been there because of his PVD. He did not have any new open areas. His legs were always discolored and appeared to be very dry and flakey.B2. On 5/22/23 at 10:48 a.m., Resident 21 was observed in his room. He had 3 circular wounds to his face: one on his forehead, one between his eyebrows, and one on the end of his nose. He pulled up the sleeves of his shirt to show multiple circular wounds on his bilateral (both) arms. No dressings were observed. On 5/24/23 at 12:37 p.m., Resident 21's wounds were observed. He continued to have the three circular wounds to his face and six circular wounds to his bilateral anterior arms. He raised his shirt and indicated he had wounds on his belly button. He raised his shirt, exposing his lower back exposing 4 wounds. He pulled up his pant legs, exposing his bilateral lower legs. There were numerous wounds, approximately 50 small wounds. He had no dressings on any of these wounds. On 5/24/23 at 12:39 p.m., Resident 21 indicated he received his shower the day before. At the end of the shower he indicated he was all bloody. On 5/23/23 at 2:08 p.m., Resident 21's record was reviewed. His diagnoses, included but were [TRUNCATED]