**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 152 residents. The sample included three residents reviewed for accidents. Based on record review, interview, and observations, the facility failed to ensure Resident (R) 1 remained free from avoidable accidents when staff failed to provide care safely using the required number of staff per the resident's plan of care. Subsequently, R1 sustained a dislocated right shoulder and a fractured right humerus (upper arm bone). This deficient practice also placed R1 at risk for increased pain and impaired well-being. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of polyosteoarthritis (a condition characterized by inflammations, stiffness, and pain in five or more joints simultaneously), Parkinson's disease (a slowly progressive neurologic disorder characterized by resting tremors, rolling of the fingers, masklike faces, shuffling gait, muscle rigidity, and weakness) without dyskinesia (inability to execute voluntary movements), dementia (a progressive mental disorder characterized by failing memory and confusion), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear) disorder, and fibromyalgia (inability to execute voluntary movements). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. R1 displayed no behaviors. R1 was dependent on staff for oral hygiene, toileting hygiene, showering or bathing, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. R1 was dependent on staff for mobility in bed, all transfers, and mobility in her wheelc hair. The MDS recorded R1 had no falls since admission. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 04/01/24 documented R1 as dependent on staff assistance with ADLs and transfers. R1 was monitored for changes in functioning. Staff were to ensure R1's needs were met and R1's room was kept free from clutter. The Falls CAA dated 04/01/24 documented R1 was dependent on staff assistance with ADLs and with transfers. R1 was a fall risk due to weakness and was monitored for changes in functioning. The Pain CAA dated 04/01/24 documented that R1 complained of pain and received scheduled and as-needed medications. The Quarterly MDS dated 07/01/24 documented a BIMS score of three, which indicated severely impaired cognition. R1 displayed no behaviors. R1 had no changes in her level of assistance needed from staff from the previous MDS. The MDS recorded R1 had two or more falls with no injury, and two or more falls with injuries. R1's Care Plan implemented on 04/10/23 documented R1 required maximum assistance of two staff members for all bed mobility and showering. An intervention implemented on 12/01/23 documented that staff would provide care in pairs for R1 so that R1 felt safe. An intervention implemented on 05/15/24 documented that staff would provide care in pairs so R1 felt safe. An intervention revised on 06/03/24 documented that R1 required the maximum assistance of two staff members with dressing, personal hygiene, and oral care. A review of the Staffing Care Sheet updated on 07/22/24 documented R1's fall interventions and directed staff to have two aides with care at all times. On 09/27/24 at 02:48 PM a Nurse's Note documented R1's representative expressed concerns about R1 being transferred with a mechanical lift and felt it was not being used consistently by all facility staff. R1's representative requested an order to have physical therapy screen R1 for falls, transfers, and recliner safety. On 09/27/24 at 04:54 PM a Weekly Skin Check documented R1 had extensive bruising to her face and forehead due to a fall the prior week. R1 also had a large hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) to her posterior (back) right forearm. On 09/28/24 at 07:57 AM a Nurse's Note documented R1 was on the floor in her room. R1 laid flat on her abdomen and face down, with her head towards the bed, and R1 had no skid socks on her feet. When R1 was asked what happened, R1 stated she fell, and her right arm was hurting. Staff rolled R1 to her back and assessed her. R1 was visibly agitated and continuously waving her right arm around. R1 had a hematoma forming on her head. Certified Nurse Aide (CNA) M stated she was assisting R1 to change her clothing, while she was in the recliner. R1 leaned forward and fell out of the recliner onto the floor. R1's provider was notified and ordered R1 to be sent to the emergency room (ER) to be evaluated. On 09/28/24 at 08:35 PM a Nurse's Note documented R1 returned from the ER very agitated and inconsolable. R1 had a closed fracture of her right shoulder, with a new order for pain medication, and an order to keep her right arm in a sling until she followed up with orthopedics (a branch of medicine that focuses on the care of the skeletal system and its interconnecting parts). R1 was very frustrated due to her good arm being injured. R1's Care Progress Note dated 10/01/24 documented R1 was seen in the ER on [DATE] and found to have a dislocation of the right shoulder with a fracture of the proximal (nearer to a point of reference or attachment) end of the humerus. R1's shoulder was reducted (to restore a fracture or dislocation to the correct alignment) at the bedside. On 10/02/24 at 12:40 PM, R1 sat in her wheelchair at the nurse's station with her right arm in a sling. Her right hand was swollen and bruised throughout her hand. R1 had a hematoma, dark purple in appearance, approximately two to two and a half inches in diameter above her right eye. R1 stated that she fell out of her recliner when CNA M was helping her. R1 stated CNA M did not have a hold of her and she jerked and fell to the floor. R1 revealed that it was only CNA M helping her when she fell. R1 called out in pain and asked Licensed Nurse (LN) H for a pain pill. R1 stated it was for her right shoulder because it was hurting and broken since shefell. R1 stated she was glad she did not have to have surgery but was upset her arm needed to stay in the sling. R1 stated she just saw the orthopedic doctor that morning and was told about what was being done with her arm. On 10/02/24 at 01:20 PM CNA M stated that when working on the hall that R1 lived on, staff were given a staffing care sheet, so staff know of knew what was going on with the residents. CNA M stated she received report when she got onto the unit. CNA M was told R1 required a Hoyer lift (full-body mechanical lift) for transfers. CNA M stated she went to provide R1 with peri care and change her clothing but was not getting R1 up, so CNA M did not get another staff member to assist with R1. When CNA M turned R1 in her recliner, R1 jerked and then fell. CNA M stated sometimes she could get into the residents' Point Of Care (POC) or [NAME] (a nursing tool that gives a brief overview of the care needs of each resident) and sometimes she would get locked out. CNA M stated she was able to get into the POC and [NAME] but it was not until halfway into her shift. On 10/02/24 at 03:17 PM, CNA N stated she heard that CNA M was not fully aware of how R1 transferred or how R1 received care. CNA N stated she was working a different hall when CNA M told her about R1's fall. On 10/02/24 at 03:21 PM LN G stated that she had not witnessed R1's fall, but CNA M alerted her to the fall around 06:00 AM. LN G arrived at R1's room and R1 was lying on the floor on her stomach, face down, with her right arm extended straight out, her head towards her bed and her feet towards the recliner. LN G said CNA M informed her that CNA M attempted to get R1's wet gown off, when R1 jolted forward, and the CNA could not catch R1. LN G revealed the CNAs gave report to oncoming CNAs before their shift started and there was also a staffing care sheet to tell the CNAs how to care for the residents. On 10/02/24 at 04:05 PM Administrative Nurse D stated she expected staff to follow the resident's care plan. Administrative Nurse D stated with R1, she expected two staff members at all times to go into R1's room to provide care. Administrative Nurse D stated R1 did not always listen to staff, and that is why Administrative Nurse D informed the staff there were to be two staff members entering R1's room to care for her. On 10/02/24 at 04:21 PM Administrative Staff A stated he expected staff to follow the residents' care plan and [NAME] when providing care for the residents. The facility's policy Accidents and Supervision dated 02/01/20 documented a resident environment remains as free of accident hazards as possible, and each resident receives adequate supervision to prevent accidents. The policy documented facility-based interventions may include educating staff, implementing specific interventions as part of the plan of care, supervising staff and residents, and facility records documenting the implementation of these interventions. The facility's policy documented that monitoring was a process of evaluating the effectiveness of the interventions and modification of adjusting the interventions as needed to address hazards and risks. The facility failed to ensure R1 remained free from avoidable accidents resulting in a dislocated right shoulder and a fracture of the humerus. This deficient practice also placed R1 at risk for increased pain and impaired well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility identified a census of 145 residents. The sample included three residents reviewed for accidents. Based on record review, interviews, and observations, the facility failed to ensure an environment free from accidents for Resident (R)1. As a result, R1 sustained an avoidable injury to her leg, which required sutures. This also placed R1 at risk for increased pain and impaired well-being. Findings included: - R1's Electronic Medical Record (EMR), under the Diagnosis tab, recorded diagnoses of Bell's palsy (paralyzed on one side of the face), localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues), chronic pain, and anemia (inadequate number of healthy red blood cells to carry adequate oxygen to body tissues). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. R1 was dependent on staff for showers, upper body dressing, lower body dressing, and toileting hygiene. R1 was dependent on staff for transfers. The Activities of Daily Living (ADL) Care Area Assessment (CAA) dated 07/11/23 documented R1 required extensive to total assistance with ADLs including transfers. The Pressure Ulcer CAA dated 07/11/23 documented R1 as at risk for skin breakdown due to decreased mobility. The Quarterly MDS dated 04/08/24 documented a BIMS score of 11, which indicated moderately impaired cognition. R1 was dependent on staff for showers, upper body dressing, lower body dressing, and toileting hygiene. R1 was dependent on staff for sit to lying, sitting, and transfers. R1's Care Plan revised on 03/07/24 documented R1 needed two staff members to help her transfer using the Hoyer lift with a full-body, large sling. R1's Nurse's Note dated 05/02/24 at 12:39 PM documented R1 had skin tears to her left and right lower legs. Staff assessed, cleaned, and covered the skin tears. R1 received orders to be sent to the emergency room for evaluation and treatment. R1's Skin and Wound Evaluation dated 05/02/24 documented a left shin skin tear. R1's skin tear was 10.8 centimeters (cm) in length, 4.3 cm in width, by 0.1 cm in depth: there was bleeding with a moderate amount of exudate (a fluid that leaks out of body vessels and tissues). R1's Skin and Wound Evaluation dated 05/02/24 documented a right shin skin tear. R1's skin tear was 3.9 cm in length, 5.2 cm in width, by 0.2 cm in depth; there was bleeding with a moderate amount of exudate. The Facility Investigation dated 05/02/24 documented R1 was assisted up in the Hoyer lift from her wheelchair into R1's recliner. While Certified Nurse Aide (CNA) M lowered R1 into the recliner, CNA N placed her hands on R1's right and left lower legs and pushed back to assist R1 to get further back into the recliner. CNA N then noted R1's lower legs were bleeding. Licensed Nurse (LN) G was notified, came to the room, and assessed R1's bilateral lower legs. CNA M's undated Unnotarized Witness Statement documented R1 wanted to sit in her recliner. CNA M pulled back on the hook of the sling to get R1's bottom back in the seat of the recliner. CNA N pushed on R1 a little to help R1 reach the recliner. CNA N noticed that R1's legs were bleeding where CNA N had placed her hand to push R1 closer to her recliner. CNA N's Unnotarized Witness Statement dated 05/01/24 documented R1 wanted to get into her recliner. CNA M and CNA N got R1 into the Hoyer lift and up against the recliner. CNA M pulled R1 back by the sling, but CNA N noted it was not back far enough. CNA N then pushed R1's legs, so R1 could go back further. CNA N noticed R1's legs were bleeding. R1's Hospital Discharge Paperwork dated 05/02/24 documented R1 had a laceration (a deep cut or tear in the skin) repair to her right lower leg. The paperwork documented R1 had a 13 cm laceration that required 15 sutures. On 05/09/24 at 11:45 AM R1 sat in her recliner with her legs elevated. LN G performed R1's dressing changes to the bilateral lower legs. R1 had a Versatel dressing (contact layer dressing coated with silicone) applied to the lacerations on both legs that would not be removed for seven days as ordered. R1 lifted her left leg and grimaced while LN G applied Kerlix (gauze) around her left leg. On 05/09/24 at 12:50 PM, R1 stated that CNA M and CNA N upset her while transferring her because they did not listen when she asked them to guide her using her heels and not her lower legs. R1 stated that her lower legs hurt. R1 also stated that her feelings were hurt because the staff did not listen to her. R1 revealed that there was a great deal of pain when the injury occurred. On 05/09/24 at 01:13 PM LN G stated that R1 historically had tender legs and that was why R1 wanted staff to use her heels instead of her legs. On 05/09/24 at 01:20 PM, CNA O stated that two staff members were required to use a Hoyer lift to transfer a resident. CNA O stated to get a resident into position in a chair or wheelchair, one staff member pulled on the sling from behind while the second staff member lowered the sling with the Hoyer controls. CNA O stated staff should not push on a resident's legs to get the resident further back into the chair as this action had the potential to cause bruising or injuries. On 05/09/24 at 01:40 PM Administrative Nurse D stated that staff informed Administrative Nurse D that CNA N pushed R1 on her legs while R1 was being lowered into the recliner. Administrative Nurse D stated that she was unsure exactly what happened, but R1 had a history of lower leg pain. Administrative Nurse D stated CNA M and CNA N received transfer training. Administrative Nurse D stated that the staff were being trained on transfers, but the training was not yet completed. The facility's policy Mechanical Lift undated, documented a mechanical lift was used appropriately to facilitate transfers of residents. The policy directed staff to use the lever to gently raise and move the resident to the destination. Once at the destination, staff were to lower the resident and position comfortably. The facility failed to ensure R1 remained free from avoidable accidents. As a result, R1 sustained a laceration to her leg which required sutures. This also placed R1 at risk for increased pain and impaired well-being.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 148 residents. The sample included 32 residents with nine reviewed for pressure ulcers. Based on observation, interview, and record review the facility failed to provide off-loading interventions to prevent the re-opening of a healed pressure ulcers for Resident (R)13 and failed to implement interventions immediately upon discovering the pressure injury. The facility also failed to ensure staff completed a weekly wound assessment which included wound measurements for R82 who had multiple skin issues. This deficient practice placed R13 and R82 at risk for complications resulting from pressure injuries and/or delayed healing. Findings included: - R13's Electronic Medical Record documented diagnoses of lymphedema (swelling caused by accumulation of lymph) and a history of cerebrovascular accident (CVA, stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain) The Quarterly Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. The MDS documented R13 required set up assistance for eating and substantial to maximum assistance for all other activities of daily living (ADL), including mobility. The MDS documented R13 had one Stage 3 (full thickness pressure injury extending through the skin into the tissue below) pressure ulcer (PU-localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) on admission. R13 had a pressure relief device on his bed and chair and received pressure ulcer care and dressings to his feet. R13's Skin Integrity Care Plan, dated 01/17/24, directed staff to ensure R13 wore appropriate footwear when ambulating or mobilizing in the wheelchair, initiated 05/05/23. R13 had a pressure relieving device on his chair and bed. His heels required elevation from the bed. He had a pressure reducing mattress and a cushion in his chair, initiated 05/05/23. The plan directed staff to cleanse R13's left heel wound with gauze and wound cleanser, apply Skin-prep (liquid skin protectant) to the peri-wound and collagen (protein derived wound treatment used to promote wound healing) to the wound bed followed by a cut-to-fit piece of Derma Blue (highly absorbent dressing embedded with antimicrobials), secure with a bordered foam dressing. Change daily and as needed if soiled or dislodged, initiated 06/20/23. The plan directed R13 had Prevalon boots (special pressure reducing heel protectors) on while in his recliner or bed and a Derma Saver bootie (cushioning boot) when he ambulated in his wheelchair, initiated 12/14/23. The Weekly Skin Assessment, dated 10/02/23 noted the left heel wound was resolved. The note documented there was a covering of skin with darker red underneath. The Weekly Skin Assessment, dated 12/01/23 at 08:30 AM, documented New skin concerns identified. R13's EMR lacked further note or mention of the new issues until the 12/04/23 wound care assessment. The Wound Care Note, dated 12/04/23, documented a total area of 4.72 centimeters (cm) with 0.2 cm depth on the left lower extremity (LLE). The left heel wound was 2.5 cm by 2.6 cm by 0.2 cm with 10 percent (%) eschar (dead tissue), 10% granulation (new tissue formed during wound healing), 10% slough (dead tissue, usually cream or yellow in color) and 70% eschar. There was moderate serosanguineous (semi-thick blood-tinged drainage) drainage. The wound care orders directed to cleanse the wound with gauze and wound cleanser, apply Skin-prep to peri-wound (skin surrounding the wound) and collagen to the wound bed followed by an absorbent dressing, rolled gauze, and tape. Change daily and as needed if soiled or dislodged. The Wound Care Note, dated 12/11/23, documented the R13's PU had a total area of 12.32 cm, with 0.2 cm depth. The Physician Order, dated 12/13/23, directed staff to ensure the resident wore Prevalon boots while in the recliner or bed and a Derma saver bootie when ambulating in his wheelchair. The Progress Note, dated 12/14/23 at 01:40 PM, documented the day shift nursing staff had not changed the dressing as ordered. The note recorded the dressing was dated 12/12/23. R13's December Treatment Administration Record (TAR) lacked evidence staff completed the left heel wound treatments on 12/11/23, 12/14/23, 12/15/23, 12/16/23, 12/21/23, 12/26/23, and 12/31/23. The treatment on 12/13/24 was recorded as refused. The Nutritional Assessment, dated 12/18/23, documented R13 met 100% of his nutritional needs, but his Stage 3 heel wound had deteriorated since the last evaluation and R13 had increased protein needs. The assessment recommended to try cottage cheese with lunches for wound healing needs. The Wound Care Note, dated 12/18/23, documented the PU had a total area of 8.9 cm. The Physician Order, dated 12/19/23, directed staff to provide Med Pass (a protein supplement) 60 milliliters (ml), twice daily. The Progress Note, dated 12/22/23 at 02:38 PM, documented R13 showered that shift, and his wound began to bleed. Upon inspection the nurse noted the peri-wound had lost integrity and appeared to be advancing in size and severity. The nurse noted the resident was non-compliant with the treatment of pressure relieving boots while in his recliner and was frequently noted sitting with his feet propped up in his recliner with his heels as the pressure point. Staff educated the resident on boot use. The Wound Care Note, dated 12/26/23, documented the PU had a total area of 12.33 cm. R13's December 2023 TAR lacked evidence R13 refused to wear the Prevalon boots or derma saver. The Registered Dietician Note, dated 01/15/24, revealed R13 had a Stage 3 left heel wound. R13 weighed 190 pounds and had weight gain over the past couple of months. R13's current diet order was carbohydrate controlled with 60 ml of Med Pass twice daily, cottage cheese with lunch, and ice cream twice daily. The note documented the dietician did not recommend supplements at that time; R13's intake with supplements was sufficient to meet needs, however his wound healing was delayed. The Progress Note dated 01/16/24, documented staff reminded R13 to let staff know if he had received his wound care changes daily. The note documented the resident was non-compliant with moon boot use and often sat in his recliner with his full weight on his heels and buttocks. R13's January 2024 and February 2024 TAR lacked evidence R13 refused to wear the Prevalon boots or derma saver. On 02/19/24 at 04:04 PM, observation revealed R13 sat in his recliner with his feet elevated on the footrest. He wore large foam boots. He stated his pressure ulcer developed after he admitted to the facility. On 02/20/24 at 03:52 PM, observation revealed Administrative Nurse E, the facility wound nurse, and Consultant Nurse HH performed wound care for R13's left heel. R13 wore a pressure relieving boot on his left foot. Administrative Nurse E removed the boot and a three-by-three dressing which had a small smear of drainage on it. Administrative Nurse E then cleansed the wound. R13's ulcer was beefy red and located on the back, bottom side of R13's heel. Consultant HH stated the wound was from pressure. Consultant HH said the wound was larger and had healed over, at one point. On 02/21/24 at 11:50 AM, Administrative Nurse E verified there were no offloading boots or floating of the heels after R13's PU resolved in October 2023. Administrative Nurse E said the wound consultant ordered to continue with the padded heel protector (Derma saver) but did not order any Prevalon boots or floating or off-loading of R13's heels. The facility's Pressure Injury Prevention and Management policy, dated 11/29/23, stated the facility would utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. A full body skin assessment would be conducted by a licensed or registered nurse upon admission, re-admission, and weekly thereafter. The assessment may be performed after a change in condition or after any newly identified pressure injury and documented in the medical record. Evidence based interventions for prevention would be implemented for all residents who are assessed at risk or have a pressure injury. The policy stated the Unit Manager or designee would review all relevant documentation regarding skin assessments, progression towards healing and compliance at least weekly and document a summary of findings. Interventions on a resident's plan of care would be modified as needed. The facility failed to provide off-loading and/or pressure relieving interventions to prevent the re-opening of a healed Stage 3 pressure injury for R13. The facility further failed to implement interventions immediately upon identification of the new wound. As a result, R13's pressure ulcer returned as a Stage 3 which also placed him at risk for pain and other complications related to the PU. - R82's Electronic Medical Record (EMR) documented diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) on the left side, hemiplegia affecting right dominant side, pressure-induced deep tissue damage of right heel, diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin) with skin complications, and bullous pemphigoid (a rare skin condition that causes large, fluid-filled blisters). The Significant Change Minimum Data Set (MDS), dated [DATE], documented a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS documented R82 required supervision for eating but was totally dependent on staff for all activities of daily living (ADL) and mobility. The MDS documented R82 had one Stage 2 pressure ulcer (PU-partial-thickness skin loss into but no deeper than the dermis including intact or ruptured blisters), one unstageable PU (depth of the wound is unknown due to the wound bed is covered by a thick layer of other tissue and pus), one diabetic ulcer, and one open lesion. R82 had pressure relief devices to his chair and bed. R82 received PU care and application of dressings to his feet. The Pressure Ulcer Care Area Assessment (CAA), dated 01/30/24, documented R82 returned from his second hospitalization that month related to syncope (fainting or passing out). He was dependent on staff for ADLs. He had multiple wounds from pressure and diabetes. He received treatments and was seen at the wound clinic. R82's Skin Integrity Care Plan, dated 02/15/24, documented R82 had skin breakdown related to a left side affected cerebrovascular accident (CVA, stroke- sudden death of brain cells due to lack of oxygen caused by impaired blood flow to the brain by blockage or rupture of an artery to the brain). The care plan directed staff to observe and assess skin weekly and ensure R82 wore a black off-loading boot on his left foot when he was up in his electric wheelchair; off load his heels on pillows when in bed, revised on 05/16/23. The 02/21/24 care plan update directed staff to assess, record and monitor wound healing, measure length, width, and depth where possible. Assess and document the status of the wound perimeter, wound bed, and healing progress. Staff were to report improvements and declines to the physician. The plan directed weekly treatment documentation should include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate (drainage). R82's Braden Scale (tool to determine risk for PU) Assessments, dated 10/10/23 listed the resident had a score of 14 which indicated moderate risk and on 01/07/24 he scored a 12 which indicated high risk for pressure injuries. The Weekly Skin Assessment, dated 12/25/23, noted R82 had a right thigh rash, an abrasion to the left little toe, an abrasion to the right little toe, and both heels had small openings. There were no wound bed or peri-wound assessments and no measurements noted. The Weekly Skin Assessment, dated 12/28/23, documented R82 continued with a rash on his right thigh and both heels had small openings. He also had small blisters to both hands. There were no wound bed or peri-wound assessments and no measurements noted. The Progress Note, dated 01/01/24, documented R82's buttocks had minor redness. His heel dressings were changed and showed some exudate. R82 denied pain and the note recorded his wound healing was progressing. The Weekly Skin Assessment, dated 01/07/24, documented previously identified areas, see notes. There were no wound bed or peri-wound assessments and no measurements noted. There were no further notes related to the assessment. The Weekly Skin Assessment, dated 01/14/24, documented see skin notes. There were no wound bed or peri-wound assessments and no measurements noted. There were no further notes related to the assessment. The Weekly Skin Assessment, dated 01/31/24, documented previously identified areas. R82 had pink healed skin on his scrotum and buttocks, and open wounds on both heels and toes. There were no wound bed or peri-wound assessments and no measurements noted. The Weekly Skin Assessment, dated 02/08/24, documented staff applied Skin-prep (liquid skin barrier) to R82's right great toe and received a new order to address itching on his arms and legs. There were no wound bed or peri-wound assessments and no measurements noted. The Wound Care Center Documentation, dated 02/13/24, documented the diabetic wound on the left calcaneus (heel) was open with an acquired date of 12/16/23, and the wound had been treated for four weeks. The wound measured 1.2 centimeters (cm) by 2.8 cm by 0.2 cm depth with a fat layer exposed, and a medium amount of drainage. The wound bed was 67-100 percent (%) necrotic (dead tissue). The left heel wound directions included to apply Hydrofera Blue (a type of moist wound dressing that provides wound protection and addresses bacteria and yeast) to the wound bed, PolyMem (non-adhesive dressing) three times weekly, and cover with gauze. The right heel wound was resolved, however, the note directed staff to keep the right heel in a suspension boot. R82's EMR Wound Assessments documented R82's wounds had resolved, and he had no current wounds being addressed in the Wound Assessments. On 02/19/24 at 10:40 AM, observation revealed R82 sat in his electric wheelchair in his room and visited with his spouse. He wore cushioning boots to both feet. He gave permission to observe wound care. He stated sometimes staff do not have all the supplies they need. He did say it was better after telling Administrative Staff A about it. On 02/20/24 at 08:20 AM, observation revealed R82 laid in bed and Certified Nurse Aide (CNA) P and CNA Q removed the pillows from his right side and from under his knees and heels. He also had a bed bolster under his lower legs. His ankles and heels were wrapped with gauze. The CNAs transferred R82 from his bed to the wheelchair with a sit to stand lift. His wheelchair had a three-inch cushion. On 02/22/24 at 08:55 AM, Administrative Nurse E, the facility wound nurse, performed a dressing change on R82's left heel. She set a clean field on the bedside table and put her supplies there. She removed the soiled dressing, cleansed the area, changed gloves and washed her hands. She applied a Hydrofera Blue dressing and a foam bordered dressing and secured with gauze wrap. She checked the right foot and found no issues. On 02/21/24 at 12:53 PM, Administrative Nurse E stated R82's physician would not allow the facility staff to assess or change orders on his patients and the physician had the resident go to his wound clinic weekly. She verified the facility staff had not documented assessment of the wounds weekly during wound care and dressing changes, since the resident went to the wound clinic. On 02/22/24 at 12:00 PM, Consultant Nurse GG verified weekly wound assessments should be done by the facility nurse. The facility's Pressure Injury Prevention and Management policy, dated 11/29/23, stated the facility would utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. A full body skin assessment would be conducted by a licensed or registered nurse upon admission, re-admission, and weekly thereafter. The assessment may be performed after a change in condition or after any newly identified pressure injury and documented in the medical record. Evidence based interventions for prevention would be implemented for all residents who are assessed at risk or have a pressure injury. The policy stated the Unit Manager or designee would review all relevant documentation regarding skin assessments, progression towards healing and compliance at least weekly and document a summary of findings. Interventions on a resident's plan of care would be modified as needed. The facility's Skin Assessment, dated 01/01/20, stated it was the facility's policy to perform a full body skin assessment as part of a systematic approach to prevent pressure injury. A full body skin assessment would be conducted by a licensed or registered nurse upon admission, re-admission, and weekly thereafter. The assessment may be performed after a change in condition or after any newly identified pressure injury. The policy directed staff to document observations of skin conditions, type of wound, measurements, color, type of tissue, drainage, odor, and pain. The facility failed to ensure staff completed a weekly skin assessment for R82 who had existing skin issues. This deficient practice placed R82 at risk for complications resulting from pressure injuries and/or delayed healing.