**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and review of the facility's policy, it was determined the facility failed to provide residents with appropriate care and services to ensure residents were free from neglect for one (1) of sixteen (16) sampled residents (Resident #18). Record review revealed the facility admitted Resident #18 on 12/10/2023 and assessed the resident as having an unstageable pressure injury to his/her right heel. However, there were no orders in place for wound care or monitoring until 01/15/2024. The facility's failure to follow its policy related to providing care for the resident's wound, after being admitted with an unstageable pressure injury, deprived the resident of his/her health care needs and created a situation which prevented the resident's wound from healing. Further, the facility's lack of communication across all shifts to address the resident's treatment of his/her wound caused the resident emotional distress. The resident stated to the State Survey Agency (SSA) surveyor that his/her wound had gotten worse due to the facility's failure to provide treatment to his/her wound upon admission. The findings include: Review of facility's policy titled, Notification of Change in Condition, revised on 06/01/2021, revealed that the facility must immediately inform the resident, consult with the physician, and notify the patients (residents) healthcare decision maker when there was a significant change in the patient's physical, mental or psychosocial status or the need to alter treatment significantly. Review of the facility's policy titled, Abuse Prohibition revised on 10/24/2022, revealed the facility prohibited abuse, mistreatment, and neglect for all patients (residents). Neglect was defined as the failure, indifference or disregard of the center, it's employees or service providers to provide care, comfort, safety, goods and services to a patient (resident) that were necessary to avoid physical harm, pain, mental anguish, or emotional distress. This included the failure to implement effective communication system across all shifts for communicating necessary care and information between the facility, patient (resident), practitioners and resident representatives. Review of the facility's policy titled, Skin Integrity and Wound Management, effective date, 07/01/2001, revised 02/01/2023, revealed, a comprehensive, initial, and ongoing nursing assessment of intrinsic and extrinsic factors that influenced skin health, skin wound impairment, and the ability of a wound to heal would be performed. The plan of care for the patient (resident) would be reflective of assessment findings from the comprehensive assessment and wound evaluation. Further review revealed staff would continually observe and monitor patients (residents) for changes and implement revisions of the care plan as needed; and notify the Medical Director, the Director of Nursing, and Administrator if deviation from the protocol was requested. Continued review revealed the purpose was to provide safe and effective care to promote optimal skin health, prevent pressure injuries, and promote healing. Review of Resident #18's admission Record revealed the facility admitted the resident on 12/10/2023 with diagnoses including History of Transient Ischemic Attack, with Cerebral Infarction, Acquired Absence of Left Leg below Knee and Type 2 Diabetes Mellitus without complications. Review of the admission Assessment, dated 12/10/2023 at 3:51 PM, signed by Licensed Practical Nurse (LPN) #3 and co-signed by the Assistant Director of Nursing (ADON), revealed Resident #18 was assessed to have a Braden Score of sixteen (16), indicating the resident was at mild risk for developing pressure injuries. Further review revealed the resident was assessed as having an unstageable Deep Tissue Injury (DTI). However, there was no documented evidence of a wound evaluation to include further description or a measurement of the right heel unstageable DTI on admission. Review of Resident #18's Physician Orders Summary Recap report, dated 12/10/2023, revealed no orders for wound care for Resident #18's right heel pressure injury on admission. Review of Resident #18's Physician's Note, dated, 12/14/2023, revealed Resident #18 was seen by the provider and his/her skin was dry, normal turgor, with no pallor or rash. However, there was no reference to Resident #18's right foot wound. Review of Resident #18's admission Minimum Data Set (MDS) Assessment, dated 12/15/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating the resident was cognitively intact. Further review of the assessment, Section M, revealed the facility assessed Resident #18 as having an unstageable pressure injury with suspected deep tissue injury in evolution, that was present on admission. Review of Resident #18's Care Plan revealed the facility did not develop and implement a person-centered care plan for Skin Integrity until 12/26/2023, sixteen (16) days following admission. The care plan revealed a focus problem that stated Resident #18 was at risk for skin breakdown related to frail fragile skin, incontinence, limited mobility and/or had actual skin breakdown, a pressure ulcer to the right heel. Further review of Resident #18's person-centered care plan for Skin Integrity, dated 12/26/2023, revealed there were no specific interventions to protect the resident's right foot wound when the resident was sitting in the wheelchair. Review of the Weekly Skin Check, dated 12/18/2023 12:05 AM, and signed by LPN #3, revealed Resident #18 had a skin injury or wound identified as other. Under location was a typed statement that read,necrotic area to heel. However, no other information was provided. Review of Resident #18's Weekly Skin Check dated 12/26/2023 at 9:34 PM, revealed the resident had a skin injury or wound. However, no other information was provided. Review of the Treatment Administration Record (TAR) for December 2023, revealed there were no orders in place for wound care or monitoring. Review of the Weekly Skin Check dated 01/01/2024 at 5:49 PM, signed by the Director of Nursing (DON), revealed the resident had a new skin injury or wound, and moisture associated skin damage to the coccyx. However, there was no documentation related to Resident #18's wound to the right foot. Review of the Weekly Skin Check dated 01/08/2024 at 8:09 PM, revealed the resident had a wound identified as other wound, necrotic to heel. However, no further information was provided. Review of the Nurse Aide Care Plan ([NAME]), dated 01/25/2024, under Skin Care, revealed staff was to observe skin condition daily during care and report abnormalities, float heels when in bed with device or pillow as resident would allow, and pat, do not rub skin when drying. There was no documentation on the nurse aide [NAME] that indicated Resident #18 had a pressure injury to the right heel, nor was there an intervention in place for protection to the resident's right foot when in the wheelchair. Review of the Progress Note, completed by the Advanced Practice Registered Nurse (APRN) on 01/12/2024, revealed Resident #18 was alert and oriented to all spheres and had a chronic right heel pressure injury, and an unroofed callus with non-blanchable redness. Continued review revealed Resident #18 had a pressure injury of the skin of the right heel, with unspecified injury, stage. Review of Resident #18's Progress Note, dated 01/14/2024 at 8:29 PM, as a late entry and signed by LPN #3, revealed a change in condition was completed due to a change in skin color or condition. Continued review revealed the calloused area on the resident's heel that was previously noted on admission, and in the medical records from the hospital, had come off with some drainage noted. The parameter was red and tender and the bed had yellow and discolored tissue noted. The provider was made aware of the changes to the resident's heel. Review of the Treatment Administration Record (TAR) for January 2024, revealed there were no orders in place for wound care or monitoring until 01/15/2024. Review of Resident #18's Physician's orders, dated 01/15/2024, revealed an order that read, right heel, paint area with Betadine every shift for one week, then reevaluate every shift for right heel wound. Further review revealed an order that read, check heels for support in place every shift, heels up cushion. This Physician's order dated 01/15/2024 was the first treatment order for this resident's right heel wound since admission [DATE]), therefore the resident went thirty-six (36) days without an order for wound treatment and monitoring. Review of the Weekly Skin Checks, dated 01/15/2024 at 9:32 PM, and 01/22/2024 at 8:50 PM, revealed the resident had a skin or wound identified as other wound and a necrotic left heel. {Resident #18 had a Left Below the Knee Amputation (BKA)}. Review of Resident #18's Wound Evaluation, dated 01/15/2024 at 11:29 AM and signed by the Director of Nursing (DON), revealed the resident had an unstageable pressure ulcer to the right heel, age unknown, that was present on admission. Measurements were recorded as, length 4.21 centimeters (cm) by width 2.42 cm. The wound bed was described as 20% (percent) slough and 80% eschar, with slight drainage. Per the evaluation, the treatment order was Betadine, with no dressing to be applied. Continued review revealed the wound was deteriorating and the Nurse Practitioner and Physician were aware. This was the first Wound Evaluation to include an assessment with measurements of the resident's right foot wound, although the resident was admitted with the pressure injury to the right foot on 12/10/2023, thirty-six (36) days earlier. Review of the Physician's Note, dated 01/16/2024, revealed Resident #18 had a right heel diabetic wound. His/her heels were to be offloaded and to continue with Betadine and close monitoring. Review of Resident #18's Wound Evaluation, dated 01/21/2024 at 5:11 PM, completed by the Assistant Director of Nursing (ADON), revealed the resident had an unstageable pressure ulcer to the right heel that was improving, age was unknown, and wound was present on admission. The wound measured 3.11 centimeters (cm) length by 3.82 cm width. Continued review revealed the wound bed was 100% eschar, had moderate drainage and the current treatment was wound cleanser and apply Betadine with no dressing. Review of Resident #18's Physician's orders dated 01/23/2024, revealed an order to clean pressure wound to right heel daily with wound cleanser and apply Betadine every day shift for his/her pressure ulcer to the right heel. Review of Resident #18's Wound Evaluation dated 01/23/2024 at 2:46 PM, signed by the ADON, revealed an unstageable pressure ulcer that measured 1.77 cm length X 3.16 cm width. Continued review revealed the wound bed had epithelial tissue at 20% and eschar at 80%. There was moderate drainage, and the treatment remained the same, to cleanse with wound cleanser and apply Betadine. Observation on 01/23/2024 at 10:55 AM, revealed Resident #18 was sitting up in the wheelchair at the bedside. While speaking with Resident #18, the State Survey Agency (SSA) surveyor asked if he/she had any wounds or skin concerns and he/she held up his/her right foot. The resident had just a sock on his/her right foot and his/her right foot was resting directly on the metal wheelchair footrest. There was no heel protector or pressure reducing device in place. Resident #18 had an elevator device on the bed and when asked if he/she used the device, his/her response was, hell no. Continued observation of Resident #18 on 01/23/2024 at 2:18 PM, revealed the resident was sitting in the wheelchair with his/her socked foot resting directly on the metal wheelchair foot rest. Observation of the wound assessment performed by LPN #1, on 01/26/2024 at 10:10 AM, revealed Resident #18's right heel wound was 100% eschar, and measured 2.45 cm length X 3.47 cm width. Observation on 01/24/2024 at 8:45 AM, revealed Resident #18 was sitting up in the wheelchair with his/her socked foot resting directly against the metal wheelchair pedal. During the observation of Resident #18, on 01/24/2024 at 10:00 AM, the resident's daughter was present in the room and she stated the resident's foot wound had worsened since admission. Per the interview, she stated the resident had what looked like a big callous on his/her right foot, and staff told her it fell off a couple of weeks ago. The daughter stated she did not know callouses could just fall off. Resident #18 was observed to be sitting up in the wheelchair with his/her socked foot resting directly against the metal wheelchair pedal. During further interview with Resident #18's daughter, on 01/24/2024 at 10:30 AM, she stated the facility should have at least been checking the area to the resident's right foot. During this conversation, the daughter took a photograph of the wound area and shared it with the SSA surveyor. The photograph revealed the right posterior ankle/heel had an area with black eschar. During as interview with Resident #18 on 01/24/2024 at 10:30 AM, he/she stated he/she had something on his/her foot that he/she thought was a callous. The resident stated he/she did nothing for it at home and the facility had not provided any treatments until the area callous came off a couple of weeks ago. She stated the wound had gotten worse in just a couple of weeks and did not feel like it would have if the facility had been watching it. Further observation of Resident #18, on 01/24/2024 at 1:48 PM, and 4:20 PM; and on 01/25/2024 at 8:50 AM, 10:25 AM, 11:58 AM, and 3:33 PM, revealed the resident was up in the wheelchair with his/her right socked foot resting directly against the metal footrest. Observation of the wound assessment performed by LPN #1, on 01/26/2024 at 10:10 AM, revealed Resident #18's right heel wound was 100% eschar, and measured 2.45 cm length X 3.47 cm width. During an interview with Certified Nursing Assistant (CNA) #2, on 01/24/2024 at 11:11 AM, he stated he was providing care for Resident #18, but was unaware the resident had a pressure injury, and was unaware of any interventions care planned to provide pressure relief of the resident's right foot when the resident was sitting in the wheelchair. During an interview with Certified Nursing Assistant (CNA) #5 on 01/26/2024 at 10:29 AM, she stated she had provided care to Resident #18 but was not aware that he/she had a pressure ulcer. She stated Resident #18 had a heel up device when in bed, but he/she had no pressure relieving device to the foot when up in the wheelchair. During an interview with Certified Nursing Assistant (CNA) #7 on 01/27/2024 at 10:51 AM, she stated that if the facility failed to provide care, goods or services to a resident that would be considered neglect. She stated if a resident had a wound and had not received treatment, that could result in a worsening wound, a possible need for hospitalization, and the potential to lose his/her limbs. During an interview with Licensed Practical Nurse (LPN) #3 on 01/26/2024 at 3:39 PM, she stated she had completed Resident #18's admission assessment. She stated Resident #18 had discolored thick skin to the right heel that was blackish brown in color. LPN #3 stated the area was unstageable and was not opened. She stated she did not measure the area or obtain any photographs. LPN #3 further stated she could not recall any treatment orders for the area, but that she reported the area to the Director of Nursing (DON). She stated the facility usually monitors unstageable pressure injuries to make sure they did not get worse, and the monitoring would be on the treatment record if an order was put in place. LPN #3 further stated she would not necessarily call not providing care to the resident's wound neglect. However, review of the facility's policy revealed that neglect was defined as the failure to provide goods and services to the resident(s) to avoid physical harm, mental anguish, or emotional distress. In an interview with Advance Practice Nurse Practitioner (APRN) on 01/26/2024 at 2:29 PM, she stated she was unaware that Resident #18 was admitted with an unstageable wound to the right foot. She stated Resident #18 was admitted with a skin tear on the right foot and had a foam dressing. The APRN stated the right heel was red from the foam dressing. She stated it was after Christmas before she saw Resident #18 and was unsure of the date that the physician saw him/her. The APRN stated she did not recall any sort of wound on admission and would have to check her notes. She stated the facility followed an algorithm provided by facility corporate staff and that she did not give wound care orders. The APRN further stated heel protectors/boots were not used as it would contribute to extra pressure on the heel. She stated if interventions were not in place, then a wound would deteriorate. In an interview with the Physician on 01/26/2024 at 4:35 PM, she stated she was informed Resident #18 had a skin tear on admission, not a pressure injury. She stated she was notified of a pressure injury on 01/16/2024. The Physician stated the facility followed corporate protocols and she expected to be notified if there were changes so orders could be given if needed. She stated if the facility did not follow protocols such as offloading the heel an outcome would be worsening of a wound. In an interview with the Assistant Director of Nursing, (ADON) on 01/27/2024 at 2:54 PM, she stated the facility nurses provided wound care and that everything was done in-house following the facility's wound protocols. She stated residents with wounds were not given referrals for outside wound care unless it was a last resort. The ADON stated she never observed or assessed Resident #18's foot on admission. Further she was not aware that any photos or measurements had been taken on admission. She stated she was not aware of any issues with Resident #18's foot until a couple of weeks ago when the calloused area fell off. She stated the facility took photos and initiated a treatment, however, no new interventions were put into place to relieve pressure from the resident's foot. She stated she was not aware of Resident #18's foot resting on the metal wheelchair footrest and was unsure if it would make it worse or do any more damage. During an interview with the Director of Nursing (DON) on 01/27/2024 at 3:54 PM, she stated the facility had a company wound care protocol and she expected that to be followed with any wound care or treatments. The DON stated she assessed Resident #18's wound and no treatments were put into place except to offload the heels. She stated Resident #18 had a growth, an extremely dry area but it was not eschar or a deep tissue injury. She further stated she was unsure why LPN #4 had documented a necrotic area on the weekly skin assessments. In an interview with the Administrator on 01/27/2024 at 6:07 PM, she stated her expectation was that wounds would be assessed on admission, a treatment put in place if applicable, and a baseline care plan initiated. The Administrator stated she believed Resident #18's foot had been assessed incorrectly on the admission assessment. She stated the facility did not know what was underneath the growth. The Administrator further stated the weekly skin assessments would be sufficient monitoring for a wound. However, review of the facility's policy related to wound management revealed staff would continually observe and monitor the residents for changes and implement revisions to the resident's care plan. Additionally, the Medical Director, Director of Nursing (DON), and Administrator would be notified should there have been deviation from the protocol. Further review of the policy revealed the purpose of the policy was to provide a safe and effective care to promote healing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of facility policy, it was determined the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for two (2) of sixteen (16) sampled residents (Resident #18 and Resident #195). Although the facility admitted Resident #18 on 12/10/2023, and assessed the resident as having a right heel unstageable Deep Tissue Injury (DTI) on that date (with no measurement of the wound), the facility did not develop a Baseline Person-Centered care plan for Skin Integrity until 12/26/2023, sixteen (16) days following admission. Additionally, the care plan dated 12/26/2023, was not developed and implemented related to interventions for weekly wound evaluations to include description and measurement of the resident's right foot pressure injury, nor was it developed and implemented related to interventions to obtain treatment orders for the wound as necessary. There was no documented evidence of a Wound Evaluation to include description and measurements until 01/15/2024, thirty-six (36) days after admission, when the wound was described as unstageable measuring 4.21 centimeters (cm) length X 2.42 cm. width with 20% (percent) slough and 80% eschar. Furthermore, there was no documented evidence of Physician's orders for wound treatment and monitoring for the right heel pressure injury until 01/15/2024, thirty-six (36) days after admission. Observation of Resident #18's skin assessment on 01/26/2024, revealed the resident's right heel wound was unstageable, and measured 2.45 cm length X 3.47 cm width and was noted to have 100% eschar. Additionally, the care plan was not developed and implemented related to interventions to protect the resident's right foot wound when the resident was up in the wheelchair. Observations on 01/23/2024, 01/24/2024, 01/25/2024, and 01/26/2024, revealed the resident was sitting in a wheelchair with his/her socked right foot resting directly on the metal wheelchair pedal. Refer to F686 Additionally, the facility admitted Resident #195 on 01/17/2024 with diagnoses to include Malignant Neoplasm of the Bladder, and Urostomy. (A urostomy is a surgical procedure that creates a stoma for the urinary system, and is made to avail for urinary diversion in cases where drainage of urine through the bladder and urethra is not possible). However, there was no baseline care plan related to urostomy/urostomy care developed for this resident. The findings include: Review of the facility's policy titled, Person-Centered Care Plan, reviewed and revised on 10/24/2022, revealed the facility would develop and implement a Baseline Person-Centered Care Plan within forty-eight (48) hours of admission for each resident that included the instructions needed to provide effective and person-centered care that met professional standards of quality care 1) Resident #18's admission Record revealed the facility admitted the resident on 12/10/2023 with diagnoses including History of Transient Ischemic Attack, with Cerebral Infarction, Acquired Absence of Left Leg below Knee and Type 2 Diabetes Mellitus without complications. Resident #18's admission Assessment, dated 12/10/2023 at 3:51 PM, signed by Licensed Practical Nurse (LPN) #3 and co-signed by the Assistant Director of Nursing (ADON), revealed the resident was assessed as having an unstageable Deep Tissue Injury (DTI). However, there was no documented evidence of further description or a measurement of the right heel unstageable DTI on admission. Resident #18's Physician Orders Summary Recap report, dated 12/10/2023, revealed no orders for wound care for the resident's right heel pressure injury on admission. Resident #18's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 12/15/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating intact cognition. Further, the facility assessed the resident as having an unstageable pressure injury with suspected deep tissue injury that was present on admission. Review of the Care Area Assessment (CAA) worksheet for Pressure Ulcer/ Injury, completed by the MDS Coordinator on 12/26/2023, revealed Resident #18 was at risk for developing pressure ulcers. Further, documentation revealed Resident #18 had an unstageable pressure ulcer due to suspected deep tissue injury and a care plan would be developed. The facility did not develop a baseline person-centered care plan for Skin Integrity until 12/26/2023, sixteen (16) days following admission. The care plan dated 12/26/2023, revealed a focus stating the resident was at risk for skin breakdown related to frail fragile skin, incontinence, limited mobility and/or had actual skin breakdown, and had a pressure ulcer to the right heel. The goals dated 12/26/2023, revealed the resident would not show signs of skin breakdown through next review, and the maintenance goal revealed the wound would remain free from signs and symptoms of infection through the next review. The interventions dated 12/26/2023, included: offload/float right heel while in bed with pillows or other device; weekly skin check by licensed nurse; provide wound treatment as ordered; observe skin condition daily with care and report abnormalities; apply barrier cream with each cleansing; provide treatment to skin tear per order and observe for signs of infection until healed; provide preventative skin care, lotions, barrier creams as ordered; provide patient and or health care decision maker education regarding risk factors; and Pat, (do not rub) skin when drying. However, Resident #18's care plan was not developed and implemented related to interventions for weekly wound evaluations to include description and measurement of the resident's right foot pressure injury, nor was it developed and implemented related to interventions to obtain treatment orders for the wound as necessary. Resident #18's Treatment Administration Record (TAR), dated December 2023, revealed there were no orders in place for wound care or monitoring. Resident #18's Progress Note dated 01/14/2024 at 8:29 PM, as a late entry and signed by Licensed Practical Nurse (LPN) #3, revealed a change in condition was noted as the calloused area on the resident's heel that was previously noted on admission, and in the medical records from the hospital, had come off with some drainage noted. The parameter was red and tender and the bed had yellow and discolored tissue noted. Further, the Provider was made aware of changes to the heel. Review of Resident #18's Wound Evaluation, dated 01/15/2024 at 11:29 AM and signed by the Director of Nursing (DON), revealed the resident had an unstageable pressure ulcer to the right heel, age unknown that was present on admission. Measurements were recorded as, length 4.21 centimeters (cm) X width 2.42 cm. The wound bed was described as 20% (percent) slough and 80% eschar, with slight drainage. Per the evaluation, the treatment order was Betadine, with no dressing to be applied. Continued review revealed the wound was deteriorating and the Nurse Practitioner and Physician were aware. This was the first Wound Evaluation to include an assessment with measurements of the resident's right foot wound, although the resident was admitted with the pressure injury to the right foot on 12/10/2023, thirty-six (36) days earlier. Resident #18's Treatment Administration Record (TAR) for January 2024, revealed there were no orders in place for wound care or monitoring until 01/15/2024. Resident #18's Physician's orders, dated 01/15/2024, revealed an order that read, right heel, paint area with Betadine every shift for one week, then reevaluate every shift for right heel wound. Further review revealed an order that read, check heels for support in place every shift, heels up cushion. This Physician's order dated 01/15/2024, was the first treatment order for this resident's right heel pressure injury since admission [DATE]), therefore the resident went thirty-six (36) days without an order for wound treatment and monitoring. Observation of Resident #18's wound assessment performed by LPN #1, on 01/26/2024 at 10:10 AM, revealed the right heel wound was 100% eschar, and measured 2.45 cm length X 3.47 cm width with no drainage noted. Additional review of Resident #18's person-centered care plan for Skin Integrity, dated 12/26/2023, revealed the care plan was not developed and implemented related to specific interventions to protect the resident's right foot wound when the resident was sitting in the wheelchair. Observation of Resident #18 on 01/23/2024 at 10:55 AM, and 2:18 PM; 01/24/2024 at 8:45 AM, 10:00 AM, 1:48 PM, and 4:20 PM; 01/25/2024 at 8:50 AM, 10:25 AM, 11:58 AM, and 3:33 PM; and on 01/26/2024 at 9:45 AM, revealed the resident had just a sock on his/her right foot and his/her right foot was resting directly on the metal wheelchair footrest. There was no heel protector or pressure reducing device in place. During an interview with Certified Nursing Assistant (CNA) #2, on 01/24/2024 at 11:11 AM, he stated he was providing care for Resident #18, but was unaware the resident had a pressure injury, and was unaware of any interventions care planned to provide pressure relief of the resident's right foot when the resident was sitting in the wheelchair. The State Agency Representative requested CNA #2 show her the CNA [NAME] (Nurse Aide Care Plan) and there was no information on the [NAME] to indicate Resident #18 had a wound to the right foot, nor were there interventions for protection of the right foot wound when the resident was sitting in the wheelchair. Additional observation on 01/26/2024 at 10:50 AM, after the wound assessment, revealed LPN #1 did not replace Resident #18's sock following wound care and evaluation, and his/her bare foot was now resting against the metal wheelchair footrest. Continued observation on 01/26/2024 at 1:48 PM, revealed the resident was sitting up in the wheelchair and the sock to the resident's right foot was noted to be half on and half off and the back of the resident's bare foot was resting on the metal wheelchair footrest. During an interview with LPN #3, on 01/26/2024 at 3:39 PM, she stated she completed Resident #18's admission assessment. She further stated the assessment had been started by another nurse on the previous shift, and she finished the assessment. LPN #3 further stated she documented the resident had discolored thick skin to the right heel that was blackish brown in color and was unstageable, with no open area. However, she confirmed she did not measure the area or obtain any photographs. She further stated she could not recall any treatment orders for the area, but they may have been obtained on the day shift. Further, she stated she did not complete a baseline care plan for the resident on admit, because they were usually completed on day shift. She stated the facility had forty-eight (48) hours to complete the baseline care plan. During interview with the Assistant Director of Nursing, (ADON), on 01/27/2024 at 2:54 PM, she stated she was unsure why she signed Resident #18's admission assessment and she verified she did not observe or assess the resident's foot wound on admission. She confirmed all wounds should be described and measured weekly by her or the floor nurses. She further stated she was unaware of any issues related to Resident #18's right heel until a few weeks ago when the calloused area fell off, and at that time treatment was initiated. During further interview with the ADON, on 01/27/2024 at 2:54 PM, she stated she thought the facility had seventy-two hours to complete the baseline care plan, and verified Resident #18's care plan was not completed timely. Further, she stated the baseline care plan needed to include specific interventions to be implemented in providing care, especially related to wounds. The ADON stated she had not observed Resident #18's foot resting directly on the wheelchair pedal and was unsure if it would make the wound worse or do any more damage. During an interview with the Minimum Data Set (MDS) Coordinator on 01/26/2024 at 3:56 PM, and 01/27/2024 at 12:33 PM, she stated she had documented Resident #18's right foot heel wound as unstageable on the MDS assessment dated [DATE]. She explained there were no measurements or photos of the resident's right heel wound when she completed the assessment, and she did not obtain them. During further interview with the MDS Coordinator, on 01/26/2024 at 3:56 PM, and 01/27/2024 at 12:33 PM, she stated the baseline care plan was to be initiated by the admitting nurse. However, she was unaware the baseline care plan was to be completed within 48 hours. She then stated Resident #18's baseline care plan should have included specific interventions to monitor, treat, and protect the right foot wound. She further stated if appropriate interventions were not in place the wound could deteriorate. Additionally, she stated the facility did not utilize boots, but staff could have used a pillow to relieve pressure for the resident's right foot when the resident was in the wheelchair. During additional interview with the MDS Coordinator, on 01/26/2024 at 3:56 PM, and 01/27/2024 at 12:33 PM, she stated the facility reviewed new admissions daily in the clinical meeting, but she did not recall anything specific about Resident #18. Further, the facility was revamping the Interdisciplinary team meeting (IDT) and there had not been a meeting in a while, nor were there weekly IDT notes available to review. During an interview with the Director of Nursing (DON), on 01/27/2024 at 3:54 PM, she stated the baseline care plan should be initiated at the time of admission by the admitting nurse. She further stated the facility had forty-eight (48) hours to complete the baseline. The DON stated if the admission nurse did not complete the care plan, she would expect the MDS Coordinator to complete it. The DON verified Resident #18's baseline care plan was not completed timely. In further interview with the DON on 01/27/2024 at 3:54 PM, she was questioned if Resident #18's care plan should have been developed with interventions related to weekly wound evaluations and a specific treatment for the wound. She stated wound evaluations should be completed on admission and weekly to include description and measurements, and if a wound was identified a treatment should be obtained and this should be care planned. However, she stated Resident #18's right heel wound was a growth or callous and not a pressure injury on admission and did not require a treatment until 01/15/2024, when the dry area fell off, and a wound was noted underneath. Per interview, a wound evaluation was then completed, and a treatment was obtained. The DON could not explain why the resident's wound was described as an unstageable Deep Tissue Injury (DTI) on admission. The DON was questioned if it was safe for the resident's socked right foot with the pressure injury to be resting directly on the wheelchair pedal, or if there should have been a care plan intervention to be implemented related to pressure relief. She stated the facility did not utilize heel protectors, and a wound such as Resident #18's needed to stay dry, so they would not keep a dressing on the wound all the time. During an interview with the Physician, on 01/26/2024 at 4:35 PM, she stated she was informed Resident #18 had a skin tear on admission, but verified she was not informed of a pressure injury. She stated she was not notified of the pressure injury until 01/15/2024, when she gave an order for treatment. In further interview, she stated it was her expectation to be notified if there were treatment orders needed or changes in condition so orders could be given if needed. Further, the physician stated if the facility did not follow protocols such as offloading the heel, an outcome would be worsening of a wound. In an interview on 01/27/2024 at 6:07 PM, the Administrator stated she thought Resident #18's foot wound had been assessed incorrectly on the admission assessment, as the staff did not know what was underneath the resident's heel growth. However, she stated it was her expectation wounds would be properly assessed and measured on admission and a treatment put in place if applicable. Further, it was her expectation an intervention such as a heel protector or blue boots (device for heel protection) be in place when a resident with a foot/heel wound was sitting in a wheelchair. Additional interview revealed the baseline care plan should be completed timely with appropriate interventions. 2) Review of Resident #195's face sheet revealed the facility admitted the resident on 01/17/2024 with diagnoses to include Malignant Neoplasm of the Bladder, and Urostomy. Observation of Resident #195 on 01/25/2024 at 3:40 PM, revealed the resident had a urostomy with pouch to the Right Quadrant that was connected to urinary tubing and a urinary drainage bag. Review of Resident #195's admission Minimum Data Set (MDS) Assessment, dated 01/24/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of five (5) out of fifteen (15), indicating severe cognitive impairment. The MDS Assessment was in progress and not fully completed. Review of Resident #195's Baseline Care Plan, dated 01/22/2024, revealed the facility did not develop a Baseline Person-Centered care plan related to Urostomy Care. In an interview with LPN #5, on 01/23/2024 at 9:00 AM, she stated Resident #195 was admitted to the facility on [DATE] with urostomy status post bladder resection, but she was unable to recall if the resident had a baseline care plan in place for the urostomy. She stated she was frequently assigned to the resident, and the resident should have been care planned related to urostomy care. In an interview with the Minimum Data Set (MDS) Nurse, on 01/27/2024 at 12:33 PM, she stated baseline care plans were initiated and set up based on the admission assessments completed by the nursing staff, and verified Resident #195 did not have a baseline care plan related to urostomy care. She further verified this care plan should have been completed within 48 hours of the resident's admission to the facility. In an interview with the Assistant Director of Nursing (ADON), on 01/27/24 at 3:10 PM, she stated she was not aware Resident #195 was not care planned for urostomy care, and stated the care plan should have included this concern. The ADON stated the facility did not have an actual urostomy procedure or process policy. Further, it was her expectation for the admitting nurse, and MDS Nurse to complete the baseline care plans accurately. She further stated she was aware baseline care plans were to be completed within forty-eight (48) hours. In an interview with the Director of Nursing (DON), on 01/27/2024 at 3:53 PM, she verified Resident#195's baseline care plan should have been initiated within forty-eight (48) hours of the resident being admitted to the facility. Further interview revealed if the admitting nurse did not complete the baseline care plan, she would expect the MDS Nurse to completed it within the forty-eight (48) hour timeframe. In continued interview, the DON stated this resident's baseline care plan should have included the diagnoses of urostomy, with interventions related to urostomy care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility's policy, it was determined the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (1) of three (3) residents reviewed for pressure out of sixteen (16) sampled residents (Resident #18). The facility admitted Resident #18 on 12/10/2023 and assessed the resident on that date as having a right heel unstageable Deep Tissue Injury (DTI). However, there was no documented evidence of a wound evaluation to include further description or a measurement of the right heel pressure injury on admission. Further, there was no documented evidence of a Wound Evaluation again until 01/15/2024, thirty-six (36) days later, when the wound was described as unstageable measuring 4.21 centimeters (cm) length X 2.42 cm. width with 20% (percent) slough and 80% eschar. Additionally, there was no documented evidence of Physician's orders for wound treatment and monitoring for the right heel pressure injury until 01/15/2024, thirty-six (36) days after the resident was admitted with the wound. Observation of a skin assessment on 01/26/2024, revealed the resident's right heel wound was unstageable, and measured 2.45 cm length X 3.47 cm width and was noted to have 100% eschar. Moreover, there were no interventions in place to protect the resident's right foot wound when in the wheelchair. Multiple observations on 01/23/2024, 01/24/2024, 01/25/2024, and 01/26/2026, revealed the resident was sitting in a wheelchair with his/her socked right foot resting directly on the metal wheelchair pedal. The findings include: Review of the facility's policy titled, Skin Integrity and Wound Management, effective date, 07/01/2001, revised 02/01/2023, revealed, a comprehensive, initial, and ongoing nursing assessment of intrinsic and extrinsic factors that influenced skin health, skin wound impairment, and the ability of a wound to heal would be performed. The plan of care for the patient (resident) would be reflective of assessment findings from the comprehensive assessment and wound evaluation. Staff would continually observe and monitor patients (residents) for changes and implement revisions of the care plan as needed; and notify the Medical Director, the Director of Nursing, and Administrator if deviation from protocol was requested. Continued review revealed the purpose was to provide safe and effective care to promote optimal skin health, prevent pressure injuries and promote healing. Review of the facility Wound Care Guidelines from Medline Skin Health, undated, revealed care guidelines were meant as a starting point for treatment based on wound bed characteristics and as a wound evolved, treatment modalities may change as well. Continued review revealed the document showed photos of wounds at different stages. However, the Guidelines did not address wounds with eschar or necrotic tissue. Review of Resident #18's admission Record revealed the facility admitted the resident on 12/10/2023 with diagnoses including History of Transient Ischemic Attack, with Cerebral Infarction, Acquired Absence of Left Leg below Knee and Type 2 Diabetes Mellitus without complications. Review of the admission Assessment, dated 12/10/2023 at 3:51 PM, signed by Licensed Practical Nurse (LPN) #3 and co-signed by the Assistant Director of Nursing (ADON), revealed Resident #18 was assessed to have a Braden Score of sixteen (16), indicating the resident was at mild risk for developing pressure injuries. Further review revealed the resident was assessed as having an unstageable Deep Tissue Injury (DTI). However, there was no documented evidence of a wound evaluation to include further description or a measurement of the right heel unstageable DTI on admission. Review of Resident #18's Physician Orders Summary Recap report, dated 12/10/2023, revealed no orders for wound care for Resident #18's right heel pressure injury on admission. Review of Resident #18's Physician's Note, dated, 12/14/2023, revealed Resident #18 was seen by the provider and skin was dry, normal turgor, with no pallor or rash. However there was no reference to Resident #18's right foot wound. Review of Resident #18's admission Minimum Data Set (MDS) Assessment, dated 12/15/2023, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of fourteen (14) out of fifteen (15), indicating intact cognition. Continued review revealed the facility assessed the resident as having an unstageable pressure injury with suspected deep tissue injury that was present on admission. Review of the weekly Braden Scale Score for Predicting Pressure Sore Risk, dated 12/17/2023, revealed a score of nineteen (19), indicating Resident #18 had no risk of developing pressure injuries. The criteria listed which affected this resident included Sensory Perception, Activity, Mobility, Moisture, Nutrition, and Friction and Shear. Review of the Weekly Skin Check, dated 12/18/2023 12:05 AM, and signed by LPN #3, revealed Resident #18 had a skin injury or wound identified as other. Under location was a typed statement that read necrotic area to heel. However, no other information was provided. Review of the weekly Braden Scale Score for Predicting Pressure Sore Risk, dated 12/24/2023, revealed a score of fifteen (15), indicating Resident #18 was at mild risk for developing pressure injuries. There was no reference to the resident already having a pressure ulcer. Review of Resident #18's Weekly Skin Check dated 12/26/2023 at 9:34 PM, revealed the resident had a skin injury or wound. However, no other information was provided. Review of the weekly Braden Scale Score for Predicting Pressure Sore Risk, dated 12/31/2023, revealed a score of fourteen (14), indicating Resident #18 was at moderate risk for developing pressure injury. Review of Resident #18's Care Plan revealed there was no baseline care plan completed within forty-eight (48) hours to address the resident's skin breakdown. Further, the facility did not develop a person-centered care plan for Skin Integrity until 12/26/2023, sixteen (16) days following admission. (Refer to F655) The care plan dated 12/26/2023, revealed a focus problem that stated the resident was at risk for skin breakdown related to frail fragile skin, incontinence, limited mobility and/or had actual skin breakdown, and had a pressure ulcer to the right heel. The goal dated 12/26/2023, stated the resident would not show signs of skin breakdown through next review, and the maintenance goal dated 12/26/2023, stated the wound would remain free from signs and symptoms of infection through the next review. Interventions dated 12/26/2023, included: offload/float right heel while in bed with pillows or other device; weekly skin check by licensed nurse; provide wound treatment as ordered; observe skin condition daily with care and report abnormalities; apply barrier cream with each cleansing; provide treatment to skin tear per order and observe for signs of infection until healed; provide preventative skin care, lotions, barrier creams as ordered; provide patient (resident) and or health care decision maker education regarding risk factors; and Pat, (do not rub) skin when drying. However, there were no specific interventions listed related to weekly wound evaluations or treatment for the wound. (Refer to F655). Review of the Treatment Administration Record (TAR) for December 2023, revealed there were no orders in place for wound care or monitoring. Review of the Weekly Skin Check dated 01/01/2024 at 5:49 PM, signed by the Director of Nursing (DON), revealed the resident had a new skin injury or wound, and moisture associated skin damage to the coccyx. However, there was no documentation related to Resident #18's wound to the right foot. Review of the Weekly Skin Check dated 01/08/2024 at 8:09 PM, revealed the resident had a wound identified as other wound, necrotic to heel. However, no further information was provided. Review of the Progress Note, completed by the Advanced Practice Registered Nurse (APRN) on 01/12/2024, revealed Resident #18 was alert and oriented to all spheres and had a chronic right heel pressure injury, and an unroofed callus with non-blanchable redness. Continued review revealed Resident #18 had a pressure injury of the skin of the right heel, with unspecified injury, stage. Review of Resident #18's Progress Note, dated 01/14/2024 at 8:29 PM, as a late entry and signed by LPN #3, revealed a change in condition was noted. Continued review revealed the calloused area on the resident's heel that was previously noted on admission, and in the medical records from the hospital, had come off with some drainage noted. The parameter was red and tender and the bed had yellow and discolored tissue noted. Provider was made aware of changes to the heel. Review of the Treatment Administration Record (TAR) for January 2024, revealed there were no orders in place for wound care or monitoring until 01/15/2024. Review of Resident #18's Physician's orders, dated 01/15/2024, revealed an order that read, right heel, paint area with Betadine every shift for one week, then reevaluate every shift for right heel wound. Further review revealed an order that read, check heels for support in place every shift, heels up cushion. This Physician's order dated 01/15/2024 was the first treatment order for this resident's right heel wound since admission [DATE]), therefore the resident went thirty-six (36) days without an order for wound treatment and monitoring. Review of the Weekly Skin Checks, dated 01/15/2024 at 9:32 PM, and 01/22/2024 at 8:50 PM, revealed the resident had a skin or wound identified as other wound and a necrotic left heel. {Resident #18 had a Left Below the Knee Amputation (BKA)}. Review of Resident #18's Wound Evaluation, dated 01/15/2024 at 11:29 AM and signed by the Director of Nursing (DON), revealed the resident had an unstageable pressure ulcer to the right heel, age unknown that was present on admission. Measurements were recorded as, length 4.21 centimeters (cm) by width 2.42 cm. The wound bed was described as 20% (percent) slough and 80% eschar, with slight drainage. Per the evaluation, the treatment order was Betadine, with no dressing to be applied. Continued review revealed the wound was deteriorating and the Nurse Practitioner and Physician were aware. This was the first Wound Evaluation to include an assessment with measurements of the resident's right foot wound, although the resident was admitted with the pressure injury to the right foot on 12/10/2023, thirty-six (36) days earlier. Review of the Physician's Note, dated 01/16/2024, revealed Resident #18 had a right heel diabetic wound. Heels were to be offloaded and to continue with Betadine and close monitoring. Review of Resident #18's Wound Evaluation, dated 01/21/2024 at 5:11 PM, completed by the Assistant Director of Nursing (ADON), revealed the resident had an unstageable pressure ulcer to the right heel that was improving, age was unknown, and wound was present on admission. The wound measured 3.11 centimeters (cm) length by 3.82 cm width. Continued review revealed the wound bed was 100% eschar, had moderate drainage and the current treatment was wound cleanser and apply Betadine with no dressing. Review of Resident #18's Physician's orders dated 01/23/2024, revealed an order to clean pressure wound to right heel daily with wound cleanser and apply Betadine every day shift for pressure ulcer to right heel. Review of Resident #18's Wound Evaluation dated 01/23/2024 at 2:46 PM, signed by the ADON, revealed an unstageable pressure ulcer that measured 1.77 cm length X 3.16 cm width. Continued review revealed the wound bed had epithelial tissue at 20% and eschar at 80%. There was moderate drainage, and the treatment remained the same, to cleanse with wound cleanser and apply Betadine. Review of the Nurse Aide Care Plan ([NAME]), dated 01/25/2024, under Skin Care, revealed staff was to observe skin condition daily during care and report abnormalities, float heels when in bed with device or pillow as resident would allow, and pat, do not rub skin when drying. There was no documentation on the nurse aide [NAME] that indicated Resident #18 had a pressure injury to the right heel, nor was there an intervention in place for protection to the resident's right foot when in the bed or wheelchair. Observation of the wound assessment performed by LPN #1, on 01/26/2024 at 10:10 AM, revealed Resident #18's right heel wound was 100% eschar, and measured 2.45 cm length X 3.47 cm width. Review of Resident #18's Wound Evaluation dated 01/26/2024, at 10:48 AM, completed by LPN #1, revealed the resident had an unstageable pressure injury to the right heel, age unknown, that was present on admission and measured 2.45 cm length by 3.47 cm width. The area was unstageable due to 100% eschar and had no drainage. Further review revealed the treatment order was to cleanse with generic wound cleanser and apply Povidone Iodine. Further review of Resident #18's person-centered care plan for Skin Integrity, dated 12/26/2023, revealed there were no specific interventions to protect the resident's right foot wound when the resident was sitting in the wheelchair. (Refer to F-655) Observation on 01/23/2024 at 10:55 AM, revealed Resident #18 was sitting up in the wheelchair at the bedside. While speaking with Resident #18, the State Survey Agency (SSA) surveyor asked if he/she had any wounds or skin concerns and he/she held up his/her right foot. The resident had just a sock on his/her right foot and his/her right foot was resting directly on the metal wheelchair footrest. There was no heel protector or pressure reducing device in place. Resident #18 had an elevator device on the bed and when asked if he/she used the device, his/her response was, hell no. Continued observation of Resident #18 on 01/23/2024 at 2:18 PM, revealed the resident was sitting in the wheelchair with his/her socked foot resting directly on the metal wheelchair foot rest. Observation on 01/24/2024 at 8:45 AM, revealed Resident #18 was sitting up in the wheelchair with his/her socked foot resting directly against the metal wheelchair pedal. During the observation of Resident #18, on 01/24/2024 at 10:00 AM, the resident's daughter was present in the room and she stated the resident's foot wound had worsened since admission. She further stated there was what looked like a big callous on his/her right foot, and staff told her it fell off a couple of weeks ago. The daughter stated she did not know callouses could just fall off. Resident #18 was observed to be sitting up in the wheelchair with his/her socked foot resting directly against the metal wheelchair pedal. During an interview with Resident #18, on 01/24/2024 at 10:00 AM, the resident stated he/she had something on his/her foot that might be a callous. The resident stated he/she did nothing for it at home and the facility had not provided any treatments until the callous came off a couple of weeks ago. He/she further stated the wound had gotten worse in just a couple of weeks and he/she did not feel like the wound would have deteriorated if the facility had been watching it. During further interview with Resident #18's daughter, on 01/24/2024 at 10:30 AM, she stated the facility should have at least been checking the area to the resident's right foot. During this conversation, the daughter took a photograph of the wound area and shared it with the SSA surveyor. The photograph revealed the right posterior ankle/heel had an area with black eschar. Further observation of Resident #18, on 01/24/2024 at 1:48 PM, and 4:20 PM; and on 01/25/2024 at 8:50 AM, 10:25 AM, 11:58 AM, and 3:33 PM, revealed the resident was up in the wheelchair with his/her right socked foot resting directly against the metal footrest. Observation on 01/26/2024 at 9:45 AM, revealed Resident #18 was sitting up in the wheelchair with just a sock on the right foot which was resting on the metal footrest. The SSA surveyor requested a wound evaluation be completed and measurements obtained. Observation of the wound assessment completed by LPN #1, on 01/26/2024 at 10:10 AM, revealed the right heel wound was 100% eschar, and measured 2.45 cm length X 3.47 cm width. Further observation on 01/26/2024 at 10:50 AM, after the wound assessment, revealed LPN #1 did not replace Resident #18's sock following wound care and evaluation, and his/her bare foot was now resting against the metal wheelchair footrest. Continued observation on 01/26/2024 at 1:48 PM, revealed Resident #18 was up in the wheelchair watching television. The sock to the right foot was noted to be half on and half off and the back of the resident's bare foot was resting on the metal wheelchair footrest. During an interview with Certified Nursing Assistant (CNA) #2, on 01/24/2024 at 11:11 AM, he stated he was providing care for Resident #18, but had no idea the resident had a pressure injury. He stated no one had shared that information with him. The State Agency Representative requested CNA #2 show her the CNA [NAME] and there was no information on the [NAME] indicating Resident #18 had a wound to the right foot, nor were there interventions for protection of the right foot wound when in the wheelchair. During an interview with CNA #5, on 01/26/2024 at 10:29 AM, she stated she had provided care to Resident #18 in the recent past, but was not aware he/she had a pressure ulcer. She stated Resident #18 had a heel up device when in bed, but he/she had no pressure relieving device to the foot when up in the wheelchair. In an interview with LPN #1, on 01/24/2024 at 9:12 AM, she stated she sometimes provided care for the resident, and could not recall staff ever telling her of any concerns related to the resident's skin, and did not recall performing any kind of treatment for Resident #18 until about two (2) weeks ago. She stated Resident #18 currently had a wound that was black eschar. In an interview with LPN #4, on 01/26/2024 at 3:15 PM, she stated she often provided care to Resident #18. LPN #5 confirmed she had completed weekly skin assessments for Resident #18 and documented the necrotic area to the heel. She stated she could not recall if the resident had a treatment order on admission for the right heel and she did not question it as treatments were usually performed on the day shift. She further stated Resident #18 currently had betadine ordered. When questioned about the resident's right socked foot resting directly on the wheelchair pedal, she stated she did not know what interventions were in place for Resident #18's wounds related to pressure relief. During an interview with LPN #3, on 01/26/2024 at 3:39 PM, she stated she was the nurse who completed Resident #18's admission assessment. She further stated Resident #18 was admitted early in the day and the assessment had been started by another nurse, but she finished the assessment as she worked the following shift. LPN #3 stated she read through Resident #18's hospital paperwork. She further stated she documented that Resident #18 had discolored thick skin to the right heel that was blackish brown in color which was unstageable and was not an open area. LPN #3 stated she did not measure the area or obtain any photographs. She further stated she could not recall any treatment orders for the area, which may have been obtained on the day shift. Per interview, she did not report the area to the Director of Nursing (DON) until the next day, when the DON relieved her for the shift. LPN #3 stated the facility usually monitored unstageable pressure injuries to make sure they did not get worse, and the monitoring would be documented on the treatment record if a physician's order was put in to monitor the area. In an interview with the Assistant Director of Nursing, (ADON), on 01/27/2024 at 2:54 PM, she stated she was an LPN and had been the ADON since 2022, but had been at the facility for twenty-one years. She stated the wound nurse resigned in November 2023, and she (ADON) had been helping with weekly wound assessments. Further, the facility floor nurses provided wound care and wound care was done in-house following the facility's wound protocols. The ADON stated the admitting nurse was to perform the wound assessments on new admissions, unless there was a late admission, and then the floor nurses were to perform the wound assessments. In continued interview, the ADON stated she was unsure why she signed Resident #18's admission assessment. She stated she never observed or assessed the resident's foot on admission. Further, she was not aware of any photos being taken on admission of the resident's wound. The ADON stated she was not aware of any issues with Resident #18's foot until a few weeks ago when the calloused area fell off. She further stated at that time, the facility took photos and initiated a treatment. The ADON stated she was not aware of Resident #18's foot resting directly on the wheelchair pedal and was unsure if it would make the wound worse or do any more damage. When questioned if there should have been a device in place to protect the resident's foot when in the wheelchair, she made no comment. Continued interview confirmed wounds should be described and measured on admit and weekly by her or the floor nurses. In an interview with the Minimum Data Set (MDS) Coordinator, on 01/27/2024 at 12:33 PM, she stated she had documented Resident #18's wound as unstageable on the MDS assessment dated [DATE]. She stated there were no measurements or photos of the wound when she completed the assessment. In further interview, she stated the baseline care plan was initiated by the admitting nurse and completed by the MDS Nurse, and an intervention should have been initiated on admission with interventions related to treatment and protection for the right foot wound. She further stated if interventions were not in place the wound could worsen, and although the facility did not utilize boots, staff could have used a pillow to relieve pressure for the resident's right foot when the resident was in the wheelchair. The MDS Coordinator stated the facility reviewed new admissions daily in the clinical meeting, but she did not recall anything specific about Resident #18. She further stated the facility was revamping the Interdisciplinary team meeting (IDT) and had not had a meeting in a while. She further stated there were no weekly IDT notes available. During an interview with the Director of Nursing (DON), on 01/27/2024 at 3:54 PM, she stated she had been in the position as DON for about a year. She further stated the facility had a wound protocol and she expected that to be followed with any wound care or treatments. The DON stated wound evaluations were to be completed on admission and weekly by the floor nurses, as there was no wound nurse in house at this time. She further stated when she assessed Resident #18's right foot wound prior to 01/15/2024, it was noted as a growth or callous, an extremely dry area, but it was not eschar or a deep tissue injury and did not require a treatment. However, the DON could not state the date of this assessment, nor was the assessment noted in the medical record. She further stated she was unsure why the resident's wound was described as unstageable Deep Tissue Injury (DTI) or necrotic prior to the wound assessment completed on 01/15/2024. The DON stated on 01/15/2024 when the area fell off, there was a wound noted underneath, and a treatment was obtained. When questioned if it was safe for the resident's socked right foot with the pressure injury to be resting directly on the wheelchair pedal, she stated the facility did not utilize heel protectors, and a wound such as Resident #18's needed to stay dry, so they would not keep a dressing on the wound all the time. In an interview on 01/26/2024 at 2:29 PM, with the APRN who signed Resident #18's Progress Note, dated 01/12/2024, she stated she was unaware Resident #18 was admitted with an unstageable wound to the right foot. She further stated she recalled the resident was admitted with a skin tear on the right foot and a foam dressing was in place. Further, she recalled the resident's right heel was red from a foam dressing. In continued interview, she stated she did not recall any sort of wound on admission and would have to check her notes. The APRN stated it was after Christmas before she saw Resident #18 and she was unsure of the date the physician saw him/her. She further stated the facility followed an algorithm for wound care provided by facility corporate staff and she did not give wound care orders. The APRN stated heel protectors/boots were not used as it would contribute to extra pressure on the heel; however, if treatment and pressure relieving interventions were not in place, then a wound would deteriorate. In an interview with the Physician, on 01/26/2024 at 4:35 PM, she stated she was informed Resident #18 had a skin tear on admission, but was not informed of a pressure injury. She stated she was notified of the pressure injury on 01/15/2024. She further stated the facility followed corporate protocol and she expected to be notified if there were treatment orders needed or changes in condition so orders could be given if needed. The physician stated if the facility did not follow protocols such as offloading the heel, an outcome would be worsening of a wound. On 01/26/2024, the Administrator informed the State Agency Representative the facility had taken photographs of Resident #18's right heel on admission and they were trying to obtain those. The facility did provide a photograph dated 12/05/2023 when Resident #18 was admitted to the hospital. However, at exit they facility had not provided facility photographs. During an interview on 01/27/2024 at 6:07 PM, the Administrator stated she believed Resident #18's foot wound had been assessed incorrectly on the admission assessment. She stated the facility did not know what was underneath the resident's heel growth on admission. However, she did state it was her expectation wounds would be properly assessed and measured on admission and a treatment put in place if applicable. Further, it was her expectation an intervention such as a heel protector or blue boots (device for heel protection) be in place when a resident with a foot/heel wound was sitting in a wheelchair.