**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intakes 2576923 & 1361498.Based on observation, interview and record review, the facility failed to ensure residents received thorough assessments and monitoring of skin impairments consistent with professional standards of practice in 2 (Resident #101 & Resident #104) of 3 residents reviewed for pressure ulcers, resulting in Resident #101 being hospitalized for sepsis (a life-threatening complication of an infection) due to an unidentified newly developed Stage 3 pressure wound on the sacrum (tailbone) and Resident #104 did not receive adequate incontinence care and skin treatments were not administered per physician orders.Findings include:Resident #101Review of an admission Record revealed Resident #101 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: nausea and vomiting. Minimum Data Set (MDS) assessment was not available.Review of Resident #101's Hospital Course Records dated 5/15/25-5/24/25 revealed, .presented to ER (emergency room) with complaints of not feeling well, syncopal (fainting) event earlier today, poor oral intake, recent nausea vomiting and diarrhea, and increased fatigue and lethargy.In the ER patient was febrile (high body temperature), with heart rates initially in the 90s respiratory rates in the 20s she had some intermittent low blood pressures. She had leukocytosis (high WBC (white blood cell) count, which indicates infection in the body).On skin examination patient has large wound on her upper buttocks that appears to be infected.This wound was not previously noted during her last recent hospitalization. Assessment/Plan: Severe sepsis likely due to likely due to infected soft tissue buttock pressure injury wound. Then on 5/20/25, On exam the wound is still slough (whitish dead tissue that accumulates in a wound) covered so unstageable (a full-thickness skin and tissue loss where the depth is obscured by slough), at least Stage 3. Decreased erythema of left buttock still with induration (thickening and hardening of the skin caused by inflammation).left buttock portion of wound also slough covered but at least full thickness. Some gluteal cleft (butt crack) and periwound (around the wound) maceration (soft broken down skin due to prolonged exposure to moisture). Then on 5/23/25, .The infectious disease service was consulted as she quickly grew an E. coli (Escherichia coli is a bacteria found in the gut) bacteremia (bloodstream infection).Wound culture grew E. coli and Enterococcus faecalis (bacteria found in gastrointestinal tract and is a significant opportunistic pathogen, meaning it can make infections challenging to treat).Her wound additionally grew bacterioides (other bacteria found in the gut that cause infections outside of the body). Review of Resident #101's Hospital Wound Images dated 5/15/25 show the entire buttocks were dark red, with a small healing wound on the right buttock, and a large open wound, covered in slough, that extended the length of the gluteal cleft (butt crack) and laterally onto the left buttocks. There were no measurements recorded in the limited documentation that was received from the hospital prior to survey exit.Review of Resident #101's Nurse's Note dated 5/15/25 at 12:20 PM revealed, Around 11:45am, CNA (Certified Nursing Assistant) alerted me (Registered Nurse/Wound Nurse (RN/WN D) that she needed me in room (room #), I observed resident fully dressed, O2 (oxygen) intact, sitting on toilet (accompanied by therapist), appearing lethargic, head looking down. She was alert but not acting her baseline. CNA stated that resident's eyes had rolled back into her head and that she was afraid that she was going to faint. Resident stated, I feel off. We attempted to take vitals, pulse OX (oxygen level in the blood) & BP (blood pressure) readings were abnormally low. I transferred her to her W/C (wheelchair) and then to her bed (Dependent x 1 both times). Resident continued to be lethargic in her bed (BSL (blood sugar level) her baseline), so I had the PA (Physician Assistant) come further assess her while I prepared her hospital paperwork. Her son arrived at this time for a visit. PA gave V/O (orders) to send to ER . In an interview on 8/6/25 at 3:53 PM, RN/WN D reported that he was unaware that Resident #101 had a large pressure wound on her sacrum until the facility had received notice from the hospital. RN/WN D reported that Resident #101 had admitted on [DATE] with a small Stage 2 pressure wound on her right butt cheek, which was almost healed by the time she was sent to ER on [DATE]. RN/WN D reported that he had changed the dressing on the resident's right buttock multiple times, but did not observe a wound on the sacrum. RN/WN D reported that Resident #101's buttocks were very firm, it was hard to spread her butt cheeks, and her bottom was always covered in creams and patches. RN/WN D reported that the resident had orders for daily full body skin checks due to her risk of developing new pressure injuries, and there were no new skin issues noted. RN/WN D reported that the facility provider allowed the nursing staff to identify, assess, and monitor skin wounds, and that the provider would not physically examine the resident's wounds. RN/WN D reported that the nurse typically would notify the provider of new wounds and or when changes to treatments were needed. RN/WN D reported that Resident #101 was not receiving any treatments to the sacral area other than barrier cream. In an interview with CNA E on 8/6/25 at 2:05 PM reported frequently working with Resident #101 and that she was on contact precautions for most of the time she was at the facility due to illness and diarrhea. CNA E reported that Resident #101's buttocks were notably big and firm. CNA E reported that Resident #101 was both continent and incontinent and was independent with personal hygiene after urinating and/or having bowel movements. CNA E reported that Resident #101's bottom was getting very red due to being in bed a lot and having diarrhea. CNA E reported that the CNA's applied thick cream to her buttocks every day. In an interview on 8/11/25 at 9:04 PM, Therapy Director (TD) P reported that Resident #101 required moderate assistance with toileting, including personal hygiene afterwards and was not able to perform the task adequately without staff physical assistance. In an interview on 8/6/25 at 3:45 PM, Licensed Practical Nurse (LPN) G reported that she could not recall Resident #101's wounds but remembered her butt cheeks were firm and pressed tight together. In an interview on 8/6/25 at 1:34 PM, RN L reported that Resident #101 had a wound on her right buttocks that was healing but was having issues with an increase in her WBC blood levels right before she was sent out to the hospital. RN L reported that Resident #101 required a lot of assistance with ADL's (activities of daily living) due to weakness. In an interview (via phone) on 8/11/25 at 10:50 AM, Resident #101 reported that she still had a deep wound on her bottom and was going to the wound clinic a couple times a week. Review of Resident #101's Care Plan revealed, Resident has a pressure ulcer. Start Date: 5/8/25 (6 days after admission). Interventions: Administer analgesics (pain reliever).Assess and record the condition of the skin surrounding the pressure ulcer, Encourage fluids.Observe and report signs of infection.Observe and report signs of pain.Obtain dietary consult.Pressure reducing mattress, pressure reducing cushion to chair, provide diet, supplements, vitamins and minerals as ordered, treatment per MD order, weekly skin assessment, measurement, and observation of the pressure ulcer and record. There were no details related to the location of the pressure ulcer and/or personalized care plan interventions. Review of Resident #101's Care Plan revealed, Profile Care Guide Start Date: 5/2/25. Interventions: .Bed mobility: 1 assist, transfers 1 assist.Toileting: 1 assist.Grooming upper and lower body 1 assist .B & B (bowel and bladder) continent (apply protective cream to peri-area skin/buttocks when providing peri-area skin care.Review of Resident #101's Nursing admission Observation and Data Collection dated 5/2/25 revealed, Skin impairment: yes, complete appropriate occurrence progress note for further assessment. The assessment also indicated the resident required extensive assistance for bed mobility and toileting. The assessment also included Resident #101's Braden Scale for Pressure Ulcer Predictability indicating 14-Moderate risk. The resident's skin was often but not always moist, her ability to walk was severely limited or nonexistent. Resident #101's ability to change and control body position was very limited. Resident #101 required moderate to maximum assist in moving, making friction and shear a problem.Review of Resident #101's Wound Management Detail Report dated 5/2/25 indicated Stage 2 pressure wound, but did not include location. There were no nurse's note created on that day regarding the wound or the resident's skin assessment. Review of Resident #101's Physician Orders start date 5/2/25 revealed, Apply protective cream topically to peri-area skin/buttocks when providing peri-area skin care twice a day. Review of Resident #101's Physician Orders start date 5/2/25 revealed, Daily skin assessment/observation completed once daily. Review of Resident #101's Physician Orders start date 5/3/25 revealed, Right buttock Wound: cleanse with NSS, pat dry, apply border foam patch once a day every 5 days.Review of Resident #101's Daily Nursing Skilled Charting from 5/4/25-5/15/25 revealed skin color and temperature normal and no additional skin issues. There was no daily skilled charting for 5/3/25. Review of Resident #101's Point of Care (CNA charting) revealed under the section Skin Issues: Indicate any skin problem for the resident? that the resident had redness on buttocks noted on 5/5/25, 5/7/25, 5/9/25, 5/12/25, and 5/13/25. There were no nursing notes or assessments related to these findings. Review of Resident #101's admission Provider Visit Note dated 5/5/25 indicated skin color and temperature was normal. There were no skin treatments listed, and no wound observations. Review of Resident #101's Provider Visit Note dated 5/6/25 indicated skin color and temperature was normal. There were no skin treatments listed, and no wound observations recorded. The note included a WBC blood level of 17.4 (normal range is 4-10) and a diagnosis of GI (gastrointestinal infection).Review of Resident #101's Provider Visit Note dated 5/7/25 indicated skin color and temperature was normal. There were no wound observations.Review of Resident #101's Wound Nurse's Note dated 5/7/25 at 1:09 PM revealed, (R) (right) buttock Stage 2 with decreased weekly measurements; denies pain at site; TXs (treatments) in place/completed; continuing with POC (point of care), (left) buttock Allevyn (a padded bandage) added for prevention.Review of Resident #101's Provider Visit Note dated 5/8/25 indicated skin color and temperature was normal. There were no wound observations.Review of Resident #101's Provider Visit Note dated 5/12/25 indicated skin temperature was normal. There were no wound observations.Review of Resident #101's Wound Nurse's Note dated 5/14/25 at 2:00 PM revealed, (R) (right) buttock Stage 2 with decreased weekly measurements; currently denies pain at site (states that it causes discomfort at times); TXs (treatments) in place/completed; PA (physician assistant) made aware; POC (point of care) change to include Triad PRN; family/resident made aware.Review of Resident #101's Physician Orders start date 5/15/25 revealed, Triad Wound Dressing (wound dressings) - paste: coverage, topical, Four Times A Day - PRN (as needed), Apply paste topically (dime thickness) to sacrum/ (BL) (bilateral) buttocks (*when cleansing, only remove soiled cream*). This order was not documented as administered and this was the same day the resident was discharged . The order indicated sacrum was the location but there was no documentation related to an identified skin issue in that location. Review of Resident #101's Provider Visit Note dated 5/15/25 indicated skin temperature was normal. There were no wound observations recorded. Assessment and Plans: .Muscle weakness: acutely episode.VS (vital signs) acutely abnormal.Send to ED (emergency department).In an interview on 8/7/25 at 4:07 PM, Nursing Home Administrator (NHA) A and Director of Nursing (DON) B reported that they received a referral from the hospital (approximately 5/16/25) to readmit Resident #101 and that she had a large pressure wound on her sacrum. DON B reported that the was when they discovered that the pressure wound was not documented in her record at the facility at the time they sent her to the hospital on 5/15/25. The facility immediately began skin assessments on all residents and education to the nursing staff regarding the proper way to complete a skin check. Resident #104Review of an admission Record revealed Resident #104 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: non-pressure chronic ulcer of left lower leg, non-pressure chronic ulcer of left ankle, foot drop left foot, unstageable pressure ulcer of left heel, stage 3 pressure ulcer of left calf. Review of a Minimum Data Set (MDS) assessment for Resident #104, with a reference date of 5/9/25 revealed a Brief Interview for Mental Status (BIMS) score of 15, out of a total possible score of 15, which indicated Resident #104 was cognitively intact. Review of the Functional Abilities revealed that Resident #104 was dependent for toileting and required substantial/maximal assistance to move side to side in bed. Review of Resident #104's Care Plan revealed, At risk for skin breakdown r/t (related to) weakness/needing assist from staff for her care needs.Start Date: 2/11/25. Interventions: .Float heels.keep linens clean and dry.Keep resident as clean and dry as possible. Minimize skin exposure to moisture. Resident requires enhanced barrier precautions (EBP) during high-contact care related to presence of: foley (catheter), wounds.Start Date: 1/14/25. Interventions: .Utilize gown and gloves per EBP policy during high contact ADL care (dressing, showering/bathing, hygiene, transfers, toileting/changing briefs) and during linen changes.In an interview on 8/11/25 at 2:38 PM, CNA K reported Resident #104 had only one skin issue and that was a wound on her lower leg. Reported the CNA's apply cream during incontinence care to her buttocks. CNA K reported that when she identified a skin issue she documented it in the POC charting and notified the nurse, but there was no paper documentation that she knew of.During an observation and interview on 8/11/25 at 2:51 PM in Resident #104's room, the resident was lying in bed on her back with the head of bed raised to 45 degrees, and there was a foley catheter bag and tubing hanging on the side of the bed. There was an odor of urine in the room. Resident #104 reported that she was uncomfortable and had not received any care since early that morning. When asked about the condition of her bottom, she reported that it was sore and that she was told it opened up again. Resident #104 reported that she was going to talk to the wound nurse about it the next time she saw him. Resident #104 reported that the CNA's apply a heavy cream to her bottom when they change her and the last time a nurse saw it was approximately 1 week earlier. Resident #104 reported that she was supposed to have protective boots on both feet but the right boot is missing. Resident #104's right foot was observed laying directly on the surface of the bed.Review of Resident #104's Treatment Administration Record for 8/11/25 revealed an order for Triad wound dressing paste twice daily prophylaxis (preventative), apply paste topically dime thickness to sacrum/bilateral buttocks. This order was documented as administered by RN F earlier that day.In an interview on 8/11/25 at 3:00 PM, RN F reported that Resident #104 had a venous wound on her lower left leg that was covered with a dressing. RN F reported that the CNA's were applying Triad cream to the resident's bottom for a preventative. RN F reported that she last saw Resident #104's buttocks a few days ago, and that there was no skin breakdown. This surveyor asked RN F to observe Resident #104's buttocks.During an observation on 8/11/25 at 3:02 PM in Resident #104's room, RN F and LPN I entered and prepared to reposition the resident in bed and observe her buttocks. The nurses were not wearing gowns as required for direct contact with EBP. RN F immediately identified that Resident #104's bedding and the back side of her shirt was soaked with a fluid that left a brown discoloration on the sheets and pad. Resident #104 was assisted by both nurses to turn on her left side. Observed Resident #104's buttocks red, macerated, had deep creases from the bedding, multiple pin-point areas of bright red bleeding, and a nickel sized wound on the left buttock that was covered in slough. There was no sign of a topical cream on the resident's bottom. Staff used disposable wipes to clean the resident buttocks and then looked for Triad cream in the resident's room. RN F reported that the CNA's apply the topical creams including the prescription Triad and that it was very thick and would still be visible if applied that day. Staff was not able to find Triad cream therefore applied petroleum barrier cream over her entire buttocks area. Staff did not clean Resident #104 on her front side and/or provide catheter care because the fluid that soaked the resident's bed was not urine, it was drainage from her legs, and the resident should have already had front incontinence/catheter care performed that morning by the CNA. RN F reported that she thought the resident's protective boot for her right foot was in the laundry. Review of Resident #104's Wound Management Reports revealed no current record of wounds on the buttocks or feet. There was a history of pressure ulcer on left buttock, extending slightly into right buttock, and also a stage 3 pressure ulcer on the left lower buttocks that were both documented as resolved on 5/7/25. There was also history of an unstageable pressure wound on the left heel.In an interview on 8/11/25 at 3:52 PM, Assistant Director of Nursing (ADON) C reported that staff are required to wear gloves and a gown when providing direct care and linen changes for Resident #104. ADON C reported that Triad cream is a topical medication that the nurse should apply twice daily to Resident #104's buttocks and should be kept in the medication cart. ADON C reported that at that time Resident #104's Triad cream was not found in her room and/or the medication cart. ADON C reported that the facility had implemented a new process after Resident #101's pressure ulcer finding, requiring the CNA's to document any skin concerns on a skin observation form and submit it to the nurse and to the DON. ADON C reported that Resident #104 did not have any skin observation forms on record at that time.Review of the Fundamentals of Nurse ([NAME] and [NAME]) revealed, When you identify the presence of a skin wound or pressure injury, closer assessment is required. Assess the type of tissue in the wound base so that you can plan appropriate interventions. The assessment includes the amount (percentage) and appearance (color) of viable and nonviable tissue . Soft yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and it must eventually be removed by a qualified clinician or by an appropriate wound dressing before the wound is able to heal. Black, brown, tan or necrotic tissue is eschar, which also needs to be removed before healing can occur . Assessment of wound exudate should describe the amount, color, consistency, and odor of wound drainage. Excessive exudate indicates the presence of infection. Wound pain, including the location, distribution, type, quality and intensity, and any aggravating or relieving factors, also should be assessed ([NAME], 2016). Examine the skin around the wound (periwound) for redness, warmth, and signs of maceration, and palpate the area for signs of pain or induration. The presence of any of these factors on the periwound skin indicates wound deterioration. [NAME], [NAME] A.; [NAME], [NAME] Griffin; Stockert, [NAME] A.; Hall, [NAME]. Fundamentals of Nursing - E-Book (p. 1247). Elsevier Health Sciences. Kindle Edition.