**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to accurately assess, provide treatments as ordered, and ensure physician oversite for wounds for 2 residents (Resident #276 and #64) out of 18 residents reviewed for alterations in skin integrity/pressure injuries, resulting in an immediate jeopardy when on 12/21/23, an alteration in skin integrity was identified on R276's left heel. R276 was not provided care in accordance with professional standards of practice and facility policy to treat and prevent the deterioration pressure injuries, did not have an accurate assessment of the pressure injury, and was not provided the necessary treatment for a deteriorating pressure injury resulting in the development of osteomyelitis. Additionally, upon return from a hospitalization, R276 was not provided the ordered treatments to prevent the worsening of his pressure injury and/or infection. R64 experienced the worsening/deterioration of the wound on his right heel and developed an additional wound to his left heel with a delay in treatment. This deficient practice placed all residents at risk for pressure injuries at high likelihood for the development of new pressure injuries. All residents with existing wounds are at risk for new and unreported wounds, the delay in wound treatment, the potential for delayed wound healing, infection, and the high likelihood for overall deterioration in health status. The Immediate Jeopardy identified on 4/24/24 and began on 12/21/23 when facility licensed nurses failed to accurately assess, provide treatments as ordered, and ensure physician oversite for R276 and R64's newly identified pressure injury. Nursing Home Administrator and Director of Nursing were notified of the Immediate Jeopardy on 4/24/24 at 4:30 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on 4/29/24, but noncompliance remains at scope of isolated and severity of actual harm due to sustained compliance that has not been verified by the State Agency. Resident #276 (R276) Review of an admission Record revealed R276 was a [AGE] year-old male, admitted to the facility on [DATE], with pertinent diagnoses which included: Type II Diabetes with neuropathy (nerve pain), history of chronic osteomyelitis of left heel, venous insufficiency, and peripheral vascular disease (poor blood flow). Review of R276's Skin & Wound-Total Body Skin Assessment dated 12/15/23 revealed no skin impairment/wounds. Review of R276's Nurses Note dated 12/22/23 at 12:02 AM revealed, Resident asked this nurse to assess left lateral heel where he has a healed scab from a previous wound. He said he was having some pain to that area and on inspection scab is closed but has green drainage. Notified NP (nurse practitioner) on call. Review of R276's Electronic Health Record revealed no order for wound treatment at the time the wound was identified, and the provider was notified. No documentation that R276 was added to residents to be reviewed by the wound team. Review of R276's Radiology Report dated 12/22/23 revealed an xray was completed and showed no signs of osteomyelitis (bone infection). Review of R276's Skin & Wound-Total Body Skin Assessment dated 12/25/23 revealed no documentation skin impairment/wounds. Review of R276's Provider Note dated 12/26/23 revealed, Nurse reports purulent drainage with foul odor to left heel wound. States when she assessed wound this evening, dressing was from 12/21 . (Soiled dressing was left on heel for approximately 5 days.). No wound treatment order was initiated at that time. Review of R276's Provider Note dated 12/27/23 revealed, Left heel with open area and mild serous drainage on old dressing. No surrounding erythema and no odor to wound. (See photo for measurements). Wound cleansed and calcium alginate covered with optifoam applied . Pressure ulcer of left heel, unspecified stage . An order for wound care was implemented following this assessment. (Approximately 6 days from the discovery of the wound). Review of R276's Skin and Wound Evaluation dated 12/27/23 revealed the wound was staged as a Stage 1: Non-blanchable erythema of intact skin, did not identify the date the wound was identified and did not include the providers observation of drainage. Review of R276's Treatment Administration Record revealed, Cleanse L heel w/ NS (cleanse left heel with normal saline). Apply Calcium Alginate to open area cover w/ Opti foam. Encourage blue boots while in bed. With a Start date of 12/28/23. No treatments were documented as completed prior to this order indicating a delay in treatment. Review of R276's Nurses Note dated 12/31/23 revealed, Drsg (dressing) changed to rt (sic) heel. Wound entirely covered with thick white slough. Foul odor persists after cleaning. Scant amt of thick yellow drainage on old dressing. Denies pain, no redness. (Note: R276 had a right leg amputation). Indicating R276's wound had deteriorated and exhibited signs/symptoms of infection. Review of the National Pressure Ulcer Advisory Panel (NPUAP) revealed If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Review of R276's Electronic Health Record revealed no documentation that the provider was notified of the change of the condition of the wound, not followed by the wound team and/or Interdisciplinary Team, and no treatment changes were initiated. Review of R276's Provider Note dated 1/4/24 revealed, LT heel with open wound, cared daily with wound nurse and nursing staff .cleanse wound and apply calcium alginate covered with optifoam daily . No wound assessment, measurements, or treatment changes documented. Review of R276's Skin and Wound Evaluations revealed no other assessments until 1/11/24 which was incomplete. R276 was assessed by provider on 1/5/24 related to a COVID diagnosis, on 1/8/24 related to a fall, and on 1/12/24, 1/17/24, and 1/22/24 for routine follow-up. Wound assessment and treatments were not discussed. Review of R276's Skin and Wound Evaluations dated 1/17/ 24 revealed an incomplete assessment. Review of R276's Order Summary dated 1/17/24 revealed an order for podiatry consult. (Approximately 4 weeks after the identification of his wound.) Review of R276's Wound Consultant Note dated 1/24/24 revealed, .1. (19) Left heel pressure stage I - This wound measures 1.59 x 0.8 centimeter with a depth of 0.2 centimeter. This wound is partial thickness .Tx: (treatment) This area is to be cleaned daily with wound cleanser and calcium alginate applied to the area for autolytic debridement. Wound should be covered with an ABD pad and wrapped in kerlix. Secure with tape initial and date. Daily . A wound with partial thickness tissue loss is considered a Stage 2 pressure injury. (This was R276's first wound consultation, approximately 5 weeks after the identification of his wound.) The NPUAP defines a Stage 1 pressure injury as intact skin with a localized area of non blanchable erythema/redness. Stage 2 pressure injures are defined as Partial-thickness loss of skin with exposed dermis. Review of R276's Treatment Administration Record revealed the recommended wound treatment was not ordered/implemented. Review of R276's Skin and Wound Evaluation dated 1/24/24 revealed the pressure injury was documented as a Stage 1 and was identified as new. The wound assessment did not include the measurable depth of 0.2 centimeters. Review of R276's Podiatry Report of Consultation dated 1/30/24 revealed the measurements of R276's left heel pressure injury to be 4 cm (width) x 2cm (length) x 0.8cm (depth). Indicating the worsening of the pressure injury. Review of R276's Wound Consultant Note dated 1/31/24 revealed, .1. (19) Left heel pressure stage I - This wound measures 1.46 x 0.79 centimeter with a depth of 0.2 centimeter. This wound is partial thickness .Tx: This area is to be cleaned daily with wound cleanser and calcium alginate applied to the area for autolytic debridement. Wound should be covered with a bordered gauze. Secure with tape initial and date. Daily . Indicating a discrepancy of the measurements of the wound and inaccurate staging of the wound. Review of R276's Skin and Wound Evaluation dated 1/31/24 revealed the pressure injury was documented as a Stage 1 and was identified as new. The wound assessment did not include the measurable depth. R276's wound treatment order was updated to reflect the providers recommendation. Review of R276's January Treatment Administration Record revealed R276's wound care was not completed on 1/4/24 or 1/17/24 with no documentation as to why it was not completed. Review of R276's Podiatry Report of Consultation dated 2/6/24 revealed Posterior ulceration with mild maceration .2.5 cm x 1cm, 0.3cm .no probing to bone .sharp excisional debridement performed today (removal of dead/infected tissue) .f/u in 2 weeks . (Sharp excisional debridement is a surgical procedures using scalpels/scissors to remove infected and dead tissue from a wound bed.) Review of R276's Wound Consultant Note dated 2/7/24 revealed, .1. (19) Left heel pressure stage I - This wound measures 1.77 x 0.92 centimeter with a depth of 0.2 centimeter. This wound is partial thickness. There is a light amount of serous drainage from this area . Review of R276's Skin and Wound Evaluation dated 2/7/24 revealed the pressure injury was documented as a Stage 1 and was identified as new. The wound assessment did not include the measurable depth or the wound drainage. Review of R276's Wound Consultant Note dated 2/14/24 revealed, .1. (19) Left heel pressure stage I - This wound measures 4.52 x 1.23 centimeter with a depth of 0.2 centimeter. This wound is partial thickness. There is a light amount of serous drainage from this area . There was no treatment change implemented. Review of R276's Skin and Wound Evaluations revealed no completed wound assessment for 2/14/24. The evaluation was In Progress. Review of R276's Wound Consultant Note dated 2/21/24 revealed, .1. (19) Left heel pressure stage I - This wound measures 2.13 x 1.47 centimeter with a depth of 0.2 centimeter. This wound is partial thickness. There is a moderate amount of serous drainage from this area .Tx: This area is to be cleaned daily with wound cleanser and santyl ointment (wound treatment) and calcium alginate applied to the area for autolytic debridement. Wound should be covered with a bordered gauze. Secure with tape initial and date. Daily. Doxycycline ordered daily for 14 days . Indicating the worsening of the wound including infection which required the use of antibiotics. Review of R276's Skin and Wound Evaluations revealed no completed wound assessment for 2/21/24. The evaluation was In Progress. Review of R276's Wound Consultant Note dated 2/28/24 revealed, .1. (19) Left heel pressure stage I - This wound measures 1.68 x 1.29 centimeter with a depth of 0.2 centimeter. This wound is partial thickness. There is a light amount of perulent (purulent-pus) drainage from this area. Wound bed consists of 100% eschar tissue. Edges are attached and there is no slough, tunneling, undermining, or odor. The surrounding tissue is fragile but without redness, warmth, swelling, pain, induration, or sign of infection . There was no treatment change ordered. Review of R276's Skin and Wound Evaluation dated 2/28/24 revealed the pressure injury was documented as a Stage 1 and was identified as new. The wound assessment did not include the measurable depth. During an interview on 04/29/2024 at 12:50 PM, Regional Nurse Consultant (RNC) A reported that a change in treatment should be implemented if a wound deteriorated or showed no signs of improvement in a 2-week timespan. Review of R276's Podiatry Report of Consultation dated 3/1/24 revealed, 2cm fibrotic wound posterior lateral (left) calcaneus (heel). + malodor (foul odor), + edema (swelling), + erythema (redness), probing to bone. Diagnosis: Cellulitis with probable osteomyelitis left heel region .Recommendations: Patient sent to ER (emergency room) for admission/IV antibiotics, debridement and possible amputation (left) lower extremity. Confirming a significant change in R276's pressure injury from 2/28/24. R276 was hospitalized from [DATE]-[DATE] for osteomyelitis (severe bone infection): *3/1/24 Hospitalist Service H&P (history and physical) He was seen at the podiatrist office this morning and was instructed to go to the emergency department for IV antibiotics His foot ulcer has been worsening over the past week .at the outlying ED, he was found to have ongoing left foot ulcer, with elevated white blood count of 17 K .LACTIC ACIDOSIS, elevated C-RP (indicates systemic infection/sepsis). *3/2/24 Wound Consult Hospital Wound Services: Asked to see patient for diabetic foot ulcer. Dressing removed with large amount of brown, foul smelling drainage. Cleansed left heel with saline moistened gauze and odor remained. Left heel injury measures 3.5 x 1.75, 1cm with undermining (erosion under the skin surface-resulting in large wound with smaller opening) from 1 to 6 o'clock (along heel bone) of 4 cm. Tissues are brown. Surrounding ulcer is soft yellow/cream tissue .Patient has been following with (name omitted) DPM (podiatrist) for heel ulcer. Yesterday patient went to [NAME] Hospital ER for ulcer to left foot and was then transferred to [NAME] main for podiatry consult and surgery. *3/3/24 Podiatric Surgery Consult Note .Cellulitis LT (left) lower extremity, necrosis (death) of bone, Acute on chronic osteomyelitis LT calcaneus .presents to ED (emergency department) with worsening of left foot ulcer. The pt (patient) had hx (history) of heel ulcer and osteomyelitis. He reports that wound was healed and reopened 3 months ago . *3/5/24-surgical wound debridement (removal of infected/dead tissue from wound) and wound vac (vacuum assisted closure of wound) 3/6/24 Review of R276's Order Summary revealed, wound vac to lt heel at 125mmHg change 3 times per week every day shift every Mon, Wed, Fri for wound care -Start Date- 03/13/2024. Review of R276's Wound Consultant Note dated 3/13/24 revealed, .1. (19) Left heel pressure stage I - This wound measures 2.25 x 1.42 centimeter with a depth of 1.0 centimeter. This wound is full thickness. There is a light amount of serosanguinous drainage from this area . Treatment for the wound vac was continued. Review of R276's Skin and Wound Evaluation dated 3/13/24 revealed the pressure injury was documented as a Stage 1 and was identified as new. The wound assessment measured the length of the wound as 0cm, the width as 0cm, and depth not applicable. Review of R276's Wound Consultant Note dated 3/20/24 revealed, .1. (19) Left heel pressure stage IV - This wound measures 2.43 x 1.18 centimeter with a depth of 1.0 centimeter. This wound is full thickness. There is a light amount of sanguinous drainage from this area . Treatment for the wound vac was continued. Review of R276's Skin and Wound Evaluation dated 3/20/24 revealed no date the wound began and no wound depth measurement. Review of R276's Wound Consultant Notes and Skin and Wound Evaluations revealed no evaluation was completed on 3/27/24. Review of R276's Skin and Wound Evaluation dated 4/3/24 revealed no date the wound began and no wound depth measurement. R276 was hospitalized for a DVT (blood clot) from 4/4/24-4/9/24. Review of R276's Wound Consultant Note dated 4/10/24 revealed, .1. (20) Rear Left Malleolus Lateral pressure stage IV - Picture was taken but did not upload into (Electronic Health Record), nursing staff informed. Wound has improved, measurements and treatment remain the same. Wound measurements from 4/3/24 are 2.85 x 1.69 centimeter with a depth of 1.0 centimeter. This wound is full thickness. There is a light amount of sanguinous drainage from this area . Indicating the wound was not assessed by the wound consultant and/or rounding wound nurse and no treatment changes were made. Review of R276's Skin and Wound Evaluations revealed no completed evaluation for 4/10/24 with the documentation In Progress. Review of R276's Skin and Wound Evaluation dated 4/19/24 revealed the onset date of the pressure injury was documented as unknown and no measurable depth was documented. (Date the area was first identified was 12/21/23). Review of R276's Podiatry Report of Consultation dated 4/19/24 revealed, .continue wound vac until next visit on May 7th . Review of R276's Wound Consultant Note dated 4/19/24 revealed, .1. (20) Rear Left Malleolus Lateral pressure stage IV - This area measures 2.54 x 1.19 centimeter with a depth of 1.0 centimeter. This wound is full thickness. There is a light amount of sanguinous drainage from this area. Wound bed consists of 100% granulation tissue. Edges are attached and there is no slough, tunneling, undermining, or odor. The surrounding tissue is fragile but without redness, warmth, swelling, pain, induration, or sign of infection. Improving. Tx: This area is to be cleaned daily with wound cleanser and calcium alginate applied to the area for autolytic debridement. Wound should be covered with a bordered gauze. Initial and date. Daily. Change to wound vac once supplies become available. Review of R276's Treatment Administration Record revealed the wound vac was not changed on 4/19/24 or 4/22/24. Review of R276's Nurses Note dated 4/22/24 at 4:35 AM revealed, .Wound vac in place . Indicating an inaccurate resident assessment. Review of R276's Medication Administration Note dated 4/22/24 at 3:32 PM revealed, (Wound Vac) supplies unavailable. Supplier number called and to be delivered Wednesday. (Podiatrist) office called to notify but unable to reach at this time. Bordered foam dressing applied while awaiting delivery. Confirming the lack of follow up for an ordered treatment and recommended treatment not completed/ordered. During an observation on 04/22/24 at 10:37 AM, R276 was in his room. He did not have a wound vac applied to his left foot. A wound vac was on his nightstand. During an observation on 04/23/24 at 08:04 AM, R276 did not have a wound vac applied to his left heel. Review of R276's Order Summary and Treatment Administration Record on 4/23/24 revealed no order for wound treatment in place of the wound vac as recommended by Wound Consultant (WC) B on 4/19/24. During an interview on 4/23/24 at 3:35 PM, Licensed Practical Nurse (LPN) C confirmed that R276 did not have a wound vac in place and was without wound treatment orders. LPN C reported there was no excuse for not having wound vac supplies and for treatments not being entered. LPN C stated a delay in care can cause sepsis and the deterioration/worsening of R276's wound. Review of R276's Order dated 4/23/24 at 4:10 PM revealed, Lt heel; clean daily with wound cleanser and calcium alginate applied to the area for autolytic debridement. Wound should be covered with a bordered gauze. Initial and date. Daily. Change to wound vac once supplies become available. every day shift for wound care -Start Date-04/24/2024 0700. During an interview on 04/24/24 at 09:26 AM, LPN C reported there was a dedicated wound nurse that was responsible for all pressure injuries and wounds in the facility. LPN C reported the wound nurse rounded with the provider, completed weekly wound measurements and pictures, and ensured the orders were entered into the electronic health record. LPN C reported the residents weekly wound assessments included measurements including depth, the description of the wounds, and treatment changes. During an interview on 4/24/24 at 11:26 AM, WC B reported that LPN D was the rounding wound nurse at the facility and would assist with wound measurements and complete the weekly wound assessment form. WC B reported the facility utilized a camera that would measure length and width, but the depth was done manually and was to be documented in the wound assessment. WC B reported he was not notified that the treatment he ordered on 4/19/24 for R276 had not been implemented and reported his expectation was that treatment orders were transcribed into the electronic health record. WC B reported he ordered a bridge (interim) treatment for R276 until the wound vac supplies came in but expected the wound vac supplies would have arrived prior to his return to the facility. During an interview on 4/24/24 at 12:13 PM, LPN D (rounding wound nurse) reported she had not been notified that R276 did not have wound vac supplies. LPN D reported there were appropriate supplies for R276's wound vac and obtained them at that time. Per the facility policy Skin Management last revised 7/14/21, A Guest/Resident at Risk meeting will be conducted at least monthly by the Interdisciplinary Team (IDT). During the meeting, the IDT will evaluate guest/resident skin changes, review treatment modalities, interventions and will make recommendations as needed .Guests/residents reviewed for skin alterations are as follows: *Newly developed vascular, diabetic/neuropathic and pressure injuries *Any pressure or non-pressure area that has shown no signs of healing within a two week time frame . During an interview on 04/25/24 at 12:51 PM, Nursing Home Administrator (NHA) reported that R276's left heel pressure injury had not been identified/reviewed during the Resident at Risk meetings until 4/15/24 when he was reviewed for readmission to the facility following a DVT. During an interview on 04/29/2024 at 12:50 PM, Regional Nurse Consultant (RNC) A reported that the information documented in the Skin & Wound Evaluation pulls over to the dashboard in the electronic health record system and alerts management if a wound is deteriorating/worsening. RNC A confirmed that an accurate depth measurement would be essential in identifying if a wound had deteriorated/worsened. Resident #3 (R3) Review of an admission Record revealed R3 was an [AGE] year-old male, admitted to the facility on [DATE]. Review of R3's Wound Consultant Note dated 3/27/24 revealed, .Sacrum pressure stage III .This wound is full thickness .Tx: This area is to be cleaned daily with wound cleanser. Apply zinc cream to surrounding areas. Apply skin prep to surrounding tissue. Wound should be covered with a bordered gauze. Initial and date. Daily . Review of R3's Order Summary revealed the wound consultant's recommendations were not entered into the electronic health record until 4/26/24. Review of R3's Total Body Skin Assessment dated 4/26/24 revealed, New stage 2 pressure injury noted to right inner buttock. Area cleansed and measured. Measurements 0.8 cm x 0.5 cm x 0.1 cm .treatment ordered . Review of R3's Order Summary on 4/29/24 revealed no order for wound treatment for the newly identified pressure injury. Resident #9 (R9) Review of an admission Record revealed R9 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R9's Wound Consultant Notes beginning on 1/31/24 revealed an area of abrasion on her scalp with the following order, This area is to be cleaned daily with wound cleanser and skin prep applied to the area. Wound should be open to air. Daily. Review of R9's Order Summary revealed that from 11/27/23-4/26/24 her treatment was ordered as Skin prep to scalp BID every day and night shift for scabbed areas. Review of R9's Order Summary dated 4/26/24 revealed an order change to, Front scalp abrasions: cleanse site with wound cleanser, pat dry. Apply skin prep, leave open to air. every day shift for scabbed areas Resident #11 (R11) Review of an admission Record revealed R11 was a [AGE] year-old male, admitted to the facility on [DATE]. Review of R11's Wound Consultant Note dated 4/19/24 revealed, .Right Dorsum-1st Digit Diabetic-This area measures 1.22 x 0.79 centimeter with a depth of 0.1 centimeter. This wound is full thickness. There is a moderate amount of serous drainage from this area . Review of R11's Skin & Wound Evaluation dated 4/24/24 revealed no documentation of the measurable depth or drainage. Review of R11's Order Summary revealed Cleanse R great toe and second digit with NS, apply Santyl to wound bed, cover w/ Calcium alginate and dry dressing every day shift for Diabetic ulcer. Start Date 2/8/24. Review of R11's April Treatment Administration Record revealed the treatment was not completed on 4/2/24, 4/9/24, 4/10/24, and 4/15/24. Resident #19 (R19) Review of an admission Record revealed R19 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R19's Skin & Wound Evaluation dated 4/24/24 revealed an area of Moisture Associated Skin Damage (MASD) on left gluteus measuring 0.8cm x 0.8cm x 0.2cm. (MASD is widespread erythema, maceration, and irregular or diffuse edges.) During an observation and interview on 4/29/24 at 1:15 PM, R19's Skin & Wound Evaluation dated 4/24/24 was reviewed with the Director of Nursing. Review of the picture of the wound revealed a circular open area on the ischial tuberosity (point of pressure on buttocks) with defined edges and a reddened wound bed. DON confirmed that the area of breakdown/injury was a Stage II pressure injury and not MASD. Review of R19's Electronic Health Record revealed no documentation that the family or provider was notified of the Stage II pressure injury. There were no treatments ordered for the newly identified pressure injury. Resident #228 (R228) Review of an admission Record revealed R228 was a [AGE] year-old female, admitted to the facility on [DATE]. Review of R228's Total Body Skin Assessment dated 4/26/24 revealed, 2 non-documented wounds noted upon total body assessment. 1 wound is localized to the left posterior heel. Area is scabbed over and pea sized. Resident explains she has history of a previous wound here. The second wound is localized to her bottom, which appears to be shearing/ skin tear caused by moisture associated damage .New orders input for daily skin prep to the left posterior heel and zinc oxide ointment for her bottom every shift. Review of R228's Order Summary dated 4/29/24 revealed, Zinc Oxide Ointment to buttocks every day and night shift for MASD and Skin prep to posterior left heel every day and night shift for prevention of skin breakdown on old healing wound. Indicating a delay in treatment. Resident #64 (R64) Review of an admission Record reflected R64 admitted to the facility on [DATE] with a primary diagnosis of unspecified dementia, severe, without behavioiral disturbance, psychotic disturbance, mood disturbance and anxiety. R64 was given a secondary, during stay diagnosis on 8/8/2023 of pressure ulcer of right heel, stage 3. R64 was also diagnosed with Methicillin susceptible staphylococcus aureus (MSSA). Review of an admission Minimum Data Set (MDS) assessment dated [DATE] reflected R64 admitted to the facility with one stage 2 pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister), and 2 unstageable pressure ulcers with suspected deep tissue injury in evolution. The most recent MDS assessment dated [DATE] reflected R64 had a stage 3 pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). The assessment indicated the stage 3 was present on admission. R64 was no longer coded as having any unstageable-deep tissue, suspected deep tissue injuries. Review of a Care Plan last revised 1/03/2024 reflected R64 has actual impairment to skin integrity r/t (related to) heel stage 3 pressure injury. The Goal of the care plan was that R64 would not develop an infection to the wound and was not centered on healing or preventing the worsening of the wound. Interventions included, Conduct weekly head to toe skin assessments and report new/abnormal findings to physicians as needed; enhanced barrier precautions: don gown and gloves during high-contact resident care; Observe location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration etc. to physician. During an observation on 4/23/2024 at 1:39 p.m., Licensed Practical Nurse (LPN) Q removed the dressing covering the pressure ulcer on R64's right heel. The dressing was dated 4/20 and indicated the dressing was last changed three days prior to the observation. The dressing was saturated with brown, serous drainage. The skin around the pressure ulcer on R64's right heel was macerated (the softening and breaking down of skin resulting from prolonged exposure to moisture). LPN Q said that the dressing was to be changed daily. R64 also had a round, nickel sized dark reddened area on the lateral aspect of his left heel. LPN Q said she was not aware of the area. Additionally, there was a thick scab on R64's right great toe. LPN Q said she wasn't comfortable reapplying a fresh dressing until R64's right heel had a chance to air dry and said she would return in an hour to reassess the area. Review of the April 2024 Treatment Administration Record (TAR) reflected an order Cleanse right heel with NS (normal saline), apply skin prep to surrounding skin, and cover with calcium alginate and bordered gauze every day shift-Start Date-02/08/2024. The record reflected the dressing had not been changed on 4/21/24 or 4/22/2024. A dressing change was not documented as done on 4/1/2024. Review of the March 2024 TAR reflected the order Cleanse right heel with NS (normal saline), apply skin prep to surrounding skin, and cover with calcium alginate and bordered gauze every day shift-Start Date-02/08/2024. The ordered treatment was not completed on 3/8/24 or 3/13/24. During a follow-up observation on 4/23/24 at 3:37 p.m., LPN Q was assisted by LPN C in getting measurements and completing the