**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to intake #MI00143146 Based on interview and record review the facility failed to provide services that meet professional standards of nursing practice related to assessing, monitoring and providing wound care dressing changes for 1 resident (Resident #101) of 3 residents reviewed for professional standards, resulting in ineffective monitoring, dressing changes not completed as ordered, inaccurate documentation, and Resident #101 having a skin tear not cared for for 4 days with signs and symptoms of a wound infection. Findings include: Review of an admission Record revealed Resident #101 had pertinent diagnoses which included: unspecified dementia, general anxiety disorder, reduced mobility, and urinary tract infection. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 1/3/24 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #101 was severely cognitively impaired. Review of Incident Note dated 2/22/24, 02:20 AM revealed . Resident has a new 5 cm skin tear to her right upper thigh .cleansed skin tear with NS (normal saline), patted dry, and covered with dry dressing .on call manager, provider, and family notified .new order to monitor skin tear till resolved and cleanse daily . Review of Midnight Census report as used for rounding requests for providers dated 2/22/24 revealed . Resident #101 was listed for an acute visit for a skin tear on the right thigh . Review of Progress Note from provider dated 2/22/24 revealed .reason for visit skin issue . chief complaint skin wound injury . right thigh skin tear .SKIN: right thigh skin tear noted .assessment: right thigh skin tear . Plan: Ensure proper wound care . Review of Physician Orders for Resident #101 revealed .monitor skin tear to right upper thigh every shift for worsening or s/s (signs and symptoms) of infection until resolved started on 2/22/24 at 07:00 AM and Cleanse skin tear to right upper thigh with NS and cover with a dry dressing daily until resolved. Review of Midnight Census report as used for rounding requests for providers dated 2/23/24 revealed Resident #101 was listed for an acute visit for a new skin issue and crossed out and indicated addressed 2/22. Review of Progress Notes for Resident #101 dated 2/25/24 revealed .continue to monitor skin tear on R (right) thigh. No s/s (sign and symptoms) infection noted . Review of Progress Notes for Resident #101 dated 2/26/24 revealed No s/s of infection to right thigh, will continue to monitor . Review of Progress Note for Resident #101 dated 2/27/24 at 07:00 revealed . skin tear to right thigh noted. Yellowish/green drainage noted on dressing. Dressing changed. Cleansed with NS, applied TAO (triple antibiotic ointment) and covered with a dry dressing . placed in dr. (doctor) book for rounds in AM r/t (related to) increased drainage. Review of handwritten communication note dated 2/27/24 revealed CNA's (certified nurse assistant) called the nurses to change resident dressing to right thigh. Observed the dressing was dated for 2/22/24 .Order is in for it to be changed daily. It has been signed out all 4 days as done . wound is a lot bigger with green drainage . Review of Treatment Administration Record (TAR) for Resident #101 revealed documentation indicated the order for cleanse skin tear on right upper thigh with NS and cover with dry dressing daily until resolved. One time a day; and monitor skin tear to right upper thigh every shift for worsening or s/s of infection until resolved every shift; both orders were noted to be documented completed on each of the shifts on the dates 2/23/24, 2/24/24, 2/25/24, and 2/26/24 by the nurses working that shift. During an interview on 3/20/24 at 6:50 AM., CNA D reported that on 2/22/24 Resident #101 was found to have a skin tear on her right upper thigh. CNA D reported that a dressing was applied to the skin tear by the nurse on 2/22/24. CNA D reported the nurse was notified on 2/27/24 that the dressing on Resident #101's right upper thigh needed to be changed. CNA D reported that the dressing present on Resident #101's right thigh on 2/27/24 was dated as 2/22/24 at 2:20 AM. CNA D reported that Resident #101 verbalized pain during the dressing change on 2/27/24. CNA D reported that the wound appeared slimy with puss and green colored drainage, and the dressing was wet with green/yellow puss and drainage. Purulent drainage (pus or exudate) is a symptom of infection. This thick, milky fluid oozes from a wound that isn ' t healing properly. It contains a mixture of dead cells and bacteria, as well as white blood cells, which rush to the site at the first sign of injury. Pus from an infected wound might be white, yellow, green, pink or brown in color. Changes in purulent drainage color or odor usually mean the infection is getting worse. Left untreated, a wound with purulent drainage can turn into a chronic wound (also called a non-healing wound). This refers to a wound that doesn ' t heal within eight weeks. This type of infection can spread to other areas of your body, causing increased pain and a range of health complications .The best way to reduce your risk of purulent drainage is to clean and dress the wound properly. (https://my.clevelandclinic.org/health/symptoms/purulent-drainage) During an interview on 3/20/24 at 6:09 AM., LPN H reported that on 2/27/24 the CNA notified her that Resident #101's dressing on her right thigh needed to be changed. LPN H reported that the dressing, dislodged from the wound area and was dated for 2/22/24 at 02:20 AM. LPN 'H reported that on 2/27/24 the dressing was noted to have green drainage, a foul odor, and the skin tear on Resident #101's right thigh appeared to be spread open with drainage present. During an interview on 3/20/24 at 7:46 AM., RN G reported that she applied a dressing to Resident #101's right upper thigh on 2/22/24 for a skin tear. RN G reported that the edges of the skin tear were well approximated (closely touching) and there was no noted blood or drainage on 2/22/24. RN G reported she completed a skin observation tool, an incident report, a progress note, and orders to change the dressing and monitor the wound daily. RN G reported she notified the manager, the provider, and family member about the injury. RN G reported that she was notified on 2/27/24 by the CNA that Resident #101's dressing needed to be changed. RN G reported that the dressing that was present on #101's right thigh was the same dressing she had applied on 2/22/24. RN G reported she verified there was an order in place to change the dressing daily and noted documentation in the TAR that the dressing change had been completed daily since the order was started on 2/22/23. RN G reported that the wound edges were no longer well approximated, and there was green/yellow drainage noted. RN G reported that the findings were noted in the doctor's book for increased drainage and as a request for a doctor's visit, and the findings were reported to the unit manager. Review of Staff Schedule for the dates of 2/23/24 through 2/26/24 revealed 8 licensed nurses had been assigned to care for Resident #101 during those dates. Review of TAR for Resident #101 for the dates of 2/23/24, 2/24/24, 2/25/24, and 2/26/24 revealed 8 licensed nurses had documented the completion of the order to monitor Resident #101's skin tear to the right upper thigh and documented completion of the ordered daily dressing change. Review of Staff Schedule for the dates of 2/23/24 through 2/26/24 revealed that RN L was scheduled to work with Resident #101 on two days during the hours of 7 am and 7 pm. Review of TAR for Resident #101 for the dates of 2/23/24 through 2/26/24 revealed that RN L documented she completed the daily dressing change to her right upper thigh on the two days she worked. During an interview on 3/19/24 at 4:06 PM., RN L reported that Resident #101 had a skin tear on her right inner thigh and the dressing was changed daily on the day shift and she did not recall any drainage. RN L reported she did not recall any time during a shift she worked when she was unable to complete the scheduled dressing change for Resident #101. During a telephone interview on 3/20/24 at 9:03 AM., RN L reported that an order to monitor a wound or dressing the nurse needs to look for changes and document if there are any. RN L reported that to monitor a dressing the nurse would make sure the dressing was clean, dry, and intact. RN L reported that dressings should be dated and timed when changed and during monitoring if the date is old that dressing should be changed. RN L stated that if a dressing had an old date, she would automatically change it. RN L reported that she recalls Resident #101 having a dressing to her right upper thigh but did not recall a time when she didn't change the dressing as ordered. Review of Staff Schedule for the dates of 2/23/24 through 2/26/24 revealed that RN J was scheduled to work with Resident #101 on one day during the hours of 7 am and 7 pm. Review of TAR for Resident #101 for the dates of 2/23/24 through 2/26/24 revealed that RN J documented she completed the daily dressing change to her right upper thigh on the one day she worked. During an interview on 3/20/24 at 8:20 AM., RN J reported that Resident #101 had a skin tear on her right upper thigh and the dressing was to be changed daily. RN J reported that dressing change documentation occurred on the TAR, and it should include when a dressing change was not completed. RN J reported that she did not have a day she documented completing Resident #101's dressing change and it did not occur. During an interview on 3/19/24 at 4:23 PM., Unit Manager (UM) I reported that Resident #101 did have a skin tear on her right upper thigh. UM I reported that the dressing was changed daily, there was no concern with the dressing change being completed. During a second interview on 3/20/24 at 10:29 AM., UM I reported that Resident #101 obtained a skin tear on 2/22/24 and there was an order for monitoring the wound every shift and an order for a daily dressing change. When asked, UM I confirmed that concerns that Resident #101's dressing changes were not being completed as ordered were brought to her attention on 2/27/24. UM I reported that she assessed Resident #101's wound by pealing back the dressing and visualizing the wound and there was no drainage present. UM I reported she asked the wound nurse to monitor Resident #101's wound. UM I reported Resident #101 was not added to the providers rounding list to be seen since the wound had no drainage when she assessed it. UM I reported that she did not document her assessment of Resident #101's wound. UM I reported that she discussed the concerns for Resident #101's dressing changes not being completed with the management team and a one-to-one education was provided to one nurse. UM I reported that there was no documentation regarding the concern, the discussion, or the one-to-one education she provided. UM I reported that she did not complete an investigation into the concern for Resident #101's dressing changes not being done. The Professional Standard of Quality for documentation of the resident's health care in a medical record is the information must be true and complete. Under no circumstances should erroneous records be removed from the overall record and new pages submitted. (Fundamentals of Nursing, Concepts, and Practice. Mosby. [NAME], P.A., [NAME], A.G., 1985) According to the Nursing's Social Policy Statement (American Nurses Association, 2003, pg. 2), Society grants the professions authority over functions vital to itself and permits them considerable autonomy in the conduct of their affairs. In return, the professions are expected to act responsibly, always mindful of the public trust. Self-regulation to assure quality in performance is at the heart of this relationship. It goes on to state (pg. 11), Professional nursing .is accountable for ensuring that its members act in the public interest in the course of providing the unique service society has entrusted to them.

This citation pertains to intake #MI00143146 Based on interview and record review the facility failed to assess, monitor, and treat a resident with a skin tear in 1 resident (Resident #101) of 3 residents reviewed for quality of care, resulting in an Resident #101 having a skin tear not cared for for 4 days and signs and symptoms of a wound infection due to lack of care. Findings include: Review of an admission Record revealed Resident #101 had pertinent diagnoses which included: unspecified dementia, general anxiety disorder, reduced mobility, and urinary tract infection. Review of a Minimum Data Set (MDS) assessment for Resident #101, with a reference date of 1/3/24 revealed a Brief Interview for Mental Status (BIMS) score of 1/15 which indicated Resident #101 was severely cognitively impaired. Review of Physician Orders for Resident #101 revealed .monitor skin tear to right upper thigh every shift for worsening or s/s (signs and symptoms) of infection until resolved started on 2/22/24 at 07:00 AM and Cleanse skin tear to right upper thigh with NS and cover with a dry dressing daily until resolved. Review of Progress Note from provider dated 2/22/24 revealed .reason for visit skin issue . chief complaint skin wound injury . right thigh skin tear .SKIN: right thigh skin tear noted .assessment: right thigh skin tear . Plan: Ensure proper wound care . Review of Progress Notes for Resident #101 dated 2/25/24 revealed .continue to monitor skin tear on R (right) thigh. No s/s (sign and symptoms) infection noted . Review of Progress Notes for Resident #101 dated 2/26/24 revealed No s/s of infection to right thigh, will continue to monitor . Review of Treatment Administration Record (TAR) for Resident #101 revealed documentation indicated the order for cleanse skin tear on right upper thigh with NS and cover with dry dressing daily until resolved. One time a day; and monitor skin tear to right upper thigh every shift for worsening or s/s of infection until resolved every shift; both orders were noted to be documented as completed on each of the shifts on the dates 2/23/24, 2/24/24, 2/25/24, and 2/26/24. No documentation was noted to indicate that the orders were not complete. Review of Staff Schedule for the dates of 2/23/24 through 2/26/24 revealed 8 licensed nurses had been assigned to care for Resident #101 during those dates. Review of TAR for Resident #101 for the dates of 2/23/24, 2/24/24, 2/25/24, and 2/26/24 revealed 8 licensed nurses had documented the completion of the order to monitor Resident #101's skin tear to the right upper thigh and 4 licensed nurses had documented completion of the ordered daily dressing change. Review of Progress Note for Resident #101 dated 2/27/24 at 07:00 revealed . skin tear to right thigh noted. Yellowish/green drainage noted on dressing. Dressing changed. Cleansed with NS, applied TAO (triple antibiotic ointment) and covered with a dry dressing . placed in dr. book for rounds in AM r/t (related to) increased drainage. Review of handwritten communication note dated 2/27/24 revealed CNA's (certified nurse assistant) called the nurses to change resident dressing to right thigh. Observed the dressing was dated for 2/22/24 .Order is in for it to be changed daily. It has been signed out all 4 days as done . wound is a lot bigger with green drainage . During an interview on 3/20/24 at 6:50 AM., CNA D reported that on 2/22/24 Resident #101 was found to have a skin tear on her right upper thigh. CNA D reported that a dressing was applied to the skin tear by the nurse on 2/22/24. CNA D reported the nurse was notified on 2/27/24 that the dressing on Resident #101's right upper thigh needed to be changed. CNA D reported that the dressing present on Resident #101's right thigh on 2/27/24 was dated as 2/22/24 at 2:20 AM. CNA D reported that Resident #101 verbalized pain during the dressing change on 2/27/24. CNA D reported that the wound appeared slimy with pus and green colored drainage, and the dressing was wet with green/yellow puss and drainage. CNA D reported that the dressing on Resident #101's right leg appeared to not have been changed for 4 days. Purulent drainage (pus or exudate) is a symptom of infection. This thick, milky fluid oozes from a wound that isn ' t healing properly. It contains a mixture of dead cells and bacteria, as well as white blood cells, which rush to the site at the first sign of injury. Pus from an infected wound might be white, yellow, green, pink or brown in color. Changes in purulent drainage color or odor usually mean the infection is getting worse. Left untreated, a wound with purulent drainage can turn into a chronic wound (also called a non-healing wound). This refers to a wound that doesn ' t heal within eight weeks. This type of infection can spread to other areas of your body, causing increased pain and a range of health complications .The best way to reduce your risk of purulent drainage is to clean and dress the wound properly. (https://my.clevelandclinic.org/health/symptoms/purulent-drainage) During an interview on 3/20/24 at 6:09 AM., LPN H reported that on 2/27/24 the CNA notified her that Resident #101's dressing on her right thigh needed to be changed. LPN H reported that the dressing, dislodged from the wound area and was dated for 2/22/24 at 02:20 AM. LPN 'H reported that on 2/27/24 the dressing was noted to have green drainage, a foul odor, and the skin tear on Resident #101's right thigh appeared to be spread open with drainage present. LPN 'H reported that the dressing appeared to have not been changed in 4 days when it should have been changed daily. During an interview on 3/20/24 at 7:46 AM., RN G reported that she applied a dressing to Resident #101's right upper thigh on 2/22/24 for a skin tear. RN G reported that the edges of the skin tear were well approximated (closely touching) and there was no noted blood or drainage on 2/22/24. RN G reported she completed a skin observation tool, an incident report, a progress note, and orders to change the dressing and monitor the wound daily. RN G reported she notified the manager, the provider, and family member about the injury. RN G reported that she was notified on 2/27/24 by the CNA that Resident #101's dressing needed to be changed. RN G reported that the dressing that was present on #101's right thigh was the same dressing she had applied on 2/22/24. RN G reported she verified there was an order in place to change the dressing daily and noted documentation in the TAR that the dressing change had been completed daily since the order was started on 2/22/23. RN G reported that the wound edges were no longer well approximated, and there was green/yellow drainage noted. RN G reported that the findings were noted in the doctor's book for increased drainage and as a request for a doctor's visit, and the findings were reported to the unit manager. During an interview on 3/19/24 at 4:23 PM., Unit Manager (UM) I reported that Resident #101 did have a skin tear on her right upper thigh. UM I reported that the dressing was changed daily, there was no concern with the dressing change being completed and that the wound had not healed prior to Resident #101 passing away on 3/15/24. During a second interview on 3/20/24 at 10:29 AM., UM I reported that Resident #101 obtained a skin tear on 2/22/24 and there was an order for monitoring the wound every shift and an order for a daily dressing change. When asked, UM I confirmed that concerns that Resident #101's dressing changes were not being completed as ordered were brought to her attention on 2/27/24. UM I reported that she assessed Resident #101's wound by pealing back the dressing and visualizing the wound and there was no drainage present. UM I reported she asked the wound nurse to monitor Resident #101's wound. UM I reported Resident #101 was not added to the providers rounding list to be seen since the wound had no drainage when she assessed it (after the dressing had already been changed). UM I reported that she did not document her assessment of Resident #101's wound. UM I reported that she discussed the concerns for Resident #101's dressing changes not being completed with the management team and a one-to-one education was provided to one nurse. UM I reported that there was no documentation regarding the concern, the discussion, or the one-to-one education she provided. UM I reported that she did not complete an investigation into the concern for Resident #101's dressing changes not being done.

Based on interview and record review the facility failed to ensure residents received care in accordance with professional standards of nursing practice for 1 of 18 residents (Resident #40) resulting in the worsening and infection of a cyst. Findings include: Review of an admission Record revealed Resident #40 was a male with pertinent diagnoses which included diabetes, weakness, anxiety, restlessness & agitation, reduced mobility, dementia, and lipomatous neoplasm of skin and subcutaneous tissue of right arm (fatty tumor located just below the skin), and cyst. Review of current Care Plan for Resident #40, revised on 3/13/23, revealed the focus, .I have been diagnosed with skin infection r/t (related to) cyst (middle upper chest) . with the intervention .Administer antibiotic medications as ordered by physician. Monitor/document side effects and effectiveness .Observe and report signs of cellulitis: Localized pain, redness, swelling, tenderness, drainage, fever, chills, malaise, tachycardia, hypotension .Observe and report signs of sepsis: fever, lassitude or malaise, change in mental status, tachycardia, hypotension, anorexia, nausea, vomiting, diarrhea, headache, lymph node tenderness/enlargement .Tx (treatment) per MD orders . Review of electronic correspondence provided on 3/22/23 at 1:30 PM, Unit Manager Z reported, .8/16/2022 (Previous Provider) states in a monthly visit, left chest wall mass-seems to be a cyst, non-infected. Will have alert charting to see whether it becomes red, painful or starts to drain. If so, can refer him to CFC to have it drained. Otherwise for now just monitor .10/25/2022 (Previous Provider) states in a monthly visit, left chest mass mass-seems to be a cyst, non-infected. Will have alert charting to see whether it becomes red, painful, or starts to drain. Review of Skin/Wound Note dated 3/6/23 at 2:06 PM, .Cyst on left side of chest has some redness around it and no drainage . Review of Doctor Visit/Chart Review dated 3/6/23 at 5:27 PM, revealed, .ACUTE VISIT .the patient is being seen today by (Provider Name) for complains of left chest cyst. Cyst is hard, immobile, not tender and measures 5x3 CM .Assessment: Left cyst chest .Plan: Continue monitoring . Review of Health Status Note dated 3/13/23 at 1:49 PM, revealed, .Cyst on left chest warm, pink/red, size has remained unchanged since Friday, 3/10; now appears with visible with head; tender to touch . Review of Health Status Note dated 3/14/2023 at 00:15 AM, revealed, .Easily aroused for po ABT for cellulitis on middle upper chest. Area swollen and appears to be slightly more swollen but remains dark pink to red in color. It is the same temperature as surrounding skin. No discomfort and (Resident #40) said, No when asked about pain in this area. I explained about infection and swelling . Review of Health Status Note dated 3/14/2023 at 11:36 AM, revealed, .Cyst on left chest warm, pink/red, size has remained unchanged since Friday, 3/10; now appears with visible white heads; tender to touch. VS WNL with the exception of temp 99.3; scheduled acetaminophen given - effective. No s/e, s/s of ABT noted . Review of Vitals Note dated 3/14/23 at 12:10 PM, revealed, .TEMPERATURE WARNING: 99.3 .High of 99.0 exceeded . Review of Skin Tool Audit completed on 3/14/23 at 1:27 PM, revealed, .(Resident #40) .Location: Lt. Upper Chest .Type: Cyst .Treatment Order: N (no) .Monitor Order: Y (yes) . Review of Health Status Note dated 3/15/23 at 00:48 AM, revealed, .Remains on antibiotic for cyst to upper chest, area red and raised with two small white pus pockets present in center . Review of Skin/Wound Note dated 3/15/2023 at 7:48 PM, revealed, .Resident alert and oriented. Chest abscess red and swollen but resident continues to tolerate ABX .ABD (abdominal gauze pads) applied over abscess to catch any drainage if needed . Review of Health Status Note dated 3/16/2023 at 11:34 PM, revealed, .Skin pink, warm, and dry. Lump on upper middle chest covered with dry dressing. (Resident) reports the area itches at times. Continues on ABT for cellulitis on chest at this time. Temperature 99.0 . Review of Health Status Note dated 3/17/2023 at 1:43 PM, revealed, .Cyst on left chest covered with bandage; oozing with yellow drainage, open red areas and yellow pustules (bulging patch of skin contains fluid or pus); tender to touch. VS WNL; scheduled acetaminophen for pain. No s/e (side effects), s/s (signs or symptoms) of ABT (antibiotic) noted . Review of Health Status Note dated 3/18/2023 at 00:57 AM, revealed, .Resting in bed with eyes closed but aroused easily for po ABT and dressing change. Skin pink, warm, and dry. Lump on upper middle chest has three open areas measuring .5cmX.5cm,.5cmX.5cm (both on left side of lump) and 1.2cmX1.2cm (on right side of lump).dressing had moderate amount of purulent drainage and slight amount of dark pink drainage. Area remained dark red in color and swollen but surrounding skin pink and intact. (Resident #40) called out with removal of old dressing and during procedure to cleanse area but closed eyes and quieted once new dressing placed over the area. Continues on ABT (antibiotic) for cellulitis on chest at this time. Afebrile . Review of Health Status Note dated 3/18/2023 at 11:22 AM, revealed, .Cyst on left chest covered with bandage; oozing with yellow drainage, open red areas and yellow pustules; tender to touch. VS WNL; scheduled acetaminophen for pain. No s/e (side effects), s/s (sign or symptoms) of ABT (antibiotic) noted . Review of Skin/Wound Note dated 3/19/2023 at 1:09 PM, revealed, .Resident alert and oriented to self .Resident up in wheelchair and continues to take his abx for the cyst on his upper chest .Cyst on upper chest continues to drain purulent drainage (a sign of infection, it is a white, yellow, or brown fluid, might be slightly thick, made up of white blood cells trying to fight infection, there may be an unpleasant smell to the fluid) at this time .Dressing changed and resident tolerated it well . Review of Social Service Note dated 3/20/2023 at 3:17 PM, revealed, .(Resident #40) is tearful and stating, I'm hurting .(Resident #40) voiced, I just want to go Review of Orders dated 3/20/23, revealed, .Referral to General Surgery for cyst extraction . In an interview on 03/21/23 at 12:53 PM, Resident #40 was observed lying in his bed. Resident #40's wife reported a nurse tried to pop the spot on his chest, she thought it was a blackhead, but it wasn't. R#40's wife reported it was a growth filled with fluid, (Resident #40) was taking medications for it. R#40's wife thought the facility referred him to (local hospital) to see a wound doctor. During an observation on 03/21/23 at 02:44 PM, observed dressing change for Resident #40. Observed bandage dated 3/20/23 with initials of nurse who completed dressing change on 3/20/23 at 7:08 PM. RN D prompted Resident #40 on how she was proceeding with the dressing change. Observed removal of previous dressing, Resident #40 was very painful, grimacing/wincing and calling out in pain. Resident #40 was observed to be painful in the areas surrounding the golf ball sized cyst as well. Resident #40 was observed to reach to grab something with his hands on the side of the bed. Resident #40's skin on and around the cyst was very red and inflamed, a dark reddish color and the dressing showed purulent drainage on the gauze. When RN D proceeded to clean the wound, Resident #40 was observed to be very painful, grimacing/wincing in pain. RN D stated to Resident #40, .No, no more .All done . Resident #40 was grabbing at side of the bed. RN D proceeded to place the new dressing, and Resident #40 grimaced/winced in pain. RN D reported Resident #40 had broken out in a rash and a new course of antibiotics was prescribed, she reported today was the last day of 10 days of the two previously prescribed antibiotics. RN D reported the resident did receive Tylenol prior to the dressing change. In an interview on 03/22/23 at 10:43 AM, CNA H reported Resident #40's wife told her the nurse popped it. CNA H reported she did that a couple of weeks ago and since then it has gotten big and really red. CNA 'H reported the cyst did not bother him, he had no complaints until now. CNA H stated, .It is bothering him since the nurse did what she did with it .Have to be careful when getting him dressed or touch in that area .It really hurts him .She doesn't work at the facility anymore .Heard she was terminated . In an interview on 03/22/23 at 02:10 PM, CNA FF reported the cyst had been there a long time. CNA FF stated, .I came in for my shift and I took his shirt off and saw it, I asked what happened to chest. (Resident #40's) wife reported the nurse took a needle to it, popped it and it smelled really, really bad . CNA FF' reported the cyst was painful and he did clutch his chest when it was bothering him, even when no one was touching it. CNA FF reported it is upsetting as it was not bothering him until she did that. CNA FF reported the nurse does not work here anymore. In an interview on 3/22/23 at 11:21 AM, Unit Manager Z reported the cyst was first noted last August and it remained stable until recently .when it got infected . When queried on how the cyst became infected, UM Z stated, .There was a floor nurse who was not here for very long .She worked first shift .She had no orders to do anything to the cyst only to just monitor the cyst .There was no investigation conducted in to her actions .Was not aware the nurse tried to pop or aspirate the cycst until after the fact when it was placed on the doctor's board on Monday, 3/6/23 .Unsure of when the incident occurred . UM Z reported monitoring was to look for redness and if it was painful .Prior to that day, there was no issue for months and months . In an interview on 3/22/23 at 11:27 AM, Unit Manager R reported the nurse had tried to aspirate it with a needle .The nurse used term blackhead, she never talked to other nurse about cyst indicating what she saw or what she had done .(Resident #40) never had pain until that happened .Couple of antibiotics started on 3/10/23 .(Resident #40 got a rash and received Benadryl .He was switched to another antibiotic to continue until he goes to surgery appointment on 4/4/23. When queried if the nurse documented on her actions in a progress note, the response was No .The cyst was currently draining fluid and due to the drainage indicating the cyst was open .the resident should be on enhanced barrier precautions. When queried if resident was currently on enhanced barrier precautions, UM R reported he was not.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent the development and /or worsening of pressure ulcers in 2 of 2 residents (R56 and R31) reviewed for pressure ulcer prevention, resulting in the worsening of a sacral pressure ulcer and deep tissue injury for R56 and the development of pressure ulcers for R31. Findings include: Resident #56: Review of an admission Record revealed Resident #56 was a female with pertinent diagnoses which included pressure ulcer of sacral region stage 2, down syndrome, adult failure to thrive, need for assistance with personal care, kidney failure, and incontinence without sensory awareness. Review of current Care Plan for Resident #56, revised on 12/31/22, revealed the focus, .I am at high risk for skin breakdown per my Braden assessment. I was admitted with an unstageable pressure injury to the sacrum and acquired a DTI (deep tissue injury) to my right ischial with the potential for further skin breakdown r/t cognitive loss, communication deficits, incontinence, immobility . with the intervention .Turn & reposition every 2 hour in bed and chair (1/12/23) .Monitor and report signs of skin breakdown to Nurse (12/17/22) .Apply- Skin Protectant to bilateral buttocks (12/16/22) .Administer treatments as ordered and monitor for effectiveness (12/18/22) .Skin observation 3x weekly per protocol (1/12/23) .Heel protector boots when in bed (2/15/23) .Please only have resident up with meals, but no longer than 2 hours in chair at a time (3/7/23) and Please assist me back to bed if I have been in my chair for more than 2 hours at a time . Review of admission Report Sheet/Hand Off Form dated 12/16/23, revealed, .Skin Condition: Coccyx .Treatments/Dressing orders: Mepilex . Review of Doctor Visit/Chart Review dated 12/20/23 at 10:24 AM, revealed, .Assessment and Plan: 4. Stage 2 PU (pressure ulcer) - local wound care measures. Does not reposition self. Will need offloading and monitoring . Review of Health Status Note dated 12/23/2022 7:38 PM, revealed, .Note Text: Resident's wounds noted on admission assessed by Wound Care Coordinator (WCC) RN. Sacrum: Unstageable pressure ulcer to medial sacrum measuring 2.4 x 1.4 X 0.1 cm with wound bed tissue consisting of 70% yellow slough tissue and 30% red granulation tissue. Wound edges well-defined and without tunneling, undermining, or epibole (wound edge curling). Peri-wound tissue WNL without erythema, heat, or induration. R. Ischium: previously noted deep tissue injury evolved into a stage II pressure injury measuring 2.1 x 2.4 x 0.1cm. Wound bed consists of 100% red granulation tissue. Wound edges ill-defined but without undermining, tunneling, or epibole. Peri-wound tissue WNL without erythema, induration, or heat .Recommend treatment with leptospermum honey to both wounds and covering with the sacral wound with a optifoam sacral dressing every three days to promote autolytic debridement. The ischial wound will also be covered with an optifoam dressing every three days . Review of Skin/Wound Note dated 12/26/2022 at 3:31 PM, revealed, .Resident's wounds reassessed during wound rounds. Unstageable wound to sacrum measures 1.8 x 1.0 x 0.1cm with wound bed tissue consisting of 80% yellow slough tissue and 20% red granulation tissue. Wound edges well-defined and without undermining, tunneling, or epibole. Peri-wound tissue without erythema, induration, or heat. The deep tissue injury to the resident's left ischial tuberosity (bony protrusion which takes the body's weight during sitting) has evolved into a stage II pressure injury measuring 0.9 x 0.8x 0.1cm with wound bed consisting of 100% red granulation tissue. Wound edges WNL without undermining, tunneling, or epibole. Peri-wound tissue without erythema, induration, or heat observed .Recommend continuing with current treatment orders . Review of Health Status Note dated 12/30/2022 at 03:14 PM, revealed, .Resting in bed with eyes closed at this time .Skin pale pink, warm, and dry. Extreme dry skin on chest and bottom of both feet with peeling, chest skin receiving medication treatment. Has two areas with intact drsg. in place, one on thigh and one over coccyx . Review of Order dated 1/2/23, revealed, .Keep resident's head of bed to 30 degrees or less except when eating/drinking and 30 minutes after PO intake . Review of Order dated 1/9/23, revealed, .Wound Consult . Review of Order dated 1/11/23, revealed, .Skin Observation Tool: every day shift every Mon, Wed, Fri Alert Wound Nurse/Unit Manager of any new skin concerns . Review of Order dated 1/12/23, revealed, .Monitor Sacrum (PI) two times a day for s/s of worsening or infection . Review of Skin/Wound Note dated 1/2/2023 at 09:31 AM, revealed, .Resident's wounds reassessed by WCC RN .The unstageable pressure injury to the resident's sacrum measures 1.7 x 1.3 x 0.1cm. No exudate noted upon dressing removal. Wound bed consists of 70% yellow slough tissue and 30% red granulation tissue. Wound edges are circular in configuration and they are without undermining, tunneling, or epibole. Peri-wound tissue WNL and without erythema, induration, or heat. Recommend increasing frequency of dressing changes to sacrum to twice daily. The head of the resident's bed should be kept to 30 degrees or lower except when the resident is eating/drinking and 30 minutes afterwards to reduce shearing forces to the wound bed. Will also add liquid protein supplementation daily . Review of Skin & Wound Evaluation dated 1/2/2023, revealed, .Sacrum: Pressure Ulcer, Unstageable .Wound Measurements: 1.7x 1.3x 0.1CM .Granulation: 30% wound filled .Slough: 70% wound filled .Surrounding Tissue: Denuded: loss of epidermis caused by exposure to urine, feces, body fluids, wound exudate, or friction .Progress: Deteriorating . Review of Skin & Wound Evaluation dated 1/2/2023, revealed, .Pressure: Stage: Deep Tissue Injury .Left Ischial Tuberosity . Note: No other data. Review of Skin & Wound Evaluation dated 1/7/2023, revealed, .Pressure: Stage: Unstageable: Obscured full-thickness skin and tissue loss .Sacrum .Measurements: 3.0 x 2.0 x 2.0 CM .Epithelial: 0% of wound covered .Granulation: 10% of wound filled .Slough: 80% of wound filled .Eschar: 10% of wound filled .Exudate: Light, Purulent (sign of infection, made up white blood cells trying to fight the infection, it's white, yellow, or brown fluid, and there may be an unpleasant smell to the fluid) .Open lesion .Left Ischial Tuberosity .Measurements: .7 x .8 x .1 CM .Granulation: 90% of wound filled .Slough: 0% of wound filled .No infection noted. Wound appears to be a shearing injury. Triad cream applied as dressing . Review of Skin & Wound Evaluation dated 1/9/2023, revealed, .Pressure: Unstageable .Due to Slough and/or eschar .Sacrum .Measurements: 3.0 x 2.8 x 1.5 CM .Slough: 100% wound filled .Exudate: Light, Serous (thin, watery fluid produced in response to local inflammation) .Surrounding Tissue: Denuded: loss of epidermis caused by exposure to urine, feces, body fluid, wound exudate, or friction .Erythema: Redness of the skin: may be intense bright red to dark red or purple . Review of Skin & Wound Evaluation dated 1/23/2023, revealed, .Pressure: Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: None entered .Slough: 100% wound filled .Exudate: Light, Serous . Surrounding Tissue: Erythema: Redness of the skin - may be intense bright red to dark red to purple .Progress: Deteriorating . Review of Doctor Visit/Chart Review dated 1/23/23 at 4:07 PM, revealed, .Late Entry: Visit per (Wound Provider) services (Wound provider) MD .Change in treatment to be made .Primary Nurse apprised . Review of Treatment Administration Report (TAR) for January 2023, revealed, .Sacrum: Cleanse with NS (normal saline) or wound cleanser. Apply leptospermum honey to wound bed. Cover with bordered gauze dressing. In the morning for Unstageable Pressure Injury .Start date: 1/18/23 .D/C date: 1/24/23 . For dates: 1/20/23 and 1/23/23 the order was not implemented and not denoted on the report. Review of Treatment Administration Report (TAR) for January 2023, revealed, .Skin Observation Tool every day shift every Mon, Wed, Fri. Alert Wound Nurse/Unit Manager of any new skin concerns .Start date: 1/11/23 at 07:00 AM . For date, 1/20/23 the order was not implemented and not denoted on the report. Review of medical record revealed, Resident #56 was in isolation from 1/31/23 to 2/11/23 due to testing positive for COVID-19. Review of Skin & Wound Evaluation dated 2/1/2023, revealed, .Pressure: Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: 1.6 x 1.2 x 1.9 CM .Epithelial 10% wound covered .Granulation: 10% wound filled .Slough: 80% wound filled .Other: Bleeding, Pink or Red .Exudate: Light, Serous . Review of Health Status Note dated 2/5/2023 at 10:47 PM, revealed, .Remains in Enhanced respiratory isolation for + COVID on 1/31. Resting in bed with eyes open. Communication per typical with looks, movement, and occasionally a word or two. Accepted offered evening snack. Skin pale pink, warm, and dry. Resp. even and unlabored. No cough heard. VS stable . Review of Doctor Visit/Chart Review dated 2/7/2023 at 6:34 PM, revealed, .Note Text: (Wound Provider) PA from (Wound Care Provide Business Name) wound care here to see resident . Review of Skin & Wound Evaluation dated 2/9/2023, revealed, .Pressure: Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: 2.8 x 2.3 x 1.5 CM . Granulation: 10% wound filled .Slough: 90% wound filled .Surrounding Tissue: Erythema: Redness of the skin - may be intense bright red to dark red to purple .Progress: Deteriorating . Review of Skin & Wound Evaluation dated 2/16/2023, revealed, .Pressure: Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: 2.7 x 1.8 x 1.9 CM .Slough: 100% wound filled . Review of Skin & Wound Evaluation dated 2/21/2023, revealed, .Pressure: Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: 4.2 x 1.9 x 3.1 CM . Eschar: 100% .Exudate: Light, Serous .Surrounding Tissue: Erythema: Redness of the skin - may be intense bright red to dark red to purple . Review of Treatment Administration Report (TAR) for February 2023, revealed, .Monitor Sacrum (PI) two times a day for s/s of worsening or infection .Start Date: 1/12/2023 . For date, 2/26/23 the order was not implemented and not denoted on the report. Review of Skin & Wound Evaluation dated 3/2/2023, revealed, .Pressure: Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: 1.7 x 1.4 x 1.5 CM . Slough: 90% .Exudate: Light, Serous .Surrounding Tissue: Erythema: Redness of the skin - may be intense bright red to dark red to purple . Review of Skin/Wound Note dated 3/7/2023 at 3:04 PM, revealed, .Resident currently in bed, alert and oriented to self .Coccyx wound cleansed with normal saline, santyl and optiform applied .Right gluteal fold red, blanchable and center is unstageable injury .Optiform applied to site . Doctor Visit/Chart Review 3/7/2023 6:23 PM, revealed, .Note Text: (Wound Care Provide Business Name) wound visit per (Wound Provider) PA . Review of Skin & Wound Evaluation dated 3/7/2023, revealed, .Pressure .Deep Tissue Injury - Persistent non-blanchable deep red, maroon, or purple discoloration .In-House Acquired .New .Measurements: 2.2 x 2.0 x 1.6 CM . Review of Skin & Wound Evaluation dated 3/7/2023, revealed, .Pressure .Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: 3.0 x 2.1 x 1.9 CM . Slough: 50% wound filled .Eschar: 50% wound filled .Exudate: Serous . Review of Skin Tool Audit completed on 3/8/23 at 1:27 PM, revealed, .(Resident #56) .Location: Sacrum .Type: Pressure .Stage: Unstageable .admitted with: Y (yes) .(Resident #56) .Location: R (right) hip .Type: Pressure .Stage: SDTI (deep tissue injury) .admitted with: N (no) .Noted: 3/7/23 . Review of Health Status Note dated 3/8/2023 at 2:34 PM, revealed, .DTI (Deep tissue injury) to right buttocks treatment continues, slight purple red in color, skin prep applied . Review of Order dated 3/8/23, revealed, .Sacral Unstageable pressure injury: Cleanse wound with normal saline or wound cleanser, apply 0.125% Dakin's gauze in wet to moist fashion, cover with bordered gauze one time a day for Sacral unstageable pressure injury AND as needed for Sacral unstageable pressure injury . Review of Order dated 3/8/23, revealed, .Monitor Rt Ischial for s/s of worsening or infection two times a day for DTI (deep tissue injury) . Review of Order dated 3/8/23, revealed, Apply Sureprep to bilateral Hips (Ischial)two times a day .two times a day for Right Ischial DTI, left hip preventive . Review of Braden Scale for Predicting Pressure Sore Risk dated 3/10/23, revealed, .Score: 14.0 .Moderate Risk . Review of Skin & Wound Evaluation dated 3/14/2023, revealed, .Pressure .Unstageable .Due to: Slough and/or eschar .Sacrum .Measurements: 3.4 x 2.8 x 1.7 CM .Granulation: 20% wound filled .Slough: 90% wound filled .Exudate: Light, Serous .Surrounding Tissue: Erythema: Redness of the skin - may be intense bright red to dark red to purple .Progress: Stalled . Review of Wound Assessments dated 3/14/23, revealed, .Wound #1 Sacral is an Unstageable Pressure Injury Obscured full-thickness skin and tissue loss Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 3.1cm length x 1.7cm width x 0.6cm depth, with an area of 5.27 sq cm and a volume of 3.162 cubic cm. There is a small amount of sero-sanguineous drainage (liquid drainage which contains blood) noted which has no odor. The patient reports a wound pain of level 1/10. The wound is improving .The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. The temperature of the periwound skin is WNL. Periwound skin does not exhibit signs or symptoms of infection Wound #2 Right Ischial is a Deep Tissue Pressure Injury Persistent non-blanchable deep red, maroon or purple decoloration Pressure Ulcer and has received a status of Not Healed. Subsequent wound encounter measurements are 2.1cm length x 1.6cm width with no measurable depth, with an area of 3.36 sq cm . There was no drainage noted. The patient reports a wound pain of level 0/10. The wound is deteriorating The periwound skin texture is normal. The periwound skin moisture is normal. The periwound skin color is normal. The temperature of the periwound skin is WNL. Periwound skin does not exhibit signs or symptoms of infection .General Notes: Portion of wound with intact serous (fluid) filled blister . Review of Treatment Administration Report (TAR) for March 2023, revealed, .Santyl Ointment 250 UNIT/GM (Collagenase) Apply to per additional directions topically in the morning for Unstageable Pressure Injury .Sacrum: Cleanse with NS only. Apply to Santyl to wound bed with approximately a nickels width thickness. Cover with bordered gauze dressing .Start Date: 1/27/2023 .D/C Date: 3/8/2023 . For date, 3/3/23 the order was not implemented and not denoted on the report. During an observation on 03/20/23 at 01:04 PM, Resident #56 was [NAME] back to her room and left seated in her chair. In an interview on 03/20/23 02:34 PM, CNA QQ reported the facility was thinking her pressure ulcers on her bottom were from the resident's chair. In an interview on 03/20/23 at 02:51 PM, Registered Nurse (RN) J reported Resident #56 had two areas, one on her sacrum and one on her coccyx. RN J stated, .She has got a few areas on her bottom .She likes to sit up and watch people and we think that from her being seated in her chair for long periods of time it was not helping that wound, it was getting worse .Had to curb that down and get her back to bed, after meals will have her get placed in bed to off load . Review of NAR Note dated 3/21/2023 at 12:44 PM, revealed, .NAR team monitoring r/t dx PCM, low BMI, compromised skin integrity, dysphagia, and UTI .Skin: Per wound physician note 3.14.23 PU sacral improving, PU R ischial deteriorating. Skin and Wound Eval 3.15.23 DTI pressure not set, PU sacrum improving, open lesion resolved .Recommend: increase additional fluids 120 ml QID (4 times a day), eval for swallow study to advance texture/liquid consistency. Continue monitor PRN and respect res choice . During an observation on 03/21/23 at 01:09 PM, Resident #56 was observed lying in her bed with the head of her bed at approximately 80 degrees. In an interview on 03/22/23 at 10:50 AM, CNA H reported Resident #56 mostly gets up on first shift. CNA H reported when she comes in for second shift and she was up in her chair, we lay her down. CNA H reported she had a time limit of how long she can be in her chair now. In an interview of 03/22/23 at 11:12 AM, Unit Manager (UM) R reported the skin audit were completed weekly, nurse would notify the UM if there was a new wound. UM would observed the wound and if it was an actual wound the resident would be referred to the wound provider who comes to the facility every Tuesday. UM R reported that was when the measurements were taken of the wound as well as photographs of the wound. In an interview on 03/22/23 at 11:15 AM, UM Z reported the skin audits were completed this morning. In an interview on 03/22/23 at 1:00 PM, Nursing Home Administrator (NHA) A reported, Wound Tracking - the facility has been working on (before we lost our wound nurse) the whole wound process. How the Braden translates to actual care. The facility has kind of done an algorithm. We had also worked on wound types and so forth. The unit managers keep a line listing of skin issues. It helps them track what all needs to happen with them. NHA A reported we do at least weekly skin observations. Based on the Braden, the nursing staff may do more frequent observations, as well as, the shower aides work with the nurse on those. NHA A reported the facility had an alert in (electronic medical record) - as a communication tool. The facility had a wound care team, and (Outside wound provider) that comes in weekly, and if there was a new wound that the outside provider needed to see, it was communicated either by verbalization or notes. Review of policy, Pressure Injury Risk Assessment dated 11/2022, revealed, .Procedure: 1.Pressure injury risk assessments will be conducted by a licensed or registered nurse on admission/re-admission, weekly times four weeks, then quarterly, and as needed. Assessments may also be conducted after a change of condition or after any newly identified pressure injury .2.Standardized pressure injury risk assessments will be conducted, using a validated risk assessment tool or scale. Braden Scale has been designated as the standardized tool .a. Each item will be scored individually (i.e. moisture, mobility, nutrition) .b. Individual scores will be added to obtain an overall score .c. Consider at risk according to the parameters set by the validated tool .3. Each item on the standardized risk assessment will be considered, individually, to ensure risk factors are addressed appropriately, regardless of the total risk score .4. The tool will be used in conjunction with assessment of other risk factors not captured by the risk assessment tool. (i.e. presence of a pressure injury, prior stage 3 or 4 pressure injury, hypoperfusion states, peripheral vascular disease, diabetes, smoking, restraint use, spinal cord injury, end-of-life/palliative care) .5. Residents determined as at risk for developing pressure injuries will have interventions documented in plan of care based on specific factors identified in the risk assessment .7. Training on the completion of the pressure injury risk assessment will be provided to licensed staff as needed . During an observation on 03/22/23 at 08:54 A.M., CNA KK was observed exiting Resident #56's room with a breakfast tray. Resident #56 was observed lying in bed with the HOB (head of bed) at approximately 90 degrees, slouched down and leaning to the left, and her head was off of the pillow. During an observation on 03/22/23 at 09:39 A.M., Resident #56 was lying in bed in the same position as the previous observation. In an interview on 03/22/23 at 09:43 A.M., CNA KK reported that Resident #56 had been checked and changed recently, and that CNA KK would be laying her down soon. During an observation on 03/22/23 at 10:10 A.M. Resident #56 was lying in bed in the same position as previous observations and CNA KK was in the room preparing to reposition Resident #56. CNA KK removed Resident #56's incontinence brief and turned Resident #56 onto her left side, this revealed pink discolored skin with deep creases from the brief and mattress, covering the entire surface of Resident #56's buttocks. There was a large bandage covering Resident #56's sacral area, and it was partially detached and soiled around the bottom edge of the bandage. CNA KK reported that she would let the nurse know that the bandage needed to be replaced. Resident #56's right hip was observed with darker red skin, and a small open wound, that was not covered with a bandage. At 10:16 A.M. Registered Nurse (RN) J entered the room and removed the soiled bandage that covered Resident #56's sacral area, which revealed a deep open wound, with a small amount of slough (dead tissue) noted in the wound bed. When the wound care was finished, CNA KK positioned Resident #56 onto her left side. R31 According to the Minimum Data Set (MDS dated [DATE], R31 scored 7/15 (moderately cognitively impaired) on his BIMS (Brief Interview Mental Status), received a formal assessment for pressure ulcer risk which determined he was at risk, with diagnoses that included stroke, and hemiplegia (partial paralysis). Review of R31's Order Summary revealed, 2/16/2023- Skin Observation Tool every day shift every Thursday. Alert Wound Nurse/Unit Manager of any new skin concerns. 3/15/2023 Skin protectant to left heel every shift for skin prevention every shift for skin prevention. Cleanse R (right) heel with wound cleanser, pat dry. Apply xerofoam dressing and bordered gauze. Change dressing daily until healed one time a day for skin treatment. Review of R31's Care Plan at Risk for Skin Breakdown 2/16/2023 reported this focus due to the resident's Braden assessment r/t (related to) cognitive loss, communication deficits, general weakness, poor awareness of needs, and acute/chronic illnesses including diabetes and stroke. The goal was to maintain intact skin. To meet this goal, interventions included monitoring and reporting signs of skin breakdown to the resident's nurse. Review of R31's [NAME] (resident care guide for CNA pulled from care plan) reported Skin Prevention to monitor and report signs of skin breakdown to nurse. During an interview and observation on 3/21/23 at 1:19 PM Registered Nurse (RN) X and Licensed Practical Nurse (LPN) BB prepared supplies to perform a wound dressing change on R31's right heel. When RN X asked resident if he was in pain, R31 stated, They (feet) burn everyday like on fire, I don't see any difference with new medication they are giving me. RN stated, You are on Gabapentin. RN stated, I told the Social Worker (SW) that (R31) may need new shoes. It looks to me like the back of his shoes are rubbing his heel and causing the wound. The orders are to change the dressing QD (every day) in the morning and PRN (as needed). RN X removed the dressing, stating, It is coming off so it needed changing anyway. Observed with the RN a small amount of serosanguineous (blood and clear yellow liquid) drainage on the bandage. The wound was round approximately 2.5 cm (centimeters) in width and length with a small open area in the middle. The RN dated the dressing 3/21/23 placed a towel as a barrier underneath his feet, donned clean gloves, cleaned the wound, applied the petroleum-based pad and covered it with the large bandage. During an interview on 3/21/23 at 1:32 PM SW Y stated, (R31), I did not know (R31) had a wound on his right heel. (RN X) did not talk to me about his shoes possibly rubbing on his heel to cause the wound. Observed on 3/22/2023 at 10:05 AM R31 sitting in room in a wheelchair watching television wearing gripper socks to both feet. During an interview and record review on 3/22/2023 at 10:15 AM Unit Managers (UM) R and W, and Director of Nursing (DON) B reviewed R31's medical records. UM R stated, (R31) has in his care plan under skin integrity, he is to wear blue protective boots while in bed. DON B stated, The nurses are doing wound care right now because the facility wound nurse left (employment) about two weeks ago. She managed all the wounds. Now, the nurses are to measure wounds weekly. Reviewed R31's medical record with UM R and W which did not reveal any measurements for the wound on the right heel. UM W stated, I audit weekly to see if the nurses have done the weekly skin/wound assessments. UM R stated, (R31) was reported as having a dry skin crack on his right heel on March 13 (2023). It was about 0.1 cm. It has not been reported as open. Review of R31's Skin Observation Tool dated 3/8/2023 reported Yes to new skin issues as redness to right heel Review of R31's Progress Note 3/10/2023 at 2:22 (2:22 AM) revealed, Health Status Note . Skin prep to right heel . Review of R31's Progress Note 3/15/2023 02:40 (AM) revealed, Health Status Note . Opti foam in place to right heel . Review of R31's Progress Note 3/15/2023 14:05 (2:05 PM) revealed, Health Status Note .R (right) heel skin treatment dc' d (discontinued) with new orders to apply xerofoam and cover with bordered gauze dressing. Skin protectant to L (left) heel for skin prevention. Staff will continue to monitor .