**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake# 2561427.Based on observation, interview, and record review, the facility failed to provide adequate supervision in 2 of 4 residents (Resident #4 and Resident #5), reviewed for accidents and hazards, resulting in R5 sustaining a 2nd-3rd degree burn when hot liquid hazards were left unattended.Findings include: Per the Bureau of Health Systems Burn Hazards Related to Heated Surfaces in Long Term Care Facilities ALERT dated 5/12/1999, Sustained skin contact with surfaces of equipment that have temperatures in excess of 107 degrees Fahrenheit can cause burns. Caution is required when exposing patients to warmed surfaces, particularly when they are helpless .Where the (heating) system is operating as designed .staff training and resident care policies to reduce the chance of exposure may also be appropriate .Resident #4Review of an admission Record revealed R4 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Alzheimer's disease.Review of a MDS assessment for R4, with a reference date of 7/28/25 revealed a BIMS score of 04/15 which indicated R4 was cognitively impaired.Further review of R4's MDS section GG-Functional Abilities revealed R4 was coded 04-Supervision.for: Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident.Supervision or touching assistance - Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.In an observation of the main dining room on 9/16/25 at 12:10 PM, R4 self-propelled her wheelchair to an open 3-tiered cart loaded with 3 discarded resident lunch trays with various amounts of uneaten food on each tray. R4 took a large piece of chicken breast off this cart and began eating it as she moved through the dining room. R4 dropped approximately half of the chicken onto the floor after taking a few big bites. R4 then proceeded back to the 3-tiered cart helping herself to vegetables off another meal tray without any staff noticing. R4 then went over to the 3-tiered cart again and began to eat food from each of the meal trays left on the cart. At 12:17 PM, R4 went back over to the 3-tiered cart and started eating mashed potatoes using her fingers. During this time, only one staff member was present in the dining room and took no action. No staff noticed R4 self-propelling through the dining room making multiple trips to the 3-tiered cart and eating food which had been rejected by other residents.In an observation on 9/16/25 at 12:32 PM., CNA O noticed R4 at the meal cart and redirected her and asked if R4 wanted more food and if she (R4) was still hungry. R4 responded that she was still hungry. CNA O proceeded to go assist another resident and get R4 a cup of coffee.In an interview on 9/16/25 at 12:40 PM., CNA O reported R4 should have a mechanical soft diet, with no large, or dry pieces of meat because she has difficulty swallowing. CNA O reported there are not enough staff to keep eyes on all the residents, to keep them safe and properly groomed. CNA O reported she let the kitchen know that R4 was still hungry and they were going to make something for her.In an observation on 9/16/25 at 12:50 PM., the Maintenance Director/CNA G delivered a sandwich to R4 and walked away R4 began eating the sandwich, this surveyor noted sizable chunks of chicken breast falling from the sandwich, which was made of white bread, chicken chunks and very little substance that appeared to be mayonnaise. R4 appeared to be struggling to keep the sandwich together, much of it fell into pieces on the floor and then R4 proceeded to stuff the sandwich underneath a blanket while self-propelling out of the dining room. No staff were present in the dining room at this time.In an observation in the hallway on 9/16/25 at 1:00 PM., CNA J noticed R4 with the sandwich falling from her blanket, and hands. CNA J intervened and redirected R4 by asking R4 if she wanted to go to her room. R4 was agreeable and taken to her room. CNA J was noted coming back from R4's room with a handful of what was left of the chicken sandwich and then knocking on the kitchen door. CNA J was greeted by kitchen staff, and then CNA J reminded kitchen staff of R4's diet restrictions.In an interview on 9/16/25 at 1:05 PM., CNA J reported there are not enough staff in the facility to keep residents safe. CNA J reported she had just filed a grievance form for R4 regarding staff/dietary staff not following R4's diet order. CNA J reported R4 was on a mechanical soft diet, and could not meats, and anything dry or she would choke. CNA J reported R4 has difficulty swallowing. CNA J stated we are running around so much that things are getting missed, overlooked and we cannot keep going at this pace or something really bad is going happen, she could have choked to death. CNA J reported the grievance/concern form she filed was because R4's chicken patty was not prepared per her dietary restrictions, so the kitchen took the sandwich with the chicken patty back, then turned around cut up the patty into large chunks and gave it back to her (R4).Review of a facility Concern/Grievance form dated 9/9/25 revealed: Description of Grievance/Concern-Kitchen staff gave a resident (R4) a full chicken patty when she's mechanical soft and upon asking for a new sandwich for (R4) they cut up previous sandwich and gave it back .During an interview on 9/16/25 at 1:20 PM., CNA M reported there are a lot of staffing challenges for the nursing departments as well as all shifts. CNA M reported she has had to care for Residents that are 2 person assists by herself because there was no one available to assist because everyone is so busy, and the shift are always running short handed. CNA M reported it is difficult to care for the residents in the facility and not cut some corners because there is not enough time and staff. CNA M stated it breaks my heart; I feel the resident's deserve better care than we can provide.Review of R4s Care Plan dated 6/24/24 revealed: Resident Diet .IDDSI Level 6 -soft bite sized/Mechanical soft texture . (IDDSI- International Dysphagia Diet Standardization Initiative).Resident #5Review of an admission Record revealed R5 was originally admitted to the facility on [DATE], with pertinent diagnoses which included: Dementia. Review of a MDS previously defined just need MDS assessment for R5, with a reference date of 6/30/25 revealed a BIMS score of 00/15 which indicated R5 was severely cognitively impaired.Further review of R5's MDS section GG-Functional Abilities revealed R5 was coded as a #2. Eating- A. The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident.02-Substanital/maximal assistance- 02. - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.In an observation on 9/12/25 at 12:30 PM., R5 was seated in the dining room with no staff assistance. R5's lunch plate was 90% full, and she was asleep. Only one staff member was present assisting another resident.During an interview on 9/12/25 at 1:45 PM., Assistant Director of Nursing (ADON) A reported R5 sustained a burn to her stomach and to her upper thighs earlier in the day. ADON A reported she was waiting for a physician order to treat the burn, currently she had a standing order to put burn cream on the burn and cover it with a gauze. ADON A reported R5 spilled her coffee during breakfast.Review of R5's Progress Notes read in part: 9/12/25 at 8:52 AM., Note Text: Went to dining room to check for residents and observed this resident who indicated she was all wet. Brought resident to floor so she could be changed when CNA stated, Oh, she may have spilt her coffee. On inspection, residents spilled coffee and had some reddened areas to right abdomen and top of legs. top of left leg with some peeling skin and resident indicated painful. reddened areas to right breast, upper right abdomen, tops of both legs with left one peeling. resident dressed into loose clothes and cool compress applied.Review of R5's Skin Evaluation photos dated 9/12/25 in the facility Electronic Medical Record (EMR) revealed: photos of R5's upper thigh area/groin to have a substantial area of reddened with multiple large (quarter sized) blisters. This surveyor did not note any measurements at this time in the EMR.Review of R5's Care Plan read in part: I have a nutritional problem or potential nutritional problem. Date Initiated: 03/28/2025.I like coffee with all meals, like it black, ensure it is in a 2 handled cup with lid. Date Initiated: 03/28/2025.Review of R5's progress notes read in part: 9/12/2025 09:39 IDT (interdisciplinary team) Note Text: IDT reviewed resident's coffee burn incident. handled spout cup with lid for coffee has been implemented. Staff education provided. OT .Review of R5's progress notes read in part: 9/12/2025 12:10 Secure Conversations Messages: Subject: interventions for burns 9/12/2025 09:38 AM ADON -may we have an order for 2 handled spout cup with lid for coffee?In a phone interview on 9/16/25 at 5:10 PM., CNA J reported last week R5 was burned by hot coffee because she (CNA J) was running around trying to get everyone set up for breakfast and the facility was short staffed. CNA J reported R5 was seated at the dining room table, and she (CNA J) went to get coffee for her, the kitchen handed her a cup of coffee, and she knew it was too hot, so she went to get ice cubes and a lid because R5 was supposed to have a lid on her coffee. CNA J reported she added the ice cubes; while walking back to get a lid for the coffee she was distracted by another resident needing something and she (CNA J) just dropped off the cup of coffee to R5 without putting a lid on it. CNA J reported another staff noticed she (R5) was wet, and she shouldn't have been because she was just changed before breakfast. CNA J realized the cup of coffee was spilled and R5 was taken back to her room, and it was noticed initially there was red on her breast, and right stomach which then went all the way down to her upper legs which had some immediate blistering on her left thigh. CNA J stated I take full responsibility for that mistake, I have no problem admitting I made a mistake. I made the mistake because we don't have enough staff to manage that many residents on our daily assignments, and remember everything, it is impossible to do that under the conditions we are working. I am so sorry.I feel absolute horrible .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide treatment and services to prevent new pressure ulcers from developing for two Residents (#22 and #29) of three residents reviewed for pressure ulcer care. This deficient practice resulted in multiple newly facility acquired pressure injuries which subsequently required debridement, use of antibiotics and the use of a wound vac. Findings include: Resident #22 (R22) On 12/18/23 at 8:45 AM, an interview was conducted with R22 who was observed lying in her bed wearing a hospital gown and covered with a white bed sheet. R22 was observed with a wound vac on the left side of her bed on the floor which was connected to her lower abdominal area. R22 was asked how long she had the wound vac and if she came into the facility with it on her original admission and replied, No. I did not have this wound on my abdomen or the wound vac on admission and I have had it for a little over a month. I just hate this thing. I don't get up out of bed and in my chair because I must drag this thing around with me everywhere I go. Review of R22's admission record, date printed 12/17/23, revealed an original admission to the facility on 5/16/23, with diagnoses of diabetes mellitus, anemia, need for assistance with personal care, and absence of the right leg below the knee (amputation). The admission Minimum Data Set (MDS) assessment, dated 5/22/23, revealed her to be at risk for developing pressure ulcers and not having any existing pressure ulcers upon her original admission. A review of the quarterly MDS assessment, dated 11/22/23, revealed her to be at risk for developing pressure ulcers, to have one existing facility acquired stage three pressure ulcer, and to be cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. On 12/19/23 at 11:00 AM, an observation was made of R22 lying in her bed in her room. R22 was noted to have her wound vac at the left side of her bed. R22 was asked if she had any other wound and if she was able to turn and reposition by herself and replied, Yes. I will show you. I used to have a wound on my left back side, but I think it is healed now. R22 was observed to roll by herself on to her right side and was observed to have a dressing on her left upper hip/buttock area with a date on the dressing 12/12/23 with initials AS. R22 was asked when the dressing was to be changed and replied, Oh. I forgot all about that one. It is healed, but I like the dressing there for protection and it is changed every three days. On 12/29/23 at 11:20 AM, Registered Nurse (RN) N was asked to observe R22 in her room and the dressing. RN N stated she was not aware of a dressing in that area, and she was only aware of the wound vac. RN N was asked if the dressing should be changed and replied, I would have to look at the orders. Review of R22's skin wound evaluation, dated 9/20/23, revealed R22 was observed to have a stage one pressure ulcer develop on her left lateral thigh measuring 5.5 cm (centimeters) x 4.0 cm, and it developed in the facility. Review of R22's skin wound evaluations for wound of the left lateral thigh between 9/20/23 through 12/19/23, revealed missing evaluations on 11/1/23, 11/8/23, 11/15/23, 11/22/23, 11/29/23, and 12/6/23. Review of R22's treatment administration record (TAR), dated December 2023, revealed the lack of an order for current dressing observed to be dated for 12/12/23. Review of R22's skin and wound evaluation, dated 10/4/23, revealed a new stage two pressure ulcer of the left lower quadrant abdominal area and measured 6.2 cm x 2.1 cm and no depth recorded. Review of physician faxed communication, dated 10/4/23, read in part, .open area on underside (of abdominal area). Measuring 5 cm x 3 cm - area was cleansed with (name brand) wound cleaner - 3 x 3 opti-foam applied - please advise on tx (treatment) if you wish something else .(physician response) Continue care as above. Notify if, worsening - increased in size, tenderness or redness . Review of R22's care plan, dated 10/4/23, read in part, Focus: I have a stage 3 (pressure ulcer) to my left abdominal area .Goal: Interventions will be put in place to prevent decline in wound and maintain my comfort. Interventions/Tasks: Administer treatments as ordered and monitor for effectiveness. Assess me and attempt to determine underlying causes of wound .Assess/record/monitor wound healing per facility policy. Measure length, width, and depth .Assess and document status of wound perimeter, wound bed and healing progress .Wound vac per wound clinic to abdominal wound, change per wound clinic orders, monitor per facility protocol (11/6/23) . *Note: R22's care plan lacked any focus, goal, or intervention/tasks related to her being at risk for developing pressure ulcers as indicated on her MDS admission and quarterly assessments. Review of R22's progress note, dated 10/29/23, read in part, .No skin issues noted at this time, see wound nurse documentation for on going. Review of R22's treatment administration record (TAR), dated October 2023, revealed orders for: Open area underside of abdominal skirt: Cleanse area with (name brand) wound cleaner, apply opti-foam. Change every other day and prn (as needed). If soiled, until healed .In the morning on even days, start 10/6/23. Review of TAR for treatment sign out dressing changes for the above order revealed, treatments left blank and or not completed on days of 10/10/23, 10/18/23, 10/30/23. and 11/2/23. Review of R22's TAR, dated November 2023, revealed orders for: Perform wound care procedure to wound vac of left lower abdomen three times weekly as follows: remove drape and all foam from wound bed, cleanse wound bed and peri wound with normal saline and gauze. Cleanse skin around wound with chloraprep (if available) and apply skin prep, then cover skin around wound with drape. Reapply wound vac dressing set wound vac to 125 mm Hg. One time a day every Mon, Wed, Fri for Wound Care, start date 11/6/23. Review of TAR for treatment sign out dressing changes for the above order revealed, treatments 11/8/23, 11/10/23, 11/13/23, and 11/15/23 marked with a 9 indicating to other/see nurse note, and on 11/22/23, 11/24/23, and 12/4/23 left blank and or not completed. Review of R22's skin wound evaluations for wound of the left lower quadrant abdominal area between 10/4/23 through 12/19/23, revealed missing evaluations on 11/1/23, 11/8/23, 11/15/23, 11/22/23, 11/29/23, and 12/6/23. Incomplete evaluation on 11/27/23, revealed wound of the left lower quadrant abdominal area, stage three pressure ulcer, and measured 15.3 cm x 5.3 cm and n/a (not applicable) for depth. Review of R22's progress note, dated 10/31/23, read in part, .This RN spoke with scheduling services from (local hospital) regarding Resident's procedure tomorrow morning scheduled for 0830 arrival time . Review of R22's progress note, date 11/1/23, read in part, .left lower abdominal wound debridement were performed. Roll gauze wet to dry dressing placed and covered with ABD (abdominal) pad and tape. This RN instructed to replace dressing with wound vac tomorrow 11/2/2023. Resident stable and had left the hospital in route returning to facility. Review of R22's wound clinic note, dated 11/9/23, read in part, .(name) nurse to change the wound vac dressing on M-W-F until patient follow up appointment on 11/22/23 at 11:30am (11:30 a.m.) with (wound care physician name) in the wound clinic . Review of R22's progress note, date 11/9/23, read in part, .Resident upset with wound vac .resident in tears stating I never wanted this I can't do anything, can't move, can't get up on the commode . Review of R22's progress note, date 11/15/23, read in part, .Wound vac not changed due to functioning properly . Review of R22's wound clinic plan of care note, dated 11/29/23, read in part, .Patient missed her last wound clinic appointment and has been in ER (emergency room) last week for the wound, she does not have the wound vac on upon arrival today and hasn't had it on since the ER visit last week .Old dressing removed from left lower abdominal wound with foul odor, large amount of foul, purulent drainage, patient states she hasn't been feeling well, has a low grade fever, pulse elevated and blood pressure lower than her normal. The wound bed is approximately 50% slough and necrotic tissue, the rest of the wound bed is pale pink, not healthy. (Wound care physician's name) is in to see and examine the patient, photos and measurements taken, a decision is made to have patient admitted for wound infection and possible sepsis .Progress/Lack of Progress: Lack of progress, there is a foul odor and foul, purulent drainage, patient is feeling ill, low grade fever upon arrival that did elevate later in the visit to 101.3 degrees Fahrenheit, patient complained of feeling cold, she is covered with blankets . Review of R22's weekly skin assessments between 11/1/23 through 12/11/23, revealed a lack of any weekly skin assessment during this time period. Review of R22's census, dated 5/16/23 through 12/4/23, revealed a hospitalization on 11/29/23 (stop billing) through 12/4/23 (activate billing) related to a wound infection. (Progress notes were reviewed during this time period and lacked any notes of R22 being transferred out or reason why R22 was transferred to the local hospital.) Review of R22's wound clinic plan of care, dated 12/13/23, read in part, .Progress/Lack of Progress: Lack of progress is seen today with pale wound bed and not much for granulation . Review of R22's wound care clinic progress note, dated 12/13/23, read in part, .Follow-up for incision and debridement of lower abdominal wound is area of Pannus. Patient had an abdominal wound measuring 9 x 6 x 5 cm with overlying eschar in need of debridement. Patient was last seen 11/29/23 .The patient had an abdominal wound measuring 4 x 2 cm in size with associated foul-smelling odor. There was a surrounding area of induration and erythema. Necrotic infected tissue was removed revealing a total wound size of 9 x 6 x 5 cm in size .Since I saw the patient last, she was brought back to the operating room for an additional incision and debridement due to significantly infected wound. Additional necrotic tissue was removed in the operating room, the patient's wound was cleaned and a wound vac was reapplied as an inpatient. She has subsequently been discharged back to the nursing home and has been following up with the wound care nursing every Monday-Wednesday-Friday .Today in the Wound Clinic, the patient's wound measures 5.1 x 15.4 x 2.8 cm .Patients 2nd incision and debridement . Review of physician nursing home progress note, dated 12/13/23, read in part, .Was in the hospital for further surgical treatment of abdominal wound. Initially hospitalized for this on November 1st (2023) and then hospitalized again due to further advancement of wound 11/29 through 12/4 . Review of R22's progress note, date 12/13/23, read in part, .during hospital stay to address infected wound . Review of R22's wound clinic plan of care, dated 12/13/23, read in part, .Spoke with (facility name) to see if the machine can be increased to 150 mm Hg (millimeters of mercury). Staff to check on this .Progress/Lack of Progress: Lack of progress is seen today with pale wound bed and not much for granulation - will see if we can increase suction . Resident #29 (R29) On 12/17/23 at 11:15 AM, an observation was made of R29 sitting up in his geri-chair in the B-Hall area near the nurses station. R29 was unable to be interviewed at the time due to his cognition. Review of R29's admission record, date printed 12/17/23, revealed an original admission to the facility on 8/24/21, with medical diagnoses of diabetes mellitus, anemia, dependence of devices, and dementia. A review of the annual MDS, dated [DATE], revealed him to be at risk for developing pressure ulcers and not having any existing pressure ulcers. MDS quarterly review, dated 11/7/23, revealed him to be at risk for developing pressure ulcers, to have one existing facility acquired stage two pressure ulcer, and to be cognitively impaired, unable to complete BIMS, and rarely or never understood. On 12/18/23 at 10:20 AM, an observation was made of R29 sitting up in his geri-chair near the B-Hall nurses' station. Several staff were noted to walk by and not acknowledge his presence. R29 appeared to be sleeping and his eyes were closed. On 12/18/23 at 2:42 PM, an observation was made of R29 sitting up in his geri-chair near the B-Hall nurses' station. R29 appeared to be resting with his eyes were closed. On 12/18/23 at 3:00 PM, a request was made of Licensed Practical Nurse (LPN) N to observe wound care on R29. LPN N stated that wound care was completed on night shift and was unsure if she would have time to accommodate this Surveyor. *Wound care was not observed at this time per request. On 12/19/23 at 11:13 AM, an observation was made of R29 sitting up in his geri-chair near the B-Hall nurses' station. On 12/19/23 at 1:25 PM, an observation was made of R29 sitting up in his geri-chair near the B-Hall nurses' station. On 12/19/23 at 1:31 PM, an observation was made of Certified Nurse Aide (CNA) I and CNA H removed R29 from B-Hall to his room and transferred him via Hoyer lift into his bed. CNA H was asked how often R29 was turned and repositioned and replied, We try and turn and reposition him every one to two hours. CNA H was asked how long R29 was to be up in his geri-chair during the day and replied, He is care planned to be up for meals and then returns to his bed after meals around 30 minutes to an hour and then we get him back up for the next meal. On 12/19/23 at 1:33 PM, a request was made of RN S to observe wound care for R29. RN S stated that night shift routinely completes this but would ensure an observation opportunity was provided for this Surveyor. RN S was asked which staff was responsible for skin and wound evaluations and measurements and replied, The wound care nurse but I feel like maybe I should be measuring and have not measured any wounds. On 12/19/23 at 1:40 PM, an observation was made of R29's wound care, which was performed by RN S. R29's dressing was removed, the wound was cleaned, and the wound was observed. R29's coccyx area was without any eschar or slough and had nice pink tissue on the wound bed. R29's wound was about the size of a large chicken egg (6 to 6.5 x 4 to 4.5 cm) and had a depth of what appeared to be 2 - 2.5 cm depth. R29's wound was through the epidermis and dermis layers of skin. RN S was asked how he felt the wound looked and what stage he would classify the wound at and replied, It looks better than it did. It no longer has eschar or slough. I would stage it as a stage three pressure ulcer. Review of R29's care plan, dated 10/17/23, read in part, Focus: I am at for skin alterations r/t (related to) decreased mobility, requiring increased staff assist, and some mixed incontinence of B/B (bowel and bladder) .I have an .pressure injury to coccyx area and pressure injuries to left heel and right lateral malleolus r/t limited mobility, incontinence .Coccyx wound infection .Goal: I will have no complication through review date. Coccyx wound infection will resolve by next review date. Interventions/Tasks: Administer antibiotics for coccyx wound infection per physician order (12/11/23) .Administer treatments as ordered and monitor for effectiveness (10/17/23). Assess/record/monitor wound healing. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress .Bilateral heel protectors (11/8/23) .I need to turn/reposition at least every 2 hours, more often as needed (10/17/23) .I will have a skin assessment by nurse weekly and prn (as needed) (12/15/23) .Wound care consult order received (11/21/23). Review of R29's weekly skin assessments, dated 7/1/23 through 12/17/23, revealed missing weekly skin assessments on 7/3/23, 7/10/23, 7/31/23, 8/7/23, 8/14/23, 8/21/23, 8/28/23, 9/4/23, 9/11/23, 9/18/23, 10/2/23, 10/9/23, 10/23/23, 10/30/23, 11/6/23, 11/13/23, 11/20/23, 11/27/23, 12/4/23, and 12/11/23. Review of physician fax communication, dated 10/14/23, read in part, Resident has an open area on bottom of scrotum. The area is about 0.6 inches in diameter, has a scab, is red and looks irritated. Another open area on bottom of left glute does not have a defined border, looks purple and red in color, area is about 1 inch in diameter, area is irritated as well. Powder was put on areas, no opti-foam though. What would you like to do? Please advise. (Physician response) Please have the wound nurse see him and advise appropriate dressing. In the meantime, he needs to be rotated every ½ hour to avoid the gluteal pressure sore being worse. *Note: Care plan was not updated to reflect new turning and repositioning physician recommendations. Review of R29's skin and wound evaluation, date 10/16/23, revealed the development of a facility acquired pressure ulcer stage II on his coccyx, measured 2.4 x 2.0 cm and no depth recorded, no drainage, edges attached, and goal of care: healable. Review of physician fax communication, dated 10/23/23, read in part, Resident wound to coccyx is now black with eschar. Could we get an order to try aquacell AG covered with opti-foam. Change daily and prn? (Physician response) Yes. As above. Review of R29's skin and wound evaluation, date 11/7/23, revealed the developed facility acquired pressure ulcer stage II on his coccyx was now unstageable per facility documentation, measured 4.2 x 2.9 cm and no depth recorded, light exudate with serous drainage, slough (no percentage recorded), and eschar (no percentage recorded). Review of R29's skin and wound evaluation, date 11/21/23, revealed the developed facility acquired pressure ulcer stage II on his coccyx now unstageable per facility documentation, measured 3.7 x 2.4 cm and 1.0 cm depth recorded, moderate exudate with sanguineous drainage, slough (no percentage recorded), and eschar (no percentage recorded). Review of R29's skin and wound evaluation, date 11/27/23, revealed the developed facility acquired pressure ulcer stage II on his coccyx now unstageable per facility documentation, measured 7.0 x 4.6 cm and no depth recorded, moderate exudate with sanguineous drainage, slough (no percentage recorded), and eschar (no percentage recorded). *In review of the photo of the wound there is clearly a depth to the wound that was not measured and worsened from the prior depth measurement. Review of R29's physician orders, dated October 2023, revealed, Opti-foam to coccyx. Change every other day and prn. Every day shift every other day for wound care. Start date 10/18/23. *Note: no as needed sign out and R29 known to be incontinent of bowel and bladder. Review of R29's physician orders, dated November 2023, revealed, To coccyx daily and prn: Clean area, apply aquacell AG, cover with opti-foam. One time a day for wound care. Start date 10/24/23. Review of the TAR for November 2023, revealed missing dressing changes on 11/22, 11/27/23 and 11/29/23. *Note: no new or changed wound care orders after this order. No as needed dressing changes signed out in addition to regular dressing changes. Review of R29's census, date printed 12/19/23, revealed a stop billing on 11/20/23 and activate billing on 11/22/23 and then another stop billing on 12/13/23 and activate billing on 12/15/23. In review of the TAR for November 2023, dressing changes were being marked as completed on 11/21/23 and for December 2023, revealed dressing changes were being marked as completed on 12/14/23 when R29 was absent from the facility. Review of physician fax communication, dated 12/3/23, read in part, Resident coccyx ulcer smells odorous .(Physician response) 1.) If possible please culture the wound. 2.) Start Augmentin 400mg/5ml - 2 tsp. po, BID x 10 days (10 ml [800 mg] by mouth, twice daily for ten days). Review of R29's skin and wound evaluation, date 11/7/23, revealed the development of a second facility acquired pressure ulcer stage II on his right lateral malleolus, measured 1.1 x 0.8 cm and no depth recorded, no drainage, edges attached, and goal of care: healable. No further skin and wound evaluations were recorded for the coccyx wound after the date of 11/27/23 and no further skin and wound evaluations for the right lateral malleolus after 11/29/23. No wound measurements for the month of December 2023 were recorded in EMR at the time of the survey date exit on 12/19/23. On 12/19/23 at 8:30 AM, an interview was conducted with the Nursing Home Administrator (NHA). The NHA was asked what her expectations were for wound care documentation, dressing changes, and skin assessments and replied, I would expect all dressing changes to be completed and signed out in the treatment record, skin wound measurements and skin assessments are completed weekly and recorded, and any missing documentation should have a nurses note for the reason why it was incomplete. The NHA was asked how long wound care treatment changes are made and referred this Surveyor to the wound care nurse who was not in today but would be in tomorrow. On 12/19/23 at 9:45 AM, the Survey team was made aware that the Director of Nursing wound is not available today and wound not be in the facility and if we needed anything to reach out to the NHA. On 12/19/23 at 11:10 AM, an interview was conducted with CNA E regarding showers and skin assessments. CNA E is the supervisor for all facility CNA's. CNA E CNA E was asked when skin assessments are scheduled for and replied, They are done on shower days each week by the nurses. CNA E further stated that the assessments had been discontinued in March 2023 and a new one was implemented but could not describe the process. CNA E replied, The CNA's takes the resident to the shower room and then calls the nurse to observe the skin and then documents the findings. On 12/19/23 at 11:40 AM, an interview was conducted with Wound Care Nurse / RN T who was asked how often wounds get measured and how often skin assessments are to be completed and by whom and replied, Residents with wounds get weekly measurements and skin sweep assessments are completed weekly with showers by nurses. RN T was asked if there was any reason a Resident would miss wound measurements, dressing changes, or skin assessments and replied, Well, I guess only if they refuse or are absent from the facility. Lately, it has been hit or miss. RN T was asked why wound measurements and skin assessments were not performed weekly for R22 and R29 and replied, A few weeks ago I had to work the floor so they did not get done. RN T was asked if she was a full-time employee or a part-time employee and replied, I work part-time. RN T was asked how long R22 has had the wound on her abdominal area and replied, She acquired it at the facility. RN T was asked how long R22 has had her wound vac and when the last time she observed R22's wound and replied, It has been awhile since I observed her wound. She has the dressing changed every Monday, Wednesday, and Friday. RN T was asked if she was the nurse who applied the dressing to R22's left lateral thigh area and replied, I am not sure I did work last week. I guess it could have been me. RN T was asked about the initials on the dressing and if the dressing for wound cares should have physician orders and replied, Yes, all dressings should have physician orders. RN T was asked if she could provide orders for R22's dressing change to that area and replied, I would have to check. RN T returned and stated that R22 did not have orders for the dressing. RN T was asked how long the dressing should be left on and when it should be changed and replied, I think is was to be changed every three days. RN T was reminded that the original date on the dressing was 12/12/23 and should have been replaced but lacked an order to be changed. RN T stated that last week another facility nurse took over wound care. RN T was asked if she was trained by her and if this nurse knew how to take pictures of the wounds and fill out the appropriate assessments and replied, She knows how to take pictures. I do not know if she has done any evaluations yet. She knows where the evaluations are in the computer charting system. I did not train her yet. Review of facility policy titled, Wound Treatment Management, dated 10/27/22, read in part, Policy: To promote wound healing of various types of wounds, it is the policy of this facility to provide evidence-based treatments in accordance with current standards of practice and physician orders. Policy Explanation and Compliance Guidelines: 1. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing change. 2. In the absence of treatment orders, the licensed nurse will notify physician to obtain treatment orders. This may be the treatment nurse, or the assigned licensed nurse in the absence of the treatment nurse. 3. Dressing changes may be provided outside the frequency parameters in certain situations: a. Feces has seeped underneath the dressing. b. The dressing has dislodged. c. The dressing is soiled otherwise or is wet . 8. The effectiveness of treatments will be monitored through ongoing assessment of the wound. Considerations for needed modifications include: a. Lack of progression towards healing. b. Changes in the characteristics of the wound (see above) . Review of facility policy titled, Skin Assessment, dated 10/7/2022, read in part, Policy: It is our policy to perform a full body skin assessment as part of our systematic approach to pressure injury prevention and management. This policy includes the following procedural guidelines in performing the full body skin assessment. Policy Explanation and Compliance Guidelines: 1. A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter. The assessment may also be performed after a change of condition or after any newly identified pressure injury .7. Documentation of skin assessment: a. Include date and time of the assessment, your name, and position title. b. Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.). c. Document type of wound. d. Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain). e. Document if resident refused assessment and why. F. Document other information as indicated or appropriate. Review of facility policy titled, Skin Audits by Nursing Assistance, dated 10/27/22, read in part, Policy: It is our policy to communicate changes in skin condition to appropriate personnel as part of our systematic approach for pressure injury prevention and management. This policy establishes responsibilities of nursing assistants in communicating changes in skin condition. Policy Explanation and Compliance Guidelines: 1. Nursing assistants shall inspect all skin surfaces during bath/shower and report any concerns to the resident's nurse immediately after the task. 2. Nursing assistants shall also report changes in skin condition that are noted during any care procedure .