**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #38 (R38) A review of R38's medical records revealed admission to the facility on [DATE] with diagnoses including non-displaced intertrochanteric fracture of right femur (fracture of long bone leg between the greater and lesser trochanter), dementia, hypertension, congestive heart failure, osteoarthritis, sarcopenia (age related progressive loss of muscle mass and strength), difficulty in walking, transient ischemic attack, and cerebral infarction without residual deficits. R38's Brief Interview for Mental Status (BIMS) from 4/11/24 indicated a score of 0/15, indicating R38 had severe cognitive impairment. A physician's order dated 12/12/23 at 4:17 PM revealed the following: Cleanse R38's right hip incision site with normal saline and apply band-aids to area every dayshift. Monitor surgical incision to right hip area every shift for signs and symptoms of infection, bleeding. Follow up with physician as needed. Document in progress note. R38's records revealed she had an admission Evaluation (whole body exam) on 12/12/23 at 9:37 PM with right hip marked in skin indicating something was not normal with the skin on the right hip. The evaluation then contradicted itself as it identified no skin abnormalities and stated that skin condition was normal. The assessment identified R38 was at risk for alteration in skin integrity, and to decrease/minimize skin breakdown risks. A review of R38's care plan noted a focus initiated on 12/13/23 for alteration in ADL's (activities of daily living) r/t (related to) fall with fracture of right hip with ORIF (open reduction and internal fixation), dementia, weakness, and decreased mobility. Interventions included encourage and/or assist to reposition frequently and encourage resident to sit up in chair for meals. Another focus identified on 12/13/24 was alteration in elimination r/t mobility/risk for constipation, functional urinary incontinence, constipation on admission. The goal to this focus was updated on 12/22/23 and read as follows avoid development of complications r/t incontinence. Interventions included: assist with toileting upon arise in AM, before/after meals, and HS (hour of sleep) and as needed. Provide incontinence cares as needed. It was also identified on 12/12/23, that R38 was at risk for alteration in skin integrity, delayed wound healing, decreased mobility, decreased sensation, malnutrition, advanced age, fragile skin. Goals identified for risk for alteration in skin integrity were decrease/minimize skin breakdown risks, interventions included barrier cream to peri area/buttocks as needed, observe skin condition with ADL care daily, report abnormalities, pressure redistributing device on bed/cushion on chair, provide preventative skin care routinely and PRN (as needed). A Skin & Wound Evaluation V7.0 was completed on 12/20/23 at 10:33 AM and was signed by RN (Registered Nurse) L on 1/17/24. The assessment was incomplete, not noting type, location, where it was acquired, how long had the wound had been present, or who it was staged by, and if any provider was notified. The assessment noted wound measurements with an area of 0.7 cm2 (square centimeter), length of 0.7 cm (centimeters), and width of 0.7 cm, without depth, undermining, or tunneling. The remainder of the assessment did not accurately describe the wound portrayed in the photo taken of the wound and noted no exudate, when there was visible exudate on incontinence pad, and stated the progress was stable. A review of the admission assessment for R38 dated 12/12/23 revealed no skin issues to their coccyx on admission. According to a Pressure Injury article in Stat Pearls published by the National Library of Medicine in February of 2024, [NAME], N. & [NAME], P.M. (2024, February 28) Pressure Injury. Stat Pearls National Library of Medicine. located at https://www.ncbi.nlm.nih.gov/books/NBK557868/, Characteristics of pressure injuries that should be assessed include, but are not limited to: Location, Length, Width, Depth (both quantitative and qualitative). Document the presence of any of the following: Undermining, Tunneling, Necrosis, Signs of infection: Erythema (redness), Induration (thickening or hardening of soft tissues), Warmth, Tenderness or pain with palpation, Drainage (also noting amount, type, odor, and color). A physician order was placed on 12/20/23 at 12:23 PM to apply barrier cream to R38's coccyx due to incontinence, every shift for incontinence barrier. Nursing progress notes on 12/22/23 stated R38 had open area to coccyx. Area cleaned and dry dressing applied until response from physician. The next nursing progress note that mentioned the coccyx's wound care was on 3/22/24. A Skin & Wound Evaluation V7.0 was completed at 3:07 PM and signed on 1/3/24 by RN J. The assessment was incomplete, not noting type, location, where it was acquired, how long the wound was present, or who it was staged by. The assessment noted wound measurements with an area of 0.2 cm2, length 0.5 cm, width 0.5 cm, without depth, undermining, or tunneling, and progress noted as improving. A physician's order was written on 1/3/24 at 2:19 PM for dressing change to R38's coccyx. Cleanse with normal saline (NS), pat dry, cover with small comfort foam every other day and PRN if soiled or missing and every day shift every other day for wound care, may discontinue when healed. A Skin & Wound Evaluation V7.0 was completed and signed at 10:40 AM on 1/10/24 by LPN V. The assessment was incomplete, not noting type, location, where it was acquired, how long had the wound been present, or who it was staged by and if a provider was notified. The assessment noted wound measurements with an area of 0.6 cm2, length 0.5 cm, width 1.6 cm without depth, undermining, or tunneling and progress noted as improving. This notation of improving was made despite the measurements on 1/3/24 reflecting a smaller area of 0.2 cm2, length 0.5 cm, width 0.5 cm. The first of two Skin & Wound Evaluation V7.0s that were completed and signed on 1/17/24 was by RN L at 11:04 AM. The assessment was incomplete, not noting type, location, where it was acquired, how long had the wound been present, who it was staged by, or wound measurements without depth, undermining, or tunneling, and progress was noted as improving. The second Skin & Wound Evaluation V7.0 was completed and signed on 1/17/24 by RN I at 11:31 AM. The assessment was incomplete not noting location, identified type as Moisture Associated Skin Damage (MASD) incontinence associated dermatitis, in-house acquired, unknown to how long the wound had been present. The wound measurements were noted as an area of 1.2 cm2, length 1.2 cm, width 1.1 cm without depth, undermining, or tunneling and progress noted as improving. The notation of improving made despite the wound measurements on 1/10/24 reflecting smaller area of 0.6 cm2, length 0.5 cm. On 1/24/24 the Skin Worksheet identified redness to bilateral heels, an open area to the right third toe, redness to top of the right foot, bottom of right foot by the big toe, and a dressing on the coccyx. On 1/24/23 a Total Body Eval(evaluation) was completed by nursing which noted an open area to coccyx. On 1/24/24 a physician order was placed to image open area to coccyx weekly every day shift every Friday for routine wound monitoring, may discontinue once healed. A Skin & Wound Evaluation V7.0 was completed and signed on 1/26/24 at 1:41 PM by RN L. The assessment was incomplete, identified the location as coccyx (tailbone), Moisture Associated Skin Damage (MASD) incontinence associated dermatitis, in-house acquired, unknown on how long the wound had been present, or who it was staged by and if a provider was notified. The coccyx wound measurements decreased to an area of 0.4 cm2, length 1.0 cm, width 0.5 cm without depth, undermining, or tunneling, and progress was noted as improving. A Skin & Wound Evaluation V7.0 was completed and signed on 2/2/24 at 11:46 AM by LPN V. The assessment was incomplete, identifying location as coccyx, type as (MASD) incontinence associated dermatitis, in-house acquired, unknown on how long the wound had been present, or who it was staged by and if a provider was notified. The coccyx wound measurements increased to area of 1.9 cm2, length 2.2 cm, width 1.0 cm without depth, undermining, or tunneling, progress was noted as stable. On 2/3/34 the physician notes did not indicate any wounds on R38. A Skin & Wound Evaluation V7.0 was completed and signed on 2/9/24 at 1:53 PM by an agency nurse XX. The assessment was incomplete identifying location as coccyx, type as (MASD) incontinence associated dermatitis, in-house acquired, unknown to how long the wound had been present. The evaluation did not identify if exudate or odor were present, who it was staged by, or if a provider was notified. The coccyx wound measurements decreased to an area of 0.3 cm2, length 0.8 cm, width 0.4 and progress noted as improving. On 2/16/24 the Skin & Wound Evaluation V7.0 was completed and signed at 2:31 PM by RN J. The assessment was incomplete not noting if exudate or odor were present, who it was staged by or if a provider was notified. It had noted a deteriorating MASD on R38's coccyx with wound measurements increasing to an area of 1.8 cm2, length 1.8 cm, width 1.5 cm without depth, undermining, or tunneling. The wound photo clearly appeared as a pressure injury. On 2/23/24 the Skin & Wound Evaluation V7.0 was completed and signed by LPN V at 1:28 PM. The assessment was incomplete, not noting the percentage of wound filled with slough, who the wound was staged by or if a provider was notified. The assessment identified MASD on R38's coccyx, with wound measurements of an area 1.6 cm2, length 1.1 cm, width 1.9 cm without depth, undermining, or tunneling and progress noted as deteriorating. The wound photo clearly appeared as a pressure injury. A physician's order dated 2/23/24 at 2:22 PM revealed the following: Cleanse R38's coccyx with NS, pat dry, apply Thera Honey to slough, cover with foam adhesive dressing. D/C (discontinue) Thera Honey when slough resolves, as needed if dressing to coccyx is soiled or missing and every day shift every Tuesday, Friday, Sunday for wound care, may discontinue when healed. On 3/1/24 at 11:46 AM the Skin & Wound Evaluation V7.0 was completed and signed by RN L. The assessment was incomplete not noting who staged it or whether a provider was notified. The assessment did identify coccyx, type as MASD, incontinence associated dermatitis, in-house acquired, unknown on how long the coccyx wound had been present, with increasing coccyx wound measurements of area of 2.1cm2, length 1.7, width of 1.7cm without depth, undermining, or tunneling. The wound photo clearly appeared as a pressure injury. On 3/3/24 the physician notes did not mention any wounds were present on R38. On 3/8/24 a diagnosis of pressure ulcer, stage 4 was added to R38's medical diagnoses. On 3/8/24 the Skin & Wound Evaluation V7.0 was completed and signed by RN L at 2:15 PM. The assessment was updated to an unstageable pressure wound, noting that the wound was obscured by slough (yellow/white material in wound bed) and/or eschar (dead tissue) on the sacrococcygeal area that was in-house acquired present for one month. The evaluation directions clearly read as, wound age when first assessed, which was 12/20/23. The increasing coccyx wound measurements showed an area of 4.4 cm2, length 2.9 cm, width of 2.1 cm without depth, undermining, or tunneling. The provider was notified as infection was suspected. The wound photo did not show a wound completely obscured by slough and/or eschar, and therefore should have been staged. On 3/8/24 at 4:24PM the physician placed an order to cleanse R38's coccyx with normal saline, pat dry, lightly pack wound bed with small piece of calcium alginate with silver (about the same size as the wound) apply skin prep to surrounding skin and cover with small sacral foam dressing daily, as needed if dressing to coccyx is soiled or missing, and every day shift for wound care, may discontinue when healed. On 3/11/24 a physician order was written to apply barrier cream to bilateral heels and hips twice daily. CNA's may apply. Verify application with AM and HS cares every day and evening shift for wound care. On 3/11/24 R38's care plan was updated to include a focus of resident has pressure ulcer to right heel and coccyx, with a goal to be free from signs and symptoms of infection and show healing within normal limits of disease. The interventions included body audit as ordered, diet and supplements as ordered, elevate heels as tolerated, incontinence management, pressure redistributing support surface, side to side positioning in bed, keep weight off coccyx, skin barrier liberally to heels, and hip bones with AM and HS cares, report evidence of infection such as purulent drainage, swelling, localized heat, increased pain, etcetera, notify physician. The Skin & Wound Evaluation V7.0 was completed and signed on 3/15/24 by RN BB at 11:26 AM. RN BB identified a sacrococcygeal wound as stable, leaving the stage as unstageable, obscured by slough and/or eschar, then noted that the wound was zero percent filled by slough or eschar. The coccyx wound measurements were area 2.9 cm2, length 2.0 cm, width 2.2 cm. Wound photos from these dates did not indicate an unstageable wound. The Skin & Wound Evaluation V7.0 was completed and signed on 3/22/24 by the DON at 11:58 AM. The assessment was incomplete and noted an unstageable pressure wound, obscured by slough and/or eschar on the sacrococcygeal area, that was in-house acquired, present for one month, with evidence of infection as evidenced by increased drainage, redness/inflammation, and the progress was noted as deteriorating. The measurements of the coccyx wound were identified as area 1.6 cm2, length 1.7 cm, width 1.3 cm without depth, undermining, or tunneling. The DON did not identify who staged it, if there was an odor after cleansing, or if a provider was notified. On 3/22/24 a nursing progress note stated: physician responded to fax related to wound update. R38 noted with increased drainage, foul odor, and some surrounding redness. Physician ordered doxycycline (antibiotic) 100mg (milligrams) BID (twice daily) for 7 days. On 3/25/24, R38's care plan was updated to include infection of wound/skin of coccyx, with goal to have resident's infection resolved without complications. The interventions included administer medications per physician's orders and record temperature as clinically indicated. R38 was taking doxycycline for her coccyx pressure ulcer. The Skin & Wound Evaluation V7.0 was completed and signed on 3/29/24 by LPN V at 10:13 AM. The assessment was incomplete not noting who it was staged by, identified slough but did not note percentage of wound filled with it, identified the wound as pressure located on sacrococcygeal, unstageable, obscured by slough and/or eschar, in-house acquired, present one month. The wound measured area 1.7 cm2, length 2.2 cm, width 1.1 noting 3 cm of undermining, 3 cm of tunneling, without depth. The progress was noted as deteriorating. On 3/30/24 a nursing progress note stated: temperature 97.9, dressing changed to coccyx as ordered, continues to have an odor. Resident continues antibiotic related to wound. Moderate amount of purulent drainage. On 3/31/24 a nursing progress note stated: dressing changed to coccyx, decrease in odor. The Skin & Wound Evaluation V7.0 was completed and signed on 4/5/24 by LPN V at 2:29 PM. The assessment was incomplete, it did not note who it was staged by, if there was evidence of infection, or if the provider was notified. The wound was described as pressure, unstageable sacrococcygeal, in-house acquired, present for one month, with wound measurements of area 1.4 cm2, length 1.5 cm, width 1.2 cm without depth or undermining, with 5.0 cm tunneling. Progress was noted as stalled. On 4/7/24 the physician notes stated that R38 was treated with doxycycline for 7 days on 3/22/24 for infection of sacral decubitus ulcer. All other treatment orders by the physician identified the wound as coccyx and there was not a new wound. On 4/14/24 a nursing progress note stated: dressing change to coccyx, wound cleansed with normal saline area with new pink tissue noted. On 4/18/24 R 38's care plan updated at risk for skin alterations, worsening wounds, and further skin breakdown consider unavoidable r/t incontinence of bowel and bladder, pressure injuries to include interventions of elevate heels as able, encourage and assist as needed to turn and reposition; use assistive devices as needed, use pillows/positioning devices as needed. There were no physician or nursing notes to indicate that risk for skin alterations is unavoidable due to R38's condition. On 5/20/24 at 9:22 AM this Surveyor asked to observe LPN V perform wound care on R38. LPN V was unaware R38 was due and then after review of R38's EMR determined R38 was due to have her wound care completed. Observed LPN V perform wound care. No barrier cream was noted on bilateral hips, or heels. The heels were not floating off the bed. LPN V stated the facility used to have a wound nurse, but no longer did due to a medical leave. LPN V stated that it was nursing management's job to get measurements and weekly pictures of the wounds. So, LPN V did not take a picture of the coccyx wound. When completed with wound care LPN V did not float heels and stated she would reposition R38 off her coccyx later. On 5/22/24 at 8:57 AM, an interview was conducted with the DON, who stated that the expectation of nursing staff was to complete every section of the Skin & Wound Evaluation V7.0 for every wound, as well as to make a progress note when filling out the evaluation. The DON stated he was unaware nursing could sign the evaluation without completing the entire content in the evaluation. This citation pertains to intake MI00142093 and MI00142802. Based on observation, interview and record review, the facility failed to implement a comprehensive wound care program which resulted in Immediate Jeopardy with identification of the development of multiple facility acquired stage III/IV/Unstageable facility acquired pressure injuries and/or worsening of existing pressure injuries for four Residents (R4, R19, R38, and R48) of five Residents reviewed for pressure injuries. Findings include: All times recorded in Eastern Daylight Time (EDT), unless otherwise noted. R4 developed two facility-acquired unstageable/Stage 3 pressure injuries. R19 developed a right heel wound infection requiring surgical debridement and administration of IV (intravenous) antibiotics, and developed a new, facility-acquired left heel deep tissue injury (intact skin with damage of underlying soft tissue from pressure) without implementation of interventions to prevent worsening of the wound. R38 developed a facility-acquired pressure injury which deteriorated from Moisture Associated Skin Damage (MASD) [Inaccurately identified] which deteriorated to a Stage 4 pressure injury to the coccyx (tailbone)[Inaccurately identified as unstageable] requiring the use of antibiotics for a subsequent wound infection. R48 lacked essential skin care interventions to prevent the development of additional facility-acquired pressure injuries, experienced worsening of a Stage IV sacral injury, and was observed being provided with inadequate wound care technique to prevent wound infection. The Immediate Jeopardy identified on 5/20/2024, began on 3/08/2024 when R38 was assessed with a facility-acquired Stage 4 pressure injury (wound covered with extensive dead tissue, if removed would reveal a full-thickness wound) to the coccyx following incomplete assessments and inaccurate identification of the wound as moisture-associate skin damage (MASD). All times are recorded in Eastern Daylight Time (EDT), unless otherwise noted. Resident #19 (R19) A review of the Electronic Medical Record (EMR) revealed R19 was admitted on [DATE] with diagnoses including coronary artery disease, diabetes, peripheral vascular disease, and osteoarthritis. Review of R19's quarterly Minimum Data Set (MDS) assessment, dated 3/14/2024, revealed he was dependent (Helper does all the effort. Resident does none of the effort to complete the activity) on staff for dressing, putting on/taking off footwear, and all mobility including rolling left to right, sitting to lying, lying to sitting, transfers and wheelchair mobility. Further review of the MDS assessment revealed R19 was assessed as experiencing pain that interfered with day-to-day activities almost constantly and had one unhealed, unstageable (not stageable due to the coverage of the wound bed by necrotic tissue) pressure ulcer. R19 scored 14 out of 15 on the Brief Interview for Mental Status (BIMS), indicating he was cognitively intact. An observation on 5/19/2024 at 2:49 p.m., revealed R19 lying in bed with his hips and upper body leaning to the left side of the bed wearing a blue foam heel protection boot on his right foot. R19 was not wearing footwear on his left foot, and his left heel was observed to be resting completely on the mattress. A pillow was observed to be under R19's lower legs. It was noted the pillow was flat and did not elevate R19's heels from the surface of the bed. On 5/19/2024 at approximately 2:54 p.m., immediately following the initial observation, R19 could be heard in the hallway yelling out for help. Certified Nurse Aide (CNA) N and CNA W entered R19's room and closed the door. Upon entering the room, CNA N reported they were preparing to reposition R19 in bed per his request. After repositioning R19 on his right side, CNA N replaced the flattened pillow under R19's lower legs. R19 was wearing a blue, heel protection boot on his right foot and his left foot was bare. R19's left foot was observed to be turned inward, with the medial aspect of his heel and ankle resting directly on the mattress. Registered Nurse (RN) X entered the room at that time and was observed standing on the left side of R19's bed, speaking with R19. RN X was in full view of R19's heels resting directly on the bed and did not attempt to reposition R19 or instruct CNA N and CNA W to reposition R19, so his heels were not resting directly on the bed. RN X, CNA N and CNA W left the room without elevating R19's heels. An observation on 5/20/2024 at 8:40 a.m. revealed R19 lying in bed, tilted to his left side with the head of the bed at approximately 45 degrees. The blue heel protection boot was on R19's right foot. R19 was not wearing footwear on his left foot and his left heel was observed to be resting fully on top of a flattened pillow positioned directly under his feet. An observation on 5/20/2024 at 11:30 a.m. revealed CNA N and two unidentified students enter R19's room. CNA N informed R19 they were going to prepare him for transport to an outside appointment with his Urologist. Upon removal of R19's sheet, he was observed to be wearing a blue heel protection boot on his right foot. R19 was not wearing footwear on his left foot and his left heel was observed to be resting directly on the bed. CNA N removed the blue heel protection boot from R19's right foot revealing an elastic material wrap on R19's foot extending from the base of his toes and over R19's heel and ankle. During repositioning, CNA N lifted R19's left leg, revealing an area approximately 1.5 in. (inch) by 1 in. of dark purple discoloration on the medial aspect of R19's left heel. Further observation revealed a black spot near the center of the dark purple area and the skin surrounding the discoloration appeared reddened. CNA N stated R19 was supposed to have a heel protector boot on his left foot. When asked where the boot was and why it had not been observed on R19, CNA N stated, we keep telling them (nurses/managers) he needs one, but we still don't have one. Further observation revealed CNA N and a student position a lift sling under R19 and began lifting R19 over the bed. Upon lifting R19 was observed yelling out it hurts, it hurts, I can't take it! R19 was lowered back onto the mattress. CNA N then asked R19, do you want to cancel your appointment? R19 reported he did not think he could take it. Review of R19's May 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed the following physician orders: Change bandage to right heel, cleanse with normal saline, apply silverderm 7 and cover with heel foam adhesive, comparable bandages may be used. Every evening shift every Tue [Tuesday], Thu [Thursday], Sat [Saturday] for wound. Order Status: Active . Order Date: 4/23/2024 . Start Date: 4/25/2025. Heel protection boots to bilateral feet every shift. Order Status: Active . Order Date: 5/16/2024 . Start Date: 5/16/2024. It was noted in review of R19's May 2024 MAR and TAR, nursing staff documented heels boots were in place on both of R19's feet for the 6:00 a.m. - 2:00 p.m. shift on 5/19/2024 and 5/20/204, contrary to CNA N reporting no heel protection boot available for R19 and the observations of R19's left heel resting directly on the bed on 5/19/2024 and 5/20/2024. Offload heels while in bed to prevent ulcers. Every shift for prevent pressure [sic]. Order Status: Active . Order Date: 4/18/2024 . Start Date: 4/18/2024. It was noted in review of R19's May 2024 MAR and TAR, nursing staff documented R19's heels were offloaded on 5/19/2024 and 5/20/2024, contrary to the observations on 5/19/2024 and 5/20/2024, of R19's left bare heel and right heel with a heel protection boot resting directly on the bed. Immediately following the observation, Unit Manager and Registered Nurse (RN) L entered R19's room and asked the Resident if he wanted to cancel his appointment. R19 explained to RN L the pain in his back was severe and he did not think he could handle the pain from the movement involved in transport. R19 asked why can't they give me something [for the pain] before [appointments]? RN L told R19 she could speak to the physician about pain medication prior to outside appointments but would cancel his appointment for that day. No education was provided to R19 related to the importance of keeping the appointment or offer made for pain relief medication at that time so R19 could attend the appointment. During an interview on 5/20/2024 at 4:00 p.m., R19 reported he was aware he had a wound on his right heel. R19 reported his right heel had healed after admission to the facility but since that time opened back up and worsened. R19 reported being recently hospitalized due to an infection of the right heel wound. R19 reported no injury to his right or left heels and was unaware of the area of discoloration found on the medial aspect of his left heel. R19 reported his feel always rested directly on the mattress or directly on a pillow, never floated above the mattress, and he had never been provided a heel protection boot for his left foot. R19 pulled up his sheet at which time his left foot was without footwear and his left heel was observed to be resting directly on the bed. R19's right foot, in the blue heel protection boot, was observed to be resting on top of his left foot, pushing his left heel into the bed. R19 reported the right heel protection boot was in place off and on since he returned from being hospitalized although he could not remember when the hospitalization occurred. R19 reported constant, severe pain from arthritis in his lower back that made it difficult for him to move his lower body without assistance. A review of R19's Medication MARs and Tars from March 2024 through May 20, 2024 at 2:16 p.m., revealed no order for medication to be administered or pain relief interventions to be implemented in addition to R19's scheduled medications, prior to R19's scheduled appointments with outside providers. R19's May 2024 MAR and TAR also revealed an order for acetaminophen . give 650 mg [milligrams] by mouth every 4 hours as needed for pain. No dose was recorded as administered on 5/20/2024. Review of R19's General Progress Note, dated 4/13/2024 at 6:19 p.m. (Central Daylight Time, CDT) revealed the following: 1700 (5:00 p.m. CDT) Resident noted to be very lethargic with decreased level of consciousness throughout day . skin cool to touch and extremities cold. Feet are mottled . 911 called and will send transport . 1755 (5:55 p.m. CDT) Ambulance here 1809 (6:09 p.m. CDT) Resident has left facility . Review of R19's hospital progress note, dated 4/15/2024 at 8:40 a.m. CDT, revealed the following, in part: Chief Complaint: unresponsive episode . 4/14/2024 upon evaluation of [R19] this a.m. noted to be mumbling, yelling at times and moving about the bed without following directions. Evaluated [R19's] work up and noted right heel ulcer with a very foul odor . [preliminary] right wound heel positive for gram [positive] and gram [negative] bacilli [bacteria] . 4/15/2024 spoke with [podiatrist] this a.m.: [R19] NPO [nothing by mouth] for surgical debridement [removal of dead tissue] . no seizure activity since admission . Physical Exam . Skin: malodorous right heel wound, although covered odor emits entire bed area . Review of R19's Discharge Summary [acute care facility], dated 4/18/2024 (no time provided), revealed the following, in part: Date of admission: 13-Apr-2024; Date of discharge: 19-Apr-2024 . History of Present Illness . noted right heel wound with very foul odor . concern for infection causing his leukocytosis (elevated white blood cell count, indicating infection) and mental status changes. 1 of 2 [blood cultures] returned positive for gram [positive] cocci [bacteria] in clusters: on Iv [intravenous] vancomycin [antibiotic often used to treat multi-drug resistant organisms] with IV zosyn [antibiotic commonly used for broad antimicrobial coverage and in early sepsis and critically ill patients] . Hospital Course: . 1. Seizure-like activity: CT head without acute abnormality . 2. Unresponsive episode: Prior to arrival; altered mental status and drowsy . thought to be more likely to polypharmacy . 3. Leukocytosis with right heel ulcer: Right heel likely cause of leukocytosis due to foul odor . WBC: 22.7 [normal range is 4-11] . Lactic 1.1 .[TRUNCATED]