**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and document review, the facility failed to provide care consistent with professional standard of practice to prevent worsening of pressure ulcer identified on 6/20/25 for 1 of 3 residents (R1) reviewed when the facility failed to provide appropriate assessment and treatment. This resulted in actual harm to R1 when she was identified with stage 3 pressure ulcer at coccyx area during admission at the hospital on 7/15/25. Findings include: According to the State Operations Manual, Appendix PP, Guidance to Surveyors for Long Term Care Facilities, revision 229, issued 4/25/25 a pressure ulcer and stage 3 pressure ulcer is defined as Pressure Ulcer/Injury (PU/PI) refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. A pressure injury will present as intact skin and may be painful. A pressure ulcer will present as an open ulcer, the appearance of which will vary depending on the stage and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Soft tissue damage related to pressure and shear may also be affected by skin temperature and moisture, nutrition, perfusion, co-morbidities, and condition of the soft tissue. Stage 3 Pressure Ulcer: Full-thickness skin loss Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage, and/or bone are not exposed. If slough or eschar obscures the wound bed, it is an Unstageable PU/PI. On 7/29/25 at 10:09 a.m., during R1's wound dressing observation, RN-G stated R1's pressure ulcer measurements indicated the following: length: 5.5 cm; width: 3.5 cm; and depth: 1 cm. RN-G stated he noted an excoriation around the wound, blanchable, little slough, borderline stage 3 pressure ulcer. R1's admission Record dated 3/27/24 indicated R1's diagnoses included intervertebral disc degeneration, chronic respiratory failure with hypoxia, history of diseases of the skin and subcutaneous tissue, sepsis due to Escherichia coli, and post-traumatic stress disorder. R1's care plan dated 3/27/24, indicated R1 had intact cognition and was at risk for skin breakdown related to pressure due to incontinence, inactivity, immobility, and problem with friction and shearing with staff interventions to inspect skin with care, to evaluate and notify the provider and the family immediately of any new area of skin breakdown. R1's Quarterly Minimum Data Set (MDS) dated [DATE] indicated R1 is at risk of developing pressure ulcers. The MDS also indicated R1 required extensive assistance with activities of daily living (ADL) R1's skin evaluation document dated 6/20/25 at 8:24 p.m. indicated R1 had new skin impairment with an open skin area at her coccyx. The document also indicated Mepilex border (a wound dressing) applied, monitoring task initiated. R1's care plan review lacked evidence of the focus, goal and interventions reviewed after the new skin impairment finding on 6/20/25. Review of R1's medical record including skin assessments and progress notes, indicated the facility failed to document an assessment of the pressure ulcer, measurements, or description from 6/20/25 through 7/14/25, during the time the facility nursing staff was responsible for R1's skin integrity. R1's treatment administration record (TAR) dated 6/20/25, through 7/14/25, indicated R1 refused wound care on 7/1, 7/6, 7/7, 7/8, 7/9, and 7/10. Record review lacked indication of a notification to R1's physician or the nurse manager about R1's refusal of wound care. R1's skin assessment dated [DATE] at 7:35 p.m. indicated R1 had an open skin area at her coccyx with Mepilex dressing intact. The note indicated R1 refused to reposition often from the recliner. R1's skin assessment and progress notes 7/7/25 and 7/14/25, lacked documentation of R1's pressure ulcer of the coccyx area. On 7/15/25 at 6:33 p.m., a progress note indicated R1 was very drowsy/lethargic all shift with blood pressure of 62/42 and nursing staff sent R1 to the hospital for further evaluation per provider order. On 7/15/25, an emergency department (ED) provider note indicated emergency medical services (EMS) brought R1 to the hospital for evaluation of low blood pressures, increased fatigue, increased weakness, and some disorientation. The note also indicated a discrepancy in the history from the nursing home staff and there was very minimal documentation in the chart. R1's MDS dated [DATE] indicated no unhealed pressure ulcer/pressure injury identified. On 7/24/25 at 1:15 p.m., a licensed practical nurse (LPN)-A stated if you noted a new skin impairment, nursing staff should provide assessment, description, measurement, document in the progress note, and notified the nurse manager, the provider, and the family, and initiated a task to monitor its progress. LPN-A stated with a pressure ulcer or injury she would keep the pressure off, notified the treatment team, the dietitian, and the provider. On 7/24/25 at 3:32 p.m., LPN-B stated it was the standard of practice to check the status of an existing skin impairment compared to the initial assessment during the skin assessment and documented whether it was getting better or worse. LPN-B stated with a resolved skin impairment, nursing staff had to document it in the progress note and notified the nursing manager. On 7/28/25 at 8:54 a.m., LPN-C stated she reviewed the assessment of the week before her shift and looked at the areas of concerns, documented any findings in the progress note, and notified the care manager and the provider. On 7/28/25 at 11:54 a.m., a registered nurse (RN)-A stated ED provider note on 7/16/25 indicated R1 had sacral pressure ulcer present at the admission. RN-A stated a hospital wound nurse who was consulted to see R1 evaluated R1's sacral pressure ulcer to be at least stage III with 9 cm length and 7 cm width and was unable to determine the depth. On 7/28/25 at 1:16 p.m., LPN-D stated she would update the provider, the nurse manager, and the family about a new skin impairment. LPN-D stated she was just monitoring R1's open skin area progress but she did not document its status during her skin assessment on 6/30/25 since it was not a new skin impairment. LPN-D stated usually the RNs will do an evaluation for stuff like that. She just made sure the Mepilex dressing was in place. On 7/28/25 at 1:21 p.m., RN-B stated she did not document a description and measurement about R1's new skin impairment on 6/20/25, and did not notify the nurse manager or the provider. RN-B stated she initiated the task to monitor the open skin area at R1's coccyx and could not find any documentation about when it was resolved. On 7/28/25 at 3:12 p.m., a care coordinator, registered nurse (RN)-C stated she expected licensed nurses to describe and measure any new skin impairment, documented in the progress note, initiated a task for monitoring process, and notified the care coordinator and the provider. RN-C stated nursing staff did not notify the provider about R1's new skin impairment. RN-C stated she could not find any documentation about R1's resolved skin impairment prior to her hospitalization. RN-C stated R1 was back from hospital today and she sustained pressure ulcer at her coccyx area with 9.0 cm length, 8.2 cm width, and 0.7 cm depth with tunneling. On 7/29/25 at 10:09 a.m., during R1's wound dressing observation, RN-G stated R1's pressure ulcer measurements indicated the following: length: 5.5 cm; width: 3.5 cm; and depth: 1 cm. RN-G stated he noted an excoriation around the wound, blanchable, little slough, borderline stage III pressure ulcer. On 7/29/25 at 10:42 a.m., R1 stated the sore at her bottom was there for a little bit before she went to the hospital. R1 stated it hurt sometimes but she did not have pain at this time. R1 stated she could not remember what happened before she left for hospital. R1 stated she did not sleep in bed before her hospitalization, she preferred to sleep in her recliner. On 7/29/25 at 11:38 a.m., RN-D from R1's medical team office stated she could not find any new skin impairment notification in their system about R1 from 6/20/25 through 7/14/25. RN-D stated she received the only notification about R1's wound status today on 7/29/25 and they ordered a wound care consult. On 7/29/25 at 12:07 p.m., RN-E stated she assessed R1 when she came to the intensive care unit (ICU) for septic shock. RN-E stated the only reason she made the report to the State Agency (SA) was the skin impairment. RN-E stated R1 had a massive open skin area which looked like a pressure ulcer at her sacral area. On 7/29/25 at 12:09 p.m., a nursing assistant (NA)-A stated during the week when R1 went to the hospital, she reported a purple bluish bruising around R1's coccyx area to RN-F who looked at it but when she came back the next day, she could not find any documentations about the bruising. On 7/29/25 at 12:34 p.m., the medical director (MD)-A stated he expected nursing staff to follow change in condition and wound care policies. MD-A stated nursing staff had to notify the provider about a new skin impairment depending on the resident diagnosis. On 7/29/25 at 1:32 p.m., RN-F stated nurses had to report any new skin impairments to the case manager, the provider, and the family. RN-F stated nurses had to document the size, characteristics, status of an existing skin impairment or reopened, and initiated a risk management if the case manager wanted to do more investigation. RN-F did not recall getting a report from nursing staff about R1's coccyx area condition. On 7/29/25 at 3:34 p.m., the director of nursing (DON) stated she expected nursing staff to follow a change in condition and wound care policies about a new skin impairment finding. The DON stated with new skin impairment, nurses had to update the care team, record the measurement and the description of the wound, open a task to monitor its healing process, updated the dietary department, the care plan, the provider, and the family. The DON stated she could not find any care plan updated about R1's new skin impairment finding on 6/20/25. The DON stated she could not find any documentations about when R1's open skin area at her coccyx was resolved. Nursing staff did not update the nurse manager about R1's new skin impairment and staff failed to implement a pressure reduction cushion in the recliner for R1. The DON stated the professional standard of practice would be to describe and measure the wound, documented in the progress note, update the care team and the provider, initiated offload pressure reduction measures, and follow the provider recommendation. The facility policy for Change in Condition dated 7/2025 directed nurses to make detailed observations and gather relevant and pertinent information for the provider of a change in the resident's condition. The policy also directed nurses to record in the resident's medical record information relative to changes in the resident's status and update to the resident's plan of care. The facility Wound Care policy dated 1/2025 directed nurses to follow the professional standards of practice, to observe the wound and surrounding skin taking note of the appearance of the wound bed, surrounding skin, edema, redness, drainage, indications of wound status. The policy also indicated to notify the supervisor if the resident refuses the wound care.