**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident #62's POS dated 11/27/23 showed the following physician's orders: -Skin checks weekly. Every day shift, every Friday. Must open and document skin evaluations for each assessment (including no new areas found). Review of the resident's care plan dated 11/28/23 showed: -The resident was at risk for alteration in skin integrity. -The resident would remain free of new skin impairment through the review date of 8/2/2024. -The resident would receive skin/wound treatments as ordered. Review of the resident's quarterly MDS dated [DATE] showed: -The resident was at risk for developing pressure ulcers. -The resident did not have one or more unhealed pressure ulcer(s) at stage I or higher. -The resident did not have any other ulcers, wounds, or skin problems. Review of the resident's POS dated 6/11/24 showed the following physician's orders: -Wound Care: Right Ankle: Cleanse with normal saline (NS), pat dry, Skin Prep (A topical barrier between skin and adhesives) to the peri wound, apply Silver Alginate (Silver Alginate contains silver ions. It is typically used on infected wounds or wounds that are at a high risk of infection. Silver has antimicrobial properties that can help to prevent and treat wound infections) to the wound bed, cover with dry dressing. Every day shift for wound care. Review of the resident's TAR dated June 2024 showed the resident's daily wound care to be completed on 6/27/24 had no nursing initial or check mark. Review of the resident's care plan revision dated 7/8/24 showed: -The resident had actual impairment to skin integrity related to a Stage III pressure ulcer on the right ankle. -The resident's pressure ulcer will show signs of healing and remain free from infection through review date. -Facility protocols would be followed for treatment of injury. Review of the resident's POS dated 7/9/24 showed the following physician's orders: -Wound Care: Right Outer Ankle: Cleanse with wound cleanser, pat dry, Skin Prep to the peri wound, apply Hydrafera Blue (Hydrofera Blue's capillary action continuously pulls harmful bacteria- laden slough, exudate, and debris away from the wound bed) to the wound bed, cover with dry dressing. Every day shift for wound care. Review of the resident's POS dated 7/17/24 showed the following physician's orders: -Wound Care: Right Outer Ankle: Cleanse with wound cleanser or NS, pat dry, Skin Prep to the peri wound, apply Hydrogel (Hydrophilic starch polymers (predominately composed of water). These are available in sheets, amorphous gels, or gauze) to the wound bed, cover with dry dressing. Every day shift for wound care. Review of the resident's POS dated 7/24/24 showed physician's orders for skin checks weekly. Every day shift, every Wednesday. Must open and document skin evaluations for each assessment (including no new areas found). Review of the resident's significant change MDS dated [DATE] showed: -The resident was at risk for developing pressure ulcers. -The resident did have one or more unhealed pressure ulcer(s) at stage 1 or greater. -The resident did have one Stage III pressure ulcer. -The resident did have pressure ulcer care. Review of the resident's TAR dated July 2024 showed: -The resident's daily wound care to be completed on 7/5/24 had no nursing initial or check mark. -The resident's weekly skin check to be completed on 7/5/24 had no nursing initial or check mark. -The resident's daily wound care to be completed on 7/10/24 had no nursing initial or check mark. -The resident's daily wound care to be completed on 7/16/24 had no nursing initial or check mark. Review of the resident's TAR dated August 2024 showed the resident's daily wound care to be completed on 7/15/24 8/15/24 had no nursing initial or check mark. Observation on 8/21/24 at 10:06 A.M. of wound rounds showed: -NP A and ADON A assessed the resident's ankle wound. -The wound measured 0.8 cm long (an increase of 0.2 cm from previous weeks wound rounds), 0.9 cm wide (an increase of 0.4 cm from previous weeks wound wounds), and 0.2 cm depth. The peri wound area was painful to touch for the resident during assessment. Edema and redness were noted. -The NP staged the pressure ulcer as a Stage III and said that he/she was worried about the wound getting infected. NP ordered an x-ray and antibiotics. During an interview on 8/23/24 at 8:59 A.M. LPN B said: -Charge nurses were responsible for weekly skin assessments and documentation of those assessments. -Charge nurses and the wound care nurse (ADON-A) were responsible for completing wound care orders daily. During an interview on 8/23/24 at 12:47 P.M. ADON A said: -Floor nurses were responsible for weekly skin assessment and documentation of assessments. -He/She was the current facility wound nurse. -He/She was not yet certified but had completed wound certification training. -He/she was responsible for implementing wound care orders as well as the floor nurses. -He/She would expect floor nurses to implement any wound care orders that were put in place. 4. During an interview on 8/23/24 at 1:09 P.M. the DON said: -ADON A was responsible for wound care throughout the facility. -Skin assessments were to be completed by the floor nurses weekly. -Skin assessments should include a full assessment of a wound including measurements. -Floor nurses and the ADON should be completing wound care orders daily. -The NP completed wound assessments and measurements every seven days. -The facility did not measure stage one pressure ulcers or other identified reddened areas. -If ADON A felt an area did not need followed because it may heal on it's own, there would be no measurements or evaluations and it would not be considered a wound. -He/She would expect orders for treatment or prevention to be put in immediately upon identification of a pressure injury. -He/She would expect all treatment and prevention orders to be carried out by nursing staff, including implementation of a low air loss mattress. -Resident #74 should have had a low air loss mattress in place. -Staff should have notified a provider of a pressure injury to have it evaluated. -The admitting nurse would be expected to document a detailed wound assessment and to follow-up with the wound nurse. -The wound nurse would be responsible for completing a comprehensive wound assessment within 24-48 hours of admission for all resident's with wounds. -He/she expected wound care documentation to reflect the currant condition of the wounds and to include the type of wound, type of dressing, frequency of dressing change, and detailed wound descriptions (e.g., measurement, characteristics). -Resident #1 was admitted with three pressure injury wounds and a surgical wound. -The admitting nurse was responsible for assessing and documenting a detailed assessment of Resident #1's wounds and overall general skin assessment. -The wound nurse was responsible for the detailed documentation into the wound round report for follow-up with the wound NP. -He/she would expect the floor nurse to notify the wound nurse and physician of any new or worsened wounds or skin changes immediately. -He/She would expect to have physician orders transcribed and implemented upon admission for any wound care required. -Resident #74, #1, and #62 should not have any missing documentation of wound care being provided. -Resident #74, #1, and #62 should not have any missing skin assessments. Based on observation, interview, and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent the development of pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) which resulted in the development of a pressure ulcer; failed to implement ordered interventions to promote healing of developed ulcers for one sampled resident (Resident #74) which resulted in the worsening of the pressure ulcer; and failed to accurately assess resident's skin for the monitoring of pressure ulcer development and progression for three sampled residents, (Residents #74, #1 and #62) out of 18 sampled residents. The facility census was 84 residents. Review of the facility policy titled Skin Integrity, dated 11/2019, showed: -Staff would ensure a resident who entered the facility without a pressure sore [pressure ulcer] would not develop one unless unavoidable (hospice, end of life skin failure). -A nurse would perform a full body skin assessment within two to six hours after admission and weekly thereafter. -Preventative measures would be put into place for residents at risk of developing a pressure ulcer. -A resident who had or developed a pressure ulcer would receive treatment to promote healing and prevent further development. -Staff would ensure pressure relieving devices were placed on the resident's bed. 1. Review of Resident #74's after visit summary (discharge orders) from the resident's hospital stay, dated 7/19/24, showed instruction to facility staff to monitor an ulcer to his/her left heel and change the wound dressing daily as needed. Review of the resident's Care Plan, dated 7/20/24, showed: -He/She was at risk for alteration in skin integrity. -An addendum on 8/1/24 showed he/she had an actual impairment to skin integrity related to a suspected deep tissue injury to the left heel with a goal of showing signs of healing. Review of the resident's admission Minimum Data Set (MDS-a federally mandated comprehensive assessment completed by facility staff for care planning), dated 7/26/24, showed: -Diagnoses of high blood pressure, renal failure (inability of the kidneys to adequately filter blood), chronic lung disease and pneumonia (an infection in the lungs) and malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things, or being unable to use the food that one does eat). -The resident had a Stage I pressure ulcer (intact skin with non-blanchable redness of a localized area usually over a bony prominence) but lacked indication of the location. -The resident was cognitively intact. -The resident did not reject cares within the seven-day look-back period (a period in which staff observe a resident to document MDS data). -The resident needed substantial assistance with lower body dressing including putting on and taking off footwear. Review of the resident's pressure ulcer Care Area Assessment (CAA, a focused worksheet in the MDS assessment), dated 7/26/24, showed: -The resident admitted with a Stage I pressure ulcer to the coccyx (area just above the buttock). -The resident had a pressure relieving mattress on his/her bed. -The resident was a high risk for pressure ulcer development. -No other documented pressure ulcers. Review of the resident's Physician Order Summary, dated 8/19/24, showed orders for: -Weekly skin assessments dated 7/19/24. -A low air loss mattress (a pressure relieving air mattress that reduces the risk of pressure injury development) dated 7/22/24. -Prevalon boots (a pressure reducing boot) when in bed every shift for skin injury prevention dated 7/22/24. -Encouragement of turning and repositioning, beginning 8/8/24. -Wound care to the left heel, cleansing with normal saline, pat dry, apply skin prep and cover with a dry dressing, beginning 8/14/24. --A discontinued order for cleansing bilateral heels with normal saline, pat dry, apply skin prep and leave open to air twice daily, valid from 7/22/24 to 8/14/24. Review of the resident's Treatment Administration Record (TAR) dated July 2024 showed: -Administration of an order for cleansing bilateral heels with normal saline, pat dry, apply skin prep and leave open to air twice daily with missing documentation on 7/23/24's day shift. -Administration of a low air loss mattress with no documentation of resident refusal. -Administration of Prevalon boots with missing documentation on 7/23/24 and no documentation of resident refusal. Review of the resident's TAR dated August 2024 showed: -Administration of an order for cleansing bilateral heels with normal saline, pat dry, apply skin prep and leave open to air twice daily with missing documentation on 8/7/24 and 8/8/24 day shift. -Encouragement of turning and repositioning, beginning 8/8/24, with missing documentation on day shift 8/18/24. -Administration of a low air loss mattress with no documentation of resident refusal. -Administration of Prevalon boots with missing documentation on day shifts for 8/8/24 and 8/18/24, and no documentation of resident refusal. -Administration of wound care to the left heel, cleansing with normal saline, pat dry, apply skin prep and cover with a dry dressing, beginning 8/14/24, with missing documentation on day shift 8/18/24, night shift 8/21/24 and omission of the administration on night shift of 8/17/24 due to resident sleeping. Review of the resident's weekly skin assessments showed: -An admission skin assessment on 7/19/24 showed non-blanchable redness to the coccyx and genital area as well as blanchable redness to the left heel. -A skin assessment on 7/27/24 showed swelling to both legs but no other skin issues. -A skin assessment on 8/4/24 showed swelling and no other skin issues. -A skin assessment on 8/10/24 showed a blister with drainage on the left heel. --No further nursing skin assessments were documented as of 8/19/24. Review of the resident's wound rounds documentation (documentation from weekly Nurse Practitioner (NP) wound rounds with the facility wound nurse) showed: -The first visit on 8/1/24 showed a wound to the left heel measuring 3.2 centimeters (cm) long, 5.1cm wide, and an unknown depth. The wound was 80% deep maroon and 20% blanchable redness and marked present on admission. A low air loss mattress was part of the treatment plan. No staging was provided by the NP during this visit and no progress note was provided by the facility on this date. All documentation was performed by the facility wound nurse. -No provider notes or assessments provided by the facility documented an assessment of the wound to the resident's left heel until 8/14/24. -On 8/14/24 a visit showed the pressure ulcer to the left heel measuring 3.2cm long, 4.2cm wide and an unknown depth. The wound was 100% hard necrotic tissue and marked present on admission. Review of an attached progress note by NP A showed the wound was an unstageable pressure ulcer (a wound that is covered in necrotic tissue that prevents the assessment of the wound depth, but if the tissue was removed would reveal a Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling) or IV pressure ulcer (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) Observation on 8/19/24 at 9:34 A.M., showed the resident was lying in bed without a low air loss mattress in place and with no Prevalon boots. Observation on 8/21/24 at 9:52 A.M., of wound rounds with NP A and Assistant Director of Nursing (ADON) A showed: -NP A and ADON A assessed the resident's wound. At this time, the wound measured 4.3cm long (an increase of 0.9cm), 6.5cm wide (an increase of 2.3cm) and an unknown depth. The wound was 85% hard necrotic tissue, but now had a surrounding border of broken-down skin appearing red (10%) and with 5% slough (a yellow material made up of dead cells). The resident did not have a low air loss mattress at this time. During an interview on 8/21/24 at 9:53 A.M., NP A said the resident's wound was worsening. During an interview on 8/21/24 at 10:30 A.M., NP A said: -Wound rounds were a focused assessment, not all skin was evaluated. -He/She and other NPs make progress notes each time they see a resident for wounds. -Skin assessments should have been completed at least once per week. -All wound assessments should have measurements and a full description of the wound. -He/She believed Resident #74's wound was present on admission. -He/She would expect documentation of the wound with a full assessment as soon as the wound was noted. -He/She would expect orders for prevention and treatment to be implemented immediately after the identification of a skin integrity impairment. -He/She would expect all physician orders to be carried out by staff including the implementation of a low air loss mattress. During an interview on 8/22/24 at 8:22 A.M., the Director of Nursing (DON) said Resident #74: -Did not have a low air loss mattress in place. -Should have had one on the bed. During an interview on 8/23/24 at 8:54 A.M., Certified Nursing Aide (CNA) F said: -He/She was aware the resident had a pressure ulcer. -Nurses did wound treatments to the resident's foot daily. -CNA's and other staff tried to ensure the resident's heels were elevated off the bed. -He/She was unaware of a low air loss mattress for the resident. During an interview on 8/23/24 at 11:38 A.M., ADON A said: -He/She was responsible for the wound care in the facility. -Skin assessments populated weekly, and the floor nurses were responsible for doing them. -Weekly skin assessments should have listed every skin condition the resident had along with a full assessment including wound measurements. -Stage I pressure ulcers and other identified redness were not monitored by the facility because they could heal within a few weeks and would take too long to document on. -He/She was not wound care certified. -If a wound was identified by nursing staff, orders for prevention and treatment would have been put in up to 72 hours after identification when he/she had a chance to evaluate the wound. -No skin or pressure ulcer treatments should lack documentation. -A lack of documentation on an order in the medical record indicated the treatment was not done. -There should have been a low air loss mattress in place for Resident #74, and any refusals of interventions should have been documented. -Since redness was documented on Resident #74 on admission, the unstageable pressure ulcer to the left heel would be either recurring or worsening, not a facility acquired ulcer. 2. Review of Resident #1's face sheet showed the resident admitted with the following diagnoses: -Quadriplegia (paralysis of all four extremities and usually the trunk). -Osteomyelitis (an infection in a bone) of right upper arm. -Pressure injury/ulcer right elbow. Review of the resident's Hospital Discharge summary dated [DATE] at 4:24 P.M., showed: -The resident had documentation that he/she had wounds noted on 6/14/24 while in the community and was admitted to the hospital with worsening wounds on 7/18/24. -The resident was discharged from the hospital on 8/1/24 and admitted to the facility with pressure wounds. -Wound #1, was unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) on the left buttocks. The wound measurements at that time were length (L) of 3.5 cm by width (W) of 2.0 cm by depth (D) of 0.5 cm. The wound bed was moist, yellow, slough and pale pink in color. -Wound #2 was a Stage IV pressure injury (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling) on the left hip. The wound bed was moist with yellow slough and was the shape of an oval. The wound measurements were L of 1.5 cm by W of 2 cm by D of 0.8 cm. -Wound #3, was a Stage IV pressure injury on the right buttocks, The wound bed was moist, with yellow slough, and pale pink in color. The wound measurements were L of 4.0 cm by W of 2.5 cm by D of 2 cm. -Wound #4 on the right elbow presented as a pressure injury. The resident had surgery on the elbow area which made it a new surgical wound. Review of the resident's nursing evaluation for admission dated 8/2/24 at 12:29 A.M. showed: -The resident admitted to the facility on [DATE] at 4:30 P.M. -Staff should document the impairment site and the initial wound measurements. -Documentation of a large wound to right buttocks, left buttocks, and left hip, a surgical wound to the right elbow wound where he/she underwent debridement (the removal of dead tissue) and was closed with sutures. -There were no initial wound measurements transcribed to the initial skin assessment form or in the comments note. Review of the resident's Physician Order Sheet (POS) dated 8/2/24 at 3:12 P.M. showed: -Wound care to the resident's right and left buttocks and left hip: cleanse with normal saline, pat dry, apply Dakin's solution (used to kill germs and prevent germ growth in wounds) soaked gauze, cover with an Abdominal (ABD, is a gauze dressing that absorbs fluid from large or heavily draining wounds) dressing pad and secure with tape, every shift for wound care and as needed for missing or soiled dressing. Review of the resident's wound care plan initiated on 8/2/24 showed: -The resident was at risk for alteration in skin integrity. --Provide skin/wound treatments as ordered. Review of the resident's TAR dated 8/1/24 to 8/23/24 showed: -Order dated 8/2/24 at 3:12 P.M., for wound care treatment to the resident's right buttocks, left buttocks and left hip: nursing staff were to cleanse wounds with normal saline, pat dry, apply Dakin's-soaked gauze, cover with ABD and secure with tape, every shift for wound care and as needed for missing or soiled dressing. --No documentation of wound care treatment completed on admission and 8/2/24. Review of the resident's medical record dated 8/1/24 to 8/7/24 showed there was no documentation of a comprehensive wound assessment that included wound measurements and detailed descriptions of the wounds upon admission to the facility. Review of the resident's wound care plan initiated on 8/7/24 showed the resident had an actual impairment to skin integrity related to pressure injury to the left buttock, left hip, right buttock, and right elbow. Review of the resident's POS dated 8/8/24 showed the resident was to have weekly skin checks on Thursday during the day shift. Must open and document the skin evaluation for each resident assessment (including no new areas found). Review of the resident's TAR dated 8/8/24 showed the resident's weekly skin observation/assessment to be completed on 8/8/24 had no nursing initial or check mark documented to indicate the assessment was completed. Review of the resident's weekly skin observation/assessment dated [DATE] showed: -Nursing documented the resident had pressure wounds to bilateral buttocks, left hip, and a surgical wound on his/her right elbow. -Did not have a comprehensive wound assessment of the resident's wound to include wound measurements and detail description of the wounds. Review of the resident's NP wound encounter note dated 8/14/24 at 3:37 P.M., showed: -The resident had a diagnosis that included infection, irrigation debridement of right upper extremity. -Was seen for wound rounds. --The resident who was recently admitted to hospital on [DATE] for worsening wound infections from community. He/she did have a medical history of quadriplegia secondary to driving accident many years ago and was wheelchair-bound with muscle spasms. He/she also presented with complaints of chills and not feeling well and drainage from his/her right elbow. Patient was found to have a wound of his/her right elbow as well as three separate wounds on his/her buttocks and coccyx. His/her elbow wound did require surgical debridement by an orthopedist while at the hospital. Patient was initially started on antibiotic for elbow wound. No surgical interventions were necessitated on resident's buttock and coccyx wounds. Patient was ultimately started on Intravenous (IV) antibiotic daily and would continue this through 9/7/24. The resident was ultimately stabilized and deemed appropriate for discharge to a skilled nursing care facility on 8/1/24. -The resident had three pressure injuries on his/her left and right buttocks and coccyx region. Furthermore, he/she had a new surgical wound to his/her right elbow. The pressure injury of his/her left and right buttocks and coccyx regions were deep with undermining (the destruction of tissue or ulceration extending under the skin edges so that the pressure is larger at its base than at the skin surface. Undermining often develops from shearing forces and is differentiated from tunneling by the larger extent of the wound edge involved in undermining and the absence of a channel or tract extending from the pressure ulcer under the adjacent intact skin). They did not have heavy exudate however the current treatment included Dakin's solution they are considered to be wet. There was slough within the wound beds however there did not appear to be a concern for infection at that time. The resident did not endorse significant pain to any of the sites. -The resident's skin included three pressure injury/wounds to his/her left and right buttocks and coccyx regions, with a new surgical wound to the right elbow. -Wound #1 Stage IV pressure injury on his/her left buttock, measured Length of 5.30 cm by Width of 4.00 cm By Depth of 0.50 cm. --Base: Epithelial (Pale Pink or Red) at 70% and Slough Loosely Adherent at 30%. Had clear serous drainage. -Wound #2 Stage IV pressure injury on left hip measured L of 2.50 cm by W of 4.00 cm and D of 0.90 cm. --Had Undermining at 9 o'clock to 1 o'clock with a depth of 3.90 cm. --Base epithelial (pale pink or red) at 20%, Bright Pink or Red at 30% and Slough Loosely Adherent at 50%. Had clear serous drainage. -Wound #3 right buttock stage IV pressure injury. Measurement of L of 3.00 cm by W of 2.60 cm and D of 2.10 cm. Had undermining at 9 o'clock to 1 o'clock and d of 6.60 cm. --Base of wound had epithelial at 10%, bright pink or red at 5% and slough loosely adherent at 85%. Had clear serous drainage. -Cleanse the wounds with normal saline and primary dressing: Cleanse with normal saline, pat dry, skin prep peri wound, pack with Dakin's soaked gauze, cover with ABD and secure with tape. -Wound #4 now a surgical wound on right elbow. --Closed well-approximated at 100%. --Measurement of size L at 7.00 cm by W of 0.20 cm and D of 0.00 cm --Intact Skin: 100% --Cleanse with normal saline, pat dry, apply Xeroform ( sterile, non-adherent gauze dressing that's used to cover and protect wounds, abrasions, and burns), cover with ABD Kerlix, and secure with Ace wrap. -Plan: Surgical wound right elbow: Cleanse with normal saline, pat dry, apply xeroform, cover with ABD Kerlix, and secure with Ace. Three pressure ulcers of left and right buttocks and coccyx region: Cleanse with normal saline, pat dry, skin prep peri wound, pack with Dakin's soaked gauze, cover with ABD and secure with tape. Continue Intravenous (IV) Daptomycin (antibiotic) 500 milligram (mg) per IV daily. Review of the resident's wound round documentation written by the wound nurse dated 8/21/2024 at 7:32 A.M., showed: -Wound #1 Stage IV pressure injury on left buttock, measured Length of 5.30 cm by Width of 4.00 cm By Depth of 0.50 cm --Base: Epithelial (Pale Pink or Red) at 70% and Slough Loosely Adherent at 30%. Had clear serous drainage. -Wound #2 Stage IV pressure injury on left hip measured Length of 2.50 cm by Width of 4.00 cm and Depth of 0.90 cm --Had Undermining at 9 o'clock to 1 o'clock /with depth of 3.90 cm --Base Epithelial (Pale Pink or Red) at 20%, Bright Pink or Red at 30% and Slough Loosely Adherent at 50%. Had clear serous drainage. -Wound #3 stage IV pressure injury on right buttock, Measure Length of 3.00 cm by Width of 2.60 cm and Depth of 2.10 cm. Had undermining at 9 o'clock to 1 o'clock and depth of 6.60 cm --Base of wound had Epithelial (Pale Pink or Red) at 10%, Bright Pink or Red at 5% and Slough Loosely Adherent at 85%. Had clear serous drainage. -NOTE: the documentation had the same measurements and descriptions the resident's NP wound note dated 8/14/24. During an interview on 8/21/24 at 11:47 A.M., the resident said: -He/she did not have wound care treatment completed on the morning of 8/21/24. -He/she was informed the wound nurses would complete treatment after lunch time that day. -He/she thought nursing reported his/her wounds were improving. -Nursing staff were completing wound care twice a day or as needed. Observation on 8/21/24 at 1:45 P.M., of the resident's wound care showed: -Wound nurse and NP provided assessment and care of the resident wounds. -Had barrier for supplies, staff washed hands and applied gown and gloves for wound care. -NP removed old dressing dated 8/20/24 and measured each wound area. -The resident's right buttock wound was size of a golf ball and measured L 2.5 cm by W of 3.7 cm by D of 1.3 cm. Had undermining from 11 o'clock to 1 o'clock with tunneling of 4.4 cm at deepest area. -The left hip wound was about golf ball size, and measured L of 2.5 by W of 3.7 by D of 0.8, had undermining from 9 o'clock to 12 o'clock with tunneling of 2.2 cm at the deepest area. -The left buttock wound was about [NAME] size, and measured L of 5.3 by W of 4.0 by D of 0.6, had undermining from 12 o'clock to 3 o'clock, with tunneling of 0.9 at deepest area. The wound had white outer edges, inner edges pink, cream color inner wound and was healing muscle base. -NP said all wounds appeared to be improving and had no excessive drainage noted. -The resident's right elbow was a healed surgical wound. Preventive treatment with padding noted. -Wound Nurse took pictures of each of the wounds and recorded measurements to be uploaded into the resident's electronic record under wound rounds. -Wound nurse cleansed each wound with normal saline, pat dry, then applied Dakin's soaked gauze pad in wounds, covered with ABD and secured with dressing. Review of resident's wound documentation showed: - On 8/22/24 at 9:04 A.M., the facility provided wound care documentation and pictures of the resident's wounds dated 8/7/24, 8/14/24 and 8/21/24 that were not accessible to surveyor. -The resident did not have documentation upon admission of a comprehensive initial wound assessment that included measurements and descriptions of all the wounds by facility nursing staff or wound nurse. During an interview on 8/21/24 at 10:31 A.M., NP A said: -The facility had a dedicated wound round documentation section. The NP and physician were able to review wound rounds for monitoring active wounds or reoccurring wounds. -He/she would do wound rounds only for open active wounds. -The facility had just completed a facility wide wound and skin assessment for all residents at the facility. -The NP and physician wound round templates flowed into the NP/physician progress notes. -Wound rounds included measurements of the wound by the NP and the wound nurse transcribed the wound measurements and descriptions of the wounds in the wound rounds report. -Weekly skin assessments were to be completed by nursing staff for those residents who were at high risk for skin issues. -The charge nurse would be responsible for completing the resident's weekly skin observations and documenting them in the electronic record. -He/she had not seen Resident #1 related to his/her wounds.