**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility staff failed to routinely assess one resident's skin (Resident #4) under a [NAME] brace (hard brace used to stabilize a fracture to the upper arm while leaving the elbow free, allowing motion in the forearm and hand), causing a Stage IV pressure ulcer to develop to the resident's left upper arm. Furthermore, facility staff failed to notify the resident's physician for two days after the pressure ulcer was identified to obtain treatment orders. In addition, facility staff failed to keep the resident's air mattress set at the recommended setting, causing the mattress to be too firm. Further, facility staff failed to notify the physician when one resident's (Resident #221) unstageable coccyx (tailbone) wound deteriorated and obtain a dietary consult for the resident. Additionally, facility staff failed to accurately stage, and perform complete assessments for multiple pressure injuries and failed to accurately classify a wound as a pressure injury. The facility census was 75. The administrator was notified on 3/29/21 at 12:30 P.M. of an Immediate Jeopardy (IJ) which began on 3/1/21. The IJ was removed on 3/29/21, as confirmed by surveyor onsite verification. Review of Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, defined the following: -Pressure ulcer/injury: localized injury to the skin and/or underlying tissue, usually over a bony prominence as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful; -Stage I pressure injury: an observable, pressure-related alteration of intact skin whose indicators, as compared to an adjacent or opposite area on the body, may include changes in one or more of the following parameters: skin temperature (warmth or coolness), tissue consistency (firm or boggy), sensation (pain, itching) and/or a defined area of persistent redness; -Stage II pressure ulcer: partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red-pink wound bed, without slough (non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture) or bruising. May also present as an intact or open/ruptured blister; -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; -Stage IV pressure ulcer: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar (dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like) may be present on some parts of the wound bed; -Unstageable pressure ulcer: Known but not stageable due to coverage of the wound bed by slough and/or eschar. Pressure ulcers that are covered with slough and/or eschar, and the wound bed cannot be visualized, -Epithelial tissue: New skin that is light pink and shiny (even in persons with darkly pigmented skin). In Stage two pressure ulcers, epithelial tissue is seen in the center and at the edges of the ulcer. In full thickness Stage III and IV pressure ulcers, epithelial tissue advances from the edges of the wound. -Granulating tissue: Red tissue with cobblestone or bumpy appearance; bleeds easily when injured; -Undermining: The destruction of tissue or ulceration extending under the skin edges (margins) so that the pressure ulcer is larger at its base than at the skin surface; -Slough: Non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed. -Eschar: Dead or devitalized tissue that is hard or soft in texture; usually black, brown, or tan in color, and may appear scab-like. Necrotic tissue and eschar are usually firmly adherent to the base of the wound and often the sides/ edges of the wound. -Deep tissue injury: Purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer or cooler as compared to adjacent tissue. 1. Review of the facility's Protocol for Certified Nursing Assistant (CNA) & Licensed Nurse Skin Inspections, dated 10/1/10, provided the following guidelines for staff: -CNAs will conduct body inspections of residents at risk for pressure sores on a daily basis. Results of the inspection will be documented on the body audit sheet or in Smart Charting beside appropriate resident's name; -Licensed nurses will conduct body inspection of residents at risk for pressure sores on a weekly basis. Any skin concerns will be reported to the designated treatment nurse immediately for evaluation and treatment orders. If the treatment nurse is unavailable, the nurse identifying the concern should evaluate the wound and notify the MD for initial treatment orders. -Pressure ulcers will be assessed at least weekly by a trained registered nurse (RN) as part of the interdisciplinary team review; -Residents at greater risk for development of pressure ulcers include, but is not limited to the following: history of pressure ulcer, immobility, decreased functional ability, under-nourished, malnutrition, hydration deficits, associated diagnosis/co-morbidities and skin changes; -Infections should be treated as necessary; -The physician should be informed of the presence of a pressure ulcer, or the failure of an ulcer to respond to treatment; -The status of ulcers should be recorded on the Wound Flow Record weekly; -The Dietary Manager should be consulted to assist with interventions; actions are recorded in the dietary progress notes; -Observations pertinent to the resident's skin status should be recorded in the nurse's notes, as appropriate; -The interdisciplinary team communicates plan of care instructions to staff. The interdisciplinary team consists of the Director of Nursing (DON)/designated RN, wound care nurse, restorative nurse designee, and dietary manager. 2. Review of Resident #4's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 11/28/20, showed staff assessed the resident as follows: -Active diagnoses of severe protein-calorie malnutrition (inadequate intake of calories), alcohol abuse, osteoporosis (bones become weak and brittle), and chronic obstructive pulmonary disease (COPD-progressive lung disorders characterized by increasing breathlessness); -Short and long term memory problems; -Required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene; -Dependent on staff for locomotion; -One facility acquired Stage II pressure ulcer; -Always incontinent of bladder and bowel; -Weighed 114 pounds (lbs). Review of the resident's Left Arm Fracture care plan, dated 12/4/20, showed it instructed staff as follows: -Elevate affected extremity as indicated for comfort, and to decrease/prevent edema; -Observe for signs and symptoms of decreased circulation of the affected extremity; -Maintain immobilization of the affected extremity; -Observe skin condition during care rounds; -Observe site for signs and symptoms of infection; -Monitor placement of immobilizer. Review of the Skin Breakdown care plan, dated 12/17/20, showed the resident had a total of 13 pressure ulcers. Further review, showed the care plan instructed staff as follows: -Provide pillows or other supportive/protective devices to assist with positioning; -Turn and reposition per resident's individual turning schedule; -Provide pressure reducing surfaces on the bed and chair; -Assist with repositioning to avoid friction/shearing; -Avoid use of restrictive clothing; -Perform wound care as ordered; -Assess wound healing weekly; -Full skin evaluation with bath/shower; -Assess skin daily with routine care; -Assess changes in skin status that indicate worsening of pressure ulcer and notify the physician; -Maintain head of bed at less than 30 degrees; -Reassess treatment plan. If not healing within two to four weeks; -Provide incontinent care as needed. Additional review of the Left Arm Fracture and Skin Breakdown care plans showed they did not contain direction for the staff in regards to the alternating air mattress or [NAME] brace. During an interview on 3/9/21 at 5:47 P.M., the MDS coordinator said the settings for the air mattress should be on the care plan, but he/she did not know what the setting should be. He/She said the resident's [NAME] brace should have been on the care plan, but he/she did not know the resident had one. He/she is normally made aware of new orders through morning meeting and by reviewing nurse's notes, and orders. He/she said he/she did not see the order. Review of the resident's CNA New Skin Audit Report Roster, dated 11/1/20-2/28/21, showed: -Staff failed to complete a report on 11/1, 11/6, 11/11, 11/13, 11/14, 11/18, 11/30, 12/11, 12/20, 12/25/20, 1/6/21, 1/15, 2/2, 2/10, 2/17, 2/22, and 2/28/21; -On 11/10/20, the resident had a new skin problem and the nurse was notified; -Staff documented no new skin problems for all other entries. During an interview on 3/10/21 at 2:10 P.M., the Director of Nursing (DON) said staff typically put the specialty mattress on the care plan. Additionally, he/she said the [NAME] brace should have been on the care plan. During an interview on 3/5/21 at 11:55 A.M., the hospice CNA said he/she did not remove the resident's brace when he/she gave the resident a bath. Furthermore, he/she said he/she was told by a nurse at the facility to wash around the brace. Observation on 3/1/21 at 2:34 P.M., showed the resident lay on an alternating air mattress with raised edges, with his/her legs drawn up to the left side of his/her chest. The head of the bed was elevated 45 degrees. His/her back laid flat against the bed and he/she was bent at the neck. Further observation, showed the resident had a hard plastic brace on his/her left shoulder that was up towards his/her jaw. The air mattress was set to 325 lbs, and was firm to the touch. Observation on 3/2/21 at 12:00 P.M., showed the resident lay in bed. Further observation, showed a dressing on the resident's upper left arm, dated 3/1, and an immobilizer strapped around the resident's chest that held his/her left arm to his/her chest. Additional observation, showed the hard, plastic brace on the resident's bedside table, and the air mattress was set to 325 lbs. During an interview on 3/3/21 at 9:00 A.M., hospice licensed practical nurse (LPN) AA said the durable medical equipment (DME) company is responsible for setting up the air mattresses. He/she said the mattresses are set to the resident's weight, and facility staff can adjust the mattress if it needs to be softer or harder. He/she went on to say, the resident's first wound was small, and he/she was placed on an air mattress after his/her first wound was identified. LPN AA said he/she did not like the brace the facility used on the resident's left arm, because it did not seem to fit. During an interview on 3/3/21 at 4:00 P.M., LPN F said hospice is responsible for the settings on the resident's air mattress. He/she thought the setting went by the resident's weight. Furthermore, he/she said he/she had adjusted the setting on the bed before and it would be changed back when he/she would come back to the room. Review of the dietician notes, dated 3/3/21 at 3:41 P.M., showed the resident's current body weight was 91 lbs, a 29 percent weight loss in five months, most occurring in the last 60 days. During an interview on 3/5/21 at 11:45 A.M., the Hospice Coordinator, who provided the resident's air mattress, said they had not been setting up the mattresses since the pandemic. He/She said the air mattress should be set by resident weight, and needed to be turned down if the resident weighed between 90-100 pounds and the mattress was set on 325 lbs. Observation and interview with LPN F on 3/3/21 at 2:50 P.M., showed the resident lay in bed with his/her knees drawn up to the left side of his/her chest. The resident wore an immobilizer on his/her left arm and the [NAME] brace was on a bedside table. Observation showed the resident's air mattress was set on 325 lbs. The resident had a bandage on his/her upper left arm dated 3/1, approximately 12 to 15 centimeters (cm) below his/her shoulder. LPN F, the facility's wound nurse, said the bandage was new. He/she said he/she did not know what was under the bandage, and did not have a treatment order for it. LPN F removed the dressing on the upper left arm revealing a pressure ulcer, 0.7 cm L (length) x 1 cm W (width) x 0.2 cm D (depth). Bone was visible in the center of the ulcer. The area surrounding the ulcer was deformed from a previous fracture. LPN F covered the area with a foam dressing until he/she could reach the physician for further orders. Further observation, showed the resident had two pressure ulcers on his/her left outer elbow. Pressure ulcer number one was a Stage II, 0.3 cm L x 0.7 cm W, depth superficial (shallow). Pressure ulcer number two was a Stage III, 1.3 cm L x 1.8 cm W, approximately 50 percent covered with brown slough. Review of the resident's Wound Assessment Reports, dated 3/3/21, showed staff assessed the resident as follows: -Left elbow ulcer number one Stage II wound bed 100 percent granulation tissue; -Left elbow ulcer number two Stage II wound bed 100 percent covered by epithelial tissue; -Left upper arm Stage IV ulcer wound bed 100 percent granulation tissue. Review of the resident's nurse's notes showed staff documented the following: -On 3/3/21 at 5:42 P.M., the physician was notified of a wound caused by the [NAME] brace. New orders were received to discontinue the brace. The physician said he/she did not think the brace was effective. New orders were received for Bactroban ointment (antibiotic ointment) to wound, cover with foam, and to splint with a board splint (a strip of rigid material used for supporting and immobilizing a broken bone), and secure with gauze and Coban (self-adherent compression bandage), or ACE wrap (elastic bandage). -On 3/3/21 at 9:48 P.M., late entry: at approximately midnight of 3/2/21, the nurse was called to asses a wound found by staff after they had removed the brace on the resident's left upper arm and shoulder. The open wound was cleaned with wound cleanser (WC) and covered with Tegaderm foam dressing. The nurse felt the wound should be assessed by an RN or another nurse better versed in designing wound treatments. Staff were advised to leave the brace off until the wound could be reassessed. Observation on 3/4/21 08:29 A.M., showed the resident lay in his/her bed, and on his/her back. Additional observation, showed the air mattress was set on 325 lbs. During an interview on 3/4/21 at 10:08 A.M., RN E said the resident got the [NAME] brace after his/her arm fracture. RN E said by the time it was fitted, staff were told to leave it on. He/She said the brace had a protective sleeve underneath it that could be taken off to wash when it became soiled. He/she did not know how often the sleeve was changed and there was not a set schedule. He/she went on to say he/she did not know if staff were looking at the skin unless the brace needed adjusted. During an interview on 3/4/21 at 9:59 A.M., CNA O said the CNAs never took the brace off, because they were told to keep it on. He/She said staff were supposed to monitor to make sure there was no skin breakdown underneath the brace, so when staff noticed the skin started to breakdown they put a cloth protector underneath it. He/She said the skin under the brace was red and starting to breakdown about a month ago. During an interview on 3/4/21 at 12:35 P.M., LPN F said it had been a while, probably December, since staff first noticed the brace on the resident's left arm was causing pressure. He/she said staff were supposed to do weekly skin checks. Furthermore, he/she said he/she was not aware of an order to remove the brace and assess the skin under the brace. During an interview on 3/4/21 at 4:50 P.M., LPN F said he/she had not called the resident's physician regarding the resident's wounds, and had not requested any treatment changes. During an interview on 3/4/21 10:49 A.M., the DON said he/she was not aware the resident had a Stage IV pressure ulcer on his/her left arm until yesterday. He/she said the nurses are supposed to let him/her know, as well as complete body audits. He/she said he/she looks at the body audits daily and there was nothing new charted on them. He/she said he/she called the nurse who put the dressing on the resident's arm on 3/1/21 and the nurse told him/her he/she forgot about it. Furthermore, he/she said the physician was made aware of the pressure sore on the resident's left arm last night. He/she said his/her expectations for skin care was the CNAs were to look for redness around the brace daily and licensed nurses were to check under it weekly and complete a weekly skin audit. He/She said staff did not document when they found the wound under the brace. Additionally, he/she said the air mattress setting should be set at the resident's weight and the nurses or hospice should adjust it when they come in. He/she said hospice was supposed to let the facility know the setting and it should be in with air mattress order. He/she was not aware the air mattress had been on 325 lbs this week. Observation during the interview, showed the DON walked to the resident's room, touched the bed, and said the resident's bed was a little firm. He/she turned the bed down to the resident's weight. During an interview on 3/4/21 at 4:15 P.M., the resident's physician said the resident originally came back from the hospital with an immobilizer and it was changed to the [NAME] brace. He/she said it took three to four weeks to get the brace after the resident was fitted for it and it did not look like the brace fit well. He/she said he/she was not aware there was any skin breakdown under the resident's brace on his/her left arm until 3/3/21. Furthermore, he/she said the nurses should have looked under the brace once a week or so. He/she said the nurses could have reached out to Physical Therapy (PT) if they did not feel comfortable messing with the brace. He/she also said he/she felt the current treatment was sufficient because the brace needed to come off. He/she said he/she suspected if the air mattress was set on 325 pounds it could have led to further skin breakdown since the resident weighed much less than that. 3. Review of Resident #221's admission MDS, dated [DATE], showed staff assessed the resident as: -admitted on [DATE]; -Did not exhibit rejection of care; -Required total assistance of two staff members for bed mobility, transfers, and toilet use; -Not capable of increased independence in at least some activities of daily living (ADLs); -Active diagnoses of atrial fibrillation, hypertension (high blood pressure), septicemia (bacterial infection that spreads throughout the body), urinary tract infection, diabetes, cerebrovascular accident (damage to the brain from interruption of its blood supply), and hemiplegia (paralysis of one side of the body); -Three unstageable pressure ulcers; -Received insulin and antibiotics; -Received intravenous (IV) (technique that delivers medications directly into a person's vein) medications. Review of the resident's nurse's notes, dated 2/25/21 showed the resident was admitted to the facility with a suspected deep tissue injury (SDTI) on his/her right heel, an unstageable pressure ulcer on his/her left hip, and an unstageable pressure ulcer on his/her coccyx. Review of the Wound Assessment Report, dated 2/25/21, showed facility staff assessed a pressure ulcer on the resident's sacrum (tailbone). Additional review showed staff measured the wound as 10 cm L by (x) 4.5 cm W. The pressure ulcer was listed as unstageable due to slough and eschar. Review of the Resident Risk Review for Pressure Ulcers, dated 2/26/21, showed LPN CC assessed the resident had a previous skin ulcer, was debilitated (weak), and had impaired or decreased mobility and functional ability. He/She identified the resident as being at risk of developing pressure ulcers. Review of the Dietary Communication Form, dated 2/26/21, showed LPN CC ordered the resident a mechanical soft (designed for people who have trouble chewing and swallowing), consistent carbohydrate (focus is on eating the same amount of carbohydrates every day) diet. Further review, showed it did not contain communication with the Dietician, or further evaluation from the Dietary Manager (DM). Review of the resident's care plan, dated 3/4/21, showed staff were directed as follows: -Refer to dietician for evaluation of current nutritional status; -Assess changes in the resident's skin status that indicate worsening of pressure ulcer and notify the physician; -Registered Dietician consult as needed; Review of the POS, dated March 2021, showed the following orders: -Cleanse the sacrum with normal saline (NS) or WC, pat the site dry, apply a barrier film (waterproof barrier to protect the peri-wound (tissue surrounding a wound) skin and acts as a protective barrier against fluids, waste, perspiration, and friction), apply a thick layer of silver alginate (absorbent dressing that protects the wound from infections and maintains a moist environment that promotes quicker and more efficient healing) to wound bed, and cover with medipore (tape used to secure wound dressings) daily until healed. Review of the resident's Wound Assessment Report, dated 3/3/21, showed staff measured the sacral wound as 11.5 cm L x 7.7 cm W, and noted a moderate amount of purulent drainage. Staff identified the wound had deteriorated. Additional review showed the physician was not notified of the drainage, or the deterioration. Observation on 3/4/21 at 12:38 P.M., showed LPN F perform wound care on the resident while he/she was lying in bed. LPN F removed a green saturated dressing from the resident's sacrum. The wound had green drainage and was covered with slough and eschar. The wound had a purulent odor (pungent, foul, or musty). Review of the nurse's notes, dated 3/4/21, showed facility staff did not notify the physician of the green purulent drainage from the resident's sacral wound. Review of the Wound Assessment Report, dated 3/10/21, showed the resident's sacral wound had a moderate amount of purulent drainage. Further review showed the physician was not notified of the drainage from the wound. Review of the nurses's notes, dated 3/10/21, showed facility staff did not notify the physician of the purulent drainage. Review of the resident's Wound Assessment Report, dated 3/17/21, showed staff documented the resident's wound had deteriorated and measured 15.4 cm L x 9.7 cm W. Staff noted a large amount of exudate from the wound and the silver alginate was no longer in place and saturated with drainage. Staff contacted the resident's physician 14 days after they identified the resident's wound started to deteriorate. Review of the resident's Discharge MDS, dated [DATE], showed the resident was discharged to the hospital, three days after the facility informed the physician of the resident's deteriorated wound. During an interview on 3/23/21 at 2:47 P.M., the Social Worker (SW) at the Veteran Affairs (VA) Hospital said the resident was initially sent to [NAME] Hospital in Sedalia for complaints of shortness of breath (SOB) and chest pain. Furthermore he/she said the resident was transferred to the VA Hospital for shortness of breath secondary to sepsis (extreme response to infection). During an interview on 3/23/21 at 3:00 P.M., an RN at the VA Hospital said the general surgery team had been in the process of debriding (surgical removal of dead tissue) the sacral wound. He/She said the wound has become a massive, gaping hole and they are unable to stage the wound due to its depth. During an interview on 3/24/21 at 3:21 P.M., CNA J said the sacral wound became more foul-smelling as the wound got bigger. During an interview on 3/24/21 at 3:42 P.M., LPN F said the admitting nurse is responsible for documenting wound measurements, filling out the initial Wound Healing Progress Report, and entering treatment orders. LPN F said if an order is not working for a wound, he/she will change the orders after contacting the physician to discuss treatment options. He/she said on 3/17 the resident's wound was macerated (skin looks soggy, feels soft, or appears whiter than usual). He/she said the silver alginate was not being used to cover the wound bed so he/she revised the original order to say a thick layer of the silver alginate should cover the wound. LPN F said when a wound deteriorates, he/she notifies the physician and he/she notified the ADON of the resident's wound deterioration. During an interview on 3/24/21 at 4:15 P.M., the ADON said the admitting nurse is responsible for entering orders for new residents. He/she said the orders are determined based on the initial wound measurements and the facility wound protocol policy. He/she went on to say the admitting nurse is expected to assess the resident and discuss treatment options with the resident's physician. He/She said if a resident's wound deteriorates, the nurse is expected to notify the physician and find another treatment option. He/She said he/she would expect staff to involve dietary for help in treatment as well. He/she said he/she did not visualize the resident's wounds during his stay at the facility. During an interview on 3/25/21 at 12:06 P.M., the resident's physician said he/she usually allows the wound care nurse to assess a resident and contact him/her to discuss treatment options, and if a resident's wound deteriorates, he/she would recommend sending the resident to the wound clinic. Additionally, he/she said he/she would expect a dietary consult to be completed to promote wound healing. During an interview on 3/29/21 at 1:37 P.M., the Dietician said he/she had not seen the resident while he/she was at the facility and he/she was not informed this resident had wounds. He/She expects staff to inform him/her of resident's wounds and when consultations are ordered. Furthermore, he/she said he/she is available by phone if the staff need assistance with care for a resident or recommendations for care. During an interview on 3/29/21 at 2:35 P.M., the ADON said he/she does not know why dietary was not involved in this resident's care. Furthermore, the ADON said he/she expects any communication with the physician to be documented in nurse's notes or the wound assessment module. During an interview on 3/29/21 at 2:39 P.M., the Administrator said when the facility admits a new resident, the dietary manager is notified and a user-defined assessment is completed. During an interview on 3/30/21 at 3:02 P.M., the MDS Coordinator said the User Defined Assessment for dietary staff, is completed with each MDS assessment. During an interview on 3/30/21 at 3:10 P.M., the DON said the Dietary Manager usually talks to residents upon admission to the facility. He/she said the Dietary Communication Form is filled out by the admitting nurse when a new resident arrives to the facility. The DON said the Dietary Manager usually approaches a new resident after his/her admission and then he/she fills out the user-defined assessment. During an interview on 4/6/21 at 3:50 P.M., the resident's physician said he/she did not see the resident's pressure sores. He/she went on to say he/she did not know why a dietary consult would not have helped with wound healing. During an interview on 3/29/21 at 3:09 P.M., the Social Worker at the VA Hospital said the resident's family decided to pursue comfort care measures for the resident. The Social Worker said the resident was transferred to comfort care due to wound sepsis. He/she said the resident will be discharged with hospice care and the resident's admitting diagnosis for hospice is respiratory failure and his/her large sacral ulcer. 4. Review of the facility's Pressure Ulcer policy, dated 10/1/10, instructed staff as follows: -Pressure ulcers cannot be adequately staged when covered with eschar or necrotic (dead) tissue. In compliance with federal guidelines, these ulcers should be staged as unstageable and should be noted in the wound care record, unable to determine depth. However, if the wound bed is partially covered by eschar or slough, but the depth of the tissue loss can be measured, do not code as unstageable; -As wounds progress through the various stages of healing, it should be noted that they are not reverse staged, due to the requirements of the MDS, but are actually healing ulcers of the most severe stage they were previously; -Pressure ulcers will be assessed at least weekly by a trained registered nurse (RN) as part of the interdisciplinary team review; -Residents at greater risk for development of pressure ulcers include, but is not limited to the following: history of pressure ulcer, immobility, decreased functional ability, under-nourished, malnutrition, hydration deficits, associated diagnosis/co-morbidities and skin changes; -Debriding (removing of dead tissue from a wound) agents should be used only when non-viable tissue is present (eschar, necrosis) and per medical doctor (MD) order; -Products should be selected based upon wound characteristics and treatment goals; -The physician should be informed of the presence of a pressure ulcer, or the failure of an ulcer to respond to treatment; -The status of ulcers should be recorded on the Wound Flow Record weekly. Review of Resident #4's Significant Change Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 11/28/20, showed staff assessed the resident as follows: -Active diagnoses of severe protein-calorie malnutrition, alcohol abuse, osteoporosis, and chronic obstructive pulmonary disease (COPD); -Required extensive assistance of two staff members for bed mobility, transfers, dressing, toilet use, and personal hygiene; -One facility acquired Stage II pressure ulcer. Review of the resident's Wound Assessment Report, dated 12/12/20, showed staff documented a newly identified pressure ulcer on the resident's sacrum/coccyx and assessed the wound as follows: -Unstageable due to slough/eschar; -No pain with wound treatment; -No infection; -Wound bed 100 percent granulation tissue; -Measured 6.2 cm L by (x) 5.7cm W x 0.0 cm D; -Wound edges with well defined boarders and normal, healthy skin; -Moderate amount of serous (thin, watery) drainage; -Further review showed staff failed to provide an accurate stage and depth for the wound. Review of the Skin Breakdown care plan, dated 12/17/20, showed the resident had a total of 13 pressure ulcers. The resident had one on his/her left calf/Achilles (lowest part of calf extending into the ankle), two on his/her left elbow, one on his/her left heel, one on his/her left hip, one on his/her left shoulder rear axilla (underarm), three on the top of his/her left foot, one on his/her right chest axilla, one on his/her right hip, one on his/her right upper mid back, and one to his/her sacrum/coccyx (tailbone). Observation on 3/1/21 at 2:34 P.M., showed the resident lay on an alternating air mattress with raised edges, in the fetal position, with his/her legs drawn up to the left side of his/her chest. His/her back lay flat against the bed and he/she was bent at the neck. Observation on 3/3/21 at 2:50 P.M., showed the resident lay in bed in fetal position with[TRUNCATED]