**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D2a Based on record review and interviews; the facility staff 1) failed to assess residents for skin impairment, existing pressure ulcers (localized injury to the skin and/or underlying tissue over a bony prominence as a result of pressure, or pressure in a combination with shear and/or friction), or new pressure ulcers; 2) failed to implement interventions to treat and prevent the development of pressure ulcers; 3) failed to monitor residents' skin, 4) failed to follow provider orders to promote wound healing for 2 (Residents 2 and 1) of 4 sampled residents. The facility identified a facility census of 31 residents at the time of the survey. Findings are: A. A record review of Resident 2's admission Record with an admission date of 4/1/2019 and a printed date of 1/22/2024 revealed under Diagnosis Information, the resident had diagnoses of morbid (severe) obesity with unspecified complications. A record review of Resident 2's MDS dated [DATE] revealed Section C-Cognitive Patterns read that the resident had a BIMs score of 3 (severe cognitive impairment). Section GG-Functional Abilities and Goals revealed Resident 2 utilized a w/c and a walker for mobility. Resident 2 required substantial/maximal assistance with toileting hygiene, showering/bathing self, upper and lower body dressing, putting on/taking off footwear, sitting to lying, lying to sitting, sit to stand, chair/bed-to-chair transfer, toilet transfer, tub/shower transfer, and walking 150 feet. Section H-Bladder and Bowel revealed Resident 2 had an indwelling catheter and an external catheter. Resident 2 was frequently incontinent of bowel and not rated for urinary incontinence. A record review of Resident 2's Braden Scale Predicting Pressure Ulcer Risk with an effective date of 11/15/2023 revealed the resident had a total score of 17 (at risk for pressure ulcers). A record review revealed skin assessments were not found in Resident 2's health record. A record review of Resident 2's PNs revealed the following: -On 12/12/2023 at 4:49 PM it was revealed that Resident 2 had a skin lesion on their left shin. Resident 2 continued to have a wound that was steri stripped. -On 12/19/2023 at 7:08 AM it was revealed that Resident 2 had no skin issues noted. -On 12/23/2023 at 9:26 PM it was revealed that Resident 2 was found to have a 2 cm x 2.5 cm sore to their upper left thigh with moderate bleeding noted. -On 12/26/2023 at 5:56 AM it was revealed that Resident 2 had an open area to their left buttock and was bleeding. -On 1/4/2023 at 11:07 AM it was revealed that Resident 2 had a 6.5 cm x 6 cm wound to their left buttock as well as a 2 cm x 2.5 cm wound to their right ankle. Both wounds were covered with slough. -On 1/9/2023 at 3:29 PM it was revealed that Resident 2 had a stage III PU/injury on their right buttocks that had full-thickness skin loss. The wound bed had slough and purulent wound exudate. The peri-wound was fragile. The wound dressing was moderately saturated. The wound had an odor, and the tissue was painful. A record review revealed skin assessments were not found in Resident 1's health record. A record review of Resident 2's Medication Administration Record (MAR) with dates from 1/1/2024-1/31/2024 revealed an order for calmoseptine external ointment 0.44%-20.6% (menthol-Zinc Oxide) to be applied to the resident's buttocks topically three times a day (TID) for excoriation with a start date of 12/23/2023 and a d/c'd date of 1/12/2024. A record review of Resident 2's Care Plan with an initiated date of 3/16/2023 and a revised date of 1/17/2024 revealed a Focus of I have open wounds to my left ischium. Interventions were as follows: Educate myself/family/caregivers of causative factors and measures to prevent skin injury; Encourage good nutrition and hydration to promote healthier skin (initiated on 3/16/23); follow facility protocols for treatment of injury (initiated on 3/16/23); if a cushion is placed in my w/c I will push myself out of it (initiated on 1/17/24); monitor for side effects of the antibiotics and over-the-counter pain medications (initiated on 3/16/23); monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration, etc. to the medical doctor (initiated on 3/16/23); obtain bloodwork, blood cultures, and culture and sensitivity of any open wounds as ordered by the physician (initiated on 3/16/23); provide me with an air mattress to sleep on (initiated on 1/17/24); trim my fingernails as I will allow because I pick at my skin (initiated on 3/16/23); and use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface (initiated on 3/16/23). A record review of provided PNs with PCP communication Regarding Resident 2's wound on their left ischium revealed the following: -On 11/14/2023 at 11:10 AM, the facility notified Resident 2's PCP of an open sore on the outside of their right calf with black tissue and requested a referral to the Wound Clinic. There was a handwritten response on the PN from the provider that read, Yes. Please refer to Wound Clinic. The provider's response was noted by the DON. -On 1/4/2024 at 11:07 AM revealed that Resident 2 had a 6.5 cm x6 cm wound on their left buttock and a 2 cm x 2 cm wound to their right ankle and the communication had been faxed to Resident 2's PCP on 1/5/2024 at 11:11 AM asking for an order to see wound care. The provider had faxed back a handwritten response to the facility on 1/5/2024 again read, Please have patient see wound care. The faxed response from the provider was not noted by facility staff. -On 1/12/2024 at 6:55 AM it was revealed that Resident 2 had an open wound to their left ischium and asked Resident 2's PCP for referral for the resident to see the Wound Clinic. Again, the provider had hand-written a response on the PN that read, Yes. A record review of the Wound Clinic Office Clinic Notes with a service date of 1/16/2024 revealed Resident 2 was a new patient and was being evaluated for wounds. Resident 2 had a wound to their left thigh/ischial area which consisted of an unstageable ulcer and a chronic wound to their right lateral ankle. Resident 2 was non-ambulatory and transferred via a Hoyer lift. Resident 2 had a Foley catheter. Under Physical Exam it was revealed that Resident 2 had a large necrotic pressure ulcer to their left ischium that was unstageable, but likely a stage IV and was at full thickness. The wound was malodorous and measured 7.0 x 3.5 x 5 cm. The periwound had erythema. There was an area to the right lateral malleoli area that was open and adhered yellow slough. The wound was at full thickness and measured 3.0 x 2.8 x 0.1 cm and there was mild erythema in the periwound. Under Assessment Plan it was revealed Resident 2's pressure ulcer to the resident's ischium was significant with necrosis and there was concern of underlying infection with systemic signs of behavioral changes. Resident 2 would likely need surgical debridement and it was recommended for inpatient management including sepsis workup. Resident 2 was transferred to the hospital ER from the Wound Clinic. A record review of the hospital's Encounter Information with a date of 1/16/2024 and a time of 5:19 PM revealed an estimated time of Resident 2's arrival to be 1/17/2024 at 12:30. The admission reason was sepsis. A record review of the hospital's Consultation Notes revealed the reason for the consult was a left hip wound. The assessment plan was a decubitus ulcer of the sacral area and a plan for operative intervention, wound debridement, and possible placement of a wound vac. A record review of the hospital's Progress Notes revealed on 1/19/2024 Resident 2 had been in the hospital for three days and on day two status post debridement of the left sacral decubitus ulcer. Resident 2 was seen at that time for a wound vac change. Cultures had been obtained and results were pending. Resident 2 was on IV vancomycin and Zozyn. On 1/22/2024 the left buttock wound had improved after debridement and NPWT placement with decreased odor and necrotic tissue. There was some odor and necrotic tissue that remained. The provider was able to palpate the bone. Resident 2's left hip wound was now a stage 4. An interview on 1/22/2024 at 12:35 PM with the DON revealed Resident 2's pressure ulcer was noted at the end of December 2023. Resident 2 had a left ischium wound (lower buttock, upper thigh, more towards the back and not quite toward the outside). The DON confirmed that Resident 2's wound was facility-acquired. There was no area of concern initially. When Resident 2's skin was initially identified to have an area of concern, the area was not open but was red in color. The staff were treating the affected area with calmoseptine. Once it was discovered that the area on Resident 2's left ischium had opened, facility staff called the provider and received orders for medihoney and an Optifoam dressing. The medihoney and Optifoam dressing was no longer an effective treatment for Resident 2's wound. Therefore, the facility had sent a fax to Resident 2's PCP requesting a new dressing change order and the PCP never sent a fax back with new dressing change orders or recommendations. The DON confirmed Resident 2's wound on their left ischium had not been measured and said, it should have been. There was a referral to the Wound Clinic, however, they were not able to get an appointment at the Wound Clinic until 1/16/2024. The wound treatment order did not change in the meantime. When Resident 2 was seen at the Wound Clinic on 1/16/2024, they did not return to the facility because the Wound Clinic had decided to admit the resident to the hospital for sepsis. The DON further revealed facility staff had placed an air mattress on Resident 2's bed and a roho cushion in their w/c. The DON revealed Resident 2's provider had not seen their wound to date as they were supposed to see them last week (the week of January 15th-19th 2024), however the provider had canceled the visit. An interview on 1/22/2024 at 2:55 PM with NA/MA-D revealed that at first, Resident 2 had a reddened area on their bottom around the coccyx area towards the right side that was not open. The nurses were treating the reddened area with calmoseptine. NA/MA-D had went on leave and returned to work a few days ago and heard that the reddened area was open. The facility staff were using preventative measures of encouraging Resident 2 to lie down in between meals, a cushion in the wheelchair. An interview on 1/23/2023 at 3:28 PM with RN-G revealed Resident 2 had been admitted from the clinic to the hospital ER on [DATE] for sepsis without shock, leukocytosis, encephalopathy, and an infected decubitus ulcer stage IV. A culture of the wound had been obtained and the results were positive for methicillin-resistant staphylococcus aureus (MRSA-bacteria) and ESBL. The sepsis was from status post incision and drainage (IND) of the decubitus ulcer. Resident 2 had a wound vac placed. RN-G revealed the facility had never reached out to the Wound Clinic about any concerns they may have had regarding Resident 2's wounds worsening/not getting better, nor did they reach out to try and get Resident 2 in for an appointment earlier than scheduled. An interview on 1/22/2023 at 3:40 PM with the Administrator revealed the area on Resident 2's left ischium/hip was a little bruised area. The skin was intact and there was no shearing. The facility staff started the affected area with calmoseptine. There was a big change, the wound had opened and was identified as a stage IIII pressure ulcer. Resident 2 was admitted to the hospital (1/16/2024) and the attending physician had identified that the wound had gone from stage III to stage IV. Resident 2's pressure wound on the left ischium/hip was debrided down to the bone. An interview on 1/23/2024 at 3:58 PM with Director-H revealed Resident 2 had been admitted to the PCU and was transferred to the medical surgical floor on the evening of 1/18/2024. Resident 2 had agitated sepsis without shock. Resident 2 had general surgery for an IND on the morning of 1/17/2024 on their left hip wound. An interview on 1/24/2024 at 11:40 AM with the DON revealed Resident 2's left ischium/buttock wound had been discovered on 12/23/2023. An interview on 1/24/2024 at 11:40 AM with the Administrator confirmed Resident 2 had not been seen by a provider since the wound was discovered. An interview on 1/24/2024 at 12:15 PM with NA/MA-E revealed Resident 2 had an unopened reddened area where their buttock met the upper thigh (the fold/crease). Resident 2 had slid out of their w/c, so it was initially thought the reddened area was a bruise. The Administrator was working as the CN on the resident's bath day and when NA/MA-E had stood the resident up to put their brief on, they noted the reddened area was slightly open. The Administrator had gone to the tub room to look at the area and then applied a barrier foam dressing on the area. On Resident 2's next bath day, the affected area looked the same, and the same dressing was applied. NA/MA-E was gone on a Friday and when they returned to work the following Monday it had been mentioned to them that Resident 2's buttock/upper thigh wound had gotten significantly worse over the weekend. On Tuesday, NA/MA-E was preparing to give Resident 2 a bath and noticed the wound had significantly changed as it was more open and bigger. An interview on 1/24/2024 at 4:40 PM with the Administrator confirmed weekly wound measurements and assessments were not being completed weekly by facility staff. An interview on 1/24/2024 at 4:40 PM with the DON confirmed weekly wound measurements and assessments were not being completed weekly by facility staff. It was also confirmed that they were unable to provide documentation of provider visits with Resident 2. A record review of the facility's policy, Pressure Ulcers/Skin Breakdown-Clinical Protocol with a revised date of April 2018 under the section titled, Assessment and Recognition revealed number 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; c. Resident's mobility status; d. Current treatments, including support surfaces; and all active diagnoses. 3. The staff and the practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions.: 4. The physician will assist the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue, status of wound bed, etc.) of an ulcer. 5. The physician will help identify and define any complications related to pressure ulcers. Under the section Monitoring revealed number 1. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive, or poorly-healing wounds. A record review of the facility's policy, Wound Care with a revised date of October 2010 revealed under the section titled, Documentation The following information should be recorded in the resident's medical record: 1. The type of wound care given. 2. The date and time the wound care was given. 5. Any changes in the resident's condition. 6. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound. B. A record review of Resident 1's admission Record, Diagnosis Information with an admission date of 11/7/2023 revealed the resident had diagnoses of multiple sclerosis and paralytic gait. A record review of Resident 1's MDS (Minimum Data Set- a comprehensive assessment tool used to develop a resident's care plan) with a date of 11/20/2023, Section M-Skin Conditions revealed the resident was at risk of developing pressure ulcers/injuries. The MDS revealed Resident 1 did not have one or more unhealed pressure ulcers/injuries but did indiciate Resident 1 had mositure-associated skin damage (MASD) (e.g., incontinence-associated dermatitis, perspirations, or drainage). The MDS revealed the resident utilized a wheelchair for mobility and required substantial/maximal assistance for toileting hygiene, shower/bathing, upper and lower body dressing, personal hygiene, rolling left an dright when lying on their back, sitting to lying, chair/bed to chair transfer, toilet transfer, tub/shower transfer. Resident 1 was dependent (Helper does ALL of the effort. Resident does none of the effort to complete the activity) for putting on/taking off footwear and picking up objects. A record review of Resident 1's Care Plan dated 1/17/2023 revealed a Focus of I have pressure sore development r/t (related to) immobility. The interventions were as follows: Administer medications as ordered and monitor for side effects; administer treatments as ordered and monitor for effectiveness; educate the resident/family/caregivers as to causes of skin breakdown; follow facility policies/protocols for the treatment of skin breakdown; inform the resident/family/caregivers of any new area of skin breakdown; monitor nutritional status; obtain and monitor lab/diagnostic work as ordered and report results to the doctor; weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate. A record review of Resident 1's Braden Scale for Predicting Pressure Ulcer Risk with a date of 12/5/202023 at 10:08 AM revealed the resident had very limited sensory perception, was occasionally moist, was chairfast, mobility was very limited, and had a potential problem of friction and shear. Resident 1 had a Braden score of 14 which indicated the resident was at moderate risk for the development of a pressure ulcer. A record review of Resident 1's Progress Notes (PN) revealed the following: -On 11/8/2023 at 5:00 PM it was revealed Resident 1 had moisture-associated (MASD) skin damage. The skin issue location was on the resident's coccyx and measured 1.5 length x 0.5 width, no exudate. There was a wound odor noted and the tissue was painful. -On 11/14/2023 at 11:06 AM it was revealed Resident 1 had multiple scabs to their left lower extremities (LE) that were present on admission to the facility. There were scabs on Resident 1's bilateral knees and toes. Resident 1 had an open sore on the outside of their right calf with black tissue present. -On 11/22/2023 at 2:08 PM it was revealed that Resident 1 had no skin issues at that time. -On 12/6/2023 at 12:36 PM it was revealed Resident 1 had a Skin issue of a pressure ulcer/injury on their right lower leg, outer calf. The wound dressing had moderate (26-75%) saturation. The wound had an odor, and the tissue was painful. There was also another area of concern on Resident 1's left inner ankle which had a scabbed area with black streaking present. -On 12/13/2023 at 4:54 PM it was revealed Resident 1 had an open lesion (other than ulcers, rashes, and cuts) on their right lower leg which had an odor. There continued to be MASD on Resident 1's coccyx. -On 12/20/2023 at 1:45 PM it was revealed Resident 1 had a 5 cm x 5 cm open area to their right lateral lower leg. A 1 cm x 1 cm area to their bilateral (both) ankles on the medial aspect. Resident 1 also had a 2 cm x 2 cm to their left heel. -On 12/27/2023 at 4:53 PM it was revealed that Resident 1 had a deep tissue injury on their buttocks that had tunneling. The wound bed had slough, there was serous wound exudate (clear, thin, and watery), and the dressing saturation was heavy (>75%). There was a wound odor, and the tissue was mushy. There was a deep tissue injury on Resident 1's left heel that was tunneling. The wound dressing was moderately (26-75%) saturated. There was a deep tissue injury on the resident's left foot that had tunneling and an odor. The tissue was painful. Resident 1 had a deep tissue injury to their right calf. The wound bed had slough and was mushy. -On 1/1/24 at 7:19 AM it was revealed that Resident 1 had a wound dressing change completed due to the dressings being saturated. Wound measurements were taken which revealed: Resident 1's left ankle measured 3.6W x 3L; their right calf measured 5.6 L x 4.4 W; the right ischium wound measured 7.6 L x 5.7 W x 1.8 D, the coccyx wound measured 5L x 2.5 W, the scrotum wound measured 5W x 4 L. There were blanchable red areas on Resident 1's right ankle, outside of their right foot, and small toe. -On 1/3/2024 at 5:00 PM it was revealed Resident 1 had pressure ulcers (PU)/injuries on their right buttock and scrotum that were unstageable. The tissue of the wounds was painful. There was a stage III (full thickness skin loss) pressure ulcer/injury on their right lower leg. There was slough on the wound bed. The wound dressing had moderate (25-75%) purulent drainage. The wound had an odor. There was also MASD ON Resident 1's sacrum peri-wound that had erythema (superficial reddening of the skin as a result of injury or irritation causing dilation of the blood capillaries). There was a pressure ulcer/injury on the resident's right buttock that was unstageable, and the tissue was painful; a pressure ulcer/injury on their scrotum that was unstageable, and the tissue was painful. -On 1/6/2024 at 6:33 AM it was revealed Resident 1 had needed dressings changed due to saturation. There was a red blanchable area noted on the resident's right outer foot. -On 1/14/2023 at 8:00 PM the following were revealed: there was a stage IV deep tissue pressure injury (DPTI) on their right buttocks with full thickness tissue loss. The wound bed had slough and purulent exudate. There was maceration (prolonged and excessive exposure to moisture that can result in skin damage and softening). The wound dressing had moderate saturation. The wound was odorous, and the tissue was painful. There was a stage III pressure ulcer/injury on Resident 1's mid buttocks with full-thickness skin loss. The wound bed was necrotic, was macerated, and there was purulent exudate. The wound dressing had moderate saturation. The wound had an odor. Resident 1 had a stage II PU/injury on their left lower buttocks with partial thickness skin loss. The wound bed was necrotic with purulent exudate. The peri-wound condition was fragile. The wound dressing had moderate saturation. The wound had an odor, and the skin tissue was painful. There was a stage II PU/injury on the resident's left inner ankle that had partial thickness skin loss. The wound bed had slough with purulent exudate and the wound had an odor. The peri-wound was fragile, and the tissue was painful. The wound dressing had moderate saturation. Resident 1 had a stage II PU/injury on their left heel with partial thickness skin loss. The wound bed had slough, purulent exudate, and the wound had an odor. The peri-wound was fragile, and the tissue was painful. There was a stage II PU/injury with partial skin loss on the resident's right outer lower leg. The wound bed had granulation and there was serous (a type of fluid that comes out of a wound with tissue damage). The peri-wound was fragile. The wound dressing was minimal (<25%). -On 1/17/2024 at 6:00 PM there was a Transfer to Hospital Summary that revealed Resident 1 was transferred to the hospital for evaluation due to being found to have a blue nose, purple lips, abnormal heart rhythm, and complaints of (c/o) not feeling well. A record review of Resident 1's Regional [NAME] Medical Center (RWMC) encounter, Progress Notes with a service date of 1/18/2024 at 3:50 PM revealed the resident had been admitted to the hospital for weakness. Under Assessment Plan revealed the resident had a decubitus ulcer, sepsis, urinary tract infection, and a sacral wound infection. Resident 1 had a surgical debridement of their sacral and ischial sites with various depths. A record review revealed skin assessments were not found in Resident 1's health record. A record review of the Resident 1's Treatment Administration Record (TAR) dated 1/1/2024-1/31/2024 revealed an order with a start date of 12/22/2023 to cleanse the site (wounds) with saline gauze in the shower (the right ischium, right lateral leg, left medial malleolus, and left heel), apply therahoney to the wound base, and pack with silvercel, apply an additional silvercel layer on top, and secure with foam border dressings. The dressing was ordered to be changed every 3 days/bath days/as needed (prn) with soiling and dislodgement and to offload feet/heels at all times. The order was discontinued on 1/3/2024. A record review of Resident 1's TAR dated 1/1/2024-1/31/2024 revealed an order with a start date of 1/6/2024, Cleanse site with saline and gauze or in shower. R (right) ischium and inferior scrotum: apply Anasept moistened gauze, cover with ABD, secure with tape, and secure scrotal dressing with brief. Change BID (twice a day). R (right) lateral leg, L (left) medial malleolus, L (left) medial heel, L (left) ischium: apply Therahoney to base, cover with Silvercel, secure with foam border dressings. Change 2x (times)/wk (week) on bath days or PRN (as needed) with soiling and dislodgement. Conservative sharp debridement PRN in wound clinic. One time a day every Wednesday, Saturday. A record review of Resident 1's POC Response History, Bed Mobility: Self-Performance with dates 12/24/2023 to 1/14/2023 revealed it was documented that the resident was repositioned and there were no refusals from Resident 1 documented. A record review of the Order Sheet dated 1/3/2024 at 5:09 PM revealed the Wound Clinic's Provider/Surgeon had ordered, Skin Integrity Impairment Prevention Special Instructions: Turn Pt (patient) q (every)1 hr., heel off-loading boots on at all times, obtain ROHO cushion for wheelcahir. Ensure the resident is on a pressure redistribution mattress. A record review of the Wound Clinic orders revealed an order with an admission date of 12/20/2023 revealed Resident 1 had scabs on their lower extremities, bilateral knees, and toes. There was an open sore on Resident 1's right calf. There was no diagnosis (dx) revealed. An order with a date of 1/10/2024 at 6:38 PM revealed Resident 1 had multiple pressure injuries. The order was to, Apply anasept, moistened gauze to sacral, scrotal, and ischial sites. Cover with dry gauze and ABD pads then secure with tape or pts brief. Changed BID and PRN including after bowel movements. Start NPWT (Negative-pressure wound therapy) as soon as possible to L (left) ischial site. Pt needs off-loading cushion in w/c (wheelchair) (ROHO or equivalent) and off loading mattress. Turn pt q1-2 hrs when in bed and limit time up in chair. Follow up with the provider on 1/17/2024. The order was noted on 1/11/2024 by facility Registered Nurse's (RN). There was a handwritten note on the bottom right corner of the order that indiciated the order was sent to a equiptment supplier. There was another handwritten note on the bottom of the order with a sent date of 1/19/2024 at 3:24 PM, after contract was signed with the equiptment supplier. The contract and order was sent 9 days after the provider ordered the equipemnt (negative-pressure wound therapy). A record review the Wound Clinic Office Clinic Notes with a date of service of 12/20/2023 at 7:10 AM revealed Resident 1 had developed multiple lesions of their lower extremities. Upon physical examination, Resident 1 had a full-thickness wound on their right ischium that measured 2.5 cm x 3 x 0.5 cm, There was a moderate amount of drainage with devitalized tissue. A wound on their right lateral leg with full thickness and measured 4.5 x 6.8 x 0.1 cm and a second one that measured 6.3 x 7.5 x 0.3 cm with a moderate amount of drainage. A wound on their left medial malleolus that measured 3.1 x 4.7 x 0.4 cm and a moderate amount of drainage. A wound on their right heel with partial thickness, a minimal amount of drainage, and measured 4 x 5 cm. On Resident 1's right midfoot, there was a 0.7 x 0.6 lesion (this wound did not require debridement at the time of the appointment). The wounds had been debrided with a knife and all devitalized tissue (also called slough or necrotic tissue and is classified according to its color and constancy) was removed. Under Assessment/Plan, the pressure injury of the buttock, right leg, and ankle were unstageable and there was a deep tissue injury listed. A record review of the Wound Clinic Office Clinic Notes with a date of service of 1/3/2024 at 6:51 AM revealed Resident 1 had a follow-up appointment for multiple ulcers of their lower extremities and ischium. Resident 1 had two new pressure ulcers over the sacrum. The ulcer on Resident 1's right lower extremity was full thickness and measured at 5.2 x 4.6 x 0.2. There was a heavy amount of drainage. Sharp debridement was done, and devitalized tissue was taken from the epidermis, dermis, and subcutaneous tissues. The wound on the resident's left malleolus had full thickness and measured 3.5 x 4.5 cm with a heavy amount of drainage. Debridement consisted of the epidermis, dermis, and subcutaneous tissues. The wound on the resident's left medial heel had full thickness and measured 4.2 x 3.5 cm with a heavy amount of drainage. Sharp debridement was completed and the devitalized tissue from the epidermis, dermis, and subcutaneous tissues was removed. Resident 1 had a large right ischial ulcer that was full thickness with a moderate amount of drainage. Sharp debridement had been completed and devitalized tissue from the epidermis dermis, and subcutaneous tissue down to the fascia was undertaken. Under Assessment/Plan the pressure injury of the right leg, pressure injury of the ankle, pressure injury of the heel, pressure injury of the right ischium, pressure injury of the buttock, and pressure injury of the sacral region were unstageable. Resident 1 also had a deep tissue injury. A record review of the Wound Clinic Office Clinic Notes with a date of service of 1/10/2024 at 7:20 AM revealed Resident 1 had a follow-up appointment for multiple pressure injuries. Resident 1 had some new pressure injuries from the last clinic visit a week ago. Resident 1 had a pressure injury of their ankle on the left malleolus that had full thickness and measured 3.8 x 4 with a heavy amount of drainage. Sharp debridement of dead tissue had been completed. A second pressure injury of the left medial side of their heel had full thickness with a heavy amount of drainage and measured 3.5 x 5. Sharp debridement had been completed. A third pressure injury of their right leg on the lateral aspect of their lower extremity was full thickness with a heavy amount of drainage and measured 5.2 x 5 cm. No debridement was needed for that wound. The fourth wound was a pressure injury of their lateral heel that had full thickness with a low amount of drainage and measured 3.5 x 5 cm. [TRUNCATED]