**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident representative interview, staff interview, medical record review, hospital record review, and review of facility policy, the facility failed to ensure the facility bowel protocol was implemented timely for residents who have not had bowel movements and failed to ensure residents received timely intervention for constipation. This resulted in Actual Harm when Resident #45 had no recorded bowel movement for five days, experienced abdominal pain, and had episodes of emesis with a fecal odor. Resident #45 was transferred to a local hospital and admitted for treatment for dehydration and constipation. Additionally, the facility failed to timely implement their bowel protocol, placing Resident #18 at risk for the potential for more than minimal harm that was not Actual Harm. This affected two (#45 and #18) of three residents reviewed for bowel and bladder. The facility census was 58. Findings include: 1. Review of the medical record for Resident #45 revealed an admission date of 12/21/22 with diagnoses of Parkinson's Disease, peripheral vascular disease, and dementia. Review of Resident #45's care plan dated 12/30/22 revealed the resident had the potential for bowel incontinence related to impaired mobility, cognitive loss, and functional diarrhea. Listed interventions included checking the resident frequently, assist with toileting as needed, and to provide peri care after each incontinent episode. An additional care plan focus dated 12/30/22 and revised on 07/27/23 revealed Resident #45 had Parkinson's Disease. A listed goal included the resident would remain free from further signs, symptoms, discomfort, or complications related to Parkinson's Disease. Listed interventions included to give medications as ordered by the physician, monitor for constipation, and to implement the bowel regimen if no bowel movement in three days. Review of Resident #45's physicians orders dated 12/21/24 revealed an order for bowel protocol as follows: if no bowel movement in three days, give 30 milliliters (ml) Milk of Magnesia (a saline laxative which draws water into the intestines and softens the stool, making it easier to pass). If no result, give Bisacodyl [rectal] suppository (a stimulant laxative which stimulates the intestinal muscles to encourage stool movement) on the fourth day. If there is no result on the next shift after suppository, administer Fleet enema (a liquid medication administered rectally which works by increasing the water content in the large intestine, softening the stool and helping to stimulate bowel movement). Notify the doctor if there were no results and/or severe abdominal pain, rectal bleeding, or vomiting noted during this regimen. Continued review of Resident #45's physicians orders revealed corresponding medication orders dated 12/21/24 for Milk of Magnesia 400 milligrams (mg) per 5 ml, give 30 ml by mouth every 24 hours as needed for constipation, Bisacodyl suppository 10 mg suppository administered rectally every 24 hours as needed for constipation, and Fleet enema 7-19 grams (gm) per 118 ml, insert one application rectally every 24 hours as needed for constipation. Review of Resident #45's quarterly continence evaluation dated 01/01/25 revealed Resident #45 had bowel movements daily, was incontinent of both bowel and bladder, and occasionally needed laxatives, suppositories, or enemas for bowel regulation. Review of the January 2025 bowel elimination records for Resident #45, completed by the Certified Nursing Assistants (CNA), revealed Resident #45 had a medium-sized bowel movement with loose/diarrhea consistency on 01/31/25. Review of bowel elimination record for Resident #45 between 02/01/25 and 02/05/25, completed by the CNAs, revealed there was no documentation or evidence Resident #45 had a bowel movement between 02/01/25 through 02/04/25. Resident #45 had a small-sized bowel movement with formed/normal consistency recorded on 02/05/25. Review of the Medication Administration Record (MAR) for 02/01/25 through 02/05/25 revealed no doses of Milk of Magnesia, Bisacodyl suppository, or Fleet enema were administered during this time frame. Furthermore, there was no documentation the bowel protocol had been implemented. Review of Resident #45's medical record from 02/01/25 through 02/05/25 revealed there was no evidence Resident #45 had been assessed for constipation and there was no documentation Resident #45's bowel sounds had been assessed. Review of a progress note dated 02/05/25 and timed 5:49 P.M. revealed Registered Nurse (RN) #709 assessed Resident #45 and noted the resident had an emesis that looked and smelled like a bowel movement. RN #709 noted Resident #45 had been constipated throughout the shift without relief. RN #709 updated Nurse Practitioner (NP) #901 who then ordered a Kidney, Ureter, and Bladder (KUB) x-ray (an abdominal x-ray examination used to visualize the urinary system and surrounding structures) examination, Miralax (an osmotic laxative taken orally that works to increase the water content of the stool), and a suppository. The note referenced if Resident #45 had another emesis, to send to the emergency room (ER) for evaluation for possible small bowel obstruction. Review of the nursing progress notes on 02/05/25 at 6:49 P.M. revealed RN #709 documented while providing Resident #45 with Miralax, Resident #45 had another emesis and was being sent to the ER for evaluation. Review of imaging results dated 02/05/25 completed in the ER revealed a Computed Tomography (CT) scan was completed with results indicating moderate to large amount of retained stool throughout the colon which was consistent with constipation and a possible rectal fecal impaction. Review of the ER record dated 02/05/25 revealed Resident #45 arrived at a local ERto be evaluated for not having a bowel movement for about six to seven days. Additionally, Resident #45 was noted to be having issues with nausea, vomiting, decreased appetite, significant abdominal pain, and abdominal distention. Upon arrival at the ER, Resident #45 was tachycardic with a heart rate of 118 beats per minute (normal range is between 60 to 100 beats per minute). Resident #45's abdomen was assessed to be distended and tender. While in the ER, Resident #45 was given intravenous fluids, ondansetron (an antiemetic) 4 mg to treat nausea and vomiting, and a Fleet enema. Resident #45 was placed on supplemental oxygen due to mild hypoxia, which was noted by the ER provider to have been contributed or worsened by the large amount of stool within the abdominal cavity as well as having limited chest wall excursion secondary to a distended abdomen (indicating a reduced ability of the chest wall to expand during inhalation and contract during exhalation). Resident #45 was admitted to the hospital for treatment of moderate dehydration, constipation, and abnormal labs. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #45 had a Brief Interview for Mental Status (BIMS) score of 00 indicating severely impaired cognition. Resident #45 required substantial/maximum assistance for toilet transfers and was dependent on staff for toileting hygiene tasks. Resident #45 was recorded to be always incontinent of bladder and frequently incontinent of bowel. Interview on 05/05/25 at 10:32 A.M. with a family member of Resident #45 revealed Resident #45 was hospitalized three months ago due to constipation. Interview on 05/06/25 at 12:13 P.M. with Licensed Practical Nurse (LPN) #711 revealed the CNA's recorded each resident's bowel movements in the electronic medical record (EMR) and then there was a notebook for communication between the aides and the nurses, where the bowel movements were additionally recorded. LPN #711 stated that the night shift nurse would check the bowel record and then report to the day shift nurse what residents were on the bowel movement list, meaning the resident had not have a bowel movement in over three days. Interview on 05/07/25 at 9:45 A.M. with Registered Nurse (RN) #709 revealed she was on duty and her nurse when Resident #45 had vomited what appeared to be fecal matter on 02/05/25. RN #709 stated she assessed the resident and completed a head-to-toe assessment, including vital signs and listening to Resident #45's bowel sounds, but could not recall what they were. RN #709 verified there was no documentation in the resident's record reflecting that she had completed a head-to-toe assessment, including assessing the resident's bowel sounds. RN #709 confirmed she documented that Resident #45 had unrelieved constipation and was told Resident #45 had not had a bowel movement. RN #709 also confirmed she had not followed the facility bowel protocol. RN #709 stated Resident #45 had a total of three emesis before the emergency medical service (EMS) arrived to transport the resident to a local hospital. Interview on 05/07/25 at 10:29 A.M. with CNA #723 revealed if there is no documentation of a bowel movement in the bowel record, that means the resident did not have one. CNA #723 stated Resident #45 had frequent large and hard bowel movements. On 02/05/25, CNA #723 charted the resident had a small bowel movement with normal consistency, but actually appeared as a small, pebble-like bowel movement. CNA #723 stated the Director of Nursing (DON) and Assistant Director of Nursing (ADON) #702 monitored the residents' bowel movements based off the charting completed by the CNAs. Interview on 05/07/25 at 10:56 A.M. with ADON #702 revealed the DON printed out a list of residents on the bowel list, but there was no one to give the list to on the weekend. ADON #702 stated three days without a bowel movement was when the facility wanted to be proactive and would start to follow the bowel protocol. ADON #702 verified staff had not followed the bowel protocol for Resident #45 and should have administered Milk of Magnesia on 02/03/25, a Bisacodyl suppository on 02/04/25, and Fleet enema on 02/05/25. ADON #702 stated the medications were available on-hand at the facility. ADON #702 stated the nurse should have completed an assessment and charted it in the progress notes. ADON #702 revealed if the intervention on the fourth day had not worked then the doctor should have been notified. Interview on 05/07/25 with the DON revealed he kept a list of residents who have not had a bowel movement on a piece of paper. The DON revealed he got the information from the electronic medical record (EMR). The DON revealed he called the facility on the weekends to inform the nurses of the residents without a recorded bowel movement. The DON verified the staff should follow the bowel protocol and the facility NP should be made aware if the bowel protocol does not work. The DON confirmed Resident #45 was on his list on 02/03/25 for three plus days of not having a bowel movement. The DON stated he was not aware Resident #45's bowel protocol was not implemented or followed. The DON further revealed a small bowel movement would not be counted as a bowel movement. Interview on 05/07/25 at 1:47 P.M. with NP #901 revealed the nurse should initiate the bowel protocol if the resident had no bowel movement in three days. NP #901 stated on day three, the staff should call her and update her. NP #901 stated she was not aware Resident #45 had five days of undocumented bowel movements. NP #901 was also not aware the facility had not implemented the bowel protocol for Resident #45. NP #901 revealed she was informed the resident had an emesis and ordered the resident Miralax. NP #901 further revealed staff will typically contact her for bowel issues, and she was present at the facility twice a week and would check with the nurses regarding any issues prior to leaving the facility. NP #901 confirmed the facility had not contacted her about Resident #45 prior to Resident #45 having an emesis containing possible fecal matter. Interview on 05/08/25 at 10:45 A.M. with Medical Director (MD) #900 revealed the nurse on duty should have completed focused gastrointestinal assessment, and that he would not have gone the route of giving Miralax orally if the resident was vomiting. MD #900 stated he would have asked the nurse what the bowel sounds were, and that it was necessary to complete an assessment to be sure the resident had active bowel sounds. MD #900 stated if he would have been contacted, he would have ordered to give a suppository due to the vomiting, rather than Miralax. 2. Review of Resident #18's medical records revealed an admission date of 10/22/24. Diagnoses included constipation. Review of care plan dated 02/02/25 revealed Resident #18 had constipation related to decreased mobility. Interventions included following the facility bowel protocol and recording bowel movement patterns each day. Review of current physician orders for May 2025 included bowel protocol, if no bowel movement in three days give 30 ml of Milk of Magnesia. If no result, give a Bisacodyl suppository on the fourth day. If there is no result on the shift after the suppository, administer Fleet enema. Notify the doctor if there were no results and/or severe abdominal pain, rectal bleeding, or vomiting noted during this regimen. Resident #18's physician orders also included Miralax 17 grams every 24 hours as needed for constipation and Docusate (a stool softener) 100 mg one time a day. Review of bowel movement tracking for April 2025 revealed Resident #18 had a bowel movement on 04/30/25. Review of bowel movement tracking for May 2025 revealed Resident #18 had no bowel movements recorded on 05/01/25, 05/02/25, or 05/03/25. Review of Medication Administration Record (MAR) for May 2025 revealed Milk of Magnesia, Bisacodyl suppository, and Fleet enema had not been recorded as administered. There was no evidence the facility had implemented the standing bowel protocol. Interview on 05/05/25 at 8:39 A.M. with Resident #18 revealed she had not had a bowel movement in four days and stated she had requested prune juice and a laxative and had not received either. Interview on 05/06/25 at 1:49 P.M. with Director of Nursing (DON) confirmed no recorded bowel movement for Resident #18 from 05/01/25-05/03/25 and stated interventions should have been implemented that included administering as needed laxatives as per the facility's bowel protocol. The DON further stated Resident #18 had informed the nurse practitioner that she would like a fiber supplement due to not having bowel movements. Review of the facility policy titled Bowel Protocol dated 01/2017, revealed the CNAs would monitor and record resident's bowel movements. The nurse will monitor the documented results. If the resident has not had a bowel movement in three days, the resident will receive 30cc of Milk of Magnesia. If there are no results, the resident will receive a bisacodyl suppository on the fourth day. If there are no results on the next shift after the suppository, a Fleets enema will be administered. The physician will be notified if the resident complains of severe abdominal pain, has rectal bleeding or vomiting during this regimen or if there are no results after these measures have been taken.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview, and review of the National Pressure Injury Advisory Panel (NPIAP) staging, the facility failed to ensure early identification and ensure treatments of skin injuries were completed. This resulted in Actual Harm when Resident #50 acquired a pressure ulcer to the coccyx and the wound was not assessed or treated until the wound progressed into a stage three pressure ulcer (full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through underlying fascia). This affected one resident (#50) out of three residents reviewed for pressure ulcers. The facility census was 49. Findings include: Review of the medical record for Resident #50 revealed an admission date of 12/22/21. Diagnoses included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting right dominant side, muscle wasting and atrophy. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #50 was severely cognitively impaired. Resident #50 was at risk for pressure ulcer injuries and had an unhealed unstageable pressure ulcer. Resident #50 was always incontinent of bowel and bladder. Review of the care plan dated 12/24/21 revealed Resident #50 had an activity of daily living self-performance deficit related to hemiplegia following a cerebral vascular accident, muscle wasting and atrophy. Resident #50 also had potential for wounds or pressure ulcer development. Interventions included to monitor, document, and report as needed any changes in skin status. Administer treatments as ordered and monitor for effectiveness. Review of the Braden scale for predicting pressure sores dated 03/23/22 revealed Resident #50 was at high risk for developing pressure sores. Review of the physician orders revealed on 02/03/22 an order was received for weekly skin assessments with a bath or a shower per the bathing schedule. Review of the Treatment Administration Record (TAR) for April 2022 revealed biweekly showers were scheduled every Monday and Thursday with skin checks. The TAR was initialed on 04/04/22 and 04/07/22. Review of the shower sheets/skin assessments for Resident #50 for April 2022 revealed shower sheets/skin assessments were completed 04/14/22 and 04/18/22. No other shower sheets were provided and no open areas were documented. Review of the Certified Nurse Practitioner (CNP) #306 consultation note dated 04/11/22 revealed a new wound on 04/11/22 to the coccyx. The wound to the coccyx was an in house pressure, stage three measuring 3.0 centimeters (cm) in length by 2.0 cm in width by 0.1 cm in depth. The wound bed had 90% slough/eschar (dead tissue). Record review of the physician orders dated 04/11/22 revealed Resident #50 received an order for normal saline, honey gel, alginate foam, three times a week and as needed to the coccyx. Observation of the wound care to Resident #50's coccyx on 08/30/22 at 2:06 P.M. with Registered Nurse (RN) #303 revealed the old dressing removed by RN #303 on Resident #50's coccyx was dated 08/28/22. RN #303 verified the dressing change was now completed daily and this was the dressing she applied two days prior. Resident #50 had a pressure ulcer to his coccyx. Interview on 08/31/22 at 10:00 A.M., with the Director of Nursing (DON) revealed skin assessments for residents were completed weekly on shower days and documented on the shower sheet or skin observation form in the residents medical record once completed. Interview on 08/31/22 at 11:09 A.M. with the Administrator, revealed she had multiple complaints from residents of showers not completed. The Administrator revealed if the shower sheet (same as the skin assessment sheet) was not completed then it was not done. The Administrator revealed the Infection Control Nurse was supposed to oversee these were completed, but she was just not doing what she was supposed to do. Review of the TAR dated 08/29/22 revealed the treatment to Resident #50's coccyx dated 08/29/22 was signed as completed by Licensed Practical Nurse (LPN) #304. Interview on 08/31/22 at 4:53 P.M., with LPN #304 confirmed she did not complete Resident #50's dressing change to his coccyx on 08/29/22 and did sign the TAR the treatment was completed. Interview on 09/01/22 at 10:50 A.M., with the Wound Care Nurse Licensed Practical Nurse (LPN) #301 verified Resident #50's wound to his coccyx developed in house and first found as a stage three pressure ulcer on 04/11/22. Wound Care Nurse LPN #301 verified assigned weekly skin assessments should be completed by the nursing staff to assess for new areas of skin breakdown. The assessments should be documented when completed in the residents medical record on the skin assessment tool. The Wound Care Nurse LPN #301 verified there were no weekly skin observation tools completed for Resident #50 in the medical record for the month of April prior to finding Resident #50's coccyx wound at a stage three on 04/11/22. A follow-up interview on 09/07/22 at 9:00 A.M. with the DON, revealed the facility had no policy available for resident routine skin assessments or the process for nurses providing wound care. Review of the National Pressure Injury Advisory Panel: Pressure Injury Stages: revealed a pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. A Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury.

Based on medical record review, review of facility policy, resident interview, and staff interviews, the facility failed to monitor daily bowel movements, failed to hold antidiarrheal medication in the absence of any bowel movements, and failed to have a care plan in place to address a resident's bowel needs. This resulted in actual harm when Resident #49 was not having her bowel movements monitored, did not have a bowel movement documented for five consecutive days, and continued to receive an antidiarrheal medication three times a day which resulted in the resident being hospitalized for a fecal impaction. This affected one (#49) of five residents sampled for medication reviews. The facility census was 78. Findings include: Review of Resident #49's medical record identified admission to the facility occurred on 06/14/18. Diagnoses included chronic kidney disease, stroke, irritable bowel syndrome (IBS) and high blood pressure. Review of the quarterly Minimum Data Set assessment, dated 06/30/19, revealed Resident #49 had intact cognition. Resident #49 was incontinent of bowel and was dependant on staff for toileting needs. The medical record identified a lack of plan of care for Resident #49 for constipation/diarrhea. Review of the physician orders revealed on 04/26/19 an order was received for Lomotil (anti-diarrheal) three times a day. An order dated 06/22/19 revealed hold all anti-diarrhea medications in the absence of stools. Review of the Certified Nurse Practitioner (CNP) progress notes dated 07/01/19 identified Resident #49 was experiencing both constipation and diarrhea secondary to her medical diagnosis of IBS. The CNP documented there was inconsistent charting by the staff of the residents's bowel movements. The notes documented nursing staff were instructed on how to administer her current medications and when to hold. Review of the progress notes dated 08/11/19 at 2:23 A.M. revealed Resident #49 was having large coffee ground emesis, was complaining of weakness, and requested to be sent to the emergency room. Review of the emergency room admission notes, dated 08/11/19, identified Resident #49 was noted to have a fecal impaction (severe bowel condition in which a mass of stool becomes stuck in the colon). Resident #49 underwent a colonoscopy in the hospital which identified a stercoral ulcer (results from prolonged constipation), which was identified by the physician as likely from the impaction of stool. Reviewed of Resident #49's bowel records for 08/01/19 through 08/11/19 revealed Resident #49 was not documented to have any bowel movements from 08/01/19 through 08/05/19 and from 08/07/19 through 08/11/19. Review of the August 2019 Medication Administration Record (MAR) revealed the Lomotil was administered three times a day from 08/01/19 through 08/11/19, with the exception of 08/08/19, when a nurse held the morning dose. The MAR also identified licensed nursing staff were to record bowel movements each shift (three times a day). The MAR for August 2019 identified no entries were completed by the nursing staff indicating if Resident #49 had any bowel movements. Interview on 09/12/19 at 10:44 A.M., Resident #49 identified she had issues with constipation and diarrhea from her diagnosis of IBS. Resident #49 stated she will sometimes go four to five days without a bowel movement and it is difficult to get staff to give her something. Interview on 09/12/19 at 9:53 A.M., State Tested Nursing Assistant (STNA) #77 identified when a resident has a bowel movement the aides document this in the facility's computerized charting system. Interview on 09/12/19 at 9:59 A.M., Licensed Practical Nurse (LPN) #210 revealed the nursing staff print off the STNA bowel record documentation daily. The nurses are supposed to review these bowel records daily to identify residents who have not had a bowel movement in the past three days. If a residents does not have a bowel movement in three days the bowel protocol should be initiated. LPN#210 confirmed the bowel movement monitoring for Resident #49 was not being completed consistently. She also verified the nursing staff should have held the medications when Resident #49 was not having bowel movements and/or diarrhea. LPN#210 confirmed the MAR for August additionally listed the physician order to hold all diarrhea medications in the absence of stools. LPN #210 also verified there was no evidence on the MAR that any licensed nursing staff started the bowel protocol for Resident #49 when she went longer than 3 days without a bowel movement on 08/03/19 and 08/10/19. Interview on 09/12/19 at 2:11 P.M., the Director of Nursing (DON) verified the facility staff were not documenting bowel movements for Resident #49 consistently and was receiving the Lomotil when the order read to hold if no bowel movement. The DON confirmed Resident #49 did not have a plan of care for the constipation and diarrhea issues prior to today. Review of the facility policy titled Bowel Protocol, dated 01/17, revealed STNAs will monitor resident bowel movements. The nurse will monitor the documented results. If the resident has not had a bowel movement in three days, the resident will receive 30 milliliters of milk of magnesia and if no results a bisacodyl suppository will be administered on the fourth day. If there are no results from the suppository, the next shift provides a Fleets enema. The physician will be notified of a resident complaint of severe abdominal pain, has rectal bleeding or vomiting during this regimen, or if no results after these measures have been taken.

Based on medical record review, staff interview, responsible party interview, observation, review of skin sweeps, and policy review, the facility failed to provide appropriate pressure ulcer prevention and treatment for a resident identified at risk. This resulted in actual harm when Resident #279 was admitted without a pressure ulcer, was assessed to be at risk for the development of a pressure ulcer, and was not provided pressure reduction prior to or immediately after the development of reddened areas on the buttocks. The reddened areas worsened into a stage 3 pressure ulcer on the right buttock and a stage 2 pressure ulcer on the left buttocks. This affected one (#279) out of four residents reviewed for pressure ulcers. The facility identified six residents with pressure ulcers. The facility census was 78. Findings included: Review of Resident #279's medical record revealed an admission date of 08/29/19. Diagnoses included dementia without behavioral disturbances, Alzheimer's disease, anxiety disorder, macular degeneration, hypertension, and chronic obstructive pulmonary disease. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/05/19, revealed Resident #279 had impaired cognition. The skin assessment identified the resident at risk for developing pressure ulcers. Review of the plan of care card, dated 08/29/19, revealed two assist for transfer, bed mobility, and not ambulatory. Interventions for pressure relieving mattress and pressure relieving device to chair. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/05/19, revealed the resident had impaired cognition. Furthermore, the skin assessment identified the resident at risk for developing pressure ulcers. Review of the admission nursing assessment identified the Resident #279 was admitted without any pressure ulcers. Review of weekly skin sweeps revealed the skin inspection dated 09/03/19 documented Resident #279 had redness to the skin on the buttocks. Review of physician orders dated 09/03/19 revealed a treatment to apply barrier cream to the buttocks for excoriation twice daily and as needed with incontinence. Review of the skin sweep dated 09/06/19 revealed the assessment was absent of documentation of any redness to buttocks. Review of the physician orders dated 09/09/19 revealed orders were received for a pressure relief mattress to the bed, a pressure reducing cushion to the wheelchair, and skin sweeps two times a week on Tuesday and Friday. Interview on 09/09/19 at 9:29 A.M., with Resident #279's responsible party revealed while visiting the resident she/he complained of pain to his/her bottom. Upon looking at the area of pain, the responsible party noticed open areas. The facility had not reported anything about the resident's skin having open areas or that they were providing treatment to the areas other than the barrier cream. Observation on 09/10/19 at 9:57 A.M., of the excoriation to the buttocks of Resident #279 with License Practical Nurse (LPN) #38 and State Tested Nursing Assistant (STNA) #86 revealed two open areas with excoriation present on the bilateral buttocks. Interview on 09/10/19 at 9:57 A.M., LPN #38 verified she/he was not aware of the Resident #279's open areas and the areas have not been addressed. LPN #38 indicated the only physician order was for the barrier cream to the excoriated areas. LPN #38 reported she/he would complete an assessment and notify the Certified Nurse Practitioner (CNP) and the responsible party. Review of the progress note dated 09/10/19 at 12:28 P.M., revealed Resident #279's left buttock had a stage 2 pressure ulcer, with partial thickness loss. The wound bed had visible granulation tissue noted, was pink in color, and no slough was noted. The left buttock ulcer measured revealed 1.0 centimeters (cm) by 4.1 cm by 0.2 cm. The peri area was pink in color without odor or drainage noted. The wound tissue was dry with a well defined edge. Review of the progress note dated 09/10/19 at 12:28 P.M., revealed Resident #279's right buttock had a stage 3 pressure ulcer, with partial thickness loss. The ulcer measured 0.3 cm by 1.6 cm by 0.2 cm, the wound bed was yellow in color, no drainage was noted, no odor present. The wound tissue was dry with well defined edges. The resident had peeling skin noted to the areas on the buttock, as well as pink blanchable skin noted to her buttock. Review of orders written by the CNP on 09/10/19 at 10:15 A.M., revealed to discontinue the barrier cream to the buttock. Start Z Guard paste protectant cream topically to affected area twice a day and as needed until healed. The responsible party was notified. Review of facility policy titled Guidelines for Prevention of Pressure Injury/skin Issues, dated 10/2017, revealed a skin prevention program recognizing the need for wound and skin preventative care is a responsibility of every nurse, including STNAs. It is important to determine a resident's risk for developing pressure injuries and other skin issues on their admission or anytime they have a change in their overall health status. A risk assessment tool, the Braden Scale, will assist the nurse in determining appropriate prevention interventions.