**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, review of the facility's policy and procedure for skin management, interviews with nursing staff, family interview, and Wound Physician #123 interview, the facility failed to implement a comprehensive and effective pressure ulcer treatment program for two residents (Residents #42 and #18). This resulted in Immediate Jeopardy that was actual harm on 08/01/22 when the facility failed to ensure Resident #18's wound care physician orders were transcribed and treatments implemented, skin assessments completed, and pressure relieving interventions were active and functional resulting in the development of pressure ulcers and the declining condition of the existing pressure ulcers to a Stage 4 pressure ulcer and an Unstageable pressure ulcer. In addition, Immediate Jeopardy that was actual harm resulted when the facility failed to identify Resident #42's pressure ulcer and provide treatment resulting in an Unstageable pressure ulcer to Resident #42's right great toe at the discovery stage. The facility identified 12 residents with pressure ulcers and the facility census was 54. In addition, a concern that did not rise to the level of Immediate Jeopardy was identified related to the facility's failure to appropriately complete pressure ulcer dressing changes as ordered by the physician for Resident #10's left heel pressure ulcer. This affected one of six residents reviewed for pressure ulcers (Resident #10). On 08/25/22 at 3:25 P.M., the Administrator was notified Immediate Jeopardy began on 08/01/22 when Resident #18 had an identified Stage 2 pressure ulcer (defined as partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer. The wound bed is viable, pink or red, moist, and may also present as an intact or open/ruptured blister) to her right heel and no physician orders were put into place for the treatment and care of the wound and no treatment was provided until 08/23/22 resulting in the right heel pressure ulcer declining in condition. The Immediate Jeopardy continued 08/25/22 when Resident #18 received surgical debridement from Wound Physician #123 who classified Resident #18's right heel pressure ulcer as Stage 4 (full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed). The Immediate Jeopardy situation continued for Resident #42 when on 08/23/22, the surveyor discovered an Unstageable pressure ulcer (defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) to the resident's right great toe and the facility was not aware. The Immediate Jeopardy was removed on 08/25/22 at 9:30 P.M. when the facility implemented the following corrective action: • On 8/24/2022 at approximately 4:30 P.M.: DON completed an audit of all wound orders ensuring that they were all transcribed into the electronic chart. • On 08/25/22 at 11:00 A.M.: An assessment of current wounds was completed by the Wound Physician and a facility nurse; all of which had the ordered treatments in place. • On 8/25/2022 at approximately 1:00 P.M.: Resident #18's air mattress air pump was replaced by maintenance assistant. • On 08/25/22 at 1:30 P.M.: The Maintenance Director completed an inspection of current air mattresses; all of which were functioning correctly. • On 08/25/22 (no start time identified): the DON and designees conducted a skin assessment on current residents to ensure any areas identified have treatment orders. Assessments completed on 8/25/2022 by 8:00 P.M. Three new areas were identified by DON and designees. Physicians were notified by DON and designees of the new areas on 8/25/2022 by 8:30 P.M. Treatment orders were received for the new areas by DON and designees on 8/25/2022 by 8:45 P.M. Treatments in place by DON and designees on 8/25/2022 by 9:30 P.M. • On 08/25/22 at 8:00 P.M.: All facility Licensed Nurses received education by the Assistant Director of Nursing on the policy titled Wound Treatment Management with emphasis on obtaining treatment orders when wounds are identified and completing wound care treatments as ordered. Education also included reporting if an air mattress is not functioning appropriately to the Maintenance Director. • On 08/25/22 (time not identified): DON or designee will be responsible for ensuring all wound physician orders are entered into the electronic chart. Administrator or designee will oversee to ensure this process is completed as appropriate, and concerns will be reported to QAPI committee. • Beginning on 08/25/22 (time not identified): An observation of five (5) wound care treatments to be completed weekly for four (4) weeks. Observation to include wound treatment in place as ordered and documentation of the treatment. Results of the observations to be forwarded to the facility QAPI committee for further review and recommendations. • Beginning on 08/25/22 (time not identified): Skin assessments to be completed on five (5) residents per week to ensure any identified areas have an order for wound care if applicable beginning on 08/25/22. Skin assessments to be completed by the DON/designee with the results forwarded to the facility QAPI committee for further review and recommendation. • Beginning on 08/25/22 (time not identified): Maintenance Director or designee will complete an inspection of air mattresses in use to ensure they function correctly weekly for four (4) weeks. Results of the inspections to be forwarded to the facility QAPI committee for further review and recommendations. • Beginning on 08/25/22 (time not identified): DON or designee will audit to ensure all new orders received from wound physician are entered into electronic charts correctly once weekly for weeks and as needed thereafter. Administrator or designee will ensure audits is completed as appropriate beginning on 08/25/22. Results of the inspections to be forwarded to the facility QAPI committee for further review and recommendations. • On 08/29/22 from 12:05 P.M. to 2:15 P.M. interviews with Licensed Practical Nurse (LPN)'s #111 and 121 revealed they had received education regarding wound treatment and management, as well as proper documentation. Although the Immediate Jeopardy was removed on 08/25/22 the deficiency remained at a Severity Level 2 (no actual harm with the potential for minimal harm that is not Immediate Jeopardy) as the facility was continuing to educate staff and was in the process of completing and reviewing audits to determine if further action is required. Findings Include: 1. Review of Resident #18's medical records revealed an admission date of 03/01/22 with diagnoses that included encephalopathy, right knee contracture, abnormal posture, muscle weakness, paraplegic, and other diseases of the tongue. Review of Resident #18's pressure ulcer risk assessment dated [DATE] revealed the resident was at high risk for the development of pressure ulcers. Review of the care plan dated 03/01/22 revealed Resident #18 required assistance with activities of daily living related to paralysis. Interventions included to inspect skin daily during routine care and report any impairments to the charge nurse and provide incontinence care with routine rounds and as needed. Resident #18 had actual skin impairments and interventions included air mattress, turn and reposition every two hours as tolerated, initiate wound treatments, provide treatments as ordered and observe for changes that included infection or worsening of the wounds. Review of Resident #18's physician orders dated 06/13/22 revealed the resident was to be repositioned every two hours and as needed while in bed. Physician orders dated 06/15/22 revealed Resident #18 was to have an air mattress to promote skin integrity. Review of Resident #18's Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed the resident did not have a cognition score documented due to resident was rarely understood. Resident #18 was dependent for transfers, toileting and personal hygiene and was incontinent of bowel and bladder. Resident #18 had two unidentified Stage 2 pressure ulcers. Review of Resident #18's skin grid dated 7/28/22 revealed the resident had a left buttock Unstageable pressure ulcer (defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) that measured 2.0 centimeters (cm) in length, 2.5 cm in width 0.1 cm in depth. Resident #18 also had a right buttock Stage 3 pressure ulcer (defined as full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and epibole [rolled wound edges] are often present. Slough and/or eschar may be visible but does not obscure the depth of tissue loss) that measured 3.0 cm in length, 4.0 cm in width and unable to determine depth. Review of progress note dated 08/01/22 revealed Licensed Practical Nurse (LPN) #124 had identified an area to Resident #18's right heel. The top layer of skin was gone from the right heel and the area was observed to be a Stage 2 pressure ulcer; however, no measurements were documented of the wound. The wound was cleaned, and a foam dressing was applied, and Physician #125 (Resident #18's primary care physician) was notified with orders given to have the resident be seen by the wound team. Review of Resident #18's skin grid pressure dated 08/04/22 (this was a facility assessment) revealed the resident had a left buttock Unstageable pressure ulcer 1.8 cm in length, 2.3 cm in width 0.2 cm in depth,a right buttock Stage 3 pressure ulcer 2.0 cm in length, 0.8 cm in width 0.1 cm in depth, a right first metatarsal pressure suspected deep tissue injury (DTI) (defined as intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue) 2.5 cm in length, 2.5 cm in width, 100% necrotic. In addition, Resident #18 had a right heel pressure ulcer and a suspected deep tissue injury (DTI), the right heel wound had been classified as both pressure as well as a DTI, that measured 3.5 cm in length, 4.0 cm in width, unable to determine depth, and 100% necrotic. The facility DON revealed the measurements contained in this document were actually copied from Wound Physician #123's notes and the areas were not independently measured by facility staff. No further skin assessments were documented for Resident #18. Review of progress note dated 08/16/22 revealed LPN #121 had contacted the physician with concerns related to the resident's right heel, and treatment orders were received. However, the progress note did not include specific information related to the orders. In addition, there was no evidence a treatment order was added to the treatment administration record (TAR) and no evidence a treatment was provided to Resident #18's right heel pressure ulcer. Review of Resident #18's physician orders dated 07/17/22 through 08/24/22 revealed to cleanse right gluteal (buttocks) with normal saline, pat dry, apply nickel sized amount of Santyl to calcium alginate and cover with foam dressing daily and as needed, cleanse left gluteal with normal saline, pat dry, apply a nickel sized amount of Santyl to calcium alginate and apply to wound. Cover with foam dressing daily and as needed. Review of Resident #18's physician orders dated 08/16/22 through 08/24/22 revealed cleanse right heel with normal saline, pat dry, apply Santyl, apply silver alginate, cover with absorbent dressing, and wrap with gauze daily and as needed. Cleanse right great toe (please note, the facility is also documenting this area as metatarsal and using the words great toe and metatarsal interchangeably) with normal saline, pat dry, apply skin prep and cover with absorbent dressing, and wrap with gauze daily and as needed. Review of Resident #18's TAR for August 2022 revealed no documentation ordered treatments had been completed from 08/16/22 through 08/22/22 for the residents' right heel, right great toe, and buttock wounds. Observation on 08/24/22 at 10:25 A.M. revealed Resident #18 was in bed with her right heel positioned underneath her buttocks due to right leg being contracted. Further observation revealed the resident had a gauze dressing to her right heel that appeared to be saturated with urine from her heavily saturated incontinence brief. LPN#119 had removed the soiled gauze and the resident's heel was macerated (softened by being soaked in liquid), and a large amount of thick purulent drainage and a foul pungent odor was detected. LPN #119 obtained measurements of the right heel, measuring 5 cm in length, 6.5 cm in width and unable to determine a depth. Further observation revealed Resident #18 had an area to her right metatarsal that appeared to be a DTI, that had no dressing around it. LPN #119 stated he was not aware of the Resident #18's right foot wounds. LPN #119 and State Tested Nurse Aide (STNA) #120 continued to provide incontinence care and removed Resident #18's incontinence brief. The surveyor observed Resident #18 had two open areas, one to her buttocks and one to her sacrum (tailbone) that appeared to also be macerated and reddened. There were no dressings on these wounds when LPN #119 removed the incontinence brief. LPN #119 stated the areas should have had a dressing over the wounds. STNA #120 stated she had not provided incontinence care to the resident since she had started her shift at 7:00 A.M. Resident #18 was not able to speak. Observation further revealed the resident had an air mattress pump at the foot of her bed that had been beeping with a red light lit up that indicated a system malfunction. Resident #18's roommate stated, that thing is always beeping and they come in and silence it and 15 minutes later its beeping again. STNA #120 had silenced the alarm at that time, and LPN #119 stated he was not aware of the reason the pump had indicated a system malfunction. Telephone interview on 08/24/22 at 11:55 A.M. with LPN #121 revealed she was not aware Resident #18 had a skin impairment that had been reported on 08/01/22. LPN #121 stated it would be on the facility's incident report. LPN #121 further stated she was not aware Resident #18's right heel had not been treated and it wasn't until 08/16/22 when the floor nurse had come to her with concerns of the resident's wound. LPN #121 stated she had observed the area and had also been concerned due to the area was open and had necrotic tissue visible. LPN #121 stated she had contacted Physician #125 for orders and had placed the orders in the computer and there had not been any previous orders. Interview on 08/24/22 at 1:12 P.M. with the DON confirmed the incident report had identified a skin impairment for Resident #18 on 08/01/22. The DON stated LPN #124 had contacted Physician #125 and had received orders to have the resident be seen by the wound team. At this time in the interview, the DON produced the wound assessments from Wound Physician #123 that the DON stated should have been uploaded in the computer system, however had not been done. Review of Physician #125's progress note dated 08/04/22 revealed Resident #18's right heel was classified as a pressure ulcer as well as a DTI that measured 3.5 cm in length, 4.0 cm in width and unable to determine depth and was 100% necrotic. This progress note stated orders were to apply calcium alginate (wound dressing) absorbent dressing and gauze daily and as needed. Area to right metatarsal was classified as a pressure ulcer and DTI that measured 2.5 cm in length, 2.5 cm in width and unable to determine depth and was 100% necrotic. Orders were to apply calcium alginate, absorbent dressing and gauze daily and as needed. Review of Wound Physician #123 wound progress note dated 08/11/22 revealed area to the right heel had measured 4.0 cm in length, 5.0 cm in width and unable to determine depth. Orders were changed to apply Santyl (wound ointment) calcium alginate, absorbent dressing and gauze daily and as needed. Area to right metatarsal measured 3.0 cm in length, 3.0 cm in width and unable to determine depth. Orders had remained the same as previous. Review of Wound Physician #123 progress note dated 08/18/22 revealed area to right heel measured 5.0 cm in length, 5.0 cm in width. Orders had remained the same as previous. Area to right metatarsal measured 2.5 cm in length, 2.0 cm in width. Orders had remained the same as previous. At this time in the interview, the DON verified the orders had not been transcribed into Resident #18's records and the orders had not been known by the nursing staff to complete wound care. The DON was unable to provide a clear explanation of the facility wound notification process as far as which physician should be contacted with concerns related to wounds and wound care, and he confirmed the policies were in place to reflect the correct process that included to contact the physician. Interview on 08/25/22 at 6:55 A.M. with Wound Physician #123 revealed he had performed weekly rounds at the facility and stated he had seen Resident #18 the previous week. Wound Physician #123 stated he had written his orders on his progress notes and had given them to the facility after he had completed them. Wound Physician #123 stated he was unaware the orders he had given had not been placed in the computer and was not aware treatments had not been performed as ordered. Wound Physician #123 stated if the staff had concerns related to a resident's wounds they should contact him, however, if he had been unavailable the primary care physician should be contacted. Observation on 08/25/22 at 7:30 A.M. with Wound Physician #123 for Resident #18 revealed area to right heel had continued to appear to have purulent drainage with a pungent odor detected. Wound Physician #123 had debrided (removal of damaged tissue with a surgical instrument) and had reclassified the right heel wound as being a Stage 4 (defined as full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer) that measured 5 cm by 5 cm and 0.5 cm in depth. Observation made during the procedure revealed Resident #18 appeared to be in pain during the surgical debridement as evidenced by the resident attempting to pull her leg away during the debridement process. Wound Physician #123 had not administered Resident #18 any numbing medication prior to the debridement and no pain medications had been administered prior. Further observation revealed Wound Physician #123 had removed the outer layer of the skin to the resident's metatarsal area and had reclassified the area as a Stage 3 pressure ulcer that measured 3.0 cm in length, 3.0 cm in width and 0.2 cm in depth. Observation at time of wound care revealed Resident #18's air mattress continued to be beeping and indicated a system malfunction. Interview on 08/25/22 at 3:05 P.M. with DON and Administrator revealed they had not been made aware of Resident #18's air mattress not working properly. Interview on 08/25/22 at 3:45 P.M. with Administrator revealed Resident #18's air mattress had been replaced and an audit of all other mattresses had been completed to ensure they had been working properly. 2. Review of Resident #42's medical records revealed an admission date of 09/21/21 with diagnoses that included muscle weakness, malnutrition, pressure ulcer of the sacrum and dysphagia (difficulty swallowing). Review of care plan dated 01/25/22 revealed Resident #42 had potential for alterations in skin integrity related to decreased mobility and sacral wound. Interventions included turn and reposition every two hours, pressure reducing mattress, and provide assistance with hygiene as needed. Care plan revised on 06/26/22 revealed Resident #42 had a Stage 4 sacral wound, left leg chronic ulcer and left foot DTI, and a right lateral leg Stage 2 pressure ulcer. Interventions included provide wound care as ordered, nursing staff to observe the wound dressing daily to ensure dressing remained intact and observe for signs and symptoms of infection. Review of Resident #42's skin risk assessment completed 06/26/22 revealed the resident was at very high risk for development of pressure ulcers. Review of the quarterly MDS dated [DATE] revealed Resident #42 had impaired cognition and required total dependence for transfers, bed mobility, toileting, and personal hygiene. Resident #42 was incontinent of bowel and bladder and had an unidentified Stage 4 pressure ulcer (sacral). Review of skin grid dated 08/04/22 revealed Resident #42 had a Stage 4 pressure ulcer to the sacrum that measured 7 cm in length, 5 cm in width and 0.5 cm in depth. The resident's right calf pressure ulcer measured 6.0 cm x 4.0 cm and 0.1 cm depth. No further skin assessments were documented in the electronic records. Review of Resident #42's physician orders dated 07/31/22 through 08/23/22 revealed to cleanse the sacral wound with normal saline, pat dry, apply calcium alginate and cover with dry dressing daily and as needed. Right calf pressure ulcer order (started 07/12/22) cleanse, apply adaptic, collagen, ABD and kerlix, every Tuesday, Thursday and Saturday and PRN. Physician orders dated 08/23/22 revealed to cleanse the right great toe with normal saline, pat dry, apply oil emulsion dressing, calcium alginate and dry dressing daily and as needed. Review of TAR for August 2022 revealed no documented evidence the sacral wound treatments had been completed on 08/10/22, 08/12/22, 08/14/22, or 08/15/22. Observation on 08/23/22 at 5:08 A.M. revealed Resident #42 was in bed slightly on her right side, multiple signs were posted outside as well as inside the resident's room that indicated the resident is to be turned every two hours. Observation on 08/23/22 at 7:31 A.M. revealed Resident #42 appeared to be in the same position as previous observation on 08/23/22 at 5:08 A.M. Interview with LPN #117 at time of observation revealed the resident was to be turned and repositioned every two hours. Further observation with LPN #117 revealed Resident #42 had an undated gauze dressing to her right calf area and the resident's right foot was placed in a pressure relieving boot (PRAFO). LPN #117 removed the Velcro strap on the right boot and a large amount of dried crusted drainage was noted on the boot; the boot also had multiple areas of dirt and debris. As LPN #117 undid the strap, further observation revealed an open area to the resident's right great toe that was draining a large amount of thick bloody mucus. LPN #117 denied being aware of the area and confirmed the area was open and draining. LPN #117 also verified the crusted area on the boot. Further observation with LPN #117 revealed Resident #42 had a large sacral wound with a foam dressing that had not been covering the wound. The sacral wound was noted to have a large amount of thick green colored drainage and a foul odor was detected. LPN #117 stated she had cared for the wound yesterday and had not detected an odor at that time. At time of observation LPN #118 had entered the resident's room to assist with care and she confirmed she had not been aware of the open area to the resident's right great toe. Interview and observation on 08/23/22 at 2:31 P.M. with DON confirmed Resident #42's pressure relieving boot had a large amount of crusted drainage and debris and also confirmed the open area to the resident's right great toe. The DON stated he did not believe the open area had recently occurred due to the large amount of drainage on the boot. The DON stated he would inform the wound physician the resident would need to be seen for the area. Observation on 08/25/22 at 7:30 A.M. with Wound Physician #123 for Resident #42, revealed the physician stated he had not been aware of the area (right great toe) previously and had classified the wound as being an Unstageable pressure ulcer. Further observation revealed Wound Physician #123 removed the dressing to the resident's right calf and observed a large amount of green colored drainage to the dressing. Wound Physician #123 asked the DON to obtain a culture of the area because he had concerns the area was infected. The DON swabbed the area and obtained the wound culture at that time. At this time, Wound Physician #123 identified the right calf pressure ulcer was a Stage 2 and measured 7.5 cm (l) x 3.5 cm (w) x 0.1 cm (d). Record review on 08/29/22 revealed no results on Resident #42's right calf wound culture taken on 08/25/22. On 08/29/22, interview with the DON at 12:05 P.M. revealed the culture had not been picked up by the lab due to it had been canceled for an unknown reason. The DON stated he had contacted the lab and they stated the specimen would be picked up today. Interview on 08/30/22 at 8:00 A.M. with LPN #118 revealed the specimen for Resident #42's right calf was still in the refrigerator and the DON had just recently come to locate it. LPN #118 was unaware why the specimen had not been sent previously. Interview on 08/30/22 at 8:20 A.M. with DON confirmed the specimen had not been picked up and stated he had obtained a new culture and it was to be taken to the lab today. DON was unable to provide an explanation as to why the culture still had not been picked up after he had already spoken with the lab the previous day. Telephone interview on 08/31/22 at 1:58 P.M. with Resident #42's daughter revealed she had concerns related to the resident's care that included wound care and turning and repositioning. Resident #42's daughter stated she had placed multiple visible signs in the resident's room to remind staff to turn and reposition the resident frequently and had placed audio and video recording devices in the room to monitor her care. Resident #42's daughter had also stated she had spoken with the DON regarding her concerns and had not seen improvements in her care. Resident #42's daughter stated she had not been made aware of the new area observed to the resident's right great toe. Review of the facility policy titled Skin Assessment revised 08/01/22 revealed a skin assessment is to be done on admission/readmission and weekly or after a change in condition or after a newly identified pressure ulcer. Review of the facility policy titled Wound Treatment Management dated 12/01/21 revealed wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and the frequency of dressing changes, and in the absence of treatment orders the licensed nurse will notify the physician to obtain treatment orders. Review of the facility's CMS-672 form identified 12 residents with pressure ulcers. The facility further identified four of the 12 residents had facility acquired pressure ulcers. 3. Record review revealed Resident #10 was admitted to the facility on [DATE]. His admitting diagnoses included obstructive and reflux uropathy, thoracic aortic aneurysm, traumatic brain injury, hypertension, and nonrheumatic aortic valve insufficiency. Review of Resident #10's Minimum Data Set (MDS) assessment dated [DATE] revealed this resident had moderate cognitive impairment. He was totally dependent on one to two staff members for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of Resident #10's skin assessment, from this MDS dated [DATE], revealed the resident was at risk for the development of pressure ulcers. At the time of this MDS, the resident did have a pressure ulcer or injury. This MDS identified Resident #10 had two Unstageable pressure injuries. Review of Resident #10's Braden Score Evaluation dated 07/19/22 revealed the resident was at a low risk for the development of pressure ulcers. His score was a 15. Review of Resident #10's plan of care dated 11/15/19 revealed this resident was at risk for impaired skin integrity secondary to decreased aortic valve insufficiency and a non-ST elevated myocardial infarction (STEMI). Interventions for this plan of care included: Assist with all transfers as needed; Encourage to turn and reposition every two hours and as needed; Inspect for any reddened areas during daily care; Pressure reducing mattress on bed; Pressure reducing cushion to wheelchair; Provide peri-care with each incontinence episode and when transferring, turning, and repositioning use proper techniques to avoid friction and shear. This care plan was not updated to include the pressure ulcers present in June 2022 and did not include other interventions in place which was dressing changes to his heel and buttocks or his prafo boots. Since the time these wounds occurred (which were facility acquired), the right heel pressure ulcer wound (healed 08/18/22) and the buttocks pressure ulcer had healed (08/16/22), but the left heel pressure ulcer remained unhealed. Review of the physician orders for the left heel pressure ulcer revealed: • Apply protectant wipe to bilateral extremities, pad and secure with kerlix daily (dated 06/16/22 until 07/14/22) • Air mattress to bed; Check placement and function every shift (dated 06/17/22 and still in effect) • Turn and reposition the resident every two hours when in bed (dated 06/17/22 and still in effect) • Elevate bilateral extremities when in bed (dated 06/17/22 and still in effect) • Pro Heal 30 cc two times a day for wounds (dated 06/22/22 and still in effect) • Heel protector boots to be worn daily and as tolerated. Remove when providing care (dated 06/24/22 and still in effect.) • Cleanse left heel with normal saline, pat dry, apply a dressing and wrap with kerlix daily and as needed if loose or soiled (dated 07/14/22 to 08/24/22) • Cleanse left heel with normal saline, pat dry, apply Santyl (skin product used to help heal skin ulcers), calcium alginate (water-soluble cream-colored substance for wound healing), cover with a dry sterile gauze and wrap with kerlix (dated 08/24/22 to 08/31/22) • Cleanse left heel with normal saline, pat dry and apply medihoney, calcium alginate to wound, cover with dry sterile pad and wrap with kerlix. Change daily and as needed if loose or soiled (dated 08/31/22 to 09/02/22) • Cleanse left heel with normal saline, pat dry and apply calcium alginate, cover with a dry sterile pad, and wrap with kerlix daily and if loose or soiled (dated 09/02/22) • Left heel dressing use copious normal saline to remove gauze from wound. Cleanse with normal saline, pat dry and apply calcium alginate, wrap with a dry sterile bad and wrap with kerlix daily and if loose or soiled (dated 09/02/22) • &nb[TRUNCATED]