**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital documentation, observation, staff interview, review of facility policy, and review of the National Pressure Injury Advisory Panel (NPIAP) guidance, the facility failed to complete accurate skin assessments, provide ongoing monitoring of pressure ulcers, failed to obtain treatment orders for pressure ulcers, and failed to provide a treatment to pressure ulcers for one resident (#39). This resulted in actual harm when Resident #39's left heel unstageable pressure ulcer had an increase in the amount of necrotic tissue present from 25% to 100% within eleven days. This affected one (#39) of one resident reviewed for pressure sores. The facility identified three residents with pressure sores. The facility census was 44. Findings include: Review of Resident #39's medical record revealed an admission date of 09/22/22 and a readmission date of 11/10/22. Diagnoses included difficulty in walking, dysphagia, asthma, multiple sclerosis, cognitive communication deficit, muscle wasting and atrophy, seizures and herpes viral meningitis. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact. Resident #39 required extensive assistance with transfers, dressing, and toilet use, and required limited assistance with personal hygiene. Resident #39 had no pressure ulcers. Review of the care plan revised 09/28/22 revealed Resident #39 had the potential to develop pressure ulcers due to impaired mobility. Interventions included float heels, Pro-Stat (supplement), and report redness, open areas, skin tears and rashes. Review of the wound care note dated 11/01/22 revealed Resident #39 had a left heel, friction wound measuring 1.5 centimeters (cm) by (x) 5.0 cm x 0.1 cm, with scant serous exudate (indicating there was moisture). Treatment orders included: cleanse with wound cleanser and apply foam two times weekly with shower days and as needed. No additional wounds were documented in the wound care note. Further review of the medical record revealed no additional wound assessments completed. Review of the physician order dated 11/03/22 revealed an order to cleanse the left heel with soap and water, pat dry, and apply foam dressing. Change every shower day, Monday, and Thursday, and as needed. Further review of current physician orders for Resident #39 revealed no additional wound care treatment orders. Further review of the medical record revealed Resident #39 went to the hospital on [DATE] for treatment of a urinary tract infection. Review of the hospital documentation, encounter date 11/08/22, revealed the resident was seen for a wound consultation for pressure injuries to the resident's bilateral heels. Resident #39 had erythema (reddening to the skin) to the right great toe tip, blistering to the right lateral foot measuring 12.0 cm x 2.0 cm, a dry scab to the right second toe tip (near the nail) measuring 0.2 cm x 0.2 cm, and erythema to the left medial ankle measuring 3.0 cm x 1.5 cm. All areas were noted to be blanchable, with no drainage, no tunneling, and no odor. Debridement of the right heel blister was completed, and the wound was described as a stage III pressure ulcer measuring 3.0 cm x 2.0 cm x 0.1 cm. Debridement of the left heel blister was completed, and the wound was described as an unstageable pressure ulcer measuring 3.5 cm x 4.0 cm x 0.1 cm with wound bed slough, necrotic (death of tissue), and granulation tissue. Further review revealed orders to cleanse bilateral heels with mild soap and water, apply Vaseline then Adaptic (dressing), cover with foam and change daily, bilateral waffle boots, and elevate bilateral lower extremities and float heels. Review of the re-admission screen, dated 11/10/22, revealed Resident #39 re-admitted to the facility from the hospital. The assessment identified Resident #39 had right heel, left heel, and right toe blisters. There were no measurements or assessments completed of the resident's pressure ulcers upon re-admission. The hospital discharge orders contained no orders for treatments to the areas. Review of the wound care note by the Certified Nurse Practitioner (CNP), dated 11/15/22, revealed Resident #39 had four wounds. Wound #1 was located on the left posterior heel and was identified as a resolved area. Wound #2 was located on the left medial heel, identified as an unstageable pressure ulcer measuring 3.5 cm x 5.0 cm x 0.1 cm, and further described as having 25% eschar (dry, dark scab), 25% necrotic tissue, and a small amount of serous exudate (clean, thin, watery substance). The note revealed the CNP documented wound care orders for the left medial heel included: clean with wound cleanser, apply silver alginate and foam, change every other day, and as needed. Wound #3 was identified as a stage III pressure ulcer to the right medial heel measuring 4.9 cm x 2.0 x 0.1 cm and described as having 10% slough with a small amount of serosanguinous exudate (wound drainage). Wound care orders for the right medial heel included: clean with wound cleanser, apply silver alginate and foam cover dressing, change every other day, and as needed and offload. Wound #4 was identified as a stage II pressure ulcer to the left medial ankle measuring 1.0 cm x 1.0 cm x 0.1 cm and described as having 100% dermis with a scant amount of serosanguineous exudate. Wound care orders for the left medial ankle included: clean with wound cleanser, apply foam, change every other day, and as needed. The note revealed adjacent tissue of wounds #2, #3, and #4 were at risk for further breakdown. Review of physician orders revealed the orders listed in the CNP's wound care note from 11/15/22 were not listed. Review of Resident #39's Treatment Administration Record (TAR) for November 2022 and the medical record revealed no evidence of any treatments being applied to Resident #39's pressure ulcers since readmission from the hospital. The care plan was updated on 11/20/22 due to Resident #39 having actual impairment to skin integrity, including an unstageable left medial heel pressure ulcer, a stage III right medial heel pressure ulcer, and a stage II left medial ankle pressure ulcer. Interventions included pressure reducing devices as ordered, staff to encourage and assist with frequent turning and repositioning, treatment as ordered and wear slippers instead of Crocs. Review of physician orders dated 11/21/22 revealed to cleanse left medial ankle with wound cleanser and cover with foam dressing every other day; cleanse left medial heel with wound cleanser, apply silver alginate to wound bed and cover with foam dressing every other day; and cleanse right medial heel with wound cleanser, apply silver alginate to wound bed and cover with foam dressing every other day. Interview on 11/20/22 at 4:19 P.M. with Licensed Practical Nurse (LPN) #101 verified there were no wound care orders in place for Resident #39's unstageable pressure ulcer to the left medial heel, stage III pressure ulcer to the right medial heel, or stage II pressure ulcer to the left medial ankle. Interview on 11/21/22 at 7:33 A.M. with the Director of Nursing (DON) verified the wound treatment orders from the wound care visit on 11/15/22 were not included in Resident #39's orders. The DON stated she caught the discrepancy this morning and she had nursing apply dressings per physician orders. The DON claimed nursing staff were following the treatment orders in the wound care note, despite the orders no orders being written. The DON did not have an explanation on how nursing staff would know how to complete the treatments if they were not included in the resident's orders or on the TAR. Interview on 11/21/22 at 9:33 A.M. with LPN #104 (an agency staff member) verified if treatments were not included in the resident's physician's orders she would not know if a treatment was even ordered or how to complete the treatment. Interview on 11/21/22 at 1:06 P.M. with Clinical Regional Nurse (CRN) #306 revealed Resident #39 had a left heel blister, which had resolved, prior to her hospitalization on 11/08/22. When Resident #39 returned from the hospital on [DATE], the resident had pressure ulcers on her left heel, right heel, and left medial ankle. Nursing completed the readmission screen on 11/10/22 and noted each of the pressure ulcers as blisters. CRN #306 stated the nurses were not comfortable measuring and staging wounds and noted them as blisters on the readmission screen. CRN #306 verified the wound treatment orders from the 11/15/22 wound care visit were not implemented until 11/20/22. Follow up interview on 11/21/22 at 3:27 P.M. with CRN #306 verified the treatments in the wound care notes from Resident #39's hospital admission were not ordered upon the resident's return to the facility. Resident #39 did not have any treatment orders implemented from 11/10/22 until 11/20/22 for the unstageable pressure ulcer to the left medial heel, stage III pressure ulcer to the right medial heel and the stage II pressure ulcer to the left medial ankle. Observation on 11/21/22 at 4:50 P.M. of Resident #39's wound care completed by LPN #104 revealed LPN #104 refused to complete wound measurements. The surveyor requested further assistance from CRN #306 and the observation was completed with CRN #306. Observation of Wound #2, located on the left medial heel, revealed measurements of 2.8 cm x 3.4 cm x 0.1 cm of necrotic tissue. Adjoining the area of necrotic tissue to the left of the wound, was an area measuring 2.2 cm x 2.9 cm x 0/unable to be determined, which was described as a healing deep tissue injury. The area was 100% necrotic tissue, indicating an increase of 75% necrotic tissue from the 11/09/22 hospital wound care note and the 11/15/22 wound care note. Due to the necrotic tissue, the depth of the wound was unable to be determined. Observation of Wound #3, located on the right medial heel, revealed measurements of 1.5 cm x 1.5 cm x 0 and was noted to be healing. Wound #4 was observed to measure 0.9 cm x 0.7 cm. Each of the wound treatments were completed per physician order. Review of the facility policy titled, Skin Care Assessment, revised 11/02/18 revealed all areas identified should be measured and recorded in the electronic medical record (EMR) and initiate the Skin Care Management Policy for any open areas or areas of concern due to pressure points. Review of policy titled Skin Care Management Procedure, dated 11/02/18, revealed upon admission a full skin assessment should be conducted within two to six hours of arrival and documented in the EMR. Additionally, monitoring included with each dressing change or at least weekly at a minimum, documentation should include the date observed, location and staging, size, exudates, pain, wound bed color and type of tissue/character including evidence of healing or necrosis and percentage of tissue and a description of wound edges and surrounding tissue. Dressing and treatments were determined based upon individual practitioner's clinical judgements. Review of the facility policy titled, Skin Care Assessment, revised 11/02/18 revealed all areas identified should be measured and recorded in the electronic medical record (EMR) and initiate the Skin Care Management Policy for any open areas or areas of concern due to pressure points. Review of the National Pressure Injury Advisory Panel (NPIAP) Guidance via https://npiap.com/page/PreventionPoints revealed skin should be assessed upon admission as soon as possible (but within 8 hours). Review of the NPIAP Guidance titled, NPIAP Pressure Injury Stages, revealed if necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle, or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4).