**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record for Resident #12 revealed an admission date of 02/25/25. Medical diagnoses included atrial fibrillation, coronary artery disease, heart failure, and hypertension. Review of the admission MDS dated [DATE] revealed Resident #12 was moderately cognitively impaired. His functional status was set up or cleanup for eating, substantial/maximal assistance for toileting, bed mobility, and transfers. Review of the care plan dated 02/25/25 revealed the resident has actual impairment related to skin integrity to the sacrum is a Stage III present on admission, left heel unstageable present on admission and the right heel present on admission. Interventions of educate the family, eliminate causative factors, promote good nutrition, encourage position change and repositioning during the night and monitor location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to physicians were initiated on 03/06/25 and implement heel boots and pressure relieving reducing mattress while in bed were initiated on 03/20/25. Review of the admission skin assessment dated [DATE] revealed he had wounds to his left heel that was unstageable, right heel that was soft and pink, and to the vertebrae mid upper back was reddened. There were no measurements included with the heel or vertebral wounds upon admission. Further review of the assessment of these wounds on 02/27/25 revealed they were all staged as unstageable. The vertebrae wound was documented, and the right buttock wound was documented as unstageable. Review of the skin assessment dated [DATE] revealed the following: right buttock measured 2.0 cm by 7.0 cm by 0.3 cm and wound was documented as unstageable; right heel measured 6.0 cm by 7.0 cm by 0.1 cm and wound was documented as unstageable and the left heel measured was 8.0 cm by 5.0 cm by 0.1 cm, with no wound classification being documented. Interview with the LPN #61 on 04/01/25 at 2:00 P.M., confirmed these wounds were not measured upon admission and should have been. She stated the wound that was documented on admission as being on the vertebrae was not on the vertebrae, but on the right buttock. LPN #61 verified there was no skin alteration on the vertebrae. Review of the policy titled Skin Care Management Procedure, dated 07/01/02 and revised on 12/09/22, states upon admission or readmission a full skin assessment should be conducted within two to six hours of arrival and documented in the electronic medical record to ensure proper documentation of existing skin condition. Weekly skin assessment will be completed and documented in the electronic health record to identify new areas of concern. Review of the National Pressure Injury Advisory Panel (NPIAP) at https://www.npuap.org/resources/educational-and-clinical-resources, 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. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated dermatitis (IAD), intertriginous dermatitis (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). 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. Stage 4 Pressure Injury: Full-thickness skin and tissue loss 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. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. 1 Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. 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). Do not use DTPI to describe vascular, traumatic, neuropathic, or dermatologic conditions. Based on observation, resident interview, staff interviews, medical record review, physician wound documentation review, hospital documentation review, National Pressure Injury Advisory Panel (NPIAP) guidleine review, and policy review, the facility failed to transcribe and implement treatment orders timely for the treatment of pressure ulcers for two (#68 and #80) residents. Actual harm occurred to one resident (#68) when wound care orders were not timely implemented on admission, and the resident received no treatment or intervention from the facility for pressure areas that were present on admission. Resident #68 was admitted with a Stage 2 pressure ulcer to the sacrum/coccyx area on 01/31/25 and received no treatment until 02/04/25, after the wound increased to an unstageable wound. Furthermore, the facility failed to assess and timely implement wound care for two (#11 and #12) additional residents that placed the residents at risk for the potential for more than minimal harm. This affected four (#11, #12, #68 and #80) of five residents reviewed for pressure ulcers. The facility census was 87. Findings include: 1. Review of medical record for Resident #68 revealed an admission date on 01/01/25, with diagnoses including sepsis, malignant neoplasm of bone, malignant neoplasm of urethra, antineoplastic chemotherapy induced pancytopenia, disorders of bone density and structure, irritable bowel syndrome, iron deficiency anemia, malignant neoplasm of cervix, and secondary malignant neoplasm of intra-abdominal lymph nodes. Resident #68 had a hospitalization on 01/27/25 and returned to the facility on [DATE]. Review of the significant change Minimum Data Set (MDS) assessment dated [DATE], for Resident #68 revealed intact cognition. Resident #68 required staff supervision assistance with eating. Resident #68 required maximum assistance for toileting, bed mobility and transfers. Resident #68 was incontinent of bowel and bladder. Resident #68 was determined to be at risk for pressure ulcers. Resident #68 was coded with one unstageable deep tissue injury present on admission. Review of the plan of care for Resident #68 revealed resident has actual pressure ulcer related to decreased mobility and weakness on the sacrum. Initially documented as a deep tissue injury present on admission. Interventions include administer/monitor effectiveness of/response to treatment(s) as ordered, assess/record changes in skin status and report changes to physician, enhanced barrier precautions, pressure reducing mattress, measure and document condition of skin weekly, monitor effectiveness of pressure relieving devices, incontinence care after each incontinent episode. Review of the hospital documentation wound care dated 01/28/25 for Resident #68 revealed resident had a Stage 2 pressure ulcer to the coccyx gluteal cleft area, red, open and 0.5-centimeter (cm) round. Review of the hospital discharge documentation on 01/31/25 for Resident #68 revealed under the assessment and recommendation section revealed Stage 2 pressure ulcer on the coccyx. Review of the facility admit/readmit screener form dated 01/31/25 (completed on 02/03/25) for Resident #68 revealed an area to the sacrum identified as moisture associated skin damage (MASD) with a length of 1.5 centimeters (cm). A width or depth was not documented for sacrum. Review of the weekly skin screener dated 01/31/25 (completed on 01/31/25) at 6:23 P.M. for Resident #68 revealed open area on sacrum with a description of open area 1.5 cm. No width or depth was documented for sacrum. Review of the Treatment Administration Record (TAR) for the month of January 2025 for Resident #68 lacked documented evidence of any orders related to sacrum wound treatments. Review of the TAR for the month of February 2025 revealed Resident #68 received the first treatment to the sacral wound on 02/04/25. Review of the wound nurse practitioner (NP) progress note, dated 02/03/25, for Resident #68 revealed patient was sent to hospital on [DATE] for altered mental status and readmitted on [DATE] with a new unstageable wound to the sacral area. The wound measurements were 6.0 cm x 2.0 cm x 0.1 cm. Review of the nurse's progress notes dated 02/03/25 at 10:40 P.M., Skin/Wound Note revealed second skin assessment done from resident's readmission and resident noted to have unstageable pressure ulcer to left sacrum. New treatment orders received. Wound nurse practitioner at bedside and classified wound as unstageable to left sacrum measuring 6.0 cm x 2.0cm x 0.1 cm. There is small amount of serosanguineous drainage noted. New treatment orders received for triamcinolone compound cream. Resident family and physician all notified and aware. Review of the TAR for the month of February 2025 for Resident #68 revealed an order dated 02/04/25, for triamcinolone acetonide external cream apply to left sacrum topically every shift for pressure (unstageable). Pharmacy to mix equal parts of Silvadene, zinc oxide 20 percent, triamcinolone 0.5 percent: Cleanse wound with soap and water and apply cream to area every shift. Review of the weekly skin screener dated 02/07/25 at 2:31 P.M. (completed on 02/09/25 at 2:33 P.M.) revealed skin assessment documentation for site: sacrum with a description documented treatment in place. A width or depth was not documented for sacrum. Review of the wound nurse practitioner (NP) progress note dated 02/10/25 for Resident #68 revealed unstageable to sacral area. Wound measures 4.5 cm x 2.0 cm x 0.1 cm. Subcutaneous is exposed, small amount of serosanguineous drainage noted. Wound bed has small pink granulation within the wound bed and a large amount of necrotic tissue within the wound bed including adherent slough. Peri-wound was macerated. During an interview on 03/25/25 at 9:00 A.M., Resident #68 stated the wound physician was in to treat the wound a couple of times now. CNA's apply cream when they provide incontinent care. Facility staff tell her it is getting better, but it is painful at times. Observation on 03/27/25 at 1:46 P.M. with Wound Physician #302 of sacral wound dressing change and assessment for Resident #68 revealed the old dressing to have serosanguineous drainage on it when removed by physician. Sacral wound is measured at 2.7 cm x 3.0 cm x 0.1 cm. Wound bed noted with small pink bumpy appearance and scattered yellow adherent slough. Wound Physician applied numbing agent to area and debrided wound bed. Wound cleaned and dressing applied. Interview on 03/31/25 at 12:55 P.M. with Director of Nursing (DON) verified that a wound treatment was not initiated when Resident #68 returned to the facility on [DATE], and further verified the length and depth of wound was not documented on the readmission documentation. DON verified the wound was documented as unstageable on 02/03/25 and a wound treatment was documented on the TAR on 02/04/25 for the first time. 2. Review of the medical record for Resident #11 revealed an admission date on 10/06/22, with diagnoses including but not limited to bipolar disorder, vascular dementia with agitation, Type II diabetes, iron deficiency anemia, and peripheral vascular disease. Review of the quarterly Minimum Data Set (MDS) assessment for Resident #11 dated 01/14/25 revealed the resident had moderate cognitive impairment. Resident #11 required assistance for eating, maximum assistance for bed mobility and was coded as dependent for toileting and transfers. Resident #11 was incontinent of bowel and bladder. Resident #11 was at risk for pressures ulcers and was not coded with any current wounds. Review of the Braden assessment completed on 02/04/25 for Resident #11 revealed the resident was at high risk for skin breakdown. Review of the plan of care for Resident #11 revealed the resident was at risk for skin breakdown and pressure ulcers related to diabetes ulcers, peripheral vascular disease, incontinence, impaired mobility and hypertension. Interventions and goals included protective barrier cream, assessing and recording changes in skin status, reporting pertinent changes to physicians, incontinence care after each incontinent episode, pressure reduction cushion to wheelchair and mattress on bed, and weekly skin assessments by nurse. Review of the active physician orders for Resident #11 revealed the following orders: enhanced barrier precautions to be used during high contact resident care activities dated 11/01/24, Santyl ointment apply to sacrum topically every day shift for wound care, cleanse wound with normal saline, pat dry, apply Santyl to wound bed and apply border gauze, dated 03/31/25. Review of the discontinued physician orders for Resident #11 revealed the following discontinued orders: Open area to lower intergluteal cleft, cleanse with normal saline, pat dry, apply zinc oxide ointment after each incontinent episode, dated 03/25/25. Open area to lower intergluteal cleft, cleanse with normal saline, pat dry, apply zinc oxide ointment after each incontinent episode, and apply Santyl and island dressing every day, dated 03/26/25. Santyl ointment apply to left gluteal cleft topically as needed for wound care, dated 03/28/25. Santyl ointment apply to left gluteal cleft topically every day shift for wound care, cleanse wound with normal saline, pat dry, apply Santyl to wound bed and apply border gauze, dated 03/28/25. Review of the Treatment Administration Record for Resident #11 revealed a treatment ordered 03/25/25 for open area to lower intergluteal cleft, cleanse with normal saline, pat dry, apply zinc oxide ointment after each incontinent episode was documented as completed on 03/25/25, 03/26/25, 03/27/25 and 03/28/25. Review of the weekly skin assessment dated [DATE] at 12:17 A.M., for Resident #11 revealed lower intergluteal cleft - new order to cleanse with normal saline, pat dry, apply zinc oxide ointment after each incontinent episode. No measurements or wound stage were included in the assessment; the wound was simply described as opened. Review of the nurse's progress note dated 03/25/25 at 12:20 A.M., for Resident #11 revealed new order for open area to lower intergluteal cleft, cleanse with normal saline, pat dry, apply zinc oxide ointment after each incontinent episode physician and nurse practitioner were notified of the opened area. Review of the wound care nurse skin observation dated 03/26/25 at 4:42 P.M., for Resident #11 revealed stage three pressure ulcer on sacrum measuring 0.5 centimeters (cm) x 3.5 cm x 0.1 cm. Treatment for area is to cleanse area with normal saline, pat dry, apply Santyl to wound bed and cover with border gauze. Family and physician aware. Review of the nurse's progress note dated 03/26/25 at 4:45 P.M. and noted as a late entry, revealed new wound discovered on routine weekly skin assessment. Area measured, physician notified, new treatment order received to cleanse area, pat dry, apply Santyl to wound bed, cover with border gauze daily and as needed (PRN), Resident #11 was referred to wound physician, placed on wound rounds. Family notified. Interview on 03/31/25 at 1:23 P.M., with Licensed Practical Nurse (LPN) Unit Manager #3 stated she observed the wound on 03/26/25 during weekly skin assessments and noted the initial location of the wound was not clear. LPN #3 verified that measurements of the wound were obtained on 03/26/25 and not at the time of discovery. LPN #3 states she notified the physician and described the appearance of the wound and was given the order for the Santyl. LPN #3 stated the wound was stage three when she observed the area on 03/26/25 and she added the resident to the wound physician's list for treatment. LPN #3 stated the wound was discovered during the weekly skin assessments. LPN #3 verified she made the change in the orders and discontinued the zinc oxide and ordered the Santyl. Interview on 03/31/25 at 2:00 P.M., with Director of Nursing (DON) verified the wound was not measured on discovery and should have been. The DON verified the wound was assessed on 03/26/25 as a stage three pressure ulcer. The DON verified the wound should not have been identified at that stage and should have been identified sooner. 3. Review of medical record for Resident #80 revealed an admission date of 02/14/25. The resident was admitted with diagnoses including cerebral infarction, dementia with behavioral disturbances, and diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe impaired cognition. He required assistance for eating, moderate assistance for toileting, bed mobility and transfers. Review of the hospital physician orders dated 02/14/25, from the discharge summary, for Resident #80 documented a right heel pressure injury. The last measurements were on 02/13/25, with a measurement of 1.5 centimeters (cm) by (x) 3.0 cm x Unable To Determine (UTD) depth due to necrotic tissue. A second wound was documented as a coccyx pressure wound. The last measurements were on 02/13/25 of 0.8 cm x 0.3 cm x 0.01 cm. Orders were Medihoney (antibacterial) and foam border every other day. Review of the 02/14/25, admission skin assessment revealed two areas were identified. The coccyx was specified as redness with no other description or measurement and the right heel was documented as scab with no other description or measurement. Review of the admission physician assessment dated [DATE] revealed all available records were reviewed and the skin assessment documented negative for rash, ulcers, itching, dryness, skin/nail changes, dry skin or lesions. Review of the 02/14/25, admission Braden scale revealed a score of 16 indicating Resident #80 was at low risk for pressure ulcers. Review of the care plan review revealed the resident had the potential for skin breakdown with interventions which included floating heels in bed, applying skin prep to heels and monitor for effectiveness of treatment and notify Medical Doctor or Nurse Practitioner if wound worsens or does not respond. Review of the progress notes did not reveal any documentation the physician had been updated on weekly wound assessments. Review of the admission physician orders, dated 02/14/25, revealed the facility did not transcribe the wound care orders from the hospital discharge paperwork which were: to cleanse the right heel and coccyx with wound cleanser and apply Medihoney to the wound every other day and cover with foam border. Review of the February 2025 Treatment Administration Record (TAR) revealed no documented treatments to the heel or the coccyx, until 02/18/25. There was no evidence of the hospital orders being completed. Review of the 02/17/25, skin assessment revealed a right heel diabetic ulcer measuring 5.0 cm x 5.0 cm and a stage three pressure sacral pressure ulcer measuring 2.5 cm x 1 cm x 0.3 cm. Review of the 02/17/25 progress note documented a stage three (full thickness) pressure ulcer to sacrum with serosanguinous drainage noted with a large amount of granulation tissue and a small amount of slough noted. Diabetic ulcer to right heel dark brow/black in color. Physicians and family were notified, and new treatment orders were received, but not documented as implemented until 02/18/25. Review of the physician orders revealed an order to paint right heel with betadine every shift with a start date of 02/18/25 and an order to cleanse sacral wound with saline, pat dry, apply Medihoney gel and cover with bordered gauze every shift with a start date of 02/18/25. Review of the February 2025 TAR revealed the treatment was initiated and completed as ordered. Review of the 02/24/25 skin assessment revealed the right heel diabetic ulcer measured 5.0 cm x 5.0 cm x unable to determine and the sacral wound measured 2.5 cm x 1.0 cm x 0.3 cm. Review of the 03/03/25 skin assessment revealed the right heel diabetic ulcer measured 5.0 cm x 3.0 cm x unable to determine and the sacral wound measured 1.0 cm x 1.0 cm x 0.3 cm. Review of the 03/06/25 skin assessment revealed the right heel diabetic ulcer measured 5.0 cm x 3.0 cm x unable to determine and the sacral wound measured 1.0 cm x 1.0 cm x 0.2 cm. Review of the wound physician notes dated 03/13/25 revealed stage two pressure wound to the sacrum measuring 0.4 cm x 0.2 cm x .01 cm. Treatment plan was for Medihoney once daily for 30 days. A second wound was documented as an unstageable pressure wound the right heel which measured 4.0 cm x 3.0 cm x UTD. The treatment plan was for Santyl (debriding ointment) once a day for 30 days. This was the first assessment completed by the wound physician and review of the March 2025 TAR revealed the orders from this assessment were not implemented by the facility until 03/22/25. Review of the wound physician notes dated 03/20/25 revealed the right heel pressure ulcer measured 5.2 cm x 2.0 cm x UTD and was documented as improved evidenced by decreased surface area and the sacral pressure wound measured 0.3 cm x 0.3 cm x 0.1 cm. and was documented as exacerbated due to generalized decline of patient. Review of the physician orders revealed an order for right heel to cleanse with saline, pat dry apply Santyl and bordered gauze with a start date of 03/22/25. Interview on 03/31/25 at 2:20 P.M., with the Director of Nursing and Unit Manager Licensed Practical Nurse (LPN) #61 verified the admission treatment orders had not been implemented on admission [DATE] and skin treatments had not been initiated until 02/18/25 after two skin assessments with documented areas of concern. Discussion was had regarding the varied right heel ulcer documentation. LPN #61 acknowledged the hospital, and wound physician diagnosed the right heel as a pressure area, while the facility diagnosed it as a diabetic ulcer. LPN #61 explained the diagnosis was made by Physician #2. The DON verified the 03/13/25 right heel treatment order had not been started until 03/22/25. She also verified Resident #80 had not been seen by a wound physician until 03/13/25. LPN #61 explained that the new wound physician did not start at the facility until 03/06/25 and a face sheet was not provided to the physician for a visit, so the resident was not seen until the wound physician visited the following week (03/13/25).