**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, facility policy review, and facility document review, the facility failed to monitor and assess residents' skin and pressure ulcers/injuries, failed to provide pressure ulcer treatment and prevention measures as ordered by the physician, and failed to implement measures to prevent pressure ulcers for 3 (Resident (R)9, R1, and R8) of 5 sampled residents reviewed for wounds. The failure resulted in non-healing and/or deterioration of pressure ulcers and had the potential to affect any resident who had or was at risk for pressure ulcers. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on [DATE], when a physician ordered a treatment for a healing sacral wound for R9 and the facility subsequently failed to conduct and document weekly assessments of the wound and the resident's overall skin condition; failed to consistently provide treatment to the resident's pressure ulcers/injuries as ordered by the physician; and failed to obtain devices/equipment to treat and prevent pressure ulcers/injuries. On [DATE], R9, a hospice resident, expired in the facility with a Kennedy ulcer on the sacrum and deep tissue injuries (DTI) to both heels and the right hip. The Administrator and Director of Nursing (DON) were notified of the IJ and provided with the IJ template on [DATE] at 3:24 PM. A Removal Plan was requested. The State Survey Agency accepted the facility Removal Plan on [DATE] at 6:28 PM. The IJ was removed on [DATE] after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance remained at a lower scope and severity of isolated harm that was not immediate jeopardy at F686. Findings include: A review of an undated facility policy titled, Pressure Injury Prevention and Management, revealed, This facility is committed to the prevention of avoidable pressure injuries and the promotion of healing of existing pressure injuries. 'Pressure Ulcer/Injury' refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. 'Avoidable' means that the resident developed a pressure ulcer/injury, and that the facility did not do one or more of the following: evaluate the resident's clinical condition and risk factors, define and implement interventions that are consistent with resident needs, resident goals, and professional standards of practice, monitor and evaluate the impact of the interventions, or revise the interventions as appropriate. The policy also indicated The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions, and modifying the interventions as appropriate. The policy indicated c. Licensed nurses will conduct a full body skin assessment on all residents upon admission/re-admission, weekly, and after newly identified pressure injury. Findings will be documented in the medical record. Continued review of the policy revealed, Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to: i. Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc.) ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; iii. Provide appropriate, pressure-redistributing, support surfaces; iv. Maintain or improve nutrition and hydration status, where feasible. A review of an undated facility policy titled, Documentation of Wound Treatments revealed, Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. 2. The following elements are documented as part of a complete wound assessment: a. Type of wound (pressure injury, surgical, etc.) and anatomical location b. Stage of the wound, if pressure injury (stage 1, 2, 3, 4, deep tissue injury, unstageable pressure injury) or the presence of skin loss if non-pressure (partial or full thickness) c. Measurements: height, width, depth, undermining, tunneling d. Description of wound characteristics: i. Color of the wound bed ii. Type of tissue in the wound bed (i.e., granulation, slough, eschar, epithelium) iii. Condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, macerated) iv. Presence, amount, and characteristics of wound drainage/exudate v. Presence or absence of odor vi. Presence or absence of pain 3. Wound treatments are documented at the time of each treatment. If no treatment is due, an indication on the status of the dressing shall be documented each shift (i.e., clean, dry intact). 4. Additional documentation shall include, but is not limited to: a. Date and time of wound management treatments b. Weekly progress towards healing and effectiveness of current intervention c. Any treatments for pain, if present d. Modification of treatments or interventions e. Notifications to physician or responsible party regarding wound or treatment changes. Review of a facility policy titled Pressure Injury Prevention Guidelines, revised [DATE], revealed 1. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency of performing them. 4. In the absence of prevention orders, the licensed nurse will utilizing [sic] nursing judgment in accordance with pressure injury prevention guidelines to provide care, and will notify [the] physician to obtain orders. The policy further indicated, When physician orders are present, the facility will follow the specific physician orders. 1. A review of R9's admission Record revealed the facility admitted the resident on [DATE] with diagnoses that included syncope and collapse, disease of the spinal cord, difficulty walking, muscle wasting and atrophy, xerosis cutis (abnormally dry skin), tinea pedis (athlete's foot), vitamin D deficiency, and orthostatic hypotension. A review of an All-Inclusive admission with Baseline Care Plans assessment, dated [DATE] at 11:15 AM, revealed the facility admitted R9 from a hospital. The resident was alert and oriented upon admission and, according to the assessment, had a non-pressure skin condition and was at moderate risk for pressure ulcer development. A review of R9's care plan, dated as initiated [DATE] and revised [DATE], revealed the facility identified the resident had skin impairment related to the diagnosis of xerosis cutis. R9's care plan directed staff to encourage good nutrition and hydration to promote healthier skin; keep the skin clean and dry; monitor/document the location, size, and treatment of skin injury; and report abnormalities including failure to heal, signs and symptoms of infection, and maceration (softening and breaking down of skin resulting from prolonged exposure to moisture). A review of an admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed R9 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The MDS indicated the resident did not reject care necessary to achieve the resident's goals for health and well-being. Further review of the MDS revealed R9 required extensive assistance of staff with bed mobility, transfers, dressing, toilet use, and personal hygiene and was dependent on staff for walking and locomotion. The MDS indicated R9 was always incontinent of bowel and bladder. The resident had complaints of difficulty or pain with swallowing, was on a mechanically altered diet, and weighed 96 pounds. Although the admission assessment indicated R9 had a non-pressure skin condition and there was no documented evidence a pressure ulcer was being treated, according to the MDS, R9 had one stage 2 pressure ulcer that was present upon admission and was at risk of developing pressure ulcers/injuries. A review of a Daily Skilled Evaluation dated [DATE], 12 days after admission, revealed the resident had moisture-associated skin damage (MASD). There was no description of the location or extent of the skin damage. A review of R9's physician orders and the resident's Treatment Administration Record (TAR) revealed no evidence the MASD was being treated. Further, a review of the resident's care plan revealed there was no indication the resident had MASD and no interventions to treat or heal the MASD. A review of R9's physician orders revealed an order dated [DATE] to cleanse a sacral (lower part of the back above the tail bone) wound with wound cleanser, pat the area dry, cover the wound bed with calcium alginate (an absorbent dressing), then apply a Derma [NAME] dressing (an absorbent, waterproof foam dressing) one time per day. A review of nurse's Progress Notes dated [DATE], revealed the wound care nurse documented that the dressing to R9's sacrum was changed, and the physician's order was clarified as a daily dressing change. According to the note, the sacral wound was healing well with minimal serous drainage. The note indicated the wound had 10% slough (dead skin tissue that may have a yellow or white appearance) and 80% granulation tissue (new skin tissue). According to the note, the wound care physician was going to see the resident in one week. The facility had no documented evidence of when the sacral wound was initially identified, nor were there any measurements of the wound, as required by the facility's policy. The resident's care plan was not revised to address the development of a pressure ulcer to the sacrum, with interventions to treat the pressure ulcer and prevent new pressure ulcers from developing. Review of R8's TAR revealed facility staff documented a treatment was provided to the sacral wound daily from [DATE] through [DATE]; however, there was no documentation the ordered treatment was provided on [DATE], [DATE], [DATE], and [DATE]. A review of a wound physician's Initial Wound Evaluation & Management Summary, dated [DATE], revealed the resident was seen for diaper dermatitis [irritation of skin in contact with an incontinence brief] of unknown duration. According to the physician's examination, the resident had irritated dermatitis to the buttocks and groin/perineal area and a wound was present. A review of the wound examination revealed the resident had a pressure wound to the sacrum that was unstageable due to the presence of necrotic tissue. The pressure ulcer covered a surface area of 10.50 centimeters (cm), measuring 3.0 cm long by (x) 3.5 cm wide x 0 cm deep, and had a moderate amount of serous exudate. The physician surgically debrided (removed damaged tissue) the pressure sore. The physician's treatment plan was to apply calcium alginate and Santyl to the wound and cover the area with a gauze island dressing with a border daily for 30 days. The wound care physician also recommended keeping pressure off the wound, repositioning the resident per facility protocol, and providing a Group-2 mattress (a low air loss mattress used to relieve pressure). In addition, the wound care physician recommended a barrier cream to treat diaper dermatitis. Further, the wound care physician indicated the resident should follow up with a wound care specialist within seven days. There was no documented evidence in the resident's medical record that the facility ensured the resident saw a wound care specialist again. In addition, review of R9's physician orders and TAR revealed there was no documentation that a barrier cream was provided for the resident. The ordered treatment for the pressure ulcer to the sacrum was not updated until [DATE], approximately 10 days after the wound physician's recommendation. Further, there was no evidence in the medical record that a group 2 mattress was acquired and provided for the resident. The care plan was not updated to address the pressure ulcer and include the wound physician's recommended interventions. A review of the wound physician's Progress Note dated [DATE] revealed the physician was signing off on R9, who remained at the facility. Again, there was no documented evidence that the resident saw another wound care specialist as recommended. A review of a Total Body Skin Assessment dated [DATE] revealed R9 had one new wound. The location of the wound was not documented and there was no assessment (stage, size, drainage, description, etc.) of the wound. A review of the resident's physician orders and TAR revealed no evidence treatment was provided to the new wound. The new wound was not addressed on the resident's care plan. According to a nurse's Progress Note nine days later, on [DATE] at 3:54 PM, the wound care nurse documented a new area had been reported to R9's left heel as a deep tissue injury (DTI - an injury to the tissue below the skin from prolonged pressure, which appears as an unopened wound that looks purple or dark red). The note indicated the left heel DTI was measured and recorded and skin prep was ordered to be applied by nursing every shift. Review of R9's physician orders and TAR revealed no evidence this treatment was ordered or provided to the left heel on [DATE]. In addition, the note revealed there was improvement noted to the sacrum, as evidenced by a decrease in size and the amount of exudate. However, there was no documented assessment of the wound's size, stage, or appearance as required by the facility's policy. The note also indicated staff were educated on the importance of repositioning per protocol and elevating the resident's heels off the mattress; however, the resident's care plan did not include this information and was not revised. A review of a Head to Toe Skin Assessment dated [DATE] revealed the resident now had DTIs to both heels. There was no documentation of the size or appearance of the injuries. The assessment indicated staff (no signature documented) notified the nurse practitioner on [DATE] and a new treatment order was obtained for skin prep to both heels, and to cover the heels with ComfiTel (a silicone wound dressing that adheres to intact skin, not wounds) and Tegaderm (a transparent dressing). The assessment indicated the resident would wear heel booties while in bed and that the resident's care plan was reviewed/revised; however, review of the resident's care plan revealed it was not revised to address the DTIs to both heels, nor were the interventions to treat the DTIs and relieve pressure addressed. A review of nurse's Progress Notes dated [DATE] at 6:52 PM revealed the wound care nurse assessed the progress of R9's sacral wound and recent DTI to the left heel. The wound care nurse indicated in the note that the sacral wound continued to slowly improve as evidenced by a decrease in wound size and the amount of exudate. The note indicated the wound bed was clean with 100% granulation with some maceration to the wound edges. The left heel had some notable evidence of improvement with a decrease in size. Further review of the note revealed the area to the right heel was in the early stages of DTI. There was no documented assessment of the pressure ulcer/injuries to include the stage/measurements or other descriptive information. The note indicated the staff and the resident were reminded of the importance of keeping the resident's heels off the bed. The care plan still did not address pressure ulcer treatment nor prevention. Further review of the note revealed the wound care nurse documented that she sent an email to the supply coordinator to order heel protecting boots and possibly an air mattress, more than one month after the wound care physician recommended an air mattress for R9. Further review of R9's Head to Toe Skin Evaluations, Skin and Wound Evaluations, Total Body Skin Assessments, and Progress Notes for August and [DATE] revealed the facility had no documented evidence skin assessments were conducted weekly, and there was no evidence the pressure ulcer to the resident's sacrum and DTIs to both heels were assessed weekly to track healing progress or promptly identify any potential deterioration. Review of a nurse's Progress Note dated [DATE] at 5:34 PM revealed the wound care nurse documented that the pressure ulcer to the resident's sacrum continued to slowly heal. The note indicated the pressure ulcer continued to have 100% granulation tissue and a moderate amount of serous drainage. According to the wound care nurse's note, the treatment for the sacral pressure ulcer was changed from Santyl (breaks down damaged tissue) to collagen paste (encourages new tissue growth) daily. The note indicated that the right heel continued to improve; however, the left heel wound edges were not attached and treatment to the left heel was changed. According to the note, Heel protectors are being shipped and air mattress order is in. There was no assessment of the pressure ulcers/injuries to include measurements, presence or absence of pain, or other descriptive information. Two days later, on [DATE], the wound care nurse completed another Progress Note for R9. A review of the note revealed the wound bed of the sacral pressure ulcer was beefy red in color, the edges were attached, and the peri-wound was improving. The right heel was also showing signs of improvement. The nurse documented that no drainage or odor was noted, and the area was less painful for resident during the dressing change. The left heel also continued to improve and a decrease in wound size was evident. No measurements or other assessment information were documented. The note indicated a new physician's order was placed to use collagen paste in place of Santyl for treatment of the sacral pressure ulcer; however, review of R9's physician orders revealed the treatment order was not changed to collagen paste until seven days later, on [DATE], and then was discontinued on [DATE]. A review of a nurse's Progress Note dated [DATE] at 9:01 PM revealed the wound care nurse noted the pressure ulcer to R9's sacrum was deteriorating. However, there was no documented assessment of the pressure ulcer that included the stage, size, pain, drainage, or appearance of the wound. The note indicated the air mattress and heel boots that were requested previously were not available. According to the note, the treatment to the sacrum was changed to a wet-to-dry dressing. A review of R9's physician orders revealed a new order was entered on [DATE] to pack the sacral wound with packing strips soaked in 0.5% Dakin's solution (an antiseptic used to cleanse wounds and prevent infection) twice daily. A review of a Skin & Wound Evaluation dated [DATE] at 9:13 PM revealed the resident had developed a hematoma to the right heel that had been present for one week (The exact date was not documented; however, the wound care nurse had documented on [DATE] that the right heel was showing signs of improvement). The area measured 4.7 cm long x 3.2 cm wide x 2.1 cm deep. The wound bed was described as 100% eschar (dead tissue) with no exudate and the edges attached. The evaluation indicated the resident had pain during dressing changes/treatment and that a calcium alginate dressing was in place. According to the evaluation, progress (healing) was stalled. Further review revealed the resident was refusing to eat, which was unusual. In addition, according to the note, the air mattress had not been installed and the resident was up sitting in the same position in a wheelchair by the nurse's station every day. A review of the resident's care plan revealed it was not revised with interventions to prevent worsening of the resident's pressure ulcers/injuries nor to prevent new ulcers/injuries from developing. A review of a Skin & Wound Evaluation dated [DATE], revealed the sacral wound was a stage 2 pressure ulcer (partial thickness skin loss with exposed dermis) that covered 9 cm of surface area and was 4.7 cm long x 2.8 cm wide x 0.2 cm deep, with 1.0 cm undermining (erosion of the tissue beneath the visible wound margins). The assessment did not address where the pressure ulcer was acquired (in the facility or present on admission), how long the pressure ulcer had been present, the appearance of the wound bed, whether there were signs of infection, whether drainage was present and if so, a description of the drainage, the appearance of the peri-wound and surrounding tissue, nor whether there was swelling, pain, or the temperature of the skin around the wound. Further there was no documentation of the progress of the wound (improving, stable, deteriorating). The devices/interventions that were noted as being in place were an air flow pad, incontinence management, moisture barrier, moisture control, and a turning/repositioning program. According to the evaluation, neither a foot cradle nor a mattress with a pump was in use. Further review revealed a Skin &Wound Evaluation, was completed on [DATE] for the hematoma to the left heel. The evaluation revealed the wound was acquired at the facility but did not specify the date it was identified. The wound measured 0.8 cm long x 0.4 cm wide with eschar covering 100% of the wound bed. There was no drainage, and the edges of the wound were attached, with dry/flaky skin surrounding the wound. No swelling was present, and the resident's pain during wound treatment was indicated to be four on a scale of zero to 10, with zero indicating no pain and 10 indicating the most severe pain. A review of a nurse's Progress Notes dated [DATE] at 4:40 AM revealed R9 complained of pain and discomfort to their bottom (sacrum). The nurse documented the dressing was changed and there was an odor from the pressure ulcer. The note indicated the nurse would continue to monitor the resident. Further review of the progress notes and a review of the physician orders revealed there was no evidence the physician was consulted regarding the odor from the wound. There was no further documentation regarding the resident's wounds until [DATE]. A review of a nurse's Progress Note dated [DATE] at 5:07 PM revealed a nurse spoke with R9's family about hospice and palliative care. According to a Progress Note dated [DATE] at 3:57 PM, R9 was admitted to hospice. A review of Progress Notes dated [DATE] at 2:41 PM, revealed a nurse completed a skin assessment which noted wounds to both heels, the right hip (this was the first reference to a wound on the right hip), and the sacrum. The note indicated the wounds to the heels were previously categorized as hematomas; however, based on the nurse's assessment and discussion with the provider, the wounds were re-categorized as unstageable wounds. The treatment for both heels was discontinued and new orders were received to apply betadine to the wound beds and cover with a foam dressing daily. The sacral wound remained categorized as a pressure ulcer and treatment orders remained for a Dakin's damp to dry dressing twice daily. Further review revealed Resident had a pressure ulcer to the right hip that was categorized as a DTI, and orders were received to treat the wound with betadine and cover with a bordered foam dressing. Review of Skin & Wound Evaluation forms dated [DATE] revealed the following: - R9 had a deep tissue injury to the right trochanter (hip) that was acquired at the facility on [DATE]. The surface area was 19.4 cm and the wound measured 4.9 cm long x 4.7 cm wide x 0 cm deep. - R9's left heel had a pressure area that was unstageable due to slough and/or eschar. The area measured 1.1 cm long x 1.3 cm wide, which was an increase in size according to the last measurements completed on [DATE]. The wound bed was described as 100% eschar. - R9's right heel had a pressure area that was unstageable due to slough and/or eschar. The area measured 3.0 cm long x 4.4. cm wide. The wound bed was described as 100% eschar. - R9's sacral wound was identified as a Kennedy terminal ulcer (a wound results from underlying skin failure associated with the dying process). According to the evaluation, the area was unstageable due to the presence of slough and eschar in the wound bed. The wound covered a surface area of 47.7 cm and measured 7.6 cm long x 7.9 cm wide x 0.4 cm deep, with 3.0 cm undermining, which was an increase in size since the last measurements were obtained on [DATE] (4.7 cm long x 2.8 cm wide x 0.2 cm deep, with 1.0 cm undermining). The wound bed was described as containing 40% slough. The wound was further described as bleeding, with? moderate sanguineous/bloody exudate and had a faint odor. On [DATE] at 8:15 AM, the Administrator, Director of Nursing (DON), and current wound care nurse approached the surveyor and stated R9 was actively dying and in too much pain to conduct wound care. Consequently, R9's wounds/wound care were not observed during the survey process. Continued review of Progress Notes dated [DATE] at 2:20 AM revealed staff found R9 at 1:50 AM, unresponsive and without respirations, breath sounds, nor a pulse. The resident's physician and hospice were notified of the resident's death. The wound care nurse who managed R9's wounds was no longer employed by the facility and was not available for interview. The Director of Nursing (DON) who was active in the care of R9's wounds was no longer employed by the facility and was not available for interview. The nursing staff who had documented the skin assessments for R9 were no longer employed by the facility and were not available for interview. During an interview on [DATE] at 9:35 AM, Licensed Practical Nurse (LPN) #2 stated the wound care nurse assessed residents' skin on admission. In the wound care nurse's absence, the staff nurse accepting the admission would conduct the skin assessment. If there were skin concerns, a treatment was entered into the computer system and the wound care nurse was notified of the findings. The resident's name was added to a list for the wound care nurse to manage the treatments and continue skin assessments. LPN #2 stated he was not sure how the ongoing weekly assessments were conducted for residents who did not have a pressure ulcer on admission. LPN #2 stated treatments and interventions for wounds were listed on the resident's TAR. LPN #2 indicated he had seen a nurse practitioner look at R9's wounds about a month ago because the wounds were getting worse, and the wound care nurse was not responding to the concerns expressed by the nursing staff. LPN #2 stated the wound care nurse was not providing the resident's treatments as ordered, and nursing staff tried to take care of the resident if they discovered the treatments had not been completed. The wound care nurse had been reported to the DON and the Administrator but always came up with excuses. LPN #2 stated all the wounds in the building worsened because the wound care nurse did not do her job. LPN #2 stated that at the end of [DATE], R9 had a small Stage 2 on the sacrum. LPN #2 moved to work on another hallway for a few weeks and when he returned to R9's hallway, the wound was horrible, undermined, tunnelling, and it was much bigger. LPN #2 indicated at that time, the resident also started to decline, and no one was assessing the wounds, and the wounds just got worse. According to LPN #2, R9 did not get an air mattress because the wound care nurse did not ensure a mattress was ordered. During an interview on [DATE] at 10:39 AM, LPN #4 stated she conducted a body audit (skin assessment) when a resident was admitted to the facility and normally had a second nurse assist with the assessment, so as not to miss any wounds. LPN #4 further stated body audits were required to be completed weekly, and if there was a pressure ulcer, another form was initiated so the location of the concern could be documented, and a description entered. When new skin concerns were found, they were entered into the physician's book and the wound care nurse was notified. The wound care nurse entered treatment orders and when she was not available, nursing staff would cover the wound with a foam dressing. LPN #4 stated nursing staff did not stage pressure ulcers and the wound care nurse was responsible for managing the treatments/interventions for all wounds. However, LPN #4 stated the wound care nurse had not been assessing wounds and was very inconsistent on how she managed the wounds. LPN #4 stated she did not normally provide care for R9 and had not seen the resident until right before the resident was admitted to hospice. She stated a Certified Nursing Assistant (CNA) told her the wound to R9's sacrum had not started out bad but became much worse. LPN #4 stated she had changed the dressing to the sacral wound and packed the wound per the physician's order but really did not have a reference point for the wound other than what the CNAs had told her. During an interview on [DATE] at 11:26 AM, CNA #2 stated nursing staff directed CNA staff on resident care, if there were any changes, and which residents needed frequent turning/repositioning. CNA #2 stated R9 had suffered for a long time. CNA #2 stated they tried to position R9 off the wound, but the wound just kept getting worse. According to CNA #2, she did not think anyone was addressing the resident's sacral wound because it was draining a lot and the dressing became soaked and needed more frequent changes. NA #2 stated R9's sacral wound was deeper and started to smell, beginning about two months ago. CNA #2 stated she went to nursing staff, but they told her it was the wound care nurse's job. During an interview on [DATE] at 2:47 PM, LPN #5 stated she had changed R9's wound dressings and thought the resident's wounds had worsened. According to LPN #5, after the wounds worsened, the resident's physical condition worsened. During an interview on [DATE] at 1:14 PM, the Plant Operations Director (POD) stated staff contacted him when an air mattress was needed. He stated if the facility had one in stock, the request would be fulfilled immediately. If they had to get an air mattress, they could get one within 24 hours from a rental company, and it took two to three days to get an air mattress if the facility had to purchase one. The POD reviewed documentation to see if a bed had been provided to R9 when requested between [DATE] and [DATE]. According to the POD, he had not rented or purchased an air mattress during that time, which would mean the facility had an air mattress available in stock. However, the POD did not keep records regarding fulfilment of a mattress order if one was already available. He stated he did not remember any concerns obtaining an air mattress for R9. During an interview on [DATE] at 11:07 AM, the Nurse Practitioner (NP) stated she had recently returned to the facility after taking leave between [DATE] and [DATE]. The providers who had attended to R9 during her absence were no longer employed with the facility. In addition, the NP stated there was not a wound care physician available to assess and monitor residents' wounds. During an interview on [DATE] at 12:08 PM, the current wound care nurse (WCN) stated her first day at t[TRUNCATED]