**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation, record review, and interview the facility failed to ensure residents received the necessary treatment and services consistent with professional standards of practice to promote healing for 9 of 9 (Residents #1, #2, #5, #11, #14, #15, #16, #18, and #19) reviewed for pressure ulcers. The facility's failure to perform wound care treatments and weekly wound assessments in accordance with facility policy contributed to the deterioration of pressure ulcers/injury for Resident #14 and #18, resulting in Harm. The findings include: 1. Review of the facility policy titled, Pressure Injury Prevention and Management, dated 2/14/2023, revealed . provide treatment and services to heal the pressure ulcer/injury, prevent infection and the development of additional pressure ulcers/injuries .Licensed nurses will conduct a full body assessment on all residents upon admission, weekly, and after any newly identified pressure injury. Findings will be documented in the medical record. Assessments of pressure injuries will be performed by a licensed nurse and documented. The staging of pressure injuries will be clearly identified to ensure correct coding on the MDS [Minimum Data Set] . The RN [Registered Nurse] Unit Manager . will review all relevant documentation regarding skin assessments, pressure injury risks, program towards healing, and compliance at least weekly, and document a summary of findings in the medical record . Review of the undated facility policy titled, Documentation of Wound Treatments, revealed The facility completes accurate documentation of wound assessments and treatments, including response to treatment, change in condition and changes in treatment .Wound assessments are documented upon admission, weekly, and as needed if the resident or wound condition deteriorates. The following elements are documented as part of a complete wound assessment: Type of wound (pressure injury, surgical .) and anatomical location. Stage of the wound, if pressure injury (stage 1, 2, 3, 4, deep tissue injury, unstageable pressure injury) or the degree of skin loss if non-pressure (partial or full thickness) Measurements: height, width, depth, undermining, tunneling .Description of wound characteristics: Color of the wound bed, type of tissue in the wound bed (granulation, slough, eschar, epithelium), Condition of the peri-wound skin (dry, intact, cracked, warm, inflamed, macerated), Presence, amount, and characteristic of wound drainage/exudate, Presence of odor, Presence of pain .Wound treatments are documented at the time of each treatment . Review of facility policy titled, Consulting Physician/Practitioner Orders, dated 12/1/2024, revealed Consulting physician/practitioner orders are those orders provided to the facility by a physician/practitioner other than the resident's attending physician .For consulting physician/practitioner orders received .the nurse will .Follow facility procedures for verbal or telephone orders . 2. Review of the medical record revealed Resident #14 was admitted to the facility on [DATE], with diagnoses including, Chronic Obstructive Pulmonary Disease, Schizophrenia, Anxiety, and Diabetes. Review of the quarterly MDS assessment dated [DATE], revealed a Brief Interview for BIMS score of 3 which indicated Resident #14 was severely cognitively impaired and was at risk for developing pressure ulcers. Review of Physician Order dated 12/6/2024, for wound care to the right and left buttock included, .cleanse .with normal saline .cover with honey alginate and cover with a foam dressing .one time a day . Review of the TAR dated 12/2024, revealed the wound care was not documented as being provided as ordered for the left and right buttock on 12/7/2024,12/8/2024 and 12/9/2024. Review of Physician Order dated 12/30/2024 for wound care to the left and right buttock included .Cleanse . with wound cleanser or normal saline .cover with calcium alginate . with super absorbent dressing .one time a day . Review of the Resident #14's Wound Assessment Report dated 12/30/2024, revealed resident had an unstageable right buttock pressure ulcer that measured 8.0 cm long x 5.5 cm wide x 0.1 cm deep with 50% slough and large serosanguineous (a thin, pink drainage that comes from an open wound) drainage. Review of the Resident #14's Wound Assessment Report dated 12/30/2024, revealed resident had a stage 3 left buttock pressure ulcer that measured 2.0 cm long x 2.0 cm wide x 0.1 cm deep and had large serosanguineous) drainage. There was no documentation the weekly wound assessment was performed the weeks of 1/6/2025 and 1/13/2025. Review of the TAR dated 1/2025, revealed the wound care was not documented as being provided to the left and right buttock as ordered on 1/9/2025, 1/11/2025, 1/13/2025, 1/14/2025, 1/15/2025 and 1/16/2025. Review of Resident #14's Wound Assessment Report dated 1/21/2025, revealed resident had an unstageable right buttock pressure ulcer that measured 8.0 cm long x 5.0 cm wide x 2.0 cm depth with 15% slough [dead tissue] 75% eschar [dead, dry black tissue] and 2 centimeters of undermining and moderate serosanguineous drainage. During observation and interview on 1/21/2025 at 11:18 AM, LPN D performed wound assessment with measurement and staging and reported foul odor noted, necrotic tissue noted to the right buttock (coccyx) wound bed. LPN D reported slough 25%, 50% necrotic, 25% granulation LPN reported measurements as 8.0 cm long x 5.0 cm wide x 2.0 cm deep with 2.5 cm undermining. LPN D reports wound was staged as Unstageable due to slough. LPN D confirmed Resident #14 currently has 1 visual wound and was unsure when the wound to left buttock closed. The right buttock wound deteriorated from 1/13/2025 to 1/21/2025 with an increase in depth, developed eschar and undermining with an odor. The facility's failure to perform weekly wound assessments and provide wound treatments as ordered resulted in a decline in the wound, resulting in a harm for Resident #14. 3. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE], with diagnoses including, Parkinson's Disease, Malnutrition, Heart Failure, Schizophrenia, and Depression. Review of the Physician Order dated 12/4/2024 revealed, .Cleanse open area to sacrum with normal saline, pack with calcium alginate, apply super absorbent dressing and cover with foam .one time a day . Review of the Physician Order dated 12/30/2024 revealed, .Cleanse sacral area with wound cleaner or normal saline .apply calcium alginate .cover with super absorbent foam dressing .one time a day . Review of the TAR dated 12/2024, revealed the wound care was not documented as being provided on the sacrum as ordered on 12/7/2024 and 12/8/2024. Review of the Resident #18's Wound Assessment Report dated 12/30/2024, revealed resident had a stage 4 pressure ulcer on her sacrum that measured 7.0 cm long x 8.0 cm wide x 1.5 cm deep. The wound had undermining and large serosanguineous drainage. Review of the Physician Order dated 12/30/2024 revealed, .Cleanse sacral area with wound cleaner or normal saline .apply calcium alginate .cover with super absorbent foam dressing .one time a day . Review of the TAR dated 1/2025, revealed the wound care was not documented as being provided on the sacrum as ordered on 1/5/2025, 1/8/2025, 1/9/2025, 1/10/2025, 1/11/2025, 1/12/2025, 1/13/2025, 1/14/2025, 1/15/2025, 1/16/2025 and 1/18/2025. There was no documentation the weekly wound assessment was completed for the week of 1/6/2025 and 1/13/2025. Review of Resident #18's Wound Assessment Report dated 1/21/2025, revealed resident had a stage 4 pressure ulcer on her sacrum that measured 7.0 cm long x 10.0 cm wide x 1.0 cm deep with 75 % granulation tissue, 5% slough, 20% eschar and 1 cm] undermining and had moderate serosanguineous drainage. There was no documentation the Weekly Wound Assessment Report was completed the week of 1/6/2024 and 1/13/2024. The wound deteriorated from 1/13/2024 to 1/21/2025 with an increase in width, now has slough and eschar. The facility's failure to perform weekly wound assessments and provide wound treatments as ordered resulted in a decline in the wound, resulting in a harm for Resident #18. 4. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE], with diagnoses including Atrial Fibrillation, Coronary Artery Disease, Hypertension, Pneumonia, Diabetes, and Malnutrition. Review of the initial Wound Assessment Report dated 8/9/2024, revealed there were no wound measurements documented in accordance with the facility's policy for the following wounds: a. Stage 2 pressure injury to middle lower back b. Deep Tissue Injury to left heel c. Deep Tissue Injury to right heel d. Deep Tissue Injury to right foot 1st digit Review of the admission MDS assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated Resident #1 was cognitively intact. Resident required maximum assistance of staff to perform Activities of Daily Living (ADLs). Resident was assessed for the following pressure injuries: one stage 2, one stage 3, and three deep tissue injuries (damage to the soft tissue beneath the skin caused by pressure or shear forces). 5. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE], with diagnoses including Parkinson's Disease, Dementia, Anxiety, and Depression. Review of the significant change MDS assessment dated [DATE], revealed a BIMS score of 3, which indicated Resident #2 was severely cognitively impaired. Two Stage 3 pressure ulcers were documented that were not present on admission. Review of Physician's Order dated 12/4/2024 revealed, .Cleanse area to left buttock with wound cleanser, apply oil emulsion to wound bed, apply calcium alginate, and cover with foam dressing one time a day every other day for pressure injury AND as needed . Review of Physician's Order dated 12/4/2024, revealed .Cleanse area to right buttock with wound cleanser, apply oil emulsion to wound bed, apply calcium alginate, and cover with foam dressing. one time a day every other day for pressure injury Review of the Treatment Administration Report (TAR) dated 12/2024, revealed the wound care was not documented as being provided as ordered on 12/7/2024 and 12/15/2024. Review of the Weekly Wound Assessments dated 12/23/2024 and 12/30/2024, revealed Resident #2's Left buttock wound stage was changed from a Stage 4 on 12/23/2024 to a Stage 3 on 12/30/2024 with the same following measurements: a. 12/23/2024 - 6.0 cm long (centimeters) x 3.0 cm wide x 0.1cm deep Stage 4 b. 12/30/2024 - 6.0 cm long x 3.0 cm wide x 0.1cm deep Stage 3 Review of Resident #2's Weekly Wound Assessments revealed wound assessments were not conducted on 12/23/2024 on the right buttock wound, and 1/7/2025 on the right and left buttock wounds, in accordance with the facility policy. Observation on 1/16/2025 at 1:31 PM in Resident #2's room, Licensed Practical Nurse (LPN) C and Certified Nursing Assistant (CNA) E entered the resident's room to perform wound care. LPN C removed the soiled bandage and reported left upper buttock wound was a Stage 2 with minimal greenish drainage and reported right buttock wound was a Stage 2 with blood-tinged greenish drainage. LPN C cleansed right buttock with Normal Saline moistened gauze, cleansed left buttock with Normal Saline moistened gauze, patted dry with gauze, and applied oil emulsion to right buttock. LPN C obtained scissors from her scrub pocket, cut and applied the calcium alginate to the right buttock . LPN C removed gloves and donned gloves without performing hand hygiene, applied oil emulsion, calcium alginate to left buttock, and covered wounds with bordered foam dressing. LPN C failed to follow physician's order for cleansing the wounds with wound cleanser. During an interview on 1/21/2025 at 8:45 AM, the Assistant Director of Nursing (ADON) B was asked regarding Resident #2's wound staging documentation. The ADON B confirmed the 12/23/2024 wound assessment for resident's left buttock documented a Stage 4 and on 12/30/2024 documented a Stage 3. The ADON B confirmed the wound care nurse should not change the staging from Stage 4 to Stage 3. ADON B was asked regarding the blanks on the resident's TAR for wound care. The ADON B confirmed that there should not be blanks on the TAR and cannot confirm if the wound care was provided. The ADON B confirmed that weekly wound assessments should be performed of all wounds with measurements included. 6. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including, Adult Failure to Thrive, Dysphagia, Depression, and Polyneuropathy. Review of the admission MDS assessment dated [DATE], revealed a BIMS score of 13, which indicated resident was cognitively intact. Resident #5 admitted to the facility with 3 unstageable pressure wounds. Review of the Physician's Order dated 12/6/2024 revealed, .Cleanse coccyx [base of spine/tailbone] area . left hip area .[and] right hip with normal saline .apply honey alginate .cover with border gauze .one time a day . Review of the TAR dated 12/2024, revealed the wound care was not documented as being provided to the right hip, coccyx and left hip as ordered on 12/11/2024 and 12/22/2024. Review of the Physician Order dated 12/25/2024 for wound care to the coccyx, and the left and right hip included, .Cleanse .with wound cleanser or normal saline .apply honey alginate .cover with bordered gauze .one time a day . Review of Resident #5's Wound Assessment Report dated 12/30/2024, revealed an unstageable pressure ulcer on the left iliac crest (curved, bony ridge at the top of the hip bone) that measured 2.5 cm long x 1.5 cm wide x 0.1 cm deep with 25% granulation (new) tissue . 75% of eschar (dead tissue/debris) .and had moderate serosanguineous (pinkish/red) drainage. Review of the Resident #5's Wound Assessment Report dated 12/30/2024 revealed an unstageable pressure ulcer on the coccyx that measured 7.5 cm long x 6.0 cm wide x 0.1 cm deep with 25% granulation tissue . 75% of eschar and . moderate serosanguineous drainage. Review of the Resident #5's Wound Assessment Report dated 12/30/2024, revealed resident had an unstageable pressure ulcer on the right iliac crest that measured 2.5 cm long x 5.0 cm wide x 0.1cm deep with 25% granulation tissue, 75% slough and .moderate serosanguineous drainage. Review of the Weekly Wound Assessment report revealed there was no documentation the wound assessments were completed the weeks of 1/6/2025 and 1/13/2025. Review of the TAR dated 1/2025, revealed the wound care was not documented as being provided to the right hip, coccyx, left hip and right hip as ordered on 1/3/2025, 1/5/2025, 1/8/2025, 1/9/2025, 1/11/2025, 1/12/2025, 1/13/2025, 1/16/2025, and 1/17/2025. Review of Resident #5's Wound Assessment Report dated 1/21/2025, revealed an unstageable pressure ulcer on the coccyx that measured 8.0 cm long x 11.5 cm wide x 1.0 cm deep, 10% granulation tissue, 50% of slough and 40% of eschar and 0.5 cm undermining (a pocket or cavity forming underneath the skin) with large amount of serosanguinous drainage. Review of Resident #5's Wound Assessment Report dated 1/21/2025, revealed an unstageable pressure ulcer on the left hip measured 2.0 cm long x 1.5 wide x 0.4 cm deep with 25% granulation tissue, 50% of slough and 25% of eschar with moderate serosanguineous drainage. Review of Resident #5's Wound Assessment Report dated 1/21/2025, revealed an unstageable pressure ulcer on the right hip that measured 3.0 cm long x 6.0 cm wide x 3.0 cm deep with 25% granulation tissue, 50% of slough (build up of dead cells/tissue) and 25% of eschar and 3 cm undermining with large serosanguineous drainage. Review of Resident #5's Wound Assessment Report dated 1/21/2025, revealed an unstageable pressure ulcer on the left buttock that measured 5.0 cm long x 5.4 cm wide x 0.3 cm deep with 25% granulation tissue, 50% of slough and 25% of eschar and 0.5 cm undermining with large serosanguineous drainage. The facility failed to conduct weekly assessments and provide treatments as ordered. 7. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Anemia, Hypertension, and Depression. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS was not assessed due to Resident #11 was severely cognitively impaired. Resident required maximum assistance of staff to perform ADLs. A Stage 2 pressure injury was documented in the assessment that was not present on admission. Review of Physician's Order dated 12/4/2024, revealed Cleanse area to right buttock with normal saline, pat dry, apply honey alginate [used to promote wound healing] to wound bed, and cover with foam dressing one time a day for pressure injury AND as needed . Review of Physician's Order dated 1/21/2025, revealed Cleanse open area to coccyx with NS [Normal Saline, used to cleanse wounds] /wound cleanser; pat dry; apply collagen [used to promote wound healing] and zinc [used to protect the skin as a barrier] to wound bed; cover with dry dressing daily and prn [as needed] one time a day for open area AND as needed for soiled or damaged Review of the TAR dated 12/2024, revealed the wound care was not documented as being provided to the right buttock as ordered on 12/8/2024. Review of Resident #11's Weekly Wound Assessments revealed there was no documentation a wound assessment was conducted the week of 1/7/2025. Observation and interview on 1/21/2025 at 9:48 AM, in Resident #11's room revealed LPN D and CNA G entered the resident's room to perform wound care. LPN D performed ordered wound care with moderate serous drainage reported. Resident did not have a dressing covering wound. LPN D reported wound as a Stage 3. LPN D measured the wound and initially stated the depth was 0.1 cm. LPN D was asked to re-measure the wound bed to the right buttock, as the depth of the wound appeared to be deeper than the first measurement. LPN D reported the measurements as 2.5 cm long x 2.0 cm wide x 0.2 cm deep with the depth measured at the center of the wound bed on the second attempt. LPN D reported wound bed tissue as 75% granulation and 25% slough. 8. Review of the medical record revealed Resident #15 was admitted to the facility on [DATE], with diagnoses including, Anxiety, Benign Prostatic Hyperplasia, Hypertension, and Retention of Urine. Review of the quarterly MDS assessment dated [DATE], revealed Resident #15 had a BIMS score of 14, which indicated resident was cognitively intact and had 1 stage 3 pressure ulcer on admission. Review of the Resident #15's Wound Assessment Report dated 12/30/2024, revealed the resident had a stage 3 pressure ulcer on his pubis (one of the bones that make up the pelvis) that measured 2.0 cm long x 1 cm wide x 0.1 deep and had moderate serosanguineous drainage. There was no documentation the weekly wound assessment was completed for the weeks of 1/6/2025 and 1/13/2025. Review of the Physician's Order dated 12/31/2024 revealed, .Cleanse area on pubis with wound cleanser or normal saline .cover with calcium alginate silver and cover with a super absorbent dressing .one time a day . Review of the Resident #15's Wound Assessment Report dated 1/21/2025, revealed resident had a stage 3 pressure ulcer on his pubis that measured 1.0 cm long x 4.0 cm wide x 0.5 cm deep with moderate serosanguineous drainage. Review of the TAR dated 1/2025, revealed the wound care was not documented as being provided on the pubis as ordered on 1/5/2025, 1/8/2025, 1/9/2025, 1/10/2025, and 1/16/2025. 9. Review of the medical record revealed Resident #16 was admitted to the facility on [DATE], with diagnoses including Dementia, Dysphagia, Hypertension, and Psychotic Disturbance. Review of the Physician's Orders dated 12/4/2024 revealed, .apply xeroform gauze and cover with band-aid .to right foot plantar [facility acquired] . one time a day . Review of the Physician's Orders dated 12/13/2024 revealed, .Cleanse area on left buttock [facility acquired] with normal saline and apply hydrogel, apply honey alginate and cover with foam dressing .one time a day . Review of the TAR dated 12/2024, revealed the wound care was not documented as being provided on the left buttock as ordered on 12/22/2024 or on the right foot planter on 12/5/2024,12/7/2024 and 12/22/2025. Review of the Physician's Orders dated 12/25/2024 revealed, .Cleanse area on left buttock with wound cleanser or normal saline .apply hydrogel, apply calcium alginate .cover with foam dressing .one time a day .Cleanse area on left hip [facility acquired] with wound cleanser or normal saline .apply calcium alginate and cover with bordered gauze daily .Cleanse outside area on right foot with wound cleanser or normal saline .apply betadine .one time a day .Cleanse wound on inside plantar area on right foot with wound cleanser or normal saline .apply betadine .one time a day . Review of the Weekly Wound Assessment dated 12/30/2024 revealed resident had a facility acquired stage 2 pressure ulcer on right foot inside that measured 1.0 cm long x 0.75 cm wide x 0.1 cm deep with 100% granulation tissue. Review of the Weekly Wound Assessment dated 12/30/2024 revealed resident had a facility acquired unstageable right foot lateral that measured 1.0 cm long x 1.0 cm wide and 0.1 cm depth, with 100% eschar and scant serosanguineous drainage. Review of the Resident #16's Wound Assessment Report dated 12/30/2024, revealed resident had a facility acquired stage 3 pressure ulcer on the left iliac crest that measured 3.0 cm long x 2.0 cm wide x 0.1 cm deep with 100% of eschar and scant serous drainage. Review of Resident #16's Wound Assessment Report dated 12/30/2024, revealed a facility acquired stage 4 pressure ulcer on the left buttock that measured 2.0 cm long x 2.0 cm wide x 2.25 cm deep, with 100% granulation tissue and had serosanguineous drainage. There was no documentation the weekly wound assessments were completed for the weeks of 1/6/2025 and 1/13/2025. Review of the TAR dated 1/2025, revealed the wound care was not documented as being provided on the left buttock, left hip, outside lateral right foot and inside planter right foot as ordered on 1/5/2025, 1/8/2025, 1/9/2025, 1/10/2025, 1/11/2025, 1/15/2025, and 1/16/2025. 10. Review of the medical record revealed Resident #19 was admitted on [DATE], with diagnoses including Stroke, Heart Failure, Neurogenic Bladder, Diabetes, and Dementia. Review of the quarterly MDS assessment dated [DATE], revealed the facility was unable to perform a BIMS due to Resident #19 was severely cognitively impaired. Resident required max assistance of staff to perform ADLs and had one Deep Tissue Injury that was not present on admission. Review of Physician's Order dated 12/4/2024, revealed Cleanse left heel [facility acquired] with normal saline, apply oil emulsion [a secondary dressing to manage drainage] to wound bed, cover with ABD [Abdominal] pad, and wrap with rolled gauze. one time a day for pressure injury AND as needed for pressure injury. Review of Physician's Order dated 12/13/2024, revealed Cleanse area on left heel with normal saline then apply oil emulsion and calcium alginate [absorbent dressing used to treat moderate to heavily draining wounds] and cover with abd pad and rolled gauze one time a day AND as needed. Review of Physician's Order dated 12/31/2024, revealed Cleanse wound on left heel with wound cleanser or normal saline, pat dry, cover eschar [dead tissue in a wound] with xeroform [used as a non-adherent primary dressing] then apply calcium alginate and abd pad and cover with rolled gauze and secure with cohesive bandage daily. one time a day AND as needed. Review of the TAR dated 12/2024 and 1/2025, revealed the wound care was not documented as being provided on 12/7/2024, 12/8/2024, 12/22/2024, 1/2/2025, 1/17/2025. Review of Resident #19's Weekly Wound Assessments revealed a wound assessment was not conducted the week of 1/8/2025. 11. During an interview on 1/22/2025 at 9:47 AM, the Director of Nursing (DON) was asked should there be blanks on the TAR for wound care treatments. The DON stated, .it means they didn't do their job . and I can't prove that they did or not .because they did not document .as you can tell I haven't been able to monitor .if I had the meetings like I normally do for my weekly wound meeting .there is definitely some new structure coming in to place for this . The DON confirmed physician orders should be followed, and weekly wound assessments should be done. The DON confirmed the ADON should have picked up the weekly wound assessments. The DON stated, That's the way it was designed .there is failure in the system .we were working on the floor and not doing our job . During a telephone interview on 1/22/2025 at 5:49 PM, the Medical Director confirmed wound care should be provided as ordered by the physician and weekly wound assessments should be done. The Medical Director stated, .does that have anything to do with staffing issue, we have had several to quit . I work here in the hospital and see wounds everyday .and hope we are going to get back up to par from where we were .didn't seem to have as many problems . The Medical Director was asked if not providing treatment to the pressure wounds could contribute to wound decline. The Medical Director stated, Definitely, it's up to us to make sure we are doing everything so the wound will heal . During an interview on 1/22/2025 at 5:49 PM, the Administrator confirmed wound care should be provided as ordered by the physician, that the treatment nurse is responsible for completing wound assessments weekly and accurately, and the ADON is ultimately responsible for ensuring that weekly wound assessments are completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, medical record review, and interview, the facility failed to ensure a resident with a knee immobilizer received services for the prevention of pressure ulcers for 1 of 3 sampled residents (Resident #7) reviewed for the use of an immobilization device. The facility's failure to provide preventative treatment resulted in Actual Harm when Resident #7 developed a Stage 3 Pressure Ulcer. The findings include: 1. Review of the facility's policy Pressure Injury Prevention and Non-Pressure Ulcer Management dated 9/28/2022 revealed, This facility is committed to the prevention of avoidable pressure injuries .It is the policy of this facility to implement evidence - based interventions for all residents who are assessed at risk .The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear .Avoidable means 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 residents needs .A pressure ulcer is any lesion caused by intense and/or prolonged pressure that results in damage to the underlying tissue .Examples of risk factors include .Impaired / decreased mobility and decreased functional ability .Resident refusal of some aspects of care and treatment . 2. Review of the closed medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Fracture Right Pubis, Fracture Left Lower Femur, Encounter of Surgical Aftercare, Osteoarthritis, Pressure Ulcer Right Buttocks Unstageable, Pressure Ulcer Left Buttocks Unstageable, Pressure Ulcer Sacral Region Unstageable, and Difficulty Walking. Review of the Care Plan dated 11/12/2022 revealed, .fractures .self-care deficit .At risk for impaired skin integrity .friction noted to left distal leg 12/29/2022 .now stage 3 pressure ulcer .left lower leg friction 12/15/2022 .Stage 3 Pressure Ulcer Left Distal Leg .Observe for changes in lower extremity skin integrity . Review of the Hospital Physician's Order dated 11/19/2022 revealed, .Knee Immobilizer may be off in bed but on any time being mobilized . Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition, and required extensive to total staff assistance Activities of Daily Living (ADLs). Review of the facility's Braden Scale for Predicting Pressure Injury Risk dated 11/29/22, 12/6/2022, and 12/13/2022 revealed Resident #7 was assessed with a score of 15, indicating Resident #7 was at risk for developing pressure ulcers. Review of the November 2022 Treatment Administration Record (TAR) revealed the knee immobilizer was applied nightly from 11/22/2022 to 11/30/2022. The facility was unable to provide documentation that the skin was assessed before or after the application of the knee immobilizer. Review of the facility's Wound assessment dated [DATE] revealed, .Facility acquired .Location of Wound .Lower Leg Left Lower/Distal .Wound Type . Friction .Partial Thickness .0.70 x [by] 0.50 x 0.1 [centimeters] .area due to brace that has rubbed skin . Review of the Wound assessment dated [DATE] revealed, .1.5 x 1.5 x 0.1 [centimeters] .area presently has 50% [percent] slough and will now be staged at 3. Resident continues to wear brace will [while] up and removed while in bed. Area is due to pressure from brace .Wound Progression .declined .Stage Increased .Yes . Review of the Orthopedic Physician's order dated 12/22/2022 revealed, .She is to have the brace off at rest .only on for ambulating . Review of the December 2022 TAR revealed the knee immobilizer was applied nightly from 12/1/2022 to 12/31/2022. The facility was unable to provide documentation that the skin was assessed before or after the application of the knee immobilizer. Review of Orthopedic Physician's order dated 1/5/2023 revealed, .Brace for ambulation only .otherwise off. Review of the January 2023 TAR revealed the knee immobilizer was applied nightly from 1/1/2023 to 1/9/2023. The facility was unable to provide documentation that the Left Lower Distal Leg was assessed underneath the immobilizer for the prevention of pressure ulcers and/or injuries. During an interview on 1/31/23 at 2:15 PM the Treatment Nurse confirmed she did the initial skin assessments after the nurses did the admission skin assessment or if a nurse found an area on a resident. The Treatment Nurse confirmed that she did not check any other areas on residents other than the areas that had wounds. The Treatment Nurse confirmed Resident #7 wore the immobilizer all the time. The Treatment Nurse confirmed the nurses checked skin weekly and not daily unless an area was found or reported to them, and then they assessed only the area of concern. During an interview on 2/2/23 at 2:36 PM, Licensed Practical Nurse (LPN) #7 confirmed she was informed by therapy staff that Resident #7 had a wound on her left lower leg. LPN #7 confirmed that nurses were supposed to check skin daily when residents wore any kind of brace or immobilizer. LPN #7 was asked if she ever had to apply or remove the immobilizer to Resident #7 left lower extremity. LPN #7 confirmed on the nights that she worked past 7:00 PM she applied the brace before she left because the resident was in the bed for the night at that time. LPN #7 was asked how often Resident #7 had the brace on. LPN #7 confirmed that Resident #7 wore the brace when she got up to go to therapy in the mornings and when she went back to bed. LPN #7 was asked if Resident #7 had a wound to her left lower leg. LPN #7 confirmed she was informed by therapy staff that there was a wound on her left lower leg. LPN #7 stated, .when it (wound) was found she [Resident #7] was wearing it (immobilizer) all the time . During an interview on 2/2/23 at 3:52 PM, LPN #8 confirmed Resident #7 was readmitted to the facility on [DATE] and had a knee immobilizer. LPN #8 confirmed that the immobilizer was to be applied at night while she was sleeping and when she was in the bed. LPN #8 confirmed she applied the immobilizer to Resident #7's left lower extremity every night she worked. During an interview on 2/2/23 at 4:37 PM, the Director of Nursing (DON) confirmed nursing failed to follow physician orders for the use of the immobilizer. The DON confirmed the nurses should be checking the skin underneath the immobilizer, and there should be a monitor to document the skin checks in the MAR or the TAR.