**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 7 residents (CR #1, Resident #2, and Resident #3) reviewed for quality of care. The facility failed to provide daily wound care/treatments for CR #1, Resident #2, and Resident #3 as ordered by the physicians and resulted in the development of skin infections for CR #1 and Resident #3. The facility failed to implement CR #1's physician's order for wet to dry dressings 2 - 3x per day (11/14/2022) when she exhibited symptoms of infection. These failures could place residents with skin breakdown at risk of further skin injury and infection. The findings included: CR #1 Record review of CR #1's face sheet dated 01/10/2023 revealed she was a [AGE] year-old female who was admitted to the facility on [DATE]. She was diagnosed with peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), acquired absence of the left leg above knee, cognitive communication deficit (difficulty with thinking and how someone uses language), chronic pain syndrome (persistent pain that carries on for longer than twelve weeks despite medication or treatment), acute kidney failure (a condition in which the kidneys suddenly cannot filter waste from the blood), and muscle wasting and atrophy (the decrease in size and wasting of muscle tissue). She was discharged to an acute care hospital on [DATE]. Record review of CR #1's MDS dated [DATE] revealed she had a BIMS score of 15 (cognitively intact); she did not exhibit behaviors of rejecting care; she required extensive physical assistance from at least one staff member for bed mobility, transfers locomotion, dressing, toilet use, and personal hygiene; she required total assistance from staff for bathing; she was wheelchair bound; she was always incontinent of bowel and bladder; she received PRN pain medications; she was at risk of developing pressure ulcers/injuries; she was admitted with one stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed, without slough [dead skin separating from living tissue]); and she had surgical wounds. Record review of CR #1's care plan revised on 11/14/2022 revealed she had pressure ulcers or the potential for pressure ulcer development (no location was specified) (Goal: Pressure ulcer will show signs of healing and remain free from infection. Interventions: Administer treatments as ordered and monitor for effectiveness. Assess/record/monitor wound healing. Measure length, width, and depth where possible. Assess and document status of wound perimeter, wound bed, and healing progress. Encourage fluid intake and assist to keep skin hydrated. Monitor nutritional status. Needs monitoring/reminding/assistance to turn/reposition. Notify nurse immediately of any new areas of skin breakdown. Obtain and monitor lab/diagnostic work. Requires pressure relieving /reducing device on bed/chair. Weekly head-to-toe assessment). Record review of CR #1's physician's orders for November 2022 revealed the following: Cleanse Left AKA surgical incision site with normal saline, pat dry. Apply Alginate calcium and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 11/23/2022. Start Date- 11/24/2022. No end date was listed. Cleanse Left AKA surgical incision site with normal saline, pat dry. Cover with dry dressing daily and PRN every day shift for wound care. Order Date- 11/20/2022. Start Date- 11/21/2022. No end date was listed (Record review of Resident #1's TAR for November 2022 revealed the D/C date was 11/23/2022). Cleanse left groin surgical area with normal saline, pat dry. Apply Alginate calcium and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 11/23/2022. Start Date- 11/24/2022. No end date was listed. Cleanse left groin surgical area with normal saline, pat dry. Cover with dry dressing daily and PRN every day shift for wound care. Order Date- 11/20/2022. Start Date- 11/21/2022. No end date was listed (Record review of Resident #1's TAR for November 2022 revealed the D/C date was 11/23/2022). Cleanse right groin surgical area with normal saline, pat dry. Apply Alginate calcium and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 11/23/2022. Start Date- 11/24/2022. No end date was listed. Cleanse right groin surgical area with normal saline, pat dry. Cover with dry dressing daily and PRN every day shift for wound care. Order Date- 11/20/2022. Start Date- 11/21/2022. No end date was listed. Cleanse sacrum open area with normal saline, pat dry. Apply Alginate calcium and cover with gauze dry dressing daily and PRN every day shift for wound care. Order Date- 11/23/2022. Start Date- 11/24/2022. No end date was listed. Cleanse sacrum open area with normal saline, pat dry. Apply Santyl and cover with gauze dry dressing daily and PRN every day shift for wound care. Order Date- 11/10/2022. Start Date- 11/11/2022. No end date was listed (Record review of Resident #1's TAR for November 2022 revealed the D/C date was 11/23/2022). Cleanse sacrum open area with normal saline, pat dry. Apply dry absorptive dressing daily and PRN every day shift for wound care. Order Date- 11/06/2022. Start Date- 11/07/2022. No end date was listed (Record review of Resident #1's TAR for November 2022 revealed the D/C date was 11/10/2022). Record review of CR #1's TAR for November 2022 revealed the following: Cleanse sacrum open area with normal saline, pat dry. Apply Santyl and cover with gauze dry dressing daily and PRN every day shift for wound care. Order Date- 11/10/2022. D/C Date-11/23/2022. The entry boxes for Saturday (11/12/2022), Sunday (11/13/2022), Saturday, (11/19/2022), and Sunday (11/20/2022) were blank, indicating the treatment had not been completed on those days. Monitor all surgical incision sites as well as left thigh surgical incision site with staples intact for s/s of infection daily every day shift for wound care. Order Date- 11/11/2022. D/C Date- 11/20/2022. The entry box was blank for Saturday (11/12/2022), Sunday (11/13/2022), Saturday, (11/19/2022), and Sunday (11/20/2022), indicating the observations had not been completed on those days. Record review of CR #1's wound care physician's progress notes dated 11/23/2022 revealed, . Focused Wound Exam (Site 1), Stage 4 Pressure Wound Sacrum Full Thickness . Wound Progress: No Change . Site 1: Surgical Excisional Debridement Procedure (Indication for procedure: Remove necrotic tissue and establish the margins of viable tissue) . Record review of CR #1's SBAR Communication Form completed by LVN B on 11/13/2022 revealed, . 9. Pain Evaluation: The resident has new pain (no location was documented) . 25. Summarize your observations and evaluation: noted yellow drainage at surgical site NP notified . Date and time of clinician notification: 11/13/2022, 4:10 p.m., Recommendation of Primary Clinician: monitor for signs and symptoms of infection . Record review of CR #1's SBAR Communication Form completed by LPN A on 11/25/2022 revealed, . 8. Skin Evaluation: Describe symptoms or signs: drainage from left stump surgical wound. 9. Pain Evaluation: The resident has new pain of the left stump . 25. Summarize your observations and evaluation: resident has purulent drainage coming from left aka surgical site with pain . Date and time of clinician notification: 11/25/2022, 9:00 a.m., Recommendation of Primary Clinician: Transfer to local acute care hospital . Record review of CR #1's progress notes for November 2022 revealed the following: On 11/13/2022 at 5:16 p.m., LVN B wrote, left leg surgical site yellow drainage noted, right surgical site small open hole dressing change was done will continue to monitor On 11/14/2022 at 2:09 p.m., LVN B wrote, NP Notified wants to continue to monitor surgical site for signs and symptoms of infection. On 11/14/2022 at 2:10 p.m., LVN B wrote, spoke with vascular surgeon's nurse, she would like wet to dry dressing 2-3 times a day. On 11/17/2022 at 1:37 p.m., LPN A wrote, Back from appointment (with vascular surgeon), No new orders. Stable. On 11/24/2022 at 4:04 a.m., RN D wrote, Blood was oozing from the incision sites in her groin. Waiting for PCP response. On 11/25/2022 at 2:50 p.m., LPN A wrote, Spoke with vascular surgeon. New order to transfer to local acute care hospital ER for possible wound infection. Record review of CR #1's hospital records, including emergency room notes, laboratory tests, treatment plan, and discharge summary, revealed she was admitted to the hospital from the ED on 11/25/2022 and was discharged on 12/04/2022. The document revealed, Chief Complaint: Wound infection. Patient had surgery in October 2022, left aka that appears to be infected, also complains of sacral pain and possible infection in groin area. History of Present Illness: . Resident is a [AGE] year-old female with status post AKA of the left lower extremity who has subsequently developed wound infections to the stump, the groin bilaterally, and the sacrum . Patient has increased drainage and pain from the sites and has been brought in for treatment . Location: Open wounds left stump AKA and bilateral groin and sacrum with drainage. Severity: Severe . Progression: Worsening . Sepsis Score: 0 . Medications Given: Ceftriaxone (Rocephin) (antibiotic) Intravenously, Vancomycin (antibiotic) Intravenously . Laboratory Findings: . 11/26/2022: WBC - 11.07 (high), 11/27/2022: WBC - 22.52 (high) . In a telephone interview with CR #1's family member on 01/10/2022 at 9:45 a.m., he stated CR #1 was admitted to the facility with wounds, but she did not get consistent wound care at the facility. He said another family member visited CR #1 on Thanksgiving Day, 11/24/2022, and during a diaper change, the other family member noted both of CR #1's groin wounds (left and right) were bleeding. The other family member said the nurse looked at the bleeding wounds and was like, What do you want me to do about it? The family member said the next day, 11/25/2022, CR #1 was in a lot of pain. He said he took photos of all CR #1's infected wounds and sent to them to CR #1's vascular surgeon. The family member said the vascular surgeon said CR #1 had infections and needed to go to hospital. The family member said CR #1 was diagnosed with infections to her sacral wound and stump. The family member said CR #1 stayed in the hospital about one week to clean out the infections the facility failed to care for. In an interview with the DON on 01/10/2023 at 11:58 a.m., she stated the facility lost their wound care nurse in December 2022 (she could not recall the exact date), so the nurses were responsible for completing wound care for their assigned halls. The DON said the vascular surgeon CR #1 had been seeing said CR #1 needed to go to the hospital for an infection on 11/25/2022. The DON said CR #1 had an appointment for wound evaluation on the following week, but the vascular surgeon said to send CR #1 to the hospital to let them look at the wounds in case they needed to be drained. The DON said CR #1's family initiated the transfer to the hospital because CR #1 complained to them about pain. The DON said CR #1's family member took pictures of her wounds and sent them to her doctor. The DON said the wound care doctor did not evaluate surgical wounds and CR #1 was seen by the wound care doctor on 11/23/2022 with no new orders related to infection. The DON said she was away from the facility quite a bit over the last three months due to illness, so she did not know all the information about CR #1. In an interview with CR #1's NP on 01/10/2023 at 12:30 p.m., she said a facility nurse (she could not recall the nurse's name) called her the day before CR #1 left the facility (11/24/2022). The NP said the nurse told her CR #1's wounds (she could not recall which wounds were discussed with the nurse at that time) started to look infected with symptoms of increased drainage and [NAME] in color. The NP said it did not sound like gangrene or emergent, so she asked them to make a surgical appointment for evaluation. In a telephone interview with CR #1's wound care physician on 01/10/2023 at 2:21 p.m., he stated he saw CR #1 on 11/23/2022 and there was no pain associated with her wounds at that time. He said he debrided CR #1's stage 4 sacral wound because it had necrotic tissue but no infection. He said he also looked at CR #1's surgical wounds at the request of her doctor. He said he would have documented any signs of infection and that would have automatically populated an order for wound culture. In an interview with RN D on 01/13/2023 at 10:53 a.m., he stated he normally worked the 7:00 p.m. - 7:00 a.m. shift. He stated he had not worked for the past month due to death in his family. He said the wound care nurse was still there the last time he worked in the facility. He said he did recall seeing residents' wound dressings with incorrect dates. He said CR #1's wounds were so bad they were oozing, and she was really in pain. He said CR #1 once complained to him that her wounds were not being dressed daily, so he provided wound care for her on that day (he could not recall the date of this incident). Resident #2 Record review of Resident #2's face sheet dated 01/10/2023 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with muscle weakness, diabetes mellitus type 2 (a chronic condition that effects the way the body processes blood sugar), heart failure, peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), acquired absence of left toes, and muscle wasting and atrophy (decrease in size and wasting of muscle tissue). Record review of Resident #2's MDS dated [DATE] revealed he had a BIMS score of 13 (cognitively intact); he did not exhibit behavior of rejection of care; he required limited physical assistance from at least one staff for bed mobility, dressing, toilet use, and personal hygiene; he was totally dependent on staff for bathing; he was wheelchair bound; he was occasionally incontinent of bladder and frequently incontinent of bowel; he did not receive pain medication; he was not at risk for developing pressure ulcers and did not have unhealed pressure ulcers/injuries; and he had surgical wounds which required wound care. Record review of Resident #2's care plan revised 11/14/2022 revealed he had actual impairment to skin integrity due to surgical wound left foot and cancerous ulcer to top of head (Goal: Will not have a re-hospitalization within 30 days. Interventions: Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. Cleanse area to the left foot with NS, apply skin prep pad and wrap with kerlex, change every other day. Cleanse area to head with NS, apply xeroform gauze and silver alginate and cover daily. Encourage good nutrition and hydration in order to promote healthier skin. Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx of infection, maceration to MD. Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface); he was on antibiotic therapy due to wound infection (date initiated 10/27/2022) (Goal: Will be free of any discomfort or adverse side effects. Interventions: Administer medication as ordered. Notify physician if signs and symptoms of infection worsen or do not resolve); and he had the potential for pressure ulcer development due to muscle weakness (Goal: Will have intact skin, free of redness, blisters or discoloration. Interventions: Administer treatments as ordered and monitor for effectiveness. Has pressure relieving/reducing device on bed. Notify nurse immediately of any new areas of skin breakdown). Observation and interview with Resident #2 on 01/10/2023 at 3:00 p.m., revealed he was alert and oriented. Observation of Resident #2's wound dressings revealed five wounds on his left leg from foot to thigh dated 1/07/23, one on the right thigh dated 01/07/2023, and one on his head dated 01/07/2023. Resident #2 said he usually received wound care every other day. He said he had not been out to the hospital or had wound infections recently. Record review of Resident #2's physician's orders for December 2022 and January 2023 revealed the following: Cleanse left leg post-surgery site open areas with normal saline, pat dry. Apply dry dressing daily and PRN every day shift for wound care. Order Status- Active. Order Date- 12/18/2022. Start Date- 12/19/2022. Cleanse left leg post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Status- Active. Order Date- 12/18/2022. Start Date- 12/19/2022. Cleanse left medial foot post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Status- Active. Order Date- 12/18/2022. Start Date- 12/19/2022. Cleanse right thigh post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Status- Active. Order Date- 12/18/2022. Start Date- 12/19/2022. Cleanse wound to scalp site with normal saline, pat dry. Apply xeroform and cover with dry absorptive dressing daily and PRN every day shift for wound care. Order Status- Active. Order Date- 12/18/2022. Start Date- 12/19/2022. Record review of Resident #2's TAR for December 2022 revealed the following: Cleanse left leg post-surgery site open areas with normal saline, pat dry. Apply dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 12/19/2022, 12/22/2022, 12/23/2022, 12/24/2022, 12/25/2022, 12/26/2022, 12/27/2022, 12/29/2022, and 12/31/2022 were blank, indicating the treatments had not been completed on those days. Cleanse left leg post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 12/19/2022, 12/22/2022, 12/23/2022, 12/24/2022, 12/25/2022, 12/26/2022, 12/27/2022, 12/29/2022, and 12/31/2022 were blank, indicating the treatments had not been completed on those days. Cleanse left leg post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/10/2022. D/C Date- 12/14/2022. The entry boxes for 12/11/2022, 12/12/2022, and 12/13/2022 were blank, indicating the treatments not been completed on those days. Cleanse left medial foot post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/10/2022. D/C Date- 12/14/2022. The entry boxes for 12/11/2022, 12/12/2022, and 12/13/2022 were blank, indicating the treatments not been completed on those days. Cleanse left medial foot post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 12/19/2022, 12/22/2022, 12/23/2022, 12/24/2022, 12/25/2022, 12/26/2022, 12/27/2022, 12/29/2022, and 12/31/2022 were blank, indicating the treatments had not been completed on those days. Cleanse right thigh post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/10/2022. D/C Date- 12/14/2022. The entry boxes for 12/11/2022, 12/12/2022, and 12/13/2022 were blank, indicating the treatments not been completed on those days. Cleanse right thigh post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 12/19/2022, 12/22/2022, 12/23/2022, 12/24/2022, 12/25/2022, 12/26/2022, 12/27/2022, 12/29/2022, and 12/31/2022 were blank, indicating the treatments had not been completed on those days. Cleanse wound to scalp site with normal saline, pat dry. Apply xeroform and cover with dry absorptive dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 12/19/2022, 12/22/2022, 12/23/2022, 12/24/2022, 12/25/2022, 12/26/2022, 12/27/2022, 12/29/2022, and 12/31/2022 were blank, indicating the treatments had not been completed on those days. Left Distal medial calf: Cleanse open areas with normal saline, pat dry. Apply Collagen sheet then secure with a dry dressing daily and PRN every day shift for wound care. Order Date- 12/04/2022. D/C date- 12/10/2022. The entry boxes for 12/06/2022, 12/08/2022, and 12/09/2022 were blank, indicating the treatments had not been completed on those days. Left leg: Cleanse open areas with normal saline, pat dry. Apply dry gauze dressing daily and PRN every day shift for wound care. Order Date- 12/04/2022. D/C date- 12/10/2022. The entry boxes for 12/06/2022, 12/08/2022, and 12/09/2022 were blank, indicating the treatments had not been completed on those days. Left medial calf: Cleanse open areas with normal saline, pat dry. Apply Collagen sheet then secure with a dry dressing daily and PRN every day shift for wound care. Order Date- 12/04/2022. D/C date- 12/10/2022. The entry boxes for 12/06/2022, 12/08/2022, and 12/09/2022 were blank, indicating the treatments had not been completed on those days. Left medial foot: Cleanse area with normal saline, pat dry. Apply Santyl to necrotic tissue then secure with dry dressing daily and PRN every day shift for wound care. Order Date- 12/04/2022. D/C Date- 12/10/2022. The entry boxes for 12/06/2022, 12/08/2022, and 12/09/2022 were blank, indicating the treatments had not been completed on those days. Right thigh: Cleanse open areas with normal saline, pat dry. Apply Collagen sheet then secure with a dry dressing daily and PRN every day shift for wound care. Order Date- 12/04/2022. D/C date- 12/10/2022. The entry boxes for 12/06/2022, 12/08/2022, and 12/09/2022 were blank, indicating the treatments had not been completed on those days. Scalp wound: cleanse area with normal saline, pat dry. Apply xeroform sterile gauze and secure with a dry dressing daily and PRN every day shift for wound care. Order Date- 12/04/2022. D/C date- 12/10/2022. The entry boxes for 12/06/2022, 12/08/2022, and 12/09/2022 were blank, indicating the treatments had not been completed on those days. Record review of Resident #2's TAR for January 2023 revealed the following: Cleanse left leg post-surgery site open areas with normal saline, pat dry. Apply dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 01/01/2023, 01/05/2023, 01/06/2023, 01/08/2023, and 01/09/2023 were blank, indicating the treatments had not been completed on those days. Cleanse left leg post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 01/01/2023, 01/05/2023, 01/06/2023, 01/08/2023, and 01/09/2023 were blank, indicating the treatments had not been completed on those days. Cleanse left medial foot post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 01/01/2023, 01/05/2023, 01/06/2023, 01/08/2023, and 01/09/2023 were blank, indicating the treatments had not been completed on those days. Cleanse right thigh post-surgery site with normal saline, pat dry. Apply Santyl and cover with dry dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 01/01/2023, 01/05/2023, 01/06/2023, 01/08/2023, and 01/09/2023 were blank, indicating the treatments had not been completed on those days. Cleanse wound to scalp site with normal saline, pat dry. Apply xeroform and cover with dry absorptive dressing daily and PRN every day shift for wound care. Order Date- 12/18/2022. The entry boxes for 01/01/2023, 01/05/2023, 01/06/2023, 01/08/2023, and 01/09/2023 were blank, indicating the treatments had not been completed on those days. Record review of Resident #2's wound care physician's notes dated 01/07/2023 revealed, Focused Wound Exam (Site 1) Wound Scalp Full Thickness. Etiology: Neoplasm. Wound Progress: No Change .; Focused Wound Exam (Site 2) Post-Surgical Wound of the Left Medial Foot Full Thickness. Wound Progress: Improved .; Focused Wound Exam (Site 3) Post-Surgical Wound of the Left Leg Full Thickness. Wound Progress: Improved. Site 3: Surgical Excisional Debridement Procedure to remove necrotic tissue and establish the margins of viable tissue .; Focused Wound Exam (Site 4) Post-Surgical Wound of the Right Thigh Full Thickness. Wound Progress: No Change .; Focused Wound Exam (Site 5) Post-Surgical Wound of the Left, Medial Leg Full Thickness. Wound Progress: Improved .; Focused Wound Exam (Site 6) Post-Surgical Wound of the Left, Medial Calf Full Thickness. Wound Progress: Improved .; Focused Wound Exam (Site 7) Post-Surgical Wound of the Left, Distal, Medial Calf Full Thickness. Wound Progress: Improved. In an interview with LVN E on 01/10/2023 at 3:10 p.m., she said the facility's nurses worked 12-hour shifts and the nurses were responsible for providing wound care for residents on their halls. LVN E said even numbered rooms got wound care during the night shift and the odd numbered rooms got wound care on the day shift. LVN E said Resident #2 should receive wound care on the night shift. In a telephone interview with RN F on 01/10/2023 at 4:10 p.m., she stated she worked the 7:00 p.m. - 7:00 a.m. shift. She said there was no wound care nurse, so each nurse did their own wounds (on their assigned hall). She said on her shift, she should do even numbered rooms. RN F said she had been doing all of her assigned wounds, but for the past two days, 01/07/2023 and 01/08/2023, the morning nurse said she did the wounds. RN F said there was a misunderstanding on 01/08/2023 because she thought the wounds had already been done. She said her mistake was that she did not go back and check for herself. She said the other nurse (the morning nurse) was an agency staff. RN F said the last time she provided wound care acre to the residents on her hall was 01/07/2023. RN F stated the negative outcome of failing to provide daily wound care could be infection, but none of the residents on her hall developed infections. She said she would be sure to check her residents' wounds daily even when someone else tells her they did the wound care. She said she worked on 01/07/2023 and 01/08/2023. Observation of wound care by LVN E on 01/13/2023 at 11:30 a.m., revealed treatment for all wounds were provided according to physician's orders. In an interview with LVN E on 01/13/2023 at 11:39 a.m., she said Resident #2's wounds were not done that morning (01/13/2023) because when she started, the resident said his wounds were not supposed to be done daily. Resident #3 Record review of Resident #3's face sheet dated 01/10/2023 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. He was diagnosed with peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), cognitive communication deficit (difficulty with thinking and how someone uses language), dysphagia (difficulty swallowing), muscle wasting and atrophy (decrease in size and wasting of muscle tissue), cellulitis of right lower limb (a potentially serious bacterial skin infection), acquired absence of right leg above knee, gangrene (dead tissue caused by an infection or lack of blood flow), heart failure, retention of urine, and gastrostomy status (opening into the stomach from the abdominal wall, made surgically for the introduction of food). Record review of Resident #3's MDS dated [DATE] revealed he had a BIMS score of 2 (severe cognitive impairment); he did not exhibit behaviors of rejection of care; he required extensive physical assistance from at least one staff member for bed mobility, dressing, and personal hygiene; he required total assistance from at least two staff for transfers; he required limited assistance for bathing; he was wheelchair bound; he did not have an indwelling catheter; he was always incontinent of bowel and bladder; he did not receive pain medications; and he was at risk of developing pressure ulcers/injuries but did not have any unhealed pressure ulcers/injuries; he had surgical wounds which required wound care. Record review of Resident #3's care plan revised on 11/05/2022 revealed he had potential for skin breakdown due to decreased mobility (Goal: Resident will be free from skin injury. Interventions: Encourage good nutrition and hydration. Heel Protectors as ordered); he had gangrene affecting the right great toe (Goal: Resident will have no complications due to gangrene. Interventions: Betadine to right great toe. Monitor for changes. Notify doctor of ant significant changes); and he had a suprapubic catheter due to neurogenic bladder (urinary condition in people who lack bladder control due to a brain, spinal cord or nerve problem) (Goal: Resident will show no s/sx of urinary infection. Interventions: Catheter care every shift, monitor urethral site for s/s of skin breakdown. Position catheter bag and tubing below the level of the bladder and away from entrance room door. Change drainage bag monthly. Change Foley catheter monthly. Record/report to doctor for s/sx of UTI). Observation and interview with Resident #3 on 01/10/2023 at 3:25 p.m. revealed he was alert and in bed. Resident #3's gastrostomy tube site dressing revealed it was dated 01/05/2023. Observation of the dressing above his suprapubic catheter revealed it was dated 01/05/2023. Resident #3 stated the nurses only did his gastrostomy tube and catheter care ever 2-3 days. He stated nobody ever did his care daily. Record review of Resident #3's physician's orders for December 2022 and January 2023 revealed the following: Suprapubic catheter site care - Cleanse with soap and water, pat dry one time a day for suprapubic catheter care. Order Status: Active. Order Date- 11/04/2022. Start Date- 11/05/2022. Cleanse G-Tube stoma with NS, pat dry and apply dry dressing every day shift. Order Status: Active. Order Date- 11/10/2022. Start Date- 11/11/2022 Record review of Resident #3's MAR for December 2022 revealed the following: Suprapubic catheter site care - Cleanse with soap and water, pat dry one time a day for suprapubic catheter care. Order Date- 11/04/2022. All entry boxes were checked and initialed, indicating all treatments were completed each day in December 2022. Cleanse G-Tube stoma with NS, pat dry and apply dry dressing every day shift. Order Date- 11/10/2022. All entry boxes were checked and initialed, indicating all treatments were completed each day in December 2022. Record review of Resident #3's MAR for January 2023 revealed the following: Suprapubic catheter site care - Cleanse with soap and water, pat dry one time a day for suprapubic catheter care. Order Date- 11/04/2022. All entry boxes were checked and initialed, indicating all [NAME][TRUNCATED]