**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing and prevent new ulcers from developing for three of six residents reviewed for pressure ulcers. (Resident #52, #46, and #2) A) The facility failed to ensure Resident #52 who was admitted to the facility without pressure ulcers and was low risk for the development of pressure ulcers did not developed a Stage II pressure ulcer that progressed to a Stage IV pressure ulcer in 26 days. Once developed the facility failed to provide wound care within professional standards regarding infection control and wound cleaning techniques. B) The facility failed to do weekly Skin assessments or develop a plan of care for Resident #46 who was found with a Stage III pressure on 08/16/2021 which progressed to a Stage IV pressure ulcer. Once developed the facility failed to provide wound care within professional standards regarding infection control. Non-Immediate Jeopardy C) The facility failed to ensure RN A followed standard precautions during wound care for Resident #2's Stage IV sacral pressure ulcer and Stage IV right and left ischial pressure ulcers when he failed to perform hand hygiene throughout the procedure, sterilize his scissors or use a cleaning technique on the wounds that did not contaminate the pressure ulcers. These failures resulted in an Immediate Jeopardy (IJ) situation on 10/06/2021. While the IJ was removed on 10/08/2021, the facility remained out of compliance at a severity level of actual harm at a scope of pattern due to staff needing more time to monitor the plan of removal for effectiveness. These failures placed the residents at risk for developing worsening pressure ulcers, Cellulitis (skin infection), Osteomyelitis (infection of the bone), Sepsis (infection of the blood), severe pain or death. Finding Include: A) Review of Resident #52's face sheet dated 10/04/2021 revealed Resident #52 was an [AGE] year old female admitted to the facility 08/30/2021 with a diagnoses of urinary tract infection, hypertension, Type II Diabetes Mellitus, abnormalities of gait and mobility, osteoporosis, acute post hemorrhagic anemia, cerebrovascular disease and history of fall with hip fracture. Review of Resident #52's care plan dated 09/20/2021 revealed Resident #52 to require an indwelling catheter, history of surgery for left hip fracture with healing incision, history of fall at home, stage IV pressure ulcer, dependence on staff for mobility and activities and on antibiotics for a urinary tract infection. Review of resident #52's admission MDS assessment dated [DATE] revealed Resident #52 had a BIMS score of 15 which indicated resident was cognitively intact, required two-person assist for bed mobility and transfer from bed to wheelchair, has an indwelling catheter and had a stage II pressure ulcer. Review of hospital history and physical dated 08/30/2021 revealed Resident #52 had surgery for a broken hip from a fall she experienced at home. There was no indication on the discharge paperwork to indicate Resident #52 had a pressure ulcer upon leaving the hospital. Review SNF rehabilitation discharge summary indicated Resident #52 was at the facility from 08/16/21 to 08/30/21. There was no indication on the discharge summary Resident #52 had a pressure ulcer or other skin issue. Review of Resident #52's initial skin assessment dated [DATE] revealed no issues noted except blanchable redness on coccyx. Review of Resident #52's care plan dated 09/05/2021 revealed Resident #52 to be a risk for development of a pressure ulcer with the following interventions Follow facility policies/ protocols for the prevention/ treatment of skin breakdown .Notify nurse immediately of any new areas of skin breakdown: Open area, redness, blisters .the resident needs assist to turn/ reposition at least every 2 hours . Review of Resident #52's nursing progress note dated 09/08/21 revealed Resident #52 to have a stage II pressure ulcer to left and right buttocks. Review of Resident #52's weekly skin assessment dated [DATE] revealed stage 2 ulcer noted to left and right buttocks (no measurements or pressure ulcer description was documented). Review of Resident #52's weekly skin assessment dated [DATE] revealed stage 2 ulcer noted to left and right buttocks. Review of Resident #52's weekly ulcer assessment dated [DATE] revealed a stage 3 pressure ulcer on coccyx with measurements of 1.8 cm in length, 0.8 cm in width and the depth was unable to be determined. The ulcer assessment revealed the pressure ulcer had slough, yellow or white tissue adhered to the wound, approximately 50% of necrotic tissue, no exudate present, and the edges had maceration with the surrounding skin color noted to be bright red. The pressure ulcer was not noted to have an odor or signs/symptoms of infection. The ulcer assessment revealed Resident #52 to have nutritional interventions including Vitamin C, Zinc and Prostat Advanced Wound care liquid supplement. Review of Resident #52's nursing progress note dated 09/16/21 revealed Resident #52 to have a stage III pressure ulcer on coccyx. Review of Resident #52's weekly skin assessment dated [DATE] revealed stage 2 ulcer noted to left and right buttocks. Review of Resident #52's weekly ulcer assessment dated [DATE] revealed a stage IV pressure on coccyx with measurements of 2.4 cm in length, 1.2 cm in width and 0.2 cm in depth. The ulcer was ntoed to have slough (yellow or white tissue adhered to the wound) with granulation. The slough was or necrotic tissue was approximately 75% of the wound and granulation was 25% of wound. The exudate was noted to light, bloody and clear with no undermining or tunneling present. There was no bone, tendon, or hardware visible or directly palpable in the wound. The wound deges were noted to have had maceration with the surrounding skin color noted to be pink. There were not signs/symptoms of infection noted. The ulcer assessment revealed Resident #52 to have nutritional interventions including Vitamin C, Zinc and Prostat Advanced Wound care liquid supplement. Review of Resident #52's physician progress note dated 09/24/21 revealed Resident #52 to have the pressure ulcer debrided by physician and the pressure ulcer noted as a stage IV. Review of Resident #52's weekly skin assessment dated [DATE] revealed stage 4 ulcer noted to coccyx. Review of Resident #52's weekly ulcer assessment dated [DATE] revealed a stage 4 pressure ulcer on coccyx with measurements of 1.5 cm in length, 0.5 cm in width and 0.75 cm in depth. The ulcer was noted to have slough (yellow or white tissue adhered to the wound) with granulation. The slough was or necrotic tissue was approximately 25% of the wound and granulation was 75% of wound. The was no exudate present and no undermining or tunneling. The wound deges were noted to not have any issues and the surrounding skin color noted to be pink. There were not signs/symptoms of infection noted. The ulcer assessment revealed Resident #52 to have nutritional interventions including Vitamin C, Zinc and Prostat Advanced Wound care liquid supplement. Review of Resident #52's Braden scaled for assessment of pressure ulcer risk revealed assessments completed weekly between 08/30/21 - 09/23/21 noted Resident #52 to be at low risk of pressure ulcer development. In an interview on 10/03/21 at 11:20 AM CNA E stated it was difficult to respond to call lights when there are only 2-3 aides working the whole facility. She said they have been short staffed for several months, but it is improving. She said they try to get to everyone as fast as they can but when you were showering a resident, you could not leave and if there is not someone else available on your hallway, residents had to wait. In an interview on 10/04/21 at 3:30 PM DON stated Resident #52's pressure ulcer was facility acquired. DON stated she spoke with Wound Care Physician and did not believe the pressure ulcer had declined to a stage IV pressure ulcer. DON stated the Treatment Nurse does the initial skin assessment upon admission and if the Treatment Nurse was not available, the charge nurse would complete it. DON said weekly skin assessments were completed by the charge nurse on the day the assessment was due. DON said she did not know of any issues Resident #52 had with being able to turn and reposition herself in bed. She said Resident #52 was weak upon admission and may have needed some help but could assist in turning herself. She said the Treatment Nurse was involved with pressure ulcers usually at stage II and floor staff complete treatment for all other skin issues like skin tears. She stated wounds are referred to Treatment Nurse the same day or next day for treatment. She confirmed the wound confirmed in progress notes as stage II for Resident #52 on 09/08/21 should have been referred to the Treatment Nurse that day or the next day. She said the Treatment Nurse was out with COVID in September and that is probably why the first weekly ulcer assessment and treatment was not completed until 09/16/21. DON did not know how Resident #52 had a stage II ulcer on 09/08/21, a stage 3 ulcer on 09/16/21 and a stage IV ulcer on 09/24/21. DON said incontinence might be an issue, but Resident #52 was confirmed to have a catheter for urinary incontinence. She said the incontinence with the Braden scale of pressure ulcer risk and resident having a current pressure ulcer should not be there. If a resident has a stage III-IV pressure and it was facility acquired, it would make them more than a low risk for pressure ulcers. She said a low air mattress is ordered for a stage III or greater pressure ulcer. All residents have a pressure relieving mattress upon admission. Observation on 10/05/2021 at 8:41 AM of wound care for Resident # 52's coccyx pressure ulcer revealed the Treatment Nurse used her clean gloved hand to move the resident's adult brief out of the way, then cleaned the ulcer with gauze using the same gloved hand. She then pushed calcium alginate into the wound with the same gloved hand that touched the brief. In an interview on 10/05/2021 at 2:55 PM with the Treatment Nurse stated I was trained to clean wounds from inside to out. She stated I don't remember touching the brief on (Resident # 52.) In an interview on 10/05/21 at 12:05 PM the Wound Care Physician stated he had only seen Resident #52 once on 09/24/2021 and debrided her pressure ulcer. He confirmed Resident #52 had no prior history of a stage III or IV pressure ulcer that he knew of or had treated. He was not sure why it was documented that she had a previous pressure ulcer. He said the pressure ulcer was a stage IV after debridement and with the resident being so new to the facility, he assumed she was admitted with the pressure ulcer. When informed she was admitted with no pressure ulcer, he confirmed the pressure ulcer did form quickly and declined quickly. When asked if he thought this was avoidable for the resident, he could not say without reviewing her record. He confirmed the resident did not have any condition that would make her more likely to form a pressure ulcer. In an interview on 10/06/21 at 12:11 PM, Resident #52's Primary Care Physician stated Resident #52 was essentially bed bound upon admission and therefore spent a lot of time sitting or lying in bed which resulted in the pressure ulcer. When asked if the pressure ulcer could have been avoided if Resident #52 was turned frequently as ordered every two hours, she said yes. She said turning and repositioning would have likely reduced the likelihood of a pressure ulcer. She said now Resident #52 was stronger and able to reposition herself but at admission to the facility she would have required staff assistance. In an interview on 10/05/21 at 2:10 PM Resident #52 stated she required assistance from staff to reposition and move in bed or to transfer from the bed to a chair. She said she was better at turning herself now, but when she was first admitted she was weak and needed help. She said she does not remember them turning and repositioning her frequently or even once per day when she was first admitted . She said she did not know she was supposed to turn or reposition in bed or in her wheelchair to prevent the pressure ulcer from forming or declining. She stated her daughter bought her a wedge pillow so she could shift her weight while she was lying in bed. She said sometimes the call light response was slow if the staff were busy. In an interview on 10/05/21 at 2:35 PM the Treatment Nurse stated she returned from leave on 09/16/21 and assessed Resident #52. She said it was the first time she saw the pressure ulcer and identified it as a stage III pressure ulcer. She stated Resident #52 did not have an underlying reason for the fast development and decline of the pressure ulcer. When asked what could have caused the fast development and decline of Resident #52's pressure ulcer, she stated it was likely caused from lack of repositioning or turning Resident #52 in bed as ordered every two hours. She confirmed the facility was short staffed and aides did not always have the time to reposition residents every two hours. Review of Resident #52's point of contact documentation of repositioning/turning dated September 2021 revealed Resident #52 to not have reposition/turning documentation for 24 out of 30 days on at least one shift per day. In an interview on 10/05/2021 at 3:00 PM the DON stated the facility was short staffed over the last month. She stated normally five aides were scheduled during the daytime shift and they frequently worked with only two to three aides. She confirmed it would have been difficult for the aides to turn and reposition residents as required every two hours. B) Review of Resident #46's Face Sheet reflected she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Alzheimer's disease, sepsis, muscle weakness, dysphagia (difficulty swallowing) and difficulty in walking. Review of Resident #46's Quarterly MDS dated [DATE] reflected she was rarely or never understood and was totally dependent on two-person physical assist for bed mobility (moving to and from a lying position, turning side to side and positioning body) and transfers. Review of Resident #46's Care plan dated 04/14/21 reflected The resident has potential for pressure ulcer development. Interventions: The resident needs assistance to turn/reposition at least every two hours. Review of a weekly skin assessment for Resident #46 completed on 07/16/21 reflected she did not have any pressure, venous, arterial or diabetic ulcers. Review of a weekly skin assessment for Resident #46 completed by the facility's Treatment nurse on 08/16/21 reflected she had a pressure ulcer. Review for weekly skin assessments for Resident #46 reflected no skin assessment were completed between 07/16/21 and 08/16/21. Review of a Weekly Ulcer Assessment for Resident #46 completed on 8/16/21 by the facility Treatment Nurse reflected discovery of a new Stage III pressure ulcer to her coccyx with slough (yellow or white tissue adhered to the wound) and 25% necrotic (dead) tissue. Stage III pressure ulcer involves the full thickness of the skin and may extend into the fatty tissue layer. The pressure injury was not present on admission. The Stage III pressure ulcer to her coccyx measured 2.5 cm length, 0.5 cm width and <0.1 cm deapth. Review of a Weekly Ulcer Assessment for Resident #46 completed on 09/30/21 reflected her coccyx ulcer had progressed to a Stage IV pressure ulcer. According to the National Institutes of Health website (nih.gov) in an article dated January 2015, a stage IV pressure ulcer is the is the most severe type of pressure ulcer. The skin is severely damaged, and the surrounding tissue begins to die. The characteristics are: full thickness skin loss with extensive destruction, tissue necrosis (death) or damage to muscle, bone or supporting structures. Observation on 10/05/2021 at 8:14 AM for wound care on Resident # 46's coccyx revealed the Treatment Nurse touched the resident's unclean bedding with her clean gloved hand and did not sanitize her hands or change gloves before she cleaned the wound. She used gauze to clean across the wound and dried all over, working from potentially contaminated areas of skin outside of the open wound. In an interview on 10/05/2021 at 2:55 PM with the Treatment Nurse stated I was trained to clean wounds from inside to out. I didn't realize I touched bedding before touching the wound on (Resident # 46.) In an interview on 10/05/2021 at 11:45 AM the DON stated the skin assessment shower sheets which had areas for staff to note alterations in skin integrity, was a new assessment she just initiated and did not have any for Resident #46 for 07/16/21 through 08/16/21. In an interview on 10/05/21 at 12:05 PM the Wound Care Physician stated the first time he examined Resident #46 was on 09/24/2021. The Wound Care Physician stated he did not know why the resident was not referred to him sooner. He stated the facility should be assessing the resident's skin frequently. In an interview on 10/05/21 at 1:13 PM Resident #46's PCP was asked his expectations for repositioning residents to prevent skin breakdown stated, he stated With folks who are confined to bed, they need to be more vigilant in moving and turning them. They need to check their vulnerable areas and keep them clean. In an interview on 10/05/2021 at 1:54 PM with the Treatment Nurse who stated When I returned from leave, someone told me Resident #46 had not been assessed in a while. The CNAs are supposed to come to me or the charge nurse with any skin issues. I found (Resident # 46's) pressure ulcer. In an interview on 10/05/21 at 3:35 PM with a CNA who chose to remain anonymous and was asked about having enough staff to turn and change residents stated, We were definitely understaffed in July, August and September. It makes everything harder and the wait times longer for residents. In an interview on 10/05/21 at 4:00 PM the ADON stated she and LVN B were Charge Nurses on Resident #46's hall during July and August 2021 when her weekly skin assessments were not completed from 07/16/2021 until 08/16/2021. On 08/16/2021 a stage three pressure ulcer was discovered on her coccyx. The facility ADON stated the charge nurses were responsible for doing the weekly skin assessments and there should always be a weekly skin assessment. In an interview on 10/06/21 at 8:40 AM LVN M, who worked at the facility and quit in September 2021, stated she did not remember if she was scheduled to do Resident #46's weekly skin assessments. She stated if it popped up on her schedule, she would do it. She stated if she did not do it the ADON (who is the current DON) would let her know the next morning. LVN M stated she did not recall any skin problems with Resident #46. In an interview on 10/06/21 at 11:39 AM the DON who stated she had been the DON for three weeks stated she was the ADON previously. When asked if it was her responsibility to ensure weekly skin assessments were completed, she stated, Yes, If I saw that it (skin assessment) was flagged on my computer and I had time to look at the computer, I would. I was working 12-hour shifts on the floor and always doing patient care. There was no opportunity to do the ADON job or ensure staff were completing the skin assessments. The DON further stated regarding issues on staffing We hire them, and they never show up or they show up and then stay for two days and quit. The pay is not competitive. We've lost four aides to (another facility in town.) In an interview on 10/06/21 at 4:00 PM CNA F stated We try to get to the residents as soon as we can. We saw redness on some of their skin, (Resident's #46). She stated Resident #46 could not turn herself. The residents need more attention which means we need more staff. Last night was the first time I've seen six staff. I've never seen that before. In an interview on 10/07/21 at 10:49 AM CNA N stated when she saw Resident # 46's coccyx area on a Thursday (08/12/2021) it was red with a white dot in the middle and she applied barrier cream. I told a nurse but I'm not sure who. She stated she was gone for a three-day weekend and when she returned on Monday, 08/16/2021, there was a hole in Resident # 46's coccyx. She stated, We were short staffed. In an interview on 10/07/21 at 10:52 AM with LVN B who stated, We were understaffed when Resident #46 got her pressure ulcer, so I don't know if she was turned or kept clean. She stated RN A mainly did the wounds during that time on the weekends and sometimes during the week. During the nighttime we don't have enough staff. There's only 2 or 3 for the whole place. C) Review of Resident #2's face sheet dated 10/04/2021 revealed resident #2 was a [AGE] year-old male admitted to the facility 04/27/20 with a diagnosis of paraplegia, left above the knee leg amputation, anemia, non-pressure chronic ulcer of back, neuropathic bladder and osteomyelitis of vertebra, sacral and sacrococcygeal region. Review of Resident #2's comprehensive care plan dated 08/09/21 revealed resident #2 to require care for an ostomy, treatment with an anticoagulant, wound care for stage 4 pressure ulcer to sacrum, require pain medication, an indwelling catheter and history of major infection. Review of resident #2's Quarterly MDS assessment dated [DATE] revealed resident #2 to have a BIMS score of 14, required two-person assist with bed mobility and transfer from bed to chair, had an indwelling catheter and colostomy, Stage IV pressure ulcer and required a prevention plan for reducing risk of pressure ulcers. Observation and interview on 10/04/21 at 11:00 AM revealed RN A in Resident #2's room to preform wound care. RN A already had the treatment field set up in room when surveyor arrived. RN A donned gloves outside at the treatment cart and entered the room. RN A did not perform hand hygiene prior to donning his gloves. RN A then removed the dressing from residents left inside knee. RN A stated the wound was from hardware from his knee replacement penetrating the skin and causing it to open. After removing the dressing RN A pushed around on the wound with his gloved hands and reached for the gauze from the table. With the same gloves' RN A cleaned around the area, cleaning across the wound. RN A then reached for a spray bottle (skin prep spray) on his field and sprayed it on the gloves and applied it to the wound with his gloves. RN A then retrieved a dressing from the field and applied it to the wound. RN A with same gloves felt up and down Resident #2's leg then repositioned Resident #2 and removed his brief and turned him over (still wearing the same gloves) and removed the coccyx dressings to reveal a large Stage IV pressure ulcer to the coccyx and Stage IV pressure ulcers to his right and left ischial tuberosity. In an interview with Resident #2 he stated he was admitted with the pressure ulcers. RN A without hand hygiene or a glove change cleaned the coccyx wound cleaning across the wound which was approximately 12 cm x 12 cm with .3 depth. RN A touched the wound all over with his gloves and cleaning with the gauze only certain areas of the wound. RN A then with same gloves began cleaning Resident #2's left and right ischial Stage IV pressure ulcers cleaning across the wounds and touching the wounds with is gloves (he did get a new gauze for each wound) he then applied hydrogel to the wounds with his gloves going from one wound to another. RN A then applied the collagen powder with his gloves patting it into the pressure ulcers going from one pressure ulcer to another. RN A without changing gloves or performing hand hygiene applied clean dressings to coccyx wound with the dressing reaching only to middle of pressure ulcer and with the tape being applied directly on the open pressure ulcer. RN A then applied a foam dressing to right ischial with the tape being on the coccyx pressure ulcer. RN A did the same with the left ischial pressure ulcer. RN A then stated he needed to get another brief, so he took off his gloves and without hand hygiene left room he came back in room with gloves on applied the brief to the resident. RN A then with the same gloves he took the spray bottle he used during treatment and put it in his left chest pocket of his scrubs, and he put the scissors that were on the overbed table with the treatment supplies in the side pants pocket of his scrubs without cleaning them. RN A then gathered the left-over treatment supplies and took them back to the treatment cart. In an interview on 10/04/21 at 3:21 PM RN A sated he was not trained in wound care and stated his training at the facility consisted of making rounds with treatment nurse. RN A stated he did not change his gloves or wash his hands throughout the procedure and did not clean his scissors before or after the procedure. RN A stated I should know better than that he stated he was not aware of the no touch technique for applying medication to wounds (the use of a sterile applicator). RN A stated he was not aware you could not remove treatment supplies from the room or that they were considered contaminated. RN A agreed he had touched the supplies with the gloves that he did not change during the entire wound care procedure. In an interview on 10/07/21 at 1:23 PM the RNC stated he expected staff to clean hands before donning gloves and before they start a treatment and when going from clean to dirty. When he was asked about going from wound to wound, he stated they should not do that. He stated no supplies should be removed from the room that cannot be sanitized and they should be sanitized. The RNC stated the remaining dressing supplies should have been disposed of. He stated there was no corporate policy regarding training staff for wound care other than the policy that was provided to surveyors. Review of the facility's policy Skin and wound management dated 2021 reflected The purpose of this procedure is to provide guidelines for the care of wounds to promote healing .Steps in the Procedure Steps in the Procedure. 1. Use disposable cloth (paper towel is adequate) to establish clean field on resident's overbed table. Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. 2. Wash and dry your hands thoroughly. 3. Position resident. Place disposable cloth next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites. 4. Put on exam glove. Loosen tape and remove dressing. 5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. Gowns will only be necessary if soiling of your skin or clothing with blood, urine, feces, or other body fluids is likely. Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely. 7. Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers. 8. Pour liquid solutions directly on gauze sponges on their papers. 9. Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound. 10. Wear sterile gloves when physically touching the wound or holding a moist surface over the wound. 11. Place one (1) gauze to cover all broken skin. Wash tissue around the wound that is usually covered by the dressing, tape or gauze with antiseptic or soap and water .16. Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly. Review of the facility's policy Skin Integrity Management dated 10/05/16 reflected .4. Reposition residents at risk for pressure sores or with pressure sores at least every two (2) hours, if unable to turn themselves. 5. Use pillows or foam wedges to keep bony prominences from direct contact .8. Any person at risk for developing a pressure ulcer should avoid uninterrupted sitting in any chair or wheelchair. The individual should be repositioned, shifting the points under pressure at least every 2 hours .12. The presence of a pressure reducing device/ specialty bed does not negate the need to turn/ reposition the resident at least every two (2) hours .15. Skin should be cleansed at the time of soiling and at routine intervals .19. Use aseptic techniques for all topical treatments . Review of the facility's policy Pressure Injury: Prevention, Assessment, and Treatment dated 08/12/16 reflected .2. Early prevention and/or treatment is essential upon initial nursing assessments of the condition of skin .9. Assess for early signs of skin breakdown and report any findings. Early signs of skin breakdown and report any abnormal findings . The Interim Administrator was notified of the Immediate Jeopardy on 10/06/21 at 5:00 PM and the IJ template was provided. The Administrator expressed understanding of the Immediate Jeopardy and a Plan of Removal was requested. The Plan of Removal was accepted on 10/08/21 at 1:04 PM and included the following: Problem: Treatment/Services to Prevent/Heal Pressure Ulcers. Interventions: o 100% skin rounds to be completed (10/7/2021) by DON, Patient Care Coordinator, and Treatment Nurse, with Regional Compliance Nurse [RCN] oversight. o Skin assessment for resident #46 and resident #52 current. Update on current wound condition provided to resident #46's primary care physician on 10/6/21 with review of current treatment order to ensure appropriate treatment in place. Weekly ulcer assessment in place with current measurements for resident # 46 and resident #52. Care plans for resident #46 and resident #52 were reviewed and revised on 10/6/21. o The following in-services were initiated by the Director of Nursing on 10/6/2021: Pressure Ulcer Prevention and Treatment (Licensed Staff), including notification and documentation of pressure ulcers (Certified Nurse Aid/Non-certified Nurse Aid) Notification of Physician with change of condition (Licensed staff) Completing Weekly Skin Assessments and Weekly Ulcer Assessments in the absence of the Treatment Nurse (Licensed staff) Ongoing in-services will be completed by DON/ADON/TREATMENT NURSE, until all nursing staff have completed the in-services. The Director of Nursing/Designee will in-service licensed staff on the proper process for wound care beginning 10/7/21. Ongoing in-services will be completed by DON/Treatment Nurse/Designee until all licensed staff has completed the in-service. <[TRUNCATED]