**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 2 of 6 residents (Resident #27 and Resident #361) reviewed for pressure injury. The facility failed to ensure Resident #27 low air loss mattress (is designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings. The facility failed to ensure Resident #27 had dressing on his back wounds. The facility failed to ensure the WCN loosening Resident #27's dressing, before removing, from his heel wound to prevent bleeding. The facility failed to ensure Resident #27 was turned and repositioned every 2 hours. The facility failed to ensure Resident #27 was positioned correctly when using his positioning aides. The facility failed to treat Resident #361's unstageable (the base of the wound was covered by a layer of dead tissue that was yellow, grey, green, brown, or black and unable to determine the stage of the wound) sacral pressure ulcer for 3 days after admission. These failures could place residents at risk for deterioration of wound. Findings included: 1. Record review of Resident #27's face sheet dated 10/30/23 indicated Resident #27 was a [AGE] year-old male and admitted on [DATE] with diagnoses including cerebral infarction ((also known as a stroke) refers to damage to tissues in the brain due to a loss of oxygen to the area), pressure ulcer of buttock (also known as bedsores, are an injury that breaks down the skin and underlying tissue), stage 3, skin changes and pain. Record review of Resident #27's annual MDS assessment dated [DATE] indicated Resident #27 was usually understood and usually understood others. The MDS indicated Resident #27 had a BIMS score of 09 which indicated moderately impaired cognition and required limited assistance with dressing, extensive assistance with bed mobility, toilet use, personal hygiene, and bathing. The MDS indicated Resident #27 had 2 Stage 4 pressure ulcers and were present upon admission/entry or reentry. The MDS indicated Resident #27 had skin and ulcer/injury treatments of pressure reducing device for bed, nutrition or hydration intervention, pressure ulcer/injury care, application of ointments/medications other than to feet, and application of dressing to feet. The MDS indicated Resident #27 received an anticoagulant (are medicines that help prevent blood clots) for 3 days during the 7 days assessment period. Record review of Resident #27's care plan dated 09/21/23 indicated anticoagulant/antiplatelet (medications that prevent blood clots from forming) related to diagnosis of atrial fibrillation (is an irregular and often very rapid heart rhythm) and history of cerebrovascular accident (stroke) as evidence by Apixaban (is used to prevent serious blood clots from forming due to a certain irregular heartbeat) 5mg tablet 1 tablet by mouth 2 times a day. Interventions included handle resident carefully when turning, positioning, or transferring and maintain pressure on skin tears, blood draws sites, and IV sites for at least five minutes. Record review of Resident #27's care plan dated 10/24/23 indicated Resident #27 was at risk for/actual of skin breakdown related to skin failure and history of pressure injury as evidence by pressure reducing/redistribution mattress (redistribute a patient's weight so as to relieve pressure points), pressure ulcer risk: high score 10-12, confined to bed most of time, wound (pressure, diabetic or stasis), open lesions. Interventions assist resident to turn and reposition frequently, report refusals, off load heels, position resident properly; use pressure reducing or pressure relieving devices if indicated, and treatments and dressings as ordered per physician. Record review of Resident #27's Consolidated Physician Orders dated 04/06/23 Pressure reducing/redistributing mattress, night shift. Record review of Resident #27's Consolidated Physician Orders dated 06/02/23 Air Mattress to bed, every 2 shifts. Check every shift for function. Record review of Resident #27's Consolidated Physician Orders dated 10/12/23 indicated cleanse wound on day shift, cleanse wound to left upper back with normal saline, pat dry, apply calcium alginate with silver (Assist with infection reduction. Primary dressing for wounds with moderate to heavy exudate (drainage)), cover with silicone bordered dressing (is highly conformable with a thin, low-profile edge to help minimize the rolling and lifting that can impact adhesion) daily. Record review of Resident #27's Consolidated Physician Orders dated 10/27/23 indicated cleanse wound on day shift, right back with normal saline, pat dry, apply alginate calcium when blister breaks and cover with silicone foam bordered dressing daily. Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated Pressure reducing/redistributing mattress, night shift. Diagnosis: Benign Prostate Hyperplasia (age-associated prostate gland enlargement that can cause urination difficulty) with lower urinary tract symptoms. Start date: 04/06/23. Documentation noted every day, night shifts. Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated Air Mattress to bed, every 2 shifts. Check every shift for function. Diagnosis: skin changes. Start date: 06/02/23. Documentation noted every day, 2 shifts. Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated cleanse wound on day shift, cleanse wound to left upper back with normal saline, pat dry, apply calcium alginate with silver, cover with silicone bordered dressing daily. Diagnosis: skin changes. Start date: 10/12/23. Documentation noted 10/12/23-10/31/23 on day shift. Record review of Resident #27's TAR dated 10/01/23-10/31/23 indicated cleanse wound on day shift, right back with normal saline, pat dry, apply alginate calcium when blister breaks and cover with silicone foam bordered dressing daily. Diagnosis: skin changes. Start dated: 10/27/23. Documentation noted 10/27/23-10/31/23 on day shift. Record review of Resident #27's wound evaluation and management summary dated 10/25/23 indicated .wounds on his sacrum .left first finger .right lateral (outside of your foot) heel .right upper lateral foot .left upper back .left back .right back .stage 4 pressure wound (There is full-thickness skin loss extending through the fascia with considerable tissue loss) of the right, upper, lateral foot full thickness .2.4cmx1.8cmx0.2cm (Lx W x D) .at goal for wound progress .stage 4 pressure wound of the right, lateral heel, full thickness .3.4cm.3.4cmx0.1cm .stage 4 pressure wound sacrum full thickness .6.8cmx10cmx2cm .at goal .recommendation off-load wound .reposition per facility protocol .group-2 mattress .stage 3 pressure wound of the left upper back full thickness .1.2cmx0.9cmx0.1cm .improved evidence by decreased surface area .non-pressure wound of the left back partial thickness .9cmx2.5cmx0.1cm .abrasion/sheer .non-pressure wound of the right back .6cmx1.5cmxnot measurable cm .blister fluid filled . Record review of Resident #27's wound evaluation and management summary dated 11/01/23 indicated .wounds on his right lateral heel .left upper back .sacrum .right upper lateral foot .left back .right back .left first finger . stage 4 pressure wound the right, upper, lateral foot full thickness .8cmx10cmx0.2cm .objective palliation .wound progress at goal . stage 4 pressure wound of the right, lateral heel, full thickness .3.5cmx4.0cmx0.1cm .wound progress at goal . stage 4 pressure wound sacrum full thickness .9cmx12.5cmx2.0cm .wound progress at goal . stage 3 pressure wound of the left upper back full thickness .19cmx12.5cmx0.1cm .wound progress at goal .unavoidable due to generalized decline .non-pressure wound of the left back .signoff-wounds has merged with another site on 11/01/23 . non-pressure wound of the right back .signoff-wounds has merged with another site on 11/01/23 Record review of the facility's weight log dated 10/04/23 indicated Resident #27 was 6'3 and 215.6 pounds. During an interview and observation on 10/30/23 at 11:24 a.m., Resident #27 was on a bariatric (a person is classified as having obesity), low air loss mattress, lying on his back. Resident #27 feet were covered but appeared to be elevated. Resident #27 low air loss mattress setting was 50 pounds. Resident #27 said he had wounds on his right foot and bottom. He said he came to the facility with the wounds. Resident #27 said he did not feel like the staff turned him enough. During an observation on 10/30/23 at 3:41 p.m., Resident #27 was lying on his back with head of his bed elevated. During an observation on 10/31/23 at 9:46 a.m., Resident #27 was lying on his right side with an elongated, balloon shaped pillow in front of him. He said he did not know what the pillow was used for, and it had not been used before. Resident #27's low air loss mattress setting was on 50 pounds. During an observation on 10/31/23 at 11:37 a.m., Resident #27 was lying on his right side with an elongated, balloon shaped pillow in front of him. During an observation on 10/31/23 at 2:08 p.m., Resident #27 was lying on his left side and the low air loss mattress setting was on 50 pounds. During an observation and interview on 10/31/23 at 3:02 p.m., Resident #27 was lying on his left side with triangular shaped positioning aide behind his back. When WCN NN removed the covers from Resident #27's legs, 2 small rectangular shaped positioning wedges were beneath his heels, but no pillow or wedge observed underneath the knees and Resident #27's calf was laying on the edge of the rectangular wedges which caused an indentation to his calf. During wound care provided by WCN NN, WCN NN removed a dressing from Resident #27's left heel. The dressing from Resident #27's left heel was slightly stuck to the skin and when removed, small amounts of frank blood dripped onto the positioning wedges. When Resident #27 was turned on his left side, one dressing was noted to the left side of his back but two other wounds were noted to the back without dressing. Resident #27's low air loss mattress setting was on 50 pounds. Resident #27 said he was 6'3 and 380 lbs. During an observation on 11/01/23 at 3:08 p.m., Resident #27's low air loss mattress setting was on 300 pounds. During an interview on 11/02/23 at 10:26 a.m., WCN NN said she started as the wound care nurse August 2023. She said everyone was responsible for checking the low air loss mattress settings. She said Resident #27's low air low mattress setting was on 50 pounds. She said when she went to do wound care with the wound care doctor today (11/02/23), they noticed the mattress looked low. She said she did not know how to unlock the bed settings, so the wound care doctor fixed the settings on Resident #27's bed. She said she thought the wound care doctor set the bed to 180 pounds. She said she only looked at the machine lights to make sure they were green, after the wound care doctor set the settings. She said she did not know why the wound care doctor set the low air loss mattress settings at 180 pounds because Resident #27 weighed more than 180 pounds. She said she normally tried to glance at the low air loss mattress machine when she did his daily dressings changes. She said she because there was no specific order on what weight to set the mattress settings on, she would look up the resident's weight to determine the settings. She said the floor nurses should check the mattress setting every shift to make sure it was working and on the right settings. She said the nurse's charted on the TAR every shift, they checked the mattress. She said correct inputted weight on the low air loss mattress was important to prevent wounds from happening and current wounds from getting worse. She said the wrong settings negatively affected the resident by worsening the wounds and be in pain. She said that could cause the need for pain medication and contributed to the slow healing of Resident #27's sacrum wounds. The WCN NN said CNAs were responsible for turning and repositioning residents every 2 hours when they made rounds. She said the hall nurse should ensure the CNAs were turning and repositioning residents every 2 hours. She said she did not know how the hall nurse monitored if every 2-hour turning happened. She said she looked into resident's rooms when she walked the halls to monitor turning and repositioning. She said turning and repositioning every 2 hours prevents further deterioration of wounds, removed pressure to prevent wounds, and reduced pressure on bony areas. She said she had not noticed Resident #27 not been tuned and repositioned every 2 hours. The WCN NN said she was responsible for dressing changes and wound care Monday-Friday and floor nurse did dressing changes on the weekend. She said the nurses were responsible for the resident's dressing staying on and changing the dressing when soiled. She said when she did Resident #27's wound care on Monday (10/30/23), he had 3 dressing to his back. She said no one notified her two of the dressing had fallen off on Tuesday (10/31/23) prior to the observed dressing change. She said the CNAs are supposed to let the nurses know when a dressing comes off. She said the wounds needed dressing to stop bacteria from getting in and help with healing. She said if no dressing is on the wounds, it could get infected and deteriorate. She said this would cause Resident #27 to need antibiotics and different treatment orders. She said she did not know if the CNAs had been instructed or in-serviced to notify nursing staff when wound dressing come off. The WCN NN said she did not know if CNAs had training on how to use and place positioning aides. She said she did not know if the positioning wedges came in different size and lengths since Resident #27 was tall and bariatric. She said she did not remember on Tuesday (10/31/23) during the dressing change if Resident #27 had a pillow underneath his knees. She said but Resident #27 should have a pillow underneath his knees to prevent pressure and give knee support. She said no knee support could cause blisters, wounds, and decreased range of motion. She said the facility was in the process of starting training on turning and repositioning. The WCN NN said Resident #27 was on a blood thinner and the Xeroform gauze dried out and stuck to the wound. She said she could have moistened the dressing to help prevent the wound from bleeding. She said Resident #27 being on a blood thinner cause him to bleed easier than other residents. During an interview on 11/02/23 at 11:35 a.m., CNA H said she had been a CNA for 20 years but started back working at the facility around August 2023. She said she worked 6am-2pm shift on the 100-hall. She said she worked with Resident #27. She said resident were supposed to be turned every 2 hours to prevent skin break down and pressure sores. She said she knew how to correctly position resident using position aides and knew why it was important. She said pillows or position aides were important because they kept the skin from touching, prevented skin breakdown, and relieved pressure areas. She said she always found Resident #27 with a pillow underneath his knees. She said she let nurses know when wound dressing came off. She said Resident #27's back dressing normally stayed on, but his butt dressing came loose often. She said the wounds needed dressings because they were pressure sores, and they needed the dressing to heal. During an interview on 11/02/23 at 2:06 p.m., LVN N said she had worked at the facility for 4 years and worked the 6am-6pm shift. She said she primarily worked the 300-hall and 400-hall but also worked the others hall too. She said residents should be turned. She said the resident should be turned and repositioned every 2 hours by the aides. She said LVN should check what position the resident are in throughout the day. She said if residents refused to be turned and repositioned, the aides needed to notify the nurse so it could be charted. She said turning and repositioning ensured resident did not develop wounds. LVN N said it was the nurse's responsibility to make sure the low air loss mattress was working every time you entered the room. She said all nurses should make sure the setting was on the correct weight by checking the weight in the computer system. She said the correct settings helped distribute the correct amount for the wounds and if the mattress is flat, it could cause more wounds or make current wounds worse. LVN N said all nurses should make sure dressings stayed on. She said if the wounds are left open, bacteria could be introduced and cause an infection. She said the infection could cause the resident to need antibiotics, develop sepsis (is a serious condition in which the body responds improperly to an infection) and c-diff ((also known as Clostridioides difficile or C. difficile) is a germ (bacterium) that causes diarrhea and colitis (an inflammation of the colon)), and death. During an interview on 11/02/23 at 3:04 p.m., the DON said the CNAs should be turning and repositioning residents every 2 hours and as needed. She said LVNs and the DON should ensure it happened by making rounds. She said the facility used to have a system in place to have residents face a certain way a specific time of the day. She said that process did not work. She said she picked a different hall a week and monitored turning and repositioning. She said turning and repositioning was important to prevent skin breakdown. She said it was always uncomfortable to the resident to stay in the same position. The DON said the WCN was responsible for making sure low air loss mattress were on the right settings or weight. She said the WCN should at least be checking weekly, if not every time she was in the room doing dressing changes. She said unfortunately, CNAs can accidently change the setting and family members. She said the wrong setting could cause pressure and effect the resident's skin integrity. She said she did not know if the low air loss mattress being on the incorrect weight could cause pressure ulcer delayed healing. She said the floor nurse were responsible to make sure the low air loss mattress was working and on the ordered type of mattress. The DON said the WCN did dressing changes and the aides should notify the LVN when the dressing came off. She said the aides know to notify the nurses when a dressing comes off. She said wounds without ordered dressing risked infection and delayed healing. She said wound dressing were important for adequate healing. The DON said she did not know if all the aides knew how the use positioning aide/wedges. She said the facility had a large turnover in aides and was in the process of training the staff. She said pillow or wedge should be between or under the knees to provide support. She said correct use of positioning aides was important for comfort, proper body alignment, and reduced pressure wounds. During an interview on 11/02/23 at 4:30 p.m., the WC MD said Resident #27 was under his care for several wounds. He said Resident #27 had recently been placed on hospice and his wound care was palliation, so not directly trying to heal the wounds. He said he had also clustered some wounds after his last visit (11/01/23) to decrease the amount of treatment needing to be performed. He said he vaguely remembered Resident #27 mattress setting being on the wrong weight. He said the low air loss mattress should be close the resident's weight and if tolerated, alternating every 15 minutes. He said Resident #27 was about 250 pounds so 50 pounds was far from what he needed. He said Resident #27 had a decline in health, decreasing the healing of his wounds. He said Resident #27 being on 50 pounds settings instead of about 250 pounds could feasibly have contributed to the increased size of the pressure and non-pressure wounds. He said he did not know the facility's policy on how often the low air loss mattress setting should be checked but they should be checked when wound care was provided. 2. Record review of Resident #361's face sheet dated 10/30/23 revealed Resident #361 was admitted to the facility initially on 2/17/17 and readmitted on [DATE] with diagnoses including lymphedema (swelling in an arm or leg caused by a blockage in the lymphatic system, part of the immune and circulatory systems), pneumonia (infection in lungs), weakness, abnormalities of gait and mobility, heart failure, and diabetes (high sugar levels in blood). Record review of Resident #361's admission MDS dated [DATE] indicated Resident #361 was understood and understood others. The MDS indicated a BIMS score of 15 which indicated Resident #361 was cognitively intact. Resident #361 required extensive assistance of 2 persons for most ADLs. Resident #361 was always incontinent of urine and frequently incontinent of bowel. The MDS said Resident #361 did not have pressure ulcers. Record review of Resident #361's undated care plan revealed he was at risk for/actual skin breakdown with onset date of 8/07/23. Record review of hospital records dated 8/3/23 revealed Resident #361 had a sacral decubital ulcer (wound caused from pressure to the lower back at the bottom of the spine) and was being treated with Santyl (ointment used to remove damaged tissue from skin ulcers). Record review of Resident #361 's admission assessment revealed there was no documentation of an admission assessment upon admission. Record review of Resident #361 's initial skin assessment revealed there was no documentation of an initial skin assessment completed. Record review of Resident #361 's nurses' notes revealed there was no documentation until 8/18/23 and it did not address Resident #361 's pressure ulcer to his sacrum/coccyx. Record review of Resident #361 's order summary report dated 10/31/23 revealed there was no orders to treat Resident #361 's pressure ulcer to his sacrum/coccyx until 8/07/23, however, the order did not match what APRN QQ had documented in his 8/07/23 note. The 8/07/23 order was to cleanse the coccyx wound every other day with wound cleanser, pat dry, apply medihoney, wet/dry dressing, and cover with mepilex. Record review of Resident #361 's physician visit note dated 8/07/23 completed by APRN QQ revealed during the visit Resident #361 complained of pain to his coccyx. APRN QQ documented Resident #361 to have an unstageable sacral wound that covered his sacrum and his left and right buttocks. APRN QQ documented the wound to have slough and eschar to the wound base with serous drainage present. APRN QQ ordered wound care to cleanse the wound with wound cleanser, pat dry, apply Santyl to moist fluffed gauzes covering the entire wound, cover with dry gauze and secure with a silicone foam dressing every other day. During an interview on 11/01/23 at 10:31 AM, APRN QQ said he did not recall being notified about Resident #361 's wound to his bottom upon his admission. APRN QQ said he would have expected the admitting nurse to notify him with abnormal findings for orders. APRN QQ said Resident #361 admitted on Friday 8/04/23 and he saw Resident #361 on Monday 8/07/23. APRN QQ said he remembered there was little mention of the pressure ulcer to Resident #361 's bottom in the hospital records during his review. APRN QQ said the wound was covered with slough (wet dead tissue) and eschar (dried out dead tissue) and he was unable to stage the pressure injury. APRN QQ said it was a pretty bad wound and he gave orders for wound care, and he made a referral for the wound care physician to see him that usually came to the facility on Wednesdays. APRN QQ said after the wound care physician saw Resident #361 and debrided the wound (cut away dead tissue), then they were able to see the extent of the wound. APRN QQ said the resident had osteomyelitis (bone infection) in his foot and he suspected that it could have come through the bone and settled in the sacrum/coccyx. APPRN QQ said he did an x-ray of the sacral area, and it was suspicious of osteomyelitis, then they decided it was best to send him to the hospital for further treatment. APRN QQ said depending on how the wound looked upon admission on [DATE], he most likely would have given the same orders and made a referral to wound care. APRN QQ said it was possible the wound could have deteriorated without appropriate care from 8/04/23 until 8/07/23, but unlikely that it would have deteriorated to the point of needing emergent intervention in that time frame. During an interview on 11/01/23 at 11:18 AM, LVN KK had worked at the facility for six months and normally worked on 600 hall on the 6am-6pm shift. LVN KK said the nurse on the floor was primarily responsible for completing the admission assessment, obtaining and entering orders, initial skin assessments upon the resident's arrival/admission. LVN KK said the first nurse to lay eyes on resident was responsible for all the admission stuff. LVN KK said if a resident was admitted during the week, he preferred to have the wound care nurse go with him and do the skin assessment with him. LVN KK said by completing the admission assessment that included the skin assessment, it would find a pressure wound and it was important to find pressure wounds on admission, so it would show it was acquired at hospital and not at the facility. He would document LVN KK said if he found any new wounds during his skin assessment, he would notify the physician for orders, and he let wound care nurse and the DON know. LVN KK said the nurses were responsible for doing the wound care on the weekends if there was no treatment nurse on the weekend. LVN KK reviewed Resident 361's chart at surveyor request and he none of Resident #361's admission assessments, including the skin assessment was not completed upon admission and still did not show to be completed. LVN KK said it appeared there was no orders to treat the pressure ulcer to Resident #361's bottom until 8/07/23. LVN KK said he could not tell what nurse had admitted Resident #361 due to there was no notes documented. During an interview on 11/01/23 at 11:49 AM, MD RR said he remembered Resident #361 and he had a really nasty coccyx wound. MD RR said he saw Resident #361 on 8/16/23 and that was the only time he saw him in August. MD RR said he debrided the wound and then staged it as a stage 4 pressure ulcer (extends to muscle, tendon, and bone). MD RR said he believed he received the referral to see Resident #361 on 8/16/23 and remembered APRN QQ asking him to see Resident #361. MD RR said any wound that did not receive the appropriate care over three days would most likely deteriorate. During an interview on 11/01/23 at 11:57 AM, LVN NN said she began working at the facility sometime in August 2023. LVN NN said she did not recall seeing Resident #361 for wound care because he may have admitted before she began working at the facility as the wound care nurse. LVN NN said the nurses were responsible for completing the admission skin assessments and if she was at the facility, she would do them with the admitting nurse. During an interview on 11/01/23 at 6/02 PM LVN O said she had worked at the facility for five years and normally worked the 600 hall on 6pm-6am shift. LVN O said on new resident admissions, the nurse had to complete a head-to-toe assessment to include weight, vital signs, assess lungs, heart, feet, and look at everywhere on their skin. LVN O said findings during the assessment should be documented in the admission assessment and skin assessment questionnaire. LVN O said if she found a pressure wound and did not have orders to treat it, then she would notify the physician for orders for treatment immediately. LVN O said Resident #361 did not admit to 600 hall, he was on the 100 hall when he came back from the hospital in August after his amputation. LVN O said she thought an agency nurse admitted him. LVN O said if a pressure ulcer did not receive appropriate care for three days, then the wound could get worse. During an interview on 11/02/23 at 8:36 AM, ADON P said she had worked at the facility since 7/26/23. ADON P said she was responsible for reviewing the 24-hour reports, reviewing nurses' notes, making sure labs were done, along with making sure the nurses were doing what they were supposed to do and helping the DON and ADM. ADON P said she also reviewed new admissions to ensure all the medications were reconciled correctly and available. ADON P said the admitting nurse was responsible for completing the admission assessments and skin assessments as soon as possible, but within 24 hours. ADON P said there was no admission assessment documented on Resident #361 and there were only two nurses' notes on Resident #361. ADON P said if the admission assessment, skin assessments, nurse's notes or anything were not documented, it affected Resident #361's care. ADON P said if it was not documented, then it was not done. ADON P said not receiving needed care to Resident #361's pressure ulcer for three days could have negatively affected the healing of his wound. During an interview on 11/02/23 at 10:05 AM, the DON said the admission assessment, skin assessment, medication review, orders, bed rail evaluation, consents, and baseline care plans should be completed by the admitting nurse. The DON said the admission assessments should be completed by the admitting nurse within 24 hours of admission. The DON said the documentation on Resident #361 was terrible and just awful due to there was no admission assessment with skin assessment and only two nurses' notes during Resident #361's 8/04/23-8/18/23 stay. The DON said she could not determine who the admitting nurse was that did not complete the admission and skin assessments on Resident #361, but she said she believed it had to be an agency nurse. The DON said she was responsible for making sure the nurses were completing the admission assessments. The DON said they had an admission audit form that was started by ADON P, and the DON was the second check. The DON said at time of Resident #361's admission, she did not have an ADON to help her and was having to work the floor frequently and at night and was not able to follow on things like she needed to. The DON said due to the admission assessments not being completed and Resident #361's pressure to his sacrum/coccyx was not discovered on admission, then his needed care was delayed and that was not good. The DON said not receiving care to Resident #361's sacrum/coccyx pressure ulcer could have negatively impacted the healing of the pressure ulcer, however, since it was not documented on his admission assessment, there was no way of determining how much or if any deterioration occurred to his pressure ulcer. During an interview on 11/02/23 at 10:52 AM, the ADM said the receiving nurse would be responsible for completing an admission assessment and the DON or her designee checks over it. The ADM said if the admission assessment was not completed, then they could miss resident care needs. The ADM said a complete admission assessment should be completed to identify any resident issues and provide interventions to prevent decline. The ADM said she would have expected Resident #361 to have been provided care to his pressure ulcer to his coccyx to prevent further breakdown. Record review of the facility's policy titled Prevention of Pressure Ulcers/Injuries dated July 2018 indicated . residents would receive care to maintain skin integrity and prevent pressure ulcers/injuries . residents will be repositioned on a routine basis based on the [TRUNCATED]