**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Per record review a hospital Discharge summary dated [DATE] reflects that Resident #9 was discharged to the facility on 8/9/2024 with pressure ulcers to their right heel, left heel, lower back, and various other wounds and abrasions. The Discharge Summary also reflects that the right heel pressure ulcer peri wound was brown and there was a clean, dry, intact foam dressing applied. The left heel pressure ulcer also had a clean, dry, intact foam dressing. An admission Skin note dated 8/9/2024 states Resident has current skin issues. The skin issues described in the note include discoloration of bilateral tops of feet, Pressure Ulcer Injury right low back, Stage II pressure ulcer - Partial thickness skin loss. Length: 1.8 Width: 1.5 with no odor or tunneling, a scab on the right heel with no measurements, an open lesion on the left thigh Length: 6 Width: 5, unstageable sacrum, left leg ulcer, mid low back pressure injury. A Wound Care Consultant (WCC) progress note dated 8/13/24 notes an unstageable pressure ulcer on the right and left heels, a burn on the upper left thigh, a stage 3 pressure ulcer on the back, and a stage 2 of the coccyx. Treatment recommendations for all the wounds were made to cleanse, apply Medihoney to ulcers, skin prep to peri-wound, cover with 4 x 4, foam border gauze QD (once a day) and PRN (as needed). The wound care note states that the plan of care was discussed with facility staff. Review of the Medication Administration and Treatment Records and review of Progress Notes for the month of August 2024 reveal that there were no documented wound treatments completed until 8/16/2024, seven days after admission. A WCC progress note dated 12/6/24 reflects recommendations to Gently clean heel and pat dry. Apply A&D to lateral heel. and over wound daily and PRN. Review of the December TAR reveals that this recommendation was not implemented. On 12/13/24 the WCC recommended the right heel and left great toe treatment Apply Skin prep daily and PRN. Review of Resident #9's December 2024 Medication and Treatment Administration Records revealed that there were no treatments in place through the month of December 2024. A WCC progress note dated 1/10/2025 reveals an unstageable pressure ulcer to the right heel that measured 0.2 cm x 0.5 cm 100% eschar. Treatment recommendations included skin prep daily and PRN (as needed) and off load heels. The progress note also reveals a stage three pressure area to the left great toe that measured 0.5 cm x 0.5 cm x 0.1 cm. Treatment recommendations made include Apply collagen to wound bed, dry protective dressing daily and PRN [as needed]. Another WCC progress note dated 1/17/25 states that the wound on the right heel is improving , however measurements reveal that the wound is now 1 cm x 4 cm x 0.1 cm. Treatment recommendations for the right heel pressure ulcer include apply collagen to open wounds and skin prep to peri wound, dry protective dressing daily and PRN. The treatment recommendation for the left great toe included apply skin prep daily. Review of the January TAR reveals there were no wound treatments for the right heel or left great toe pressure ulcers implemented until 1/21/25, 11 days after the 1/10/25 recommendations, which are Great left toe: Gently clean and pat dry. Apply skin prep daily and PRN. No pressure to area. one time a day for Wound Care, and [right] Heel: Gently clean and Pat dry. Apply collagen to open wounds/skin prep to perimeter, offload RT heel w/ bordered gauze. DPD daily and PRN one time a day for Wound Care. A WCC progress note dated 2/7/2025 reveals that Resident #9 had developed a new deep tissue injury to their left heel measuring 3 cm x 4.8 cm x 0 cm. The right heel wound was surgically debrided (the removal of dead, damaged, or infected tissue from a wound) at this visit and now measured 2.3 cm x 5 cm x 0.1 cm. A WCC progress note dated 2/14/2025 states Resident was seen today for evaluation and treatment recommendation for Pu [pressure ulcer] to the Rt [right] lateral heel and Lt [left] great toe and DTI [deep tissue injury] to the LT heel.[S/He] says that the right heel does feel more sore this week, mainly when [s/he] has pressure on the area. PU to right lateral heel appears worsened this week with odor present; left great toe PU is generally unchanged; PU to left heel is smaller in size; otherwise skin appears warm, dry, and intact. Recommendations include Apply skin prep to periwound and honey alginate to wound bed only and DPD daily and prn .Osteomyelitis work up. Ordering labs: ESR [erythrocyte sedimentation rate], CRP [C-reactive protien], CBC [complete blood count] and xray. Staff made aware. Physician progress notes dated 2/24/2025 and 4/17/2025 do address the pressure ulcers on both heels, but does not mention the WCC's recommendations or orders for the osteomyelitis work up. A WCC progress not dated 3/10/2025 states that Resident #9 reports that the right heel typically bothers her/him more than the left. The wound now measures 2.5 x 3 x 0.1. The left heel pressure ulcer measurements are now 3 x 3 x 0 with 100% eschar. On 3/21/2025 the WCC documents that the Resident reports that her/his heels really tend to bother her/him the most of all the wounds and that the right is worse than the left. The right heel wound appears smaller but has a slight odor. On 3/28/2025, 4/4/2025, and 4/11/2025, the WCC documents that the lab work and x-ray to rule out osteomyelitis have not yet been completed. A Physician's progress note dated 5/20/2025, three months after the original documented recommendation, states review of heel ulcers- improved, wound nurse suggests x-ray r/o [rule out] osteo [osteomyelitis] because of pain- ordered. On 5/26/2025 the facility Administrator confirmed via email that the above recommendations had not been implemented. Per phone interview on 5/28/2025 at 9:20 AM, the WCC stated that she was not aware that the treatment changes that she had been recommending weekly were not being implemented. She stated that she does not have access to the electronic health record therefore she would not know what orders were or were not implemented. The Wound Care Nurse confirmed that she had requested the osteomyelitis work up since 2/14/2025 and that it had not been done until May of 2025. 3. Per record review, Resident #25 has diagnoses that include Parkinson's disease, history of stroke, and vascular dementia. Per Resident # 25's care plan, s/he requires assistance with all ADLs (activities of daily living), last revised on 4/29/25, and is at risk for pressure ulcers due to decreased mobility, need for assistance, and incontinence. The care plan indicated that s/he has a history of redness to his/her heels. A 4/3/25 skin assessment indicates that Resident #25 does not have any current skin issues. There are no completed weekly skin assessments in Resident #25's medical record after this date. Review of a 5/16/25 facility skin sweep, implemented as a result of the notification of immediate jeopardy related to pressure ulcer prevention and treatment deficiencies, reveals that Resident #25 has bilateral heel deep tissue injuries. A 5/16/25 wound assessment indicates that his/her left heel deep tissue injury (DTI) measures 2 cm x 2.5 cm and his/her right heel DTI measures 1.5 cm x 1 cm. A review of Resident #25's care plan reveals that s/he did not have interventions for weekly skin assessments or offloading heels until 5/17/25. 4. Per record review, Resident #57 was admitted to the facility for rehabilitation services with diagnoses that include cerebral palsy and malnutrition on 4/11/25. Per a 4/16/25 admission MDS, Resident #57 has 0 pressure ulcers and is at risk for developing pressure ulcers. A 4/12/25 skin assessment reveals his/her skin to be intact other than a hole mark on his/her coccyx and bruises on his/her lower belly. Review of a 5/16/25 facility skin sweep, implemented as a result of the notification of immediate jeopardy related to pressure ulcer prevention and treatment deficiencies, reveals that Resident #57 has a stage 1 4 x 4 pressure ulcer on the coccyx, and the note indicated to turn resident frequently with each incontinence change, use barrier cream every shift and as needed. Per interview on 5/20/25 at approximately 5:00 PM, Resident #57 stated that s/he has a sore on his/her bottom which is painful when it is touched or is sitting on it for a while . Per record review, there is no evidence of a full assessment of Resident #57's pressure ulcer discovered on 5/16/25, including an assessment for pain of the ulcer. A 5/20/25 pressure ulcer evaluation reveals that Resident #57 now has a right gluteal fold suspected deep tissue injury that measures 5 X 8 and has pain with palpitation. While Resident #57's care plan was updated to reflect skin impairment on 5/16/25, no interventions were put into place to offload the area on his/her coccyx until 5/20/25. Per interview on 5/20/25 at approximately 6:00 PM, the Director of Nursing confirmed that a full wound assessment had not been completed for Resident #57 pressure ulcer. 5. Per record review, Resident # 555 was admitted to the facility on [DATE] for rehabilitation services with the diagnoses of pubis fractures, failure to thrive, and dementia. An admission skin assessment indicated that Resident #2 has a 3 cm x 3 cm on his/her coccyx. Review of a 5/16/25 facility skin sweep, implemented as a result of the notification of immediate jeopardy related to pressure ulcer prevention and treatment deficiencies, reveals that Resident #555's pressure ulcer had increased in size to 4 cm x 6 cm x 0.1 cm and has a pink, spongey right heel. There is no additional assessment information about these two wounds, even though one had worsened, and one was newly discovered. Per interview on 5/20/25 at approximately 6:00 PM, the Director of Nursing confirmed that a full wound assessment had not been completed for Resident #555's two pressure ulcers. The wound assessments completed after this interview revealed that Resident #555's right heel pressure ulcer measured 3 cm x 3 cm. Based on interviews and record review, the facility failed to ensure that 5 of 11 residents in the applicable sample (Residents #62, #9, #25, #57, #555) received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infection. As a result, Resident #62 developed a stage two pressure ulcer that worsened to an unstageable pressure ulcer injury, requiring hospitalization and surgical intervention due to osteomyelitis and Sepsis of the pressure injury. Additionally, Resident #25 developed deep tissue injuries to both heels. This citation is at the immediate jeopardy level due to the facility's failure to prevent and treat a pressure injury, which resulted in a life-threatening infection for 1 resident, harm for 1 resident, and put all residents who have pressure ulcers or are at risk for pressure ulcers at risk for serious harm or death. Findings include: 1. Per review of Resident # 62's medical record, s/he was admitted to the facility with a diagnosis of congestive heart failure and a goal of discharge home. On 3/10/2025, a nursing assessment revealed a score of 16 on the Braden scale (total scores range from 6-23) for predicting pressure risk, identifying Resident #62 as being at risk for pressure injury. A Skin Assessment by an LPN (Licensed Practical Nurse) with a date of 3/10/2025 indicates Redness/blanchable to coccyx area, skin warm to touch, no Edema [swelling] no dryness, redness to coccyx area .came in with Mepilex border [a dressing often used as preventative measure for pressure ulcers], I removed it, no opening noted. Per the admission Minimum Data Set (MDS) (a comprehensive assessment of each resident's functional capabilities), submitted on 3/14/2025 by the MDS coordinator, Resident #62 had a BIMS (a brief interview for mental status; a cognitive assessment) of 10, indicating s/he is moderately cognitively impaired. S/he required substantial assistance with ADLs (Activities of Daily Living), which included turning and positioning in bed, and was rarely incontinent of urine and bowel. The MDS revealed that Resident #62 had no unhealed or open pressure ulcer injuries at the time of admission but was at significant risk. A Skin Only Evaluation completed on 3/17/25 by the same LPN as the 3/10/25 assessment states no skin issues. Per review of Resident #62's care plan, initiated on 3/18/2025, states [Resident #62] was admitted without pressure ulcers but remains at risk due to decreased mobility and occasional urinary incontinence. An initial goal reads [Resident] will maintain [his/her] current skin integrity AEB [as evidenced by] allowing assistance with toileting and mobility with any treatments as ordered with a date of 3/18/2025. Care plan interventions include following facility policies/protocols for the prevention/treatment of skin breakdown, monitoring/documenting/reporting any changes in skin status: appearance, color, wound healing, signs and symptoms of infection, wound size (length, width, and depth), and stage to the medical provider. Review of a facility policy titled Pressure Injury Prevention and Management, dated 1/15/25, reads The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt evaluation and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate .after completing a thorough evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions will be documented in the care plan and communicated to all relevant staff. Compliance with the interventions will be documented in the weekly summary charting . The charge nurse will review all relevant documentation regarding skin evaluations, pressure injury risks, progression toward healing, and compliance at least weekly, and document a summary of findings in the medical record. The facility failed to follow its policy by failing to develop a person-centered care plan with measurable goals to prevent pressure ulcers. The care plan did not include interventions specific to the resident's individual risk and needs. The weekly skin assessments were all incomplete and did not convey the relevant information. Dressing change orders for this resident, written by the Wound Provider, were not implemented for two weeks, resulting in a worsening of the wound. The nursing staff noted the deterioration of the wound but failed to alert the provider for several days. According to a physician's progress note, on 3/19/2025, he identifies a stage 2 pressure ulcer (partial-thickness skin loss, which may appear as a shallow, open wound or a blister filled with clear or yellow fluid) on the gluteal cleft. He says that the resident is at high risk due to their decreased mobility and provides the following orders. Start Mepilex border bandage today, frequent repositioning, air mattress, daily dressing changes until wound care RN consult . Per review of the Medication Administration Record (MAR), there is an order for a Mepilex border bandage to the left sacral gluteal cleft, with directions to change the dressing every day until wound care evaluation, with a start date of 3/21/2025, and a discontinued date of 4/2/25. On 3/21/25, an Initial Progress Note by the Wound Provider documents a Stage three Pressure Ulcer on the Coccyx that measures 7 cm length (l) by 3 cm width (w) x 0.1 depth (d). She indicates the wound is tender with examination and with prolonged pressure to the area, but it gets better with turning and offloading. Her treatment recommendations include cleaning and gently drying the area, applying Thera honey (a wound gel containing honey) to the wound bed, applying skin prep to the peri-wound area, and applying a dry protective dressing (DPD) daily and as needed (PRN). Additionally, the resident should be turned frequently with each incontinent care. Recommendations include continuing pressure relief offloading, utilizing the Facility Pressure Ulcer Prevention protocol, and turning and repositioning according to the facility's protocol. A Skin Only Evaluation dated 3/24/2025, states that Resident #62 has a current skin issue, a Pressure Ulcer that is a stage three. The evaluation requires descriptors of the wound bed, wound exudate, peri-wound condition, dressing saturation amount, wound odor, tunneling, undermining, tissue condition, and pain; however, no information is provided about these areas on the form. In a follow up progress note by the Wound Provider dated 3/28/25, she notes the wound is now unstageable and measures 8 cm L x 6 cm W x 0.1 D, it has light serosanguinous (watery/blood) drainage and a mild odor, it demonstrates 20% slough, 20% granulation, and 60% Eschar (a hardened, dry, black or brown dead tissue that forms a scab-like covering over deep wounds.) She recommends treatment that includes applying Thera honey to the wound bed, skin preparation to the peri-wound area, and a dry, protective dressing applied daily and as needed. Turn the patient frequently with each incontinence care. A Skin Evaluation Only dated 3/31/2025, documents that Resident #62 does not have a current skin issue; however, under the skin note section, it reads, Treatment continues to the coccyx area for pressure ulcer. There is no further information provided. A Progress Note dated 4/2/2025 from the medical provider states that he visited the resident on 4/2/2025 and noted that the resident's condition had worsened, her/his wound had progressed from a stage two to a stage three, he suggests that resident may benefit from inpatient level of care for frequency of repositioning and mobilizing. He notes that there are wound care instructions to apply Thera honey to the wound bed and use a dry protective dressing, changing daily. He noted that the wound care orders written by the Wound Provider on 3/28/25 for Thera honey to the wound bed had not been implemented. Per record review of the Medication Administration Record (MAR), there is no evidence the new 3/21/25 wound care orders or the 3/28/25 wound care orders were implemented until 4/2/25. On 4/2/25, an order entered on the MAR states, Clean the sacral area with normal saline, pat it dry, and apply Thera honey to the wound bed. Cover it with a Mepilex border every shift for a pressure ulcer. There is an end date of 4/4/25. The initial order for Thera honey was written on 3/21/25 by the Wound Care provider, but it was not implemented until 4/2/25. Per interview on 5/14/25 at 9:50 AM, the Unit Manager (UM) states that the change in wound orders written on 3/21/25 and 3/28/25 by the wound provider for Thera honey to the wound bed were not implemented. She attributes this to many new staff, including travelers, and information is all over the place. Per interview with the Director of Nursing (DON) at 10:40 AM, she revealed that the orders written by the Wound Provider on 3/21/25 and 3/28/25 were not implemented until 4/2/2025. She confirms that the orders were missed, stating the Wound Consultant sometimes tells the cart nurse there are new orders, and sometimes whoever is at the desk. She reveals that the facility does not make rounds with the Wound Provider and lacks processes such as Interdisciplinary meetings to ensure that care is coordinated among providers. Per interview with Resident #62's primary medical provider, on 5/14/2025 at 1:41 PM, he explained that he covers the facility with two other providers. All three of them are employed by the University of [NAME] Medical Center. He does access the Point Click Care system that the facility uses to read nursing progress notes. He found the pressure ulcer on 3/19/25, and ordered a Wound Consult, noting that the orders given by the Wound Provider on 3/21/2025 and 3/28/2025 were not implemented, and the wound was worse. He states that the resident was less mobile and spent most of the day in bed. He spoke with the DON about the orders and his concerns; he would like a process to communicate with the consulting Wound Care provider. A follow-up progress note from the Wound Provider dated 4/4/2025 reads, unstageable wound measuring 5 cm x 4.5 cm, 80% eschar and 20% granulation, no odor. She orders Honey Alginate to the wound bed and covers the wound with a dry protective dressing daily. A Skin Only Evaluation dated 4/7/25 notes that Resident #62 has a skin issue, a Pressure Ulcer, stage three, treatment continues; no other information about the wound, drainage, odor or condition of the wound is documented in the evaluation, there is no description of the wound, drainage, or peri-wound tissue. A review of the Care Plan reveals that a revision was initiated on 4/9/25. A focus note indicates that the Resident has a stage three pressure ulcer to the coccyx. Interventions include assess for pain every shift prior to dressing change, consult and treatment by Certified Wound provider as needed. Encourage frequent position changes, follow physician orders for skin care and treatment, monitor for signs and symptoms of infection, and report to a physician for care and treatment. The wound was discovered on 3/19/25; there was no update to include the wound and any interventions in the care plan until 4/9/25. A Follow-up Progress Note written by the Wound Provider, dated 4/11/2025, notes that the wound is unstageable, measuring 6 cm x 4 cm x 0.1 cm. She also notes that these measurements are after instruments have been used to debride (remove dead tissue) from the wound. She notes a mild odor, 40% granulation, 30% Eschar, and 30% slough. She notes that the wound measurements are post-debridement, and debridement will be continued weekly as needed to remove devitalized tissue, decrease the risk of infection, and expose viable tissue to promote wound healing. A progress note dated 4/14/2025 that includes a Skin Only Evaluation by an LPN reads Pressure ulcer to coccyx area is getting worse, odor and tunneling noted. There is no documentation in the record indicating that the provider was notified of the wound's deterioration. A SNF Acute/Follow-Up Visit, dated 4/22/2025, written by the primary medical provider, generally sacral pressure now seems stage four- dramatic worsening in 2 weeks. The plastic surgeon advised urgent surgical evaluation for possible debridement. According to progress notes dated 4/22/2025 at 3:57 PM, Resident #62 was transferred to the Emergency Department of the local hospital for emergent evaluation of the coccyx. Per review of hospital records, a hospital progress note dated 4/24/2025 reads admitted from rehab., with sacral osteomyelitis [infection of the bone] and MRSA bacteremia [type of staph infection that can be resistant to several antibiotics], taken to the operating room for debridement of the wound, admitted to Surgical Intensive Care. Per interview on 5/13/2025 at 11:21 AM with the Attending Provider, he states he was not notified of the wound deterioration until days later, when he made his scheduled visit on 4/17/25. Had he been informed, he would have transferred Resident # 62 to the hospital earlier. He relates inconsistent communication between the facility's nursing staff and providers. He stated the facility lacks a process to ensure communication and coordination of care among the medical team. He states that the facility does not hold interdisciplinary team meetings to discuss issues such as wounds. He feels it is challenging as the providers document their notes in a system different from the facility's system. He does not think the current system, which includes a consultant Wound Provider, is effective, as communication between providers is limited. Per interview on 5/15/2025 at 2:40 PM, the Director of Nursing confirmed that the dressing change orders written by the Wound Care Provider on 3/21/2025 and 3/28/2025 were not implemented until 4/2/25. She confirmed that the provider was not notified on 3/14/2025 when the wound was noted to be deteriorating. She stated the facility does not implement interdisciplinary meetings regularly to facilitate resident care, they were not following their Pressure Ulcer Prevention and Management Policy, and they were not documenting a weekly summary. She confirmed the resident's care plan did not contain person-centered interventions to prevent pressure ulcers until days after there was evidence s/he had one. She confirmed that the skin assessments are incomplete, and the Unit Managers are not documenting a weekly summary of the wounds, as is the facility's policy. tcs.pressbooks.pub/nursingfundamentals/chapter/10-5-braden-scale/ (n.d.). Understanding Eschar in Wounds and Its Distinction from Slough. Westcoast Wound.com. Retrieved May 19, 2025, from westcoastwound.com/eschar-in-wounds TheraHoney® Gel | Manuka Honey Wound Care Dressing https://www.cdc.gov/mrsa/about/index.html