**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, facility document review, and clinical record review, the facility staff failed, during transport in the facility's van, to secure safety restraints for one of four residents in the survey sample (Resident #1). Upon sudden braking during a transport, Resident #1 was thrown from the wheelchair onto the van floor, and was found with an unattached lap/shoulder safety belt. Resident #1 experienced a painful right ankle fracture and left lower leg fracture that required hospitalization, surgical treatment, and a blood transfusion (harm) as a result of the accident. The findings include: Resident #1 (R1) was admitted to the facility with diagnoses that included atrial fibrillation, cardiomyopathy, congestive heart failure, hypertension, respiratory failure, osteoarthritis, osteoporosis and hypothyroidism. The minimum data set (MDS) dated [DATE] assessed R1 as cognitively intact. R1's clinical record documented a nursing note dated 1/11/24 stating, .This guest was taken to .hospital on the day shift. This guest has been admitted . R1's hospital history and physical dated 1/11/24 documented, .presents with right ankle and left knee pain. Patient was in a wheelchair transport van when it suddenly hit the brakes and [R1] .was thrown forward out of her wheelchair and pinned underneath the chair in front of her. She was unable to get up after this accident. She was found to have significant amount of bleeding from her right ankle . The hospital physician's physical exam dated 1/11/24 documented the right lower extremity with a large medial ankle wound with exposed bone and the left lower extremity was tender to palpation over left proximal tibia .ecchymosis noted over proximal tibia . R1 was diagnosed with an open right ankle fracture and left tibia fracture. R1 was hospitalized for surgical treatment of the injuries. The hospital Discharge summary dated [DATE] documented R1 had surgical repair of the fractures on 1/12/24 and experienced blood loss anemia, which required a blood transfusion. It also documented that R1 had a cast applied to the right lower leg/ankle and dressing applied to the left lower leg. Per the hospital discharge summary, R1 was discharged to the nursing facility on 1/16/24 with orders for non-weight bearing status on both legs due to the fractures, in addition to the medication orders for pain management. On 1/29/24 at 10:50 a.m., R1 was interviewed about the van incident of 1/11/24. R1 stated she was transported in the facility van on 1/11/24 with the usual driver (certified nurses' aide #1) to go to an eye appointment. R1 stated that she evidently was not buckled in properly at the time of the incident. R1 stated, Something happened in the road and the driver applied the brakes suddenly. R1 stated that when the driver hit the brakes, I went on the floor and my legs went under the seats. R1 stated that she broke both of her legs due to the incident. R1 stated that she bled bad because she was on Coumadin. R1 stated that she remembered the driver locking the wheelchair and placing the seat/shoulder straps across her. R1 stated she had a strap across her chest prior to leaving and described the strap as loose, flimsy. R1 stated that she thought the safety belts were attached but obviously something was not locked because the strap was not attached after the accident. R1 stated that there were no other residents in the van and the driver immediately called 911 after the incident. R1 stated the pain at the time of the accident was terrible. R1 stated that she had surgery, had to get a blood transfusion, and now had a cast on the right ankle with a dressing on the left leg. R1 stated that she was now non-weight bearing on both legs for approximately six to eight weeks and taking extra medication to manage the pain from the injuries. R1 stated, Something wasn't hooked right. R1 stated that she had been in transport vans before and not experienced any problems. R1 stated that prior to the accident, she was able to walk with use of a rolling walker and had plans to discharge home the next week. On 1/29/24 at 11:40 a.m., the certified nurses' aide (CNA #1) that was driving the transport van at the time of R1's accident was interviewed. CNA #1 stated that she was the designated van driver for the facility and transported residents routinely to medical appointments. CNA #1 stated that she was not new to driving the transport van and had approximately 1.5 years' experience with transporting patients. CNA #1 stated that on 1/11/24, she assisted R1, who was in a wheelchair, into the transport van for an appointment. CNA #1 stated that she secured the wheelchair to the four floor brackets and attached the lap and shoulder straps on R1 prior to leaving in the van. CNA #1 stated that on the way to the doctor's office, the car in front of her suddenly braked due to roadside construction. CNA #1 stated that this caused her to brake suddenly and harder than normal. CNA #1 stated that there was no impact with the car in front of her, only sudden braking. CNA #1 stated, I assumed the seat belt broke. CNA #1 stated that when she hit the brakes, R1 went into the floor. CNA #1 stated she pulled the van over and called 911. CNA #1 stated that when she got to R1 on the van floor, the seat/shoulder strap was unattached and laying across the resident's hip. CNA #1 stated the safety belt was unattached from the pin/bracket near the right, rear wheel of the wheelchair. CNA #1 stated that the wheelchair remained locked in place, but the safety belt was unattached. CNA #1 stated, I checked it [safety belt] before I left. I check it every time. CNA #1 stated she was not speeding as she was traveling approximately 25 mph (miles per hour) in a 35-mph speed limit zone. CNA #1 stated that she had driven the same van during her six months at the facility and had experienced no previous issues or concerns with the safety belts or lock down mechanisms. On 1/29/24 at 12:00 p.m., the administrator was interviewed about R1's van accident of 1/11/24. The administrator stated the van was immediately taken out of service after the reported incident on 1/11/24. The administrator stated she, the director of nursing, and the maintenance director had CNA #1 provide a demonstration of how she secured R1 in the van. The administrator stated CNA #1's demonstration was per procedure. The administrator stated her understanding of the events included CNA #1 hitting the brakes suddenly in response to the vehicle in front of her stopping suddenly due to road work. The administrator stated the wheelchair remained locked in position during the incident, and the resident came out of the chair. The administrator stated CNA #1 reported that the seat/shoulder strap was found unattached when she found R1 on the floor of the van. The administrator stated there had been no previous incidents or concerns with the transport van. The administrator stated the van was reviewed by the maintenance director and then sent to a local dealership for a safety inspection. On 1/29/24 at 1:20 p.m., the maintenance director (other staff #3) was interviewed. The maintenance director stated he inspected the transport van immediately after the incident. The maintenance director stated, My observation was that the belts were in perfect condition. The maintenance director stated the safety belts had a latch that, when secured, were snapped onto a pin located on the right back wheel locking mechanism. The maintenance director stated he checked the straps, pin, and locking brackets after the incident and found no malfunction or disrepair. The maintenance director stated he snapped the safety belt bracket in place, pulled on the belts, and found the locking mechanism and belts to be in proper working order. The maintenance director stated that on 1/11/24, CNA #1 demonstrated her procedure for locking/strapping the resident in the van and this was per procedure. The maintenance director stated CNA #1 reported that the seat/shoulder strap was unattached and positioned across the resident's hip after the incident. The maintenance director stated there had been no reported malfunctions or concerns with the transport van. The maintenance director stated the van had a preventive maintenance inspection performed monthly that included checking the seat restraint system. The maintenance director stated the transport van was checked prior to the incident in December 2023 with no issues identified. The maintenance director stated immediately after the incident, the van was taken out of service and then transported to a local dealership for inspection/service. The maintenance director stated his only conclusion about the incident was that the belt bracket was not securely locked or became dislodged somehow. On 1/29/24 at 3:13 p.m., the administrator was interviewed again about R1's transport van incident. The administrator stated she received the report today (1/29/24) from the dealership and there were no problems found with the safety restraint system. The administrator stated from their review of the accident, the facility had identified two possible causes leading to the unattached seat belt. The administrator stated the safety belts were either not connected securely or they were connected and inadvertently dislodged from the locking mechanism. The administrator stated CNA #1 had previous training on use of the transport van and restraint system. The administrator stated the facility only had this one transport van. The administrator stated there were no other employees trained to drive the transport van and if CNA #1 was out, a local transport service was used to take residents to appointments. The administrator presented a copy of CNA #1's initial training dated 8/1/23 that included training on safety guidelines for assisting residents with wheelchair transport and demonstrated competency in securing and releasing the wheelchair and resident with the van's restraint system per manufacturer's recommendations. The administrator presented a copy of the last preventive maintenance check of the transport van conducted by the maintenance department. The report was dated 12/18/23 and documented the wheelchair locking mechanism and seat belts were in good working order with no wear or disrepair of the belts (not frayed, torn or cut). The administrator presented a copy of the dealership service report dated 1/24/24. The dealership report documented, Check for proper function of wheel chair lift seatbelt .checked verified proper operation of the wheel chair lift .Checked for proper operation of wheel chair restraints .restraints seem to be working properly at this time . The facility's policy titled Transportation of a Resident in Facility Van (revised 2/9/23) documented, Residents will be safely transported via the facility transport van .Processes are in place to promote the safety of residents and employees during transport in company vehicles and to minimize resident/employee injury and property damage associated with vehicle accidents . Safety instructions in this policy included, .Keep all seat belts, safety restraints, and wheelchairs secure following the manufacturer instructions .The wheelchair is secured following manufacturer guidelines and facility procedure upon entering the vehicle .All resident wheelchairs are secured using the Qstraint QRT restraint system .and are secured with the lap and shoulder restraints before movement of the van These findings were reviewed with the administrator on 1/29/24 at 3:15 p.m. The administrator stated that immediate actions were taken in response to R1's accident/injury of 1/11/24 and presented a plan of correction for deficient practice listed as, Facility's van's seat belt gave way while car was in motion. Corrective actions taken in response to R1's accident/injury included the following. 1/11/24 - Transport van taken out of service after the incident. Maintenance, administrator and director of nursing (DON) inspected van and restraint system immediately following the incident. CNA #1 performed demonstration to administrator, DON, and maintenance director of procedure for locking wheelchair and securing safety belts. The transport van was taken to a local dealership for inspection of the safety restraint system. 1/11/24 - Audit was conducted identifying all other resident transports with the facility's van/driver within last 30 days. Dates of transports reviewed were from 12/5/23 through 1/11/24. All residents were interviewed/reviewed with no concerns or issues with the van's seat belt system identified. 1/11/24 - The maintenance director educated the van driver (CNA #1) with return demonstration on securing the wheelchair and resident in the van and verified competency for securing and releasing the wheelchair and resident per restraint system manufacturer's recommendations. Ongoing monitoring - the van driver will complete return demonstration of the seat belt system five times a week for four weeks, then two times per week for another four weeks, starting after the van has cleared inspection and been returned to the facility. Findings and interventions will be reviewed/discussed during QAPI (quality assurance and performance improvement) meetings to ensure ongoing compliance and to identify any further corrective actions needed. The administrator was documented in the plan of correction as the person responsible for ensuring compliance with the plan of correction. The correction date was listed as 1/11/24. The facility's transport van remained located at the local dealership at the time of the survey. A local transport company was currently being used to transport residents to appointments. On 1/30/24 at 8:15 a.m., CNA #1 was interviewed about actions taken on 1/11/24 following the incident. CNA #1 stated when she got back to the facility on 1/11/24, she demonstrated to the administrator, DON and maintenance director how she applied the safety restraints in the van. CNA #1 verified that she was re-educated on 1/11/24 about the van restraint system by the maintenance director and watched a video from the manufacturer about safely locking/releasing the resident/wheelchair in the van. The facility audits of transports with the facility van prior to the 1/11/24 incident were reviewed. The audit included documentation of 51 resident transports with no reports or concerns identified with seat belt safety. On 1/30/24 at 9:30 a.m., CNA #2 responsible for coordinating resident transports was interviewed. CNA #2 stated the van was taken out of service immediately after R1's accident on 1/11/24. CNA #2 stated no other residents were transported in the van and the van was sent to a local dealership for safety checks. CNA #2 stated scheduled transports were reassigned with use of a local transportation company. The facility's QAPI program was reviewed. According to the administrator, a meeting was held with the QAPI committee on 1/22/24 that included review/monitoring of R1's accident/injury of 1/11/24. Two residents (Resident #2 and #3) were added to the survey sample and had been identified as recently transported with the local transport company. On 1/30/24 at 8:50 a.m., Resident #2 was interviewed and stated she had experienced no problems with the local transport service and had no issues with her seat/safety belts. On 1/30/24 at 9:40 a.m., Resident #3 was interviewed about the local transportation van. Resident #3 stated she had no problems with transport and her seat belts had been applied/secured. The plan of correction was deemed acceptable with interventions implemented as listed. There were no deficiencies identified since the correction date of 1/11/24 regarding resident safety/accidents. This deficiency was cited as past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, facility document review, clinical record review and complaint investigation, the facility staff failed to assess and implement interventions for prevention/care of pressure ulcers for three of twenty-nine residents in the survey sample, Resident #215, #216, and #5. Resident #215 developed a pressure ulcer initially identified at a stage 3 status. There were no skin assessments in the weeks prior to the stage 3 ulcer and no follow up assessment of the pressure injury for sixteen consecutive days. Resident #215's pressure ulcer developed necrotic tissue, foul odor/drainage resulting in hospitalization due to sepsis from the infected wound. Resident #216 was admitted with a stage 2 pressure ulcer. There was no thorough assessment or interventions implemented for treatment of the ulcer. Resident #5 clincal record failed to include an assessment or treatment orders for a wound aquired at the facility. The findings include: 1. Resident #215 was admitted to the facility with diagnoses that included traumatic spinal cord injury with quadriplegia, hypertension, benign prostatic hyperplasia, urinary tract infection, diabetes and spinal stenosis. The minimum data set (MDS) dated [DATE] assessed Resident #215 as cognitively intact, always incontinent of bowel/bladder and as requiring the extensive assistance of two people for bed mobility and toileting. Resident #215's closed clinical record documented an admission evaluation dated 10/24/20 listing the resident was admitted with a deep tissue injury to the left heel and bogginess on the right heel. There were no other skin impairments identified upon the resident's admission. The form documented Resident #215 was at risk for impaired skin integrity/pressure injuries with interventions that included, Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician .cue to reposition self as needed .Follow facility policies/protocols for the prevention/treatment of impaired skin integrity .Turn/reposition resident every 2 hours .(Resident #215) is at risk for impaired skin integrity/pressure injury R/T (related to) decreased mobility d/t (due to) Quadriplegia . A Braden Scale for Predicting Pressure Sore Risk was completed on 10/24/20 documenting Resident #215 was a high risk for pressure ulcer development due to completely limited sensory perception, skin exposure to moisture, bedfast status, complete immobility and problems with friction/shear due to immobility. A physician's order was documented on 10/26/20 for Resident #215's buttocks to be washed/dried and a barrier cream applied each shift and as needed following incontinence. The treatment administration record (TAR) documented this order was implemented each shift as ordered until the resident's discharge on [DATE]. Resident #215's clinical record documented a physician's order dated 10/28/20 for weekly skin assessments on Wednesdays by the evening shift. There were no skin assessments documented for the week ending 10/31/20 or 11/7/20. The resident's TARs listed the weekly body audits as completed on 10/28/20 and 11/4/20 but there were no results of these assessments providing any description or condition of the resident's skin. Resident #215's clinical record documented a wound evaluation form dated 11/6/20 listing, MASD - IAD (moisture-associated skin damage - incontinence associated dermatitis) on the resident's coccyx measuring 5.18 cm (centimeters) x 1.98 cm x 0.2 cm (length by width by deepest point). The form listed notification to the physician. There were no new treatment orders entered in response to acquired moisture-associated skin damage. A total body skin assessment was completed on 11/11/20 and documented only that the resident had no new wounds. There was no description of the resident's skin, no mention of the previously identified moisture-associated skin damage on the coccyx or the condition of the resident's heels. A nursing note dated 11/12/20 documented continued presence of the moisture-associate skin damage on the buttocks. This nursing note documented, .Skin breakdown: IAD to sacral/buttocks areas .Add Active Liquid protein 30 ml (milliliters) once a day for wound healing . The first assessment indicating a sacral/coccyx pressure ulcer was on 11/18/20 with the ulcer status listed as stage 3. A nursing note dated 11/18/20 documented, .Stage 3 pressure wound on bottom .Unit Manager .notified of pressure wound . There was no other assessment on this date of the stage 3 ulcer indicating the exact location, measurements, wound bed type/appearance, presence of pain, odor or drainage or the condition of surrounding skin. A physician's order was entered for treatment of the stage 3 ulcer on 11/19/20 that stated, Cleanse buttocks and coccyx with soap and water, pat dry. Place Silver Alginate in wound bed, and cover with foam dressing. The first descriptive assessment of Resident #215's stage 3 pressure ulcer was five days later by a wound consultant nurse practitioner (NP) on 11/23/20. This wound assessment dated [DATE] documented, .Patient is seen for evaluation and management of pressure injury at left heel, and new ulceration at sacrum. Staff noted deep purple ecchymosios (ecchymosis) at site with smal (small) open area a few days ago . Physical Exam .full-thickness wound of the sacrum that measure 9.0 x 8.5 x 0.2 (length x width x depth in centimeters) .Wound base 25% slough and 75% area of purple deep ecchymosis before debridement .small to moderate serous, odorless drainage, Periwound without erythema, induration or signs of cellulitis . The wound NP performed excisional debridement of the wound with Removal of devitalized necrotic tissue . (sic) A physician's order was entered on 11/23/20 for an air mattress to the resident's bed. This was five days after the identification of the resident's stage 3 pressure ulcer. The physician's assistant (PA) assessed Resident #215 on 11/27/20, 12/2/20 and on 12/8/20 with no mention of the resident's sacral pressure injury. These PA notes documented regarding skin, No Rash, ulcers or cyanosis . There were no assessments of Resident #215's sacral pressure ulcer from 11/23/20 when assessed by the consultant wound NP, until sixteen days later on 12/9/20 when the wound was listed as unstageable and covered with slough and eschar. The skin and wound evaluation form dated 12/9/20 documented the resident had an acquired coccyx pressure ulcer classified as unstageable due to slough and eschar. This assessment listed the wound was 10.5 cm x 8.0 cm (length by width) with 80% of wound bed covered with eschar and 20% covered with slough. The wound progress was listed as deteriorating. A physician assessed Resident #215 on 12/9/20 and listed the resident with confusion and disorientation to time and place. The physician's progress note dated 12/9/20 documented the resident had a pressure ulcer with eschar on the left heel but made no mention of the sacral pressure ulcer. The wound consultant NP assessed Resident #215's sacral pressure ulcer on 12/9/20 and documented, .full-thickness wound of sacrum that measures 10.5 x 7.5 x 0.2 cm. Wound base 100% moist eschar before debridement .moderate purulent, malodorous drainage .Please treat empirically for sacral wound infection with Doxycycline 100 mg PO (by mouth) BID (twice per day) x 14 days .Wound care to sacrum as follows: Cleanse site with normal saline or wound cleanser .Apply 1/4 strength Dakins moistened gauze to wound base .Cover with ABD pad and tape or foam dressing. Provide this care BID and as needed . The clinical record documented a physician's order dated 12/9/20 for the dressing changes with Dakin's solution twice per day as recommended by the wound consultant. There was no order entered for the antibiotic Doxycyline as recommended by the wound consultant NP. The PA assessed Resident #215 on 12/10/20 for confusion and a buttock wound. The PA progress note dated 12/10/20 documented, .RN (registered nurse) states concern for worsening buttock wound that was first noted in early November .Buttock wound examined with RN. Stage 3 wound, with foul odor consistent with pseudomonas, with worsening surrounding erythema noted. Dark blood noted in dressing . The PA diagnosed Resident #215 with a urinary tract infection, wound infection and ordered Bactrim DS 800 - 160 mg (milligrams) twice per day for one week. A nursing note on 12/11/20 documented Resident #215 was assessed with low blood pressure (90/52), increased heart rate (115/minute) and respiration rate (20/minute). The physician was notified and ordered the resident to the emergency room for evaluation and treatment. The emergency room report dated 12/11/20 documented upon the physical exam, .stage IV decubitus ulcer involving sacrum with eschar and foul smelling greenish drainage . (patient) with history of incomplete quadriplegia . presents from his nursing home with concerns for sepsis secondary to either urinary tract infection and/or infected sacral decubitus ulcer .on examination patient's decubitus ulcer with eschar and necrotic tissue with foul smelling drainage .Patient is septic . The emergency room discharge summary documented Resident #215 was hospitalized and treated with antibiotics for a complicated urinary tract infection and infected pressure ulcer. The discharge summary documented, .hospital course was prolonged and characterized large sacral decubitus ulceration requiring surgical debridement . The family chose palliative care and the resident was admitted to inpatient hospice services on 12/30/20. Resident #215's plan of care (revised 11/5/20) made no mention of the sacral pressure ulcer. The care plan documented Resident #215 was at risk of skin impairment and pressure injury due to decreased mobility related to quadriplegia and incontinence and was admitted with a pressure ulcer to the left heel. Interventions to prevent pressure ulcer development included, .Braden scale per protocol .Conduct weekly head to toe skin assessments, document and report abnormal findings to the physician .Cue to reposition self as needed .Follow facility policies/protocols for the prevention/treatment of impaired skin integrity .Turn/reposition every 2 hours . On 4/13/22 at 3:55 p.m., the DON was interviewed about Resident #215's sacral pressure ulcer, lack of prior skin assessments and initially finding the ulcer at stage 3 status. The DON stated she was not working in the facility during Resident #215's stay. The DON stated the unit manager and nurses that cared for Resident #215 during his stay no longer worked at the facility. On 4/14/22 at 8:00 a.m., the DON stated she reviewed the clinical record and found no skin assessments documented in the weeks prior to the identified stage 3 pressure ulcer. The DON stated she found no rationale of why the pressure ulcer was found at stage 3 and not identified earlier. The DON stated the facility policy required a body audit/skin assessment every seven days. The DON stated the audits were supposed to be completed by nursing and the results documented on an assessment form. The DON stated an assessment should have included a description of the skin and characteristics of any wounds. The DON stated when wounds were found, the unit managers were responsible for following wounds. The DON stated a wound consultant came weekly to the facility and typically assessed/monitored stage 3 or higher wounds making recommendations as needed regarding treatments. The DON stated she had no rationale for why the skin impairment was not recognized earlier even with staff applying cream to the buttocks daily. These findings were reviewed with the administrator and director of nursing during a meeting on 4/13/22 at 4:30 p.m. and on 4/14/22 at 11:10 a.m. This was a complaint deficiency. 2. Resident #216 was admitted to the facility with diagnoses that included septic arthritis, cellulitis of left lower leg, sacral pressure ulcer, diabetes, constipation and muscle weakness. The admission assessment dated [DATE] assessed Resident #216 as alert and orient to time, place and person. Resident #216's admission assessment dated [DATE] documented, . (Resident #216) has a pressure wound to the coccyx . There was no documented assessment of the coccyx pressure ulcer indicating the exact location, measurement, wound bed appearance, odor, drainage or pain presence. There was no notification to the physician and/or provider concerning the pressure ulcer and no orders for treatment initiated. Resident #216's treatment administration record (TAR) for April 2022 made no mention of a pressure ulcer or any treatment to the coccyx area. On 4/12/22 at 4:13 p.m., Resident #216 was interviewed about a coccyx wound. Resident #216 stated she had an open area on her bottom upon admission. Resident #216 stated staff applied a cream to her bottom after using the bathroom. Resident #216 stated her bottom was not painful and she thought the area was doing ok. On 4/13/22 at 10:38 a.m., the nurses' aide (CNA #3) caring for Resident #216 was interviewed. CNA #3 stated Resident #216 was incontinent of urine at times and wore a brief or pull-up. CNA #3 stated the resident's coccyx was clearing up. CNA #3 stated she washed the resident, applied a barrier cream and nurses at one time had a patch on the coccyx area. On 4/13/22 at 10:43 a.m., the licensed practical nurse (LPN) #3 caring for Resident #216 was interviewed. LPN #3 stated she did not know anything about the resident having a pressure ulcer. LPN #3 stated skin assessments were done by the evening shift nurses. LPN #3 stated there were no current orders for treatment of a pressure ulcer. On 4/13/22 at 10:47 a.m., the unit manager (LPN #4) was interviewed about Resident #216. After reviewing the clinical record, LPN #4 stated the physician entered an order for dry dressings every other day on 4/6/22 but the order was incomplete and not activated in the electronic health record. LPN #4 stated the order did not include a wound site and the order was never implemented. LPN #4 stated the admitting nurse should have contacted the provider and obtained orders for care at the time the wound was found. LPN #4 stated the admission nurse should have thoroughly assessed the wound and included documentation of the exact location, size and appearance of the wound. LPN #4 stated the wound consultant nurse practitioner (NP) assessed Resident #216 yesterday (4/12/22) and indicated the pressure ulcer had resolved but the resident had eroded skin. The wound consultant NP note dated 4/12/22 documented, .Central buttock with inflammation, and scattered areas of superficial eroded skin .scant amount of serous, odorless drainage noted in brief . The NP diagnosed MASD (moisture-associated skin damage) and prescribed a zinc-based cream each shift as treatment with instructions to monitor skin for sign of infection, pain, redness, increased warmth, foul odor and increased drainage. Resident #216's plan of care (initiated 4/5/22) listed the resident had a pressure wound to the coccyx. Interventions to prevent complications included, .Observe location, size and treatment of skin injury. Report abnormalities, failure to heal, s/sx (signs/symptoms) of infection, maceration .Treatment to skin as ordered . This finding was reviewed with the administrator and director of nursing during a meeting on 4/13/222 at 4:30 p.m. The facility's policy titled Skin Management (originated 5/1/10, revised 7/14/21) documented prevention/treatment of skin impairments, .those at risk for skin compromise are identified, evaluated and provided appropriate treatment to promote prevention and healing. Ongoing monitoring and evaluation are provided to ensure optimal guest/resident outcomes .The licensed nurse will monitor, evaluate and document changes regarding skin condition (to include: dressing, surrounding skin, possible complications and pain) in the medical record .A weekly total body skin evaluation is completed for each guest/resident by the licensed nurse. The licensed nurse will document findings of the skin evaluation. The CNA's will report any new skin impairment to the licensed nurse that is identified during daily care .resident's (residents) with pressure injury .will be evaluated, measured and staged weekly .in accordance with the practice guidelines until resolved . The National Pressure Injury Advisory Panel (NPIAP) defines a pressure injury as, .localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear . (1) The NPIAP defines a stage 2 pressure injury as, partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis . (1) The NPIAP defines a stage 3 pressure injury as, Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location .Undermining and tunneling may occur . (1) The NPIAP defines a stage 4 pressure injury as, Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur . (1) The NPIAP defines an unstageable pressure injury as, Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, as Stage 3 or Stage 4 pressure injury will be revealed . (1) The NPIAP defines a deep tissue pressure injury as, Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood filled blister .This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury . (1) (1) NPIAP Pressure Injury Stages. National Pressure Injury Advisory Panel. 4/15/22. www.npiap.org3. Resident # 5 was admitted with diagnoses that included traumatic spinal cord dysfunction, incomplete lesion at C8 level of spinal cord, spinal stenosis, neuromuscular dysfunction of the bladder, neurogenic bladder, hypertension, renal insufficiency, diabetes mellitus, hyperlipidemia, morbid obesity, neurogenic bowel, gastroesophageal reflux disease, and history of COVID-19. According to the most recent Minimum Data Set, a Quarterly review with an Assessment Reference Date of 4/4/2022, the resident was assessed under Section C (Cognitive Patterns) as being cognitively intact, with a Summary Score of 15 out of 15. Review of the Progress Notes in the resident's Electronic Health Record revealed the following entry: 3/15/2022 - 1:07 p.m. - Skin/Wound Progress Note - Resident has a three inch open area on his left mid buttock that is open and has slough, zinc ointment and sacral patch applied, supervisor notified. A thorough review of the resident's Electronic Health Record failed to reveal an assessment of the wound or treatment orders for the wound. At approximately 4:00 p.m. on 4/12/2022, documentation of the assessment and the treatment orders was requested. No documentation was provided in response to the request. At approximately 10:30 a.m. on 4/14/2022, LPN # 1 (Licensed Practical Nurse), the Unit Manager on Unit 2 where Resident # 5's room was located, was interviewed regarding the open area on Resident # 5 identified on 3/15/2022. Asked if she was aware of the area on Resident # 5's buttock, LPN # 1 said she thought she was told about it. Asked if the area was assessed to determine the nature of the wound, and if treatment orders were obtained, LPN # 1 said there was no assessment and no treatment orders. LPN # 1 went on to say she could not explain why there was no follow-up. Asked about skin assessments, LPN # 1 said the assessments are done weekly. A review of the PCC Skin & Wound - Total Body Skin Assessments, found in Resident # 5's Electronic Health Record revealed an assessment dated [DATE] that noted the resident had no new wounds. The next PCC Skin & Wound - Total Body Skin Assessment was dated 3/16/2022, three weeks after the assessment of 2/24/2022, which noted the resident had one new wound. On 4/13/2022, during an end of day meeting with the administrative staff documentation of the assessment and the treatment orders was requested. No documentation was provided in response to the request. At 10:00 a.m. on 4/14/2022, after receiving permission from the resident, an observation of the wound was made. Also present for the observation was LPN # 7. The wound was an open area measuring 1 cm by 1 cm (centimeter) with no depth and no drainage. There was an approximately three (3) inch scar visible. The findings were discussed at 11:40 a.m. on 4/14/2022 during a meeting with the Administrator, Director of Nursing, corporate consultant, and the survey team.