**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Example 3R50 was admitted to the facility on [DATE], and has diagnoses that include acute kidney failure, neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, and cellulitis of buttock. R50 developed his pressure wound after admission.R50's MDS, dated [DATE], indicates that R50 is moderately cognitively impaired. R50's MDS shows that he requires substantial/maximal assist for hygiene and personal cares and is dependent for mobility.R50's physician orders dated 3/7/25 and 5/2/2025, state Encourage resident to lay down for at least 1 hr. on his SIDE between meals to offload pressure to buttocks twice a day AM PM. R50's Treatment Record (E-TAR) printed 6/17/25, shows the order was first implemented 5/23/25. No order for remainder 7 hours of the shift, resulting in R50 sitting on his buttocks for extended periods.R50's Kardex (CNA Resident Care Plan), dated 6/17/25, states: Skin Care . Offload side-side as much as possible during the day. Surveyor requested and was not supplied with documentation that this was being done.R50's care plan, with last revisions dated 3/27/25, states:12/18/2024 I have a skin injury I need my nurses to monitor and assess my skin with my scheduled skin check check my skin with cares check my skin weekly.My Goal is to: keep my skin healthy and intact have my skin heal3/12/25 Because I am a diabetic poor tissue perfusion 2/13/25 DTI to left heal-DTI healed 3/12/25, 2/25 25 Stage 2 to Rt posterior thigh-changed to unstageable on 3/7/25.12/18/24 I need my aides to help with hygiene and general skin care; .offer me fluids when I change positions 12/18/24 I need my restorative aide to offer me fluids before and after my program reduce pressure and friction between myself and my bed or chair.12/18/24 I need everyone to report any changes to my nurse .Make sure I change positions frequently. 3/13/25 Skin Care: .Offload side-side as much as possible during the day.On 06/17/25 at 7:31 AM, Surveyor interviewed R50, who stated that R50 came in with a blister and now R50 has a wound. R50 does not think R50 is getting better. They keep monkeying with it and I have to go to the clinic every few weeks now. R50 is sitting in his bed at about a 20-degree angle.On 6/17/25 at 8:00 AM, R50 fell back to sleep. Surveyor observed that R50 remained positioned on his back at about 20-degree angle, pillow by right shoulder but not providing offloading support to the pressure wound On 06/17/25 at 10:05 AM, Surveyor observed R50 rolled for cares. R50 was placed back on his back again about 20 degrees, no offloading support to buttocks.On 06/17/25 at 11:04 AM, Surveyor had been in hallway outside R50's room observing. Surveyor had not observed anyone going into R50's room.On 06/17/25 at 12:00 PM, Surveyor observed R50 sitting up in bed at about 45 degrees with lunch tray.R50 remained with pressure on same area of his buttocks from 8:00 AM until 12:00 PM, except for rolling for cares at 10:05 AM. At 12:00 PM, while pressure was adjusted, R50 remained on his buttocks, with no offloading.On 06/19/25 at 12:21 PM, Surveyor followed up with R50 to clarify his movement. R50 stated they do not make me move a lot; they do use pillows when I'm in bed. R50 stated that at night when R50 goes to bed pillows are placed on R50's left side, then when R50 gets up about 5 AM they put it on the right side. R50 stated the Certified Nursing Assistant (CNA) comes in about 8:00 AM and gets me ready for the day. R50 stated R50 stays in bed for breakfast. Any pillows are removed. R50 states R50 usually gets up around 10:30 AM into my wheelchair for lunch. R50 stated that sometimes R50 goes back to bed, but usually not until just before dinner at 6 PM. R50 stated R50 stays in R50's bed until the staff come in about 8:30 PM to get R50 ready for bed. Surveyor asked R50 if he is sitting on his butt most of the time, or on his side. R50 stated, I am sitting in bed or in my chair most of the day. R50 stated R50 lays on his sides at night.On 06/19/25 at 11:14 AM, Surveyor interviewed Registered Nurse (RN) N who stated the order means we (the facility) have to ensure R50 lays down if R50 gets up for meals. RN N looked and confirmed there is no order to reposition in bed or a frequency. RN N states the nurse ensures R50 lays down by asking the CNAs and trusts the CNAs are telling the truth. RN N does not believe there is anywhere CNAs can chart if CNAs reposition someone. RN N stated again there is no specific frequency it just says offload frequently. RN N stated, [R50] could be on his butt for hours at a time.On 06/19/25 at 11:23 AM, Surveyor interviewed CNA M. CNA M stated CNAs know what each residents' abilities and care needs are because it is on the Kardex. A copy of the Kardex can be found on the wall inside the door of patient's room, in the computer or chart. The computer and chart copies are more in-depth than what is on the walls. CNA M stated we reposition residents, encourage residents to get up, everyone can get up with a lift. CNA M stated if they don't want to get up, we reposition them. CNA M stated that she makes sure everyone is repositioned every 2 hours or what the orders say. CNA M stated it is policy if they have a bed sore repositioning is ordered. CNA M stated that would be listed on the Kardex. Surveyor asked CNA M to read the Kardex for R50 and explain what the frequency for repositioning is. CNA M stated R50 has a pressure wound; it should say somewhere reposition every 2 hours. CNA M stated some residents have a button in the system they can press to show someone was repositioned and in what position, but it doesn't get used often, we get too busy. CNA M stated she is not sure if that is available for R50. On 06/19/25 at 11:37 AM, Surveyor interviewed the charge nurse, Licensed Practical Nurse (LPN) O, regarding protocol for repositioning and pressure wounds. Surveyor started by asking LPN O to read R50's orders and the Kardex. LPN O stated there should be a frequency. LPN O stated it is standard to reposition dependent residents every 2 hours unless indicated by a provider. LPN O stated the CNA Kardex order to offload side to side as much as possible during the day could be interpreted many ways. Surveyor asked LPN if R50 could be in one spot for 4 hours in an 8 hour AM or PM shift. LPN O stated, yes. LPN O stated it is the responsibility of the CNAs to reposition residents and the nurses' tasks to make sure it is done. Surveyor asked LPN O if Surveyor was missing an order or a spot that has a frequency for repositioning R50. LPN O stated no.On 06/19/25 at 1:02 PM, Surveyor interviewed Director of Nursing (DON) B. Surveyor started by sharing the physician orders, care plan, and Kardex and reviewing the different statements regarding repositioning. DOB B stated a physician's order is not needed for repositioning a resident but if ordered then it is an order and followed. DON B believes R50's pressure wound was unavoidable. DON B believes they did everything the facility could do to prevent it. DON B listed all the things they have in place. DON B did not mention repositioning. Surveyor asked DON B how often a person with a pressure wound should be repositioned. DON B stated every 2 hours. Surveyor asked if R50 has a repositioning plan. DON B did not answer. Surveyor restated to DON B, that DON stated repositioning should be every 2 hours. DON B said, Yes. Surveyor asked DON B if R50 refuses care what should staff do. DON B stated it should be documented. The E-TAR would have red initials if refused. Surveyor did not observe any red initials during record review indicating patient refuses to reposition. Example 2According to the National Institute of Health (NIH), a wound clinic consult should be considered with stage 3 or 4 pressure injuries as they involve damage to deeper tissues, with non-healing wounds (wounds that do not heal within eight weeks), or wounds that are recurrent.R42 was admitted to the facility on [DATE] with pertinent diagnoses of intervertebral disc disorder with myelopathy, diabetes mellitus type 2, polyneuropathy, chronic kidney disease stage 2, and hypothyroidism.R42's quarterly Minimum Data Set (MDS) assessment dated [DATE] noted a Brief Interview of Mental Status (BIMS) score of 15 indicating cognition is intact, has impaired range of motion on both lower extremities, is frequently incontinent of bladder, and has 2 stage 3 pressure injuries not present on admission.R42's care plan, dated 02/03/25, with a target date of 08/29/25, states: .am a diabetic, with poor tissue perfusion, have trouble feeling certain sensation, can't move around well on my own, (07/11/24) have 2 stage 3s to bilateral buttocks (chronic/healed and re-open) with interventions to monitor and asses skin with scheduled skin check, monitor nutrition or hydration intake, check skin weekly, reduce pressure and friction between self and bed or chair, ensure alternating air mattress and wheel chair cushion are functioning properly, report changes to nurse, make sure to change position frequently.R42's physician orders:07/11/24 Check mattress (alternating air) & w/c cushion (alternating air) for bottoming out, replace or repair if needed. Notify maintenance of any mattress changes every shift.07/12/24 Ensure w/c cushion is plugged in whenever resident is in her room three times a day.10/15/24 Stage 3 PI to LEFT & RIGHT buttock: (Do NOT change on bath day if clean/dry/intact): 1. Use Unisolve to remove old dressing. 2. Cleanse wound with wound cleanser/pat dry. 3. Apply skin prep to peri-wound/allow to dry. 4. Cover w/hydrocolloidal dressing/secure w/transparent dressing. 1 time a week on Wednesday. 10/15/24 Stage 3 PI to RIGHT & LEFT buttock: 1. Use Unisolve to remove old dressing. 2. Cleanse wound with wound cleanser/pat dry. 3. Apply skin prep to peri-wound/allow to dry. 4. Place collagen powder in wound bed. 5. Cover w/hydrocolloidal dressing/secure w/transparent dressing as needed.10/24/24 Encourage to eat protein (example: yogurt, custard, toast with peanut butter, meat sandwich) daily. 11/26/24 Prophylactic skin protection: 1. Apply Desitin to right AND left buttock fold/cleft three times day.12/02/24 Encourage resident to lay down each shift for 1 hour to offload pressure to buttocks twice a day.Surveyor reviewed R42's nutrition assessment and noted the following:12/03/24 Nestle Mini Nutritional Assessment score of 11, indicating likely at risk for malnutrition.05/28/25 Nestle Mini Nutritional Assessment score of 13, indicating a normal nutritional status.Surveyor reviewed R42's wound/skin assessments and noted the following:-Right lower buttock: Stage 3 06/30/24 Small open area noted to right lower buttock near gluteal fold.*New intervention: Cleanse open area with soap and water, pat dry and apply a small amount of Triad ointment to area every shift until healed. Alert Wound RN to worsening condition. Provider notified. Of note: no new interventions to offload area noted. No documentation noted for root cause of skin breakdown noted. 07/11/24 Initial Assessment L 0.6 cm x W 0.8 cmAction: Physician and Charge Nurse notified. Cleansed areas w/wound cleansers, triad applied to wound bed, skin prep to peri-wound, covered w/hydrocolloidal dressing, secured w/transparent dressing.*New Interventions: -Provide offloading every shift in bed on side as tolerated three times a day.-Bilateral buttocks/gluteal fold/ischial region/sit bones/left/right: Stage 3-1. Use Unisolve to remove old dressings. 2. Cleanse bilateral wounds w/wound cleanser, pat dry. 3. Apply triad to bilateral wound beds. 4. Apply skin prep to peri-wound liberally, allow to dry. 5. Cover both wounds with hydrocolloidal dressing and secure w/transparent dressing every 3 days.08/12/24 HEALEDAction: Treatment is discontinued and provider notified. *New intervention: Triad ointment applied three times a day.Of note: no documented skin assessment of right lower buttock between 08/13/24 - 12/01/24.12/02/24 (RE-OPENED) L 1.9 cm x W 2.0 cm x D 0.1 cmSkin Treatment: Has pressure reducing device for chair/bed. Receives turning/repositioning program. Receives nutrition or hydration intervention.Action: Physician notified*New intervention: -1. Use Unisolve to remove old dressings. 2. Cleanse bilateral wounds w/wound cleanser, pat dry. 3. Apply triad to bilateral wound beds. 4. Apply skin prep to peri-wound liberally, allow to dry. 5. Cover both wounds with hydrocolloidal dressing and secure w/transparent dressing 1 time a week.-Resident encouraged to lay down for 1 hour each shift to offload pressure to area.Of note: No new interventions implemented for alternative measures to offload PI or wound clinic/specialist consult for PI re-opening.Weekly wound assessments continued to show improvement.02/03/25 L 0.4 cm x W 0.4 cm x D 0.1 cmAction: continue to observe*New intervention: Changed treatment - Apply collagen powder to wound bed. Covered w/hydrocolloidal dressing 1 time weekly and as needed. Provider notified. 02/10/25 L 0.6 cm x W 0.8 cm x D <0.1 cmAction: continue to observe*No new interventions implement. Provider not notified of worsening PI measurements.02/24/25 L 0.3 cm x W 0.5 cm x D <0.1 cmAction: continue to observe03/03/25 L 0.3 cm x W 0.5 cm x D <0.1 cmAction: continue to observe*No new interventions implemented after no improvement in PI measurements.03/31/24 L 1.2 cm x W 1.5 cm x D 0.2 cmAction: Dietician consulted. Educated resident regarding additional supplementation for wound healing. Education given to resident regarding offloading. Resident stated being unable to lay on hips. *New interventions: Prosource supplement two times daily. Start trial of Glucerna supplement. Of note: no documentation of provider notified of wound worsening. 04/14/25 L 0.4 cm x W 0.8 cm x D 0.1 cmAction: continue to observeWeekly wound assessments continued to show improvement.05/26/25 HEALEDAction: continue to observe06/02/25 Area remains closed.06/09/25 (RE-OPENED) L 0.5 cm x W 0.4 cm x D <0.1 cmAction: Discussed with resident the importance of offloading and drinking supplements. Resident states I drink my supplements and I do lay down, but not on my side. Charting reflects that resident does often times decline to lay down in bed.*No new interventions implemented for alternative measures to offload PI or wound clinic/specialist consult for PI re-opening.Of note: no documentation of provider notified of wound re-opening. 06/16/25 L 0.4 cm x W 1.0 cm x D <0.1 cm*No new interventions implement. Provider not notified of worsening wound measurements. Of note: documentation of provider assessing wound was not noted in R42's chart or provided to Surveyor.-Left Lower Buttock: Stage 307/11/24 Initial Assessment: L 0.6 cm x W 0.5 cm x D 0.2 cmAction: Physician and Charge Nurse notified. Cleansed areas w/wound cleansers, triad applied to wound bed, skin prep to peri-wound, covered w/hydrocolloidal dressing, secured w/transparent dressing.*New Interventions: -Provide offloading every shift in bed on side as tolerated three times a day.-Bilateral buttocks/gluteal fold/ischial region/sit bones/left/right: Stage 3-1. Use Unisolve to remove old dressings. 2. Cleanse bilateral wounds w/wound cleanser, pat dry. 3. Apply triad to bilateral wound beds. 4. Apply skin prep to peri-wound liberally, allow to dry. 5. Cover both wounds with hydrocolloidal dressing and secure w/transparent dressing every 3 days.Of note: no prior skin breakdown to this area was noted. No documentation noted for root cause of skin breakdown noted. 08/19/25 L 0.4 cm x W 0.3 cm x D 0.1 cmAction: Treatment plan updated and provider notified.*New intervention: Changed from Triad to collagen powder to wound bed.09/23/24 HEALEDAction: will re-assess area next Monday to ensure area remains healed/closed.*New intervention: Discontinued dressings and apply Triad ointment three times daily.Of note: no skin assessment of left lower buttock area documented between 09/24/24 - 10/14/24.10/15/24 (RE-OPENED) L 0.6 cm x W 0.4 cm x D 0.2 cmAction: New treatment added to TAR. Education provided to resident regarding offloading of pressure to buttocks when in bed and continuing ProSource supplement daily.*New intervention: 1. Use Unisolve to remove old dressing. 2. Cleanse wound with wound cleanser/pat dry. 3. Apply skin prep to peri-wound/allow to dry. 4. Place triad in wound bed. 5. Cover w/hydrocolloidal dressing/secure w/transparent dressing 1 time a week on Wednesday.11/11/24 L 0.2 cm x W 0.2 cm x D <0.5 cmAction: continue to observe11/25/24 L 0.2 cm x W 0.2 cm x D <0.5 cmAction: continue to observe*No new interventions implemented after 2 weeks without improvement in PI.12/02/24 L 0.2 cm x W 0.6 cm x D <0.5 cmAction: Resident encouraged to lay down 1 time per shift to offload. Dietician consulted. Provider notified.*No new interventions implemented when width of PI increased.12/23/24 L 0.2 cm x W 0.2 cm x D <0.1 cmWeekly wound assessments continued to show improvement.01/06/25 HEALEDAction: Treatment will remain in place prophylactically to prevent breakdown. (Area has healed and broken down x2). Will re-assess area next Monday to ensure area remains healed.01/13/25 Area remains healed. Will continue with hydrocolloidal to ensure area does not break down.01/27/25 Area remains healed.02/03/25 (RE-OPENED) L 0.4 cm x W 0.4 cm x D 0.1 cmAction: Treatment updated. Provider notified.*New intervention: Changed Triad ointment to collagen powder to wound bed.Weekly wound assessments continued to show improvement.02/24/25 HEALEDAction: will re-assess area next week to ensure area remains healed*New intervention: Discontinued collagen powder and changed treatment to cleansing with soap and water and continue with hydrocolloidal dressing.03/03/25 - 04/28/25 area remains healed.05/05/25 (RE-OPENED) L 0.3 cm x W 0.5 cm x D 0.2 cmAction: Discussed with resident importance of lying down each shift on her side and continued compliance with ProSource supplement two times daily.*New intervention: Changed wound care to wound cleanser and Triad ointment to wound bed. Continue hydrocolloidal dressing.Of note: no documentation of provider notified of wound re-opening. No root cause to identify why PI is reopening.05/26/25 HEALEDAction: continue to observe*New intervention: Discontinued Triad ointment. Area cleansed with soap and water. Continue hydrocolloidal dressing.06/02/25 (RE-OPENED) L 0.5 cm x W 0.3 cm x D 0.2 cmAction: Treatment updated.*New intervention: Changed wound treatment to collagen powder and Triad ointment to wound bed. Continue hydrocolloidal dressing. Of note: no documentation of provider notified of wound re-opening. No root cause to identify why PI has reopened, or additional offloading interventions added.06/16/25 L 0.2 cm x W 0.2 cm x D <0.1 cmAction: continue to observeOf note: documentation of provider assessing wound was not noted in R42's chart or provided to Surveyor.On 06/19/25 at 12:45 PM, Surveyor observed R42 sitting in wheelchair in room. Alternating air pressure reducing cushion observed in place and operating appropriately. Surveyor asked R42 about interventions to relieve pressure. R42 stated that since the wounds opened, no other pressure reducing devices have been used. R42 stated that it is difficult for her to lay on her side in bed due to chronic bone inflammation and it is too painful. R42 stated no other pressure reducing device has been used to offload while laying down in bed other than the alternating air mattress. R42 stated drinking the recommended protein supplements daily. R42 stated the facility had never offered a consult with a specialized wound clinic. Surveyor asked R42 if the provider at the facility had ever assessed the wounds on her buttocks. R42 stated that she could not recall the provider ever looking at her wounds personally.On 06/19/25 at 1:00 PM, Surveyor interviewed Physician Assistant (PA) I regarding R42's pressure injuries (PIs). PA I stated the wound nurse (WN) assesses all wounds and would notify one of the providers with new orders for wound treatment via hand-written order sheet in the resident's chart. PA I stated being updated regularly with wound changes regarding R42, but could not recall specific details. Surveyor asked PA I why R42 was not referred to a wound clinic. PA I stated that R42 was a complex patient that had many concerns being monitored and that R42 often refused interventions. PA I stated that her professional opinion was that R42 was being cared for appropriately, wound clinic treatment was not necessary, and both PIs were unavoidable as the facility could not have done anything different to prevent both PIs from occurring or re-opening, but also stated that additional consultation for wound healing was not utilized to know for sure if other interventions could have been utilized to improve outcomes.On 06/19/25 at 2:16 PM, Surveyor interviewed RN H, who is the facility wound nurse, regarding treatment of R42's PIs. Surveyor asked RN H when the provider should be notified about a wound. RN H stated with any significant change. Surveyor asked RN H what a significant change would mean. RN H stated a wound worsening from baseline, signs of infection, increasing in size, or a drastic change occurring quickly. Surveyor asked RN H why the provider was not always notified when R42's wounds worsened or re-opened. RN H stated that she did not feel changes were significant to warrant provider notification. Surveyor asked RN H why R42 was not referred to the wound clinic for assessment. RN H stated that R42 had superficial PIs and did not feel they were significant enough for the wound clinic. Surveyor asked RN H if any other provider or specialist was contacted to assess or offer additional interventions for R42's PIs. RN H stated no. Surveyor asked RN H if any other offloading interventions or support surfaces were tried. RN H stated no. RN H stated that R42 frequently refused to lay on her side to offload buttocks, additional protein supplements were provided, and weekly skin treatments were provided. RN H stated that due to R42's size, lack of mobility, and frequent refusal of interventions led to the development and reoccurrence of these PIs and there were no additional interventions that could have been implemented to prevent these PIs from occurring. Based on interview, observation and record review, facility did not implement professional standards of practice to ensure that a resident does not develop pressure injuries (PIs), receives necessary treatment and services to promote healing and prevent new PIs from developing for 3 of 5 residents (R) reviewed. (R10, R42, R50) R10 was determined to be at moderate risk for PI development. R10 developed a stage 3 PI and facility did not consult physician for appropriate treatment and interventions to promote healing when the area would re-open or worsen, causing actual harm to R10. Continual education was not provided to R10 and representative for the need of repositioning and offloading the pressure area. R42 acquired two stage 3 PIs. The areas have healed and then reopened with increase in size, causing actual harm to R42. The physician was not notified of changes, a root cause to identify why the PI was reopening, or new interventions to promote healing were not implemented.R50 developed a stage 2 PI on 2/26/25 and on 3/7/25 R50's PI worsened to an unstageable PI, causing actual harm to R50. R50 was not repositioned in a consistent manner with standards of practice. The care plan was last updated with approaches related to PI on 3/13/25. This is evidenced by:National Pressure Injury Advisory Panel (NPIAP) guidance recommends repositioning all individuals with or at risk of pressure injuries on an individualized schedule, unless contraindicated. Determine repositioning frequency with consideration to the individual's level of activity and ability to independently reposition. Reposition the individual in such a way that optimal offloading of all bony prominences and maximum redistribution of pressure is achieved.Facility's policy titled, Pressure Injury Prevention Guidelines with the revised date of 02/27/25, read in part, 3. Interventions will be implemented in accordance with physician orders, including the type of prevention devices to be used and, for tasks, the frequency for performing them. 4. In the absence of prevention orders, the licensed nurse will utilize nursing judgement in accordance with pressure injury prevention guidelines to provide care and will notify physician to obtain orders . 9. The effectiveness of interventions will be monitored through ongoing assessment of the resident and/or wound. Considerations for needed modifications include a. Development of a new pressure injury. B. Lack of progression towards healing or changes in wound characteristics Example 1R10 was admitted to the facility on [DATE]. Current diagnoses include hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, congestive heart failure, diabetes mellitus type 2, morbid obesity, anxiety disorder, visual hallucination, edema, vascular dementia with behavioral disturbance, Alzheimer's disease, and chronic kidney disease stage 3a.Minimum Data Set (MDS), dated [DATE], a quarterly assessment documented R10 having a Brief Interview for Mental Status (BIMS) score of 7, meaning severe cognitive impairment. R10 had impairment to one side of upper and lower extremities. R10 needs maximum assistance from staff for toilet hygiene, dressing, personal hygiene, transfers, and bed mobility. R10 is at risk for PI and has 1 stage 3 PI that was not present on admission. MDS dated [DATE] an annual assessment documented R10 having a Brief Interview for Mental Status (BIMS) score of 10, meaning moderate impaired cognition. R10 had impairment to one side of upper and lower extremities. R10 is dependent on staff for lower body dressing, toilet hygiene, sit to stand transfers, and toilet transfer. R10 needs maximum assistance from staff for upper body dressing, personal hygiene. R10 did not have bed mobility assessed. R10 is at risk for PI and has 1 stage 3 PI that was not present on admission. R10's physician orders include:06/27/24 - general diet w/ soft foods. fluid restriction 2000 ml w/ small portions not receiving supplements at this time.03/24/25 Encourage resident to lay down for 1hr between breakfast and after lunch (NOT Thursday d/t residents activities schedule this day) twice a day 03/26/25 30 ml prosource x3 daily to promote wound healing. 04/28/25 Stage 3 to left of coccyx: Use large hydrocolloidal to cover entire coccyx region - Do Not change if clean/dry intact 1. Use Unisolve to remove old dressing. 2. Cleanse wound w/ wound cleanser, pat dry. 3. Apply skin prep to peri wound, allow to dry 4. Apply Triad to wound bed. 5. Cover wound w/ hydrocolloidal dressing with secure w/ transparent dressing. Every three days. R10's care plan, dated 05/19/21, I have the potential to experience skin breakdown . 05/05/25 I show this by: .I decline to sleep in bed and request to sleep in the recliner; therefore, I need a large per pad in my recliner for staff to reposition me. I am aware that the large peripad can result in skin breakdown .08/26/24 - stage 3 to left side of coccyx---HEALED 2/3/25, reopened 2/17/25 healed 4/14/25 then re-opened 4/28/25 presenting as a stage 2 08/05/25 (date should be 05/05/25) presents as a Stage 3. Interventions: 03/05/25 .reposition at least every 1-2 hours while I'm in a bed help me reposition at least every 1 hour when I'm in a chair offer me fluids when I change positions elevate my heels in bed reduce pressure and friction between myself and my bed or chair use pressure redistribution devices promote plus mattress use a lift sheet when moving me in my bed help me stay clean and dry reposition routinely. Use roho cushion in recliner, sheep skin to back of legs in stand lift, has personalized w/c cushion Ensure the alternating air cushion to my recliner is working.Care plan history on 07/22/24 added .use roho cushion in recliner, sheep skin to back of legs in stand lift, has personalized w/c cushion.On 07/30/23 added pressure redistribution devices promat plus mattress. Surveyor reviewed manufacturer's guidelines; mattress is appropriate for up to uncomplicated Stage 3 or 4 pressure ulcers. Braden scoring assessments for risk of skin breakdown:06/18/24 score 14 risk breakdown moderate risk 13-1409/11/24 score 14 risk breakdown moderate risk 13-1411/25/24 score 14 risk breakdown moderate risk 13-1402/21/25 score 14 risk breakdown moderate risk 13-1405/27/25 score 14 risk breakdown moderate risk 13-14.Weekly wound assessments of Left of coccyx - Stage 3 PI08/26/24 initial assessment has full thickness of skin lost, exposing the subq tissues - presents as a deep crater (pressure stg 3) slough 80% granulation 20% (New area) 2.0 cm by 0.3 cm total sq cm 0.6 cm. Has pressure reducing device for chair. Alternating air cushion added to recliner Ulcer care new tx started for PI matrix cushion to w/c. Procedure area is cleansed w/wound cleanser/pat dry/triad to wound bed/covered w/hydrocolloidal dressing/secured w/transparent dressing. MD notified via incident report/Dr. [Name], placed on rounds for 8/26/24 family notified POA/[Name] called. 09/02/24 Noted after admission stage 3 slough 80% granulation 20% worsening becoming larger 1.5 x 0.6 sq cm 0.9 cm Skin treatment: has pressure reducing device for chair. ulcer care treatment remains appropriate/no changes made to wound dressing treatment. New: Additional alternating air cushion will be added to w/c upon delivery. Surveyor observed proactive alternating pressure seat cushion in use. Review of manufacturer's user manual documented for long term care home care of patients suffering from pressure ulcers. 09/09/24 Stage 3 slough 80% granulation 20% 1.5 x 0.5 sq cm 0.75 improving becoming smaller.09/16/24 stage 3 slough 70% granulation 30% 1.5 x 0.9 sq 1.35 improving appears more clean becoming more shallow - dietician consulted for additional supplements to enable/enhance healing process. 09/17/24 Scheduled a 30 ml prosource x 2 daily to help promote wound healing. 09/23/24 stage 3 slough 60% granulation 40% improving appears more clean becoming more shallow 1.3 x 0.7 by 0.1, sq cm 0.91.Weekly wound assessments continued to show improvement.10/08/24 wound note documented reviewed with R10 and son [Name] the risks associated with R10 choosing to sleep in her recliner and not in the bed. Both [Name and R10 are aware of risk of skin breakdown, despite the risk R10's wants to continue to sleep in her recliner and son is agreeable with this.11/18/24 stage 3 granulation 100% improving appears more clean 0.4 cm x 0.8 x < 0.1, sq cm .32 procedure done area is cleansed w/ wound cleanser / pat dry, collagen to wound bed/covered w/ hydrocolloidal dressing/secured w/ transparent dressing. Note this is a change to the type of treatment. Weekly wound assessments continued to show improvement.01/20/25 stage 3 closed 50% epithelial 50% improving appears more clean 0.2 cm x 0.3 x < 0.1, sq cm .06 Area is cleansed w/wound cleanser/pat dry, collagen to wound bed/covered w/ hydrocolloidal dressing/secured w/ transparent dressing/ Frequency of TX (treatment) is every 3 days AM and PRN (as needed).01/27/25 stage 3 closed 60% epithelial 40% improving appears more clean 0.3 cm x 0.3 x < 0.1, sq cm .09.02/03/25 Closed healed - will re-assess area 2/10/25 to ensure area remains healed. Tx is left in place prophylactically as resident is prone to breakdown in this area. 02/10/25 remains healed continue to follow to ensure area remains healed. 02/17/25 Stage 3 Granulation 100% scant drainage, worsening area chronically heals and reopens. TX was left in place prophylactically, updated TX to include collagen powder becoming deeper becoming larger 0.8 x 0.4 x0.2, sq cm 0.32 granulation tissue. area is cleansed w/wound cleanser/pat dry/collagen powder to wound bed/covered w/ hydrocolloidal dressing/secured w/ transparent dressing **Tx Frequency is every 3 days and PRN**Note, Surveyor unable to locate the physician was notified the area has re-opened with drainage and the treatment that was implemented. 02/25/25 stage 3 Granulation 100% scant drainage improving 0.6 x0.4x0.2, sq cm 0.2403/03/25 stage 3 Granul