**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility did not provide the necessary care and services to prevent the development of pressure injuries and/or promote healing for 1 resident (R) (R1) of 2 sampled residents. R1 developed a stage 3 pressure injury on the sacrum. The facility did not implement interventions to prevent the pressure injury from developing and did not monitor the pressure injury after it was identified. Findings include: The facility's Pressure Injuries and Non-Pressure Injuries policy indicates: This center will complete a comprehensive assessment to identify risk factors for the development of pressure injuries and put in place measures intended to achieve the goal of prevention of pressure injuries .For those residents admitted with, or who subsequently develop a pressure injury or impaired skin integrity, they will receive care, treatment, and services that seek to promote healing, prevent infection, and prevent further development of pressure injuries/impaired skin integrity .Stage 3 pressure injury: 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 .Moisture-associated skin damage (MASD): Inflammation of the skin and erosion from prolonged exposure to moisture and its contents. Common sources of moisture include urine and stool, perspiration, wound exudate .Upon admission: a. A head-to-toe body evaluation .ii. If non-pressure: Initiate the Non-Pressure Injury Tracker UDA (User-Defined Assessment) .B. Complete the Braden Scale to assess risk of development of a pressure injury .i. Upon admission/re-admission .C. Initiate the baseline plan of care related to current skin status and skin risk level. When determining skin risk status and appropriate interventions, consider the following: i. Braden Scale Score ii. Co-morbid conditions .diabetes mellitus .x. Exposure of skin to urinary and fecal incontinence .2. Weekly: a. Complete a head-to-toe skin check and document findings on the Skin Review .If new areas are present: Notify MD .iii. Initiate treatment per order .v. Update plan of care .B. Assess current wounds at least every seven days .A comprehensive skin integrity care plan is based on resident history, review of the Skin Assessment, Braden Scale .Consider the areas of risk, as well as overall risk assessment score of the Braden Scale .1. Develop interventions based on subsets of Braden Scale that may include: Sensory perception .moisture .activity .mobility .Develop turning/repositioning schedule based on resident's needs and risk factors .2. Develop interventions based on individual risk factors .The care plan should be updated to reflect the resident's choice and what interventions will be in place to minimize the risk to the resident .On 7/7/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] and had diagnoses including encounter for orthopedic aftercare (post-surgical incision to lower back), diabetes, heart failure, chronic kidney disease, and obstructive sleep apnea. R1 had an activated Power of Attorney for Healthcare (POAHC) who assisted with medical decisions. R1's admission Minimum Data Set (MDS) assessment, dated 6/18/25, had a Brief Interview for Mental Status (BIMS) score of 9 out of 15 which indicated R1 had moderately impaired cognition. The MDS assessment indicated R1 was at risk for pressure injuries but did not have a pressure injury, did not not have a pressure reducing device in bed or chair, was not on a turning/repositioning program, and required moderate assistance with rolling left and right and going from a sitting to a lying position. The MDS also indicated R1 had moisture-associated skin damage (MASD) but did not have any surgical wounds and did not receive surgical wound care. R1 had an activated Power of Attorney for Healthcare (POAHC). R1 was currently hospitalized for a surgical incision infection.An admission Assessment, dated 6/12/25, indicated R1 had a macerated area that measured 0.1 centimeters (cm) x 0.1 cm on the left inner buttock.A Braden Scale (skin integrity impairment risk), completed upon admission on [DATE], indicated R1 was at risk for impaired skin integrity.A care plan, dated 6/13/25, indicated R1 had limited mobility and needed the assistance of 1 staff with bed mobility.A baseline care plan, initiated 6/13/25 with revisions on 6/18/25, did not indicate R1 was at risk for skin impairment or contain skin impairment focus area. The baseline care plan also did not indicate interventions were implemented to prevent a pressure injury or prevent further injury after a stage 3 pressure injury was identified on 6/20/25.A non-pressure weekly tracker, dated 6/13/25, indicated R1 was admitted to the facility with a surgical wound on the lower back. No other wounds or MASD were identified.A hospital discharge record, dated 6/17/25, indicated R1 had a diagnosis of decubitus ulcer and an infectious disease workup showed leukocytosis and elevated inflammatory markers likely from underlying cellulitis around the sacral ulcer and contribution from postsurgical changes.A weekly skin assessment, dated 6/17/25, indicated R1 had an open area on the coccyx, blanchable redness to the buttocks, and a surgical incision on the spine with redness around the incision. A note, dated 6/17/25 at 9:15 AM and written by Nurse Practitioner (NP)-I, indicated R1 had a pre-existing decubitus ulcer on the sacrum and was started on Augmentin (an antibiotic). The wound had extended in size slightly but was not deeper. A non-stick dressing was applied in the hospital. A Braden Scale Assessment, completed on 6/18/25, indicated R1 was at risk for impaired skin integrity.A care plan revision, dated 6/18/25, indicated R1 had limited physical mobility, needed to be log rolled into and out of bed, should not engage in low back bending or twisting, and required the assistance of 1 staff for bed mobility.A weekly tracker, dated 6/20/25, contained a surgical wound assessment that indicated R1 had a small amount of drainage. No other wounds or MASD were identified. A wound clinic visit note, dated 6/20/25, indicated R1 had a stage 3 sacral pressure injury that measured 3.0 cm (length) x 1.3 cm (width) x 0.2 cm (depth) with a small amount of exudate. The note contained instructions to continue offloading the pressure injury and apply zinc oxide to the peri-wound twice daily (BID) and as needed with incontinence.On 7/7/25 at 9:08 AM, Surveyor interviewed Family Member (FM)-M who indicated R1 would not be returning to the facility from the hospital. FM-M indicated R1 had a surgical wound infection and a wound vac was applied. FM-M was told the bacteria found in the surgical incision indicated the infection resulted from R1 laying in urine. On 7/7/25 at 11:19 AM, Surveyor interviewed Certified Nursing Assistant (CNA)-F who indicated R1 called staff every 10 to 15 minutes to roll R1 back and forth. CNA-F indicated CNA-F checked on and repositioned R1 if R1 did not call and also checked on R1 every couple of hours because R1 was a heavier wetter. CNA-F indicated R1 always required assistance with transfers which was noted on the care card on the back of R1's door. CNA-F indicated R1 did not refuse to be repositioned or changed and had only been incontinent of urine (not stool) when CNA-F cared for R1. CNA-F did not recall if R1 had a wheelchair cushion or specialty bed. CNA-F indicated R1 had a surgical incision from the tailbone that extended 4 inches up and had a sore below the surgical wound when R1 was admitted to the facility. On 7/7/25 at 11:29 AM, Surveyor interviewed Registered Nurse (RN)-G who indicated R1 had a surgical wound on admission and a penny size open area on the left inner buttock to which staff applied barrier cream. RN-G indicated Director of Nursing (DON)-B was wound care certified and had assessed the open area. RN-G indicated R1 was able to move independently, however, staff assisted with repositioning R1 from side-to-side. RN-G indicated R1 needed assistance with repositioning until side rails were installed on R1's bed. RN-G indicated R1 did not have a specialty bed and recalled a blue foam cushion in R1's wheelchair. RN-G indicated orders from R1's neurosurgery appointment on 6/20/25 recommended R1 be seen by the wound clinic for a coccyx wound. RN-G looked at the wound on 6/20/25 and thought the wound looked the same as upon admission. RN-G stated R1 was seen by the wound clinic on 6/20/25 and RN-G would provide the notes to Surveyor. On 7/7/25 at 1:39 PM, Surveyor interviewed DON-B who verified DON-B was wound care certified and indicated the macerated area in R1's gluteal crease that was noted upon admission to the facility should have been monitored daily. DON-B indicated the area was small but should have been measured. DON-B observed the macerated area a day or two before R1 went to the wound clinic (but did not document the assessment) and stated the area was not a pressure injury. DON-B did not assess the area when R1 returned from the wound clinic on 6/20/25 or any time thereafter. DON-B stated nursing staff should be looking at wounds and if a wound looks worse or there is drainage, the nurse should document the findings. (Note: The facility did not implement monitoring, treatment, or care plan revisions and interventions after R1 returned from the wound clinic on 6/20/25 with a diagnosis of a stage 3 sacral pressure injury).On 7/7/25 at 2:40 PM, Surveyor interviewed Wound Clinic (WCRN)-H who indicated R1 was seen for the first time on 6/20/25 and had a stage 3 pressure injury. WCRN-H indicated R1 was referred to the clinic during a recent hospital visit on 6/17/25. WCRN-H indicated the wound clinic attempted to see R1 in the hospital, however, R1 was leaving and returning to the facility so an appointment was made for 6/20/25. WCRN-H indicated there was an order to apply zinc oxide to the peri-wound twice daily and as needed and stated the order was either faxed or sent with R1 back to the facility. WCRN-H indicated zinc oxide should have been started the night of 6/20/25 or the next morning. WCRN-H indicated WCRN-H had not received communication from the facility that the facility did not agree with the diagnosis of a stage 3 pressure injury (as indicated by DON-B above). WCRN-H indicated R1 was still hospitalized and was still followed by the wound clinic. WCRN-H indicated the wound was still a stage 3 pressure injury and was being treated with zinc oxide around the peri-wound.Surveyor reviewed R1's June 2025 Medication Administration Record (MAR) and Treatment Administration Record (TAR) and noted the 6/20/25 order from the wound clinic to apply zinc oxide to the peri-wound twice daily and as needed was not on R1's MAR or TAR. In addition, the MAR and TAR did not contain monitoring for MASD or the sacral wound. On 7/7/25 at 4:02 PM, Surveyor interviewed Assistant Director of Nursing (ADON)-C who assessed R1 with DON-B on 6/17/25 when R1 returned from the hospital. ADON-C indicated ADON-C observed an excoriated, superficial area no bigger than a nickel that was red with white edges and stated DON-B was going to speak to R1's family about R1 being seen by the facility's wound doctor. ADON-C was not aware R1 went to the wound clinic on 6/20/25. ADON-C stated staff send a folder with the resident to an appointment and the clinic fills out the paperwork and sends it back with the resident. ADON-C did not recall any orders from the wound clinic on 6/20/25 and indicated if zinc oxide was a treatment, it needed to be applied by the nurses. ADON-C stated if a resident does not return with documentation from an appointment, the nurse should call the clinic to get notes or orders. ADON-C confirmed wound monitoring is entered on a resident's MAR or TAR. On 7/7/25 at 4:37 PM, Surveyor interviewed R1's POAHC (POAHC-N) who indicated the facility arranged for a cab to bring R1 to the wound clinic on 6/20/25. On 7/7/25 at 4:43 PM, Surveyor interviewed Medical Records (MR)-J who did not recall R1's 6/20/25 wound clinic appointment. MR-J indicated if MR-J is aware of an appointment a week or more in advance, MR-J arranges transportation with the shared van, however, if the appointment is unexpected, MR-J schedules a cab at the nurses' station but does not keep track of the transportation. On 7/8/25 at 2:45 PM, Surveyor interviewed POAHC-N who indicated after R1's wound clinic appointment on 6/20/25, POAHC-N went to the facility and described to a nurse what occurred during R1's neurosurgery and wound clinic appointments. POAHCH-N stated DON-B joined the conversation and POAHC-N described both appointments to DON-B as well. On 7/9/25 at 1:55 PM, Surveyor received additional information from Nursing Home Administrator (NHA)-A who provided a note by Clinical Reimbursement Specialist (CRS)-K, dated 6/24/25, that indicated the Interdisciplinary Team (IDT) reviewed R1's skilled therapy, functional mobility, and discharge planning. The noted indicated the MASD in R1's gluteal crease had macerated edges and staff applied zinc oxide 20% twice daily (which was not indicated on R1's June 2024 MAR or TAR). NHA-A also provided hospital wound care notes, dated 6/25/25, that indicated R1 had a stage 3 sacral pressure injury that measured 2.0 cm (length) x 0.5 cm (width) x 0.2 cm (depth) with a small amount of exudate and pain at a level 2 out of 10. The hospital plan indicated R1 was last seen on 6/20/25 and the wound had improved with a decrease in size and improved overall tissue quality. At that time, R1 had a specialized immersion mattress and was turned and repositioned on a regular basis. The note indicated the treatment was still zinc oxide twice daily and as needed to the wound and peri-wound. On 7/10/25 at 9:43 AM, Surveyor received documentation from R1's neurosurgery clinic visit on 6/20/25 that indicated R1 complained of burning and stabbing pain to the coccyx wound. After R1's family asked for an opinion on the wound, the provider indicated based on pictures in R1's medical record from 6/16/25 and R1's diagnosis of diabetes, R1 needed to be seen by the wound clinic and staff needed to keep R1 off the coccyx as much as possible and keep the wound clean and dry. An additional note from the neurosurgery clinic, dated 6/22/25, indicated R1's surgical incision wound culture identified a multidrug-resistant organism (MDRO) (Proteus mirabilis) and the facility was updated on 6/23/25.