Goldwater Care Peoria Heights

hydrocolloid dressing every Monday, Wednesday, Friday, and as needed if soiled or dislodged

3/13/26.R2's Nurse Progress Note dated 3/17/26 documents the hydrocolloid dressings became

silicone foam dressing three times weekly and as needed if soiled or dislodged.

The physician and responsible party were notified.R2's Nurse Progress Note dated 3/18/26 at 8:48 PM, documents R2 experienced an abrupt drop in oxygen saturation levels ranging between 60% (percent) and 74% despite interventions including repositioning, elevation of the head of the bed, suctioning, nebulizer treatments, oxygen administration up to 40%, Venturi mask application, and respiratory therapy interventions.

The note documents R2's oxygen saturation levels remained unstable and continued fluctuating between 78% and 90%. V9 Assistant Director of Nursing was notified and agreed R2 should be transferred to the hospital for further evaluation and treatment.

The record further documented emergency medical transport transferred R2 to the hospital, and the party responsible and V10 (Medical Director) were notified.R2's hospital records dated 3/18/26 documents R2 had an unstageable pressure injury present on admission located at the coccyx extending into the sacrum.

The wound assessment documents measurements of 8 cm x 6 cm with no undermining or tunneling present.

The wound base consisted of 50% pink tissue, 40% purple tissue, and 10% brown tissue.

The assessment further documents intact peri wound skin, scant serosanguinous drainage, no visible structures, and no odor present.On 5/26/26 at 9:50 AM, V8 (R2's Family Member) stated R2 was admitted to the facility from the hospital on 3/10/26. V8 stated after approximately one week at the facility, R2 became dehydrated and was transferred to the emergency room by ambulance. V8 further stated R2 developed a coccyx wound that became significantly deep during R2's stay at the facility and that R2's wound was deep enough to place two eggs inside. V8 stated the staff at the facility did not notify V8 that R2 had pressure ulcers until a couple of days after he was admitted to the facility and that staff were not very good about turning or repositioning R2.On 5/27/26 at 9:00 AM, V9 (Assistant Director of Nursing/Wound Nurse) stated she was not made aware of R2's pressure ulcers until 3/13/26 because she had been on vacation prior to that date. V9 stated she completed a skin assessment with wound measurements on 3/13/26 and confirmed R2's electronic medical record did not contain a prior skin assessment with wound measurements or detailed descriptions of the pressure ulcer sites. V9 further confirmed R2 did not have treatment orders in place for the pressure ulcers until 3/13/26. V9 stated when she assessed R2 on 3/13/26, R2 had a stage two pressure ulcer to the right buttocks, a stage two pressure ulcer to the left buttocks, and a stage three pressure ulcer to the coccyx.On 5/26/26 at 2:00 PM, V2 (Director of Nursing) stated residents should receive a skin assessment upon admission to the facility and if skin concerns were identified, measurements and descriptions of the wounds should be documented. V2 further stated treatment interventions should be initiated upon admission. V2 confirmed there was no treatment order in place for R2's wounds until 3/13/26 and there is no documentation in R2's medical record that a physician was contacted for treatment orders.On 5/27/26 at 9:30 AM, V10 (Medical Director) stated the facility should contact the physician any time abnormal findings or new concerns are identified with a resident. V10 stated he did not receive notification regarding R2's wounds on admission and further stated if V10 had been notified upon admission, treatment orders would have been implemented to prevent worsening of the wounds.